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Oraii A, McIntyre WF, Parkash R, Kowalik K, Razeghi G, Benz AP, Belley-Côté EP, Conen D, Connolly SJ, Tang ASL, Healey JS, Wong JA. Atrial Fibrillation Ablation in Heart Failure With Reduced vs Preserved Ejection Fraction: A Systematic Review and Meta-Analysis. JAMA Cardiol 2024:2817829. [PMID: 38656292 PMCID: PMC11044015 DOI: 10.1001/jamacardio.2024.0675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 01/19/2024] [Indexed: 04/26/2024]
Abstract
Importance Catheter ablation is associated with reduced heart failure (HF) hospitalization and death in select patients with atrial fibrillation (AF) and heart failure with reduced ejection fraction (HFrEF). However, the benefit in patients with HF with preserved ejection fraction (HFpEF) is uncertain. Objective To investigate whether catheter ablation for AF is associated with reduced HF-related outcomes according to HF phenotype. Data Source A systematic search of MEDLINE, Embase, and Cochrane Central was conducted among studies published from inception to September 2023. Study Selection Parallel-group randomized clinical trials (RCTs) comparing catheter ablation with conventional rate or rhythm control therapies in patients with HF, New York Heart Association functional class II or greater, and a history of paroxysmal or persistent AF were included. Pairs of independent reviewers screened 7531 titles and abstracts, of which 12 RCTs and 4 substudies met selection criteria. Data Extraction and Synthesis Data were abstracted in duplicate according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Pooled effect estimates were calculated using random-effects Mantel-Haenszel models. Interaction P values were used to test for subgroup differences. Main Outcomes and Measures The primary outcome was HF events, defined as HF hospitalization, clinically significant worsening of HF, or unscheduled visits to a clinician for treatment intensification. Secondary outcomes included cardiovascular and all-cause mortality. Results A total of 12 RCTs with 2465 participants (mean [SD] age, 65.3 [9.7] years; 658 females [26.7%]) were included; there were 1552 participants with HFrEF and 913 participants with HFpEF. Compared with conventional rate or rhythm control, catheter ablation was associated with reduced risk of HF events in HFrEF (risk ratio [RR], 0.59; 95% CI, 0.48-0.72), while there was no benefit in patients with HFpEF (RR, 0.93; 95% CI, 0.65-1.32) (P for interaction = .03). Catheter ablation was associated with reduced risk of cardiovascular death compared with conventional therapies in HFrEF (RR, 0.49; 95% CI, 0.34-0.70) but a differential association was not detected in HFpEF (RR, 0.91; 95% CI, 0.46-1.79) (P for interaction = .12). Similarly, no difference in the association of catheter ablation with all-cause mortality was found between HFrEF (RR vs conventional therapies, 0.63; 95% CI, 0.47-0.86) and HFpEF (RR vs conventional therapies, 0.95; 95% CI, 0.39-2.30) groups (P for interaction = .39). Conclusions and Relevance This study found that catheter ablation for AF was associated with reduced risk of HF events in patients with HFrEF but had limited or no benefit in HFpEF. Results from ongoing trials may further elucidate the role of catheter ablation for AF in HFpEF.
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Affiliation(s)
- Alireza Oraii
- Population Health Research Institute, Hamilton, Ontario, Canada
| | - William F. McIntyre
- Population Health Research Institute, Hamilton, Ontario, Canada
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Ratika Parkash
- Queen Elizabeth II Health Sciences Center, Halifax, Nova Scotia, Canada
| | - Krzysztof Kowalik
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Ghazal Razeghi
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - Emilie P. Belley-Côté
- Population Health Research Institute, Hamilton, Ontario, Canada
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - David Conen
- Population Health Research Institute, Hamilton, Ontario, Canada
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Stuart J. Connolly
- Population Health Research Institute, Hamilton, Ontario, Canada
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Anthony S. L. Tang
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Jeff S. Healey
- Population Health Research Institute, Hamilton, Ontario, Canada
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jorge A. Wong
- Population Health Research Institute, Hamilton, Ontario, Canada
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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McIntyre WF, Benz AP, Becher N, Healey JS, Granger CB, Rivard L, Camm AJ, Goette A, Zapf A, Alings M, Connolly SJ, Kirchhof P, Lopes RD. Direct Oral Anticoagulants for Stroke Prevention in Patients With Device-Detected Atrial Fibrillation: A Study-Level Meta-Analysis of the NOAH-AFNET 6 and ARTESiA Trials. Circulation 2024; 149:981-988. [PMID: 37952187 DOI: 10.1161/circulationaha.123.067512] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 11/07/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND Device-detected atrial fibrillation (also known as subclinical atrial fibrillation or atrial high-rate episodes) is a common finding in patients with an implanted cardiac rhythm device and is associated with an increased risk of ischemic stroke. Whether oral anticoagulation is effective and safe in this patient population is unclear. METHODS We performed a systematic review of MEDLINE and Embase for randomized trials comparing oral anticoagulation with antiplatelet or no antithrombotic therapy in adults with device-detected atrial fibrillation recorded by a pacemaker, implantable cardioverter defibrillator, cardiac resynchronization therapy device, or implanted cardiac monitor. We used random-effects models for meta-analysis and rated the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation framework (GRADE). The review was preregistered (PROSPERO CRD42023463212). RESULTS From 785 citations, we identified 2 randomized trials with relevant clinical outcome data: NOAH-AFNET 6 (Non-Vitamin K Antagonist Oral Anticoagulants in Patients With Atrial High Rate Episodes; 2536 participants) evaluated edoxaban, and ARTESiA (Apixaban for the Reduction of Thrombo-Embolism in Patients With Device-Detected Sub-Clinical Atrial Fibrillation; 4012 participants) evaluated apixaban. Meta-analysis demonstrated that oral anticoagulation with these agents reduced ischemic stroke (relative risk [RR], 0.68 [95% CI, 0.50-0.92]; high-quality evidence). The results from the 2 trials were consistent (I2 statistic for heterogeneity=0%). Oral anticoagulation also reduced a composite of cardiovascular death, all-cause stroke, peripheral arterial embolism, myocardial infarction, or pulmonary embolism (RR, 0.85 [95% CI, 0.73-0.99]; I2=0%; moderate-quality evidence). There was no reduction in cardiovascular death (RR, 0.95 [95% CI, 0.76-1.17]; I2=0%; moderate-quality evidence) or all-cause mortality (RR, 1.08 [95% CI, 0.96-1.21]; I2=0%; moderate-quality evidence). Oral anticoagulation increased major bleeding (RR, 1.62 [95% CI, 1.05-2.50]; I²=61%; high-quality evidence). CONCLUSIONS The results of the NOAH-AFNET 6 and ARTESiA trials are consistent with each other. Meta-analysis of these 2 large randomized trials provides high-quality evidence that oral anticoagulation with edoxaban or apixaban reduces the risk of stroke in patients with device-detected atrial fibrillation and increases the risk of major bleeding.
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Affiliation(s)
- William F McIntyre
- McMaster University and Population Health Research Institute, Hamilton, Canada (W.F.M., A.P.B., J.S.H., S.J.C.)
| | - Alexander P Benz
- McMaster University and Population Health Research Institute, Hamilton, Canada (W.F.M., A.P.B., J.S.H., S.J.C.)
| | - Nina Becher
- Department of Cardiology, University Heart and Vascular Center Hamburg, Germany (N.B., P.K.)
| | - Jeffrey S Healey
- McMaster University and Population Health Research Institute, Hamilton, Canada (W.F.M., A.P.B., J.S.H., S.J.C.)
| | | | | | - A John Camm
- St George's University of London and Imperial College London, United Kingdom (A.J.C.)
| | - Andreas Goette
- Department of Cardiology and Intensive Care Medicine, St Vincenz Hospital Paderborn, Germany (A.G.)
| | - Antonia Zapf
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Germany (A.Z.)
| | | | - Stuart J Connolly
- McMaster University and Population Health Research Institute, Hamilton, Canada (W.F.M., A.P.B., J.S.H., S.J.C.)
| | - Paulus Kirchhof
- Department of Cardiology, University Heart and Vascular Center Hamburg, Germany (N.B., P.K.)
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G., R.D.L.)
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Oraii A, Healey JS, Kowalik K, Pandey AK, Benz AP, Wong JA, Conen D, McIntyre WF. Mineralocorticoid receptor antagonists and atrial fibrillation: a meta-analysis of clinical trials. Eur Heart J 2024; 45:756-774. [PMID: 38195054 DOI: 10.1093/eurheartj/ehad811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 11/05/2023] [Accepted: 11/28/2023] [Indexed: 01/11/2024] Open
Abstract
BACKGROUND AND AIMS Mineralocorticoid receptor antagonists (MRAs) improve cardiovascular outcomes in a variety of settings. This study aimed to assess whether cardioprotective effects of MRAs are modified by heart failure (HF) and atrial fibrillation (AF) status and to study their impact on AF events. METHODS MEDLINE, Embase, and Cochrane Central databases were searched to 24 March 2023 for randomized controlled trials evaluating the efficacy of MRAs as compared with placebo or usual care in reducing cardiovascular outcomes and AF events in patients with or at risk for cardiovascular diseases. Random-effects models and interaction analyses were used to test for effect modification. RESULTS Meta-analysis of seven trials (20 741 participants, mean age: 65.6 years, 32% women) showed that the efficacy of MRAs, as compared with placebo, in reducing a composite of cardiovascular death or HF hospitalization remains consistent across patients with HF [risk ratio = 0.81; 95% confidence interval (CI): 0.67-0.98] and without HF (risk ratio = 0.84; 95% CI: 0.75-0.93; interaction P = .77). Among patients with HF, MRAs reduced cardiovascular death or HF hospitalization in patients with AF (hazard ratio = 0.95; 95% CI: 0.54-1.66) to a similar extent as in those without AF (hazard ratio = 0.82; 95% CI: 0.63-1.07; interaction P = .65). Pooled data from 20 trials (21 791 participants, mean age: 65.2 years, 31.3% women) showed that MRAs reduce AF events (risk ratio = 0.76; 95% CI: 0.67-0.87) in both patients with and without prior AF. CONCLUSIONS Mineralocorticoid receptor antagonists are similarly effective in preventing cardiovascular events in patients with and without HF and most likely retain their efficacy regardless of AF status. Mineralocorticoid receptor antagonists may also be moderately effective in preventing incident or recurrent AF events.
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Affiliation(s)
- Alireza Oraii
- Population Health Research Institute, McMaster University, 237 Barton St East, DBVSRI C3-13A, Hamilton, ON L8L 2X2, Canada
| | - Jeff S Healey
- Population Health Research Institute, McMaster University, 237 Barton St East, DBVSRI C3-13A, Hamilton, ON L8L 2X2, Canada
- Division of Cardiology, Department of Medicine, McMaster University, 1200 Main Street West, Hamilton, ON L8N 3Z5, Canada
| | - Krzysztof Kowalik
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Avinash K Pandey
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Alexander P Benz
- Population Health Research Institute, McMaster University, 237 Barton St East, DBVSRI C3-13A, Hamilton, ON L8L 2X2, Canada
| | - Jorge A Wong
- Population Health Research Institute, McMaster University, 237 Barton St East, DBVSRI C3-13A, Hamilton, ON L8L 2X2, Canada
- Division of Cardiology, Department of Medicine, McMaster University, 1200 Main Street West, Hamilton, ON L8N 3Z5, Canada
| | - David Conen
- Population Health Research Institute, McMaster University, 237 Barton St East, DBVSRI C3-13A, Hamilton, ON L8L 2X2, Canada
- Division of Cardiology, Department of Medicine, McMaster University, 1200 Main Street West, Hamilton, ON L8N 3Z5, Canada
| | - William F McIntyre
- Population Health Research Institute, McMaster University, 237 Barton St East, DBVSRI C3-13A, Hamilton, ON L8L 2X2, Canada
- Division of Cardiology, Department of Medicine, McMaster University, 1200 Main Street West, Hamilton, ON L8N 3Z5, Canada
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Rostock T, Benz AP, Spittler R. Artificial intelligence-guided mapping of persistent atrial fibrillation: Complementary to or better than the electrophysiologist? J Cardiovasc Electrophysiol 2024; 35:415-417. [PMID: 38351476 DOI: 10.1111/jce.16214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 01/31/2024] [Indexed: 03/08/2024]
Affiliation(s)
- Thomas Rostock
- Department of Cardiology II/Electrophysiology, Center for Cardiology, University Hospital Mainz, Mainz, Germany
| | - Alexander P Benz
- Department of Cardiology II/Electrophysiology, Center for Cardiology, University Hospital Mainz, Mainz, Germany
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Raphael Spittler
- Department of Cardiology II/Electrophysiology, Center for Cardiology, University Hospital Mainz, Mainz, Germany
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Benz AP, Amit G, Connolly SJ, Singh J, Acosta-Vélez JG, Conen D, Deif B, Divakaramenon S, McIntyre WF, Mtwesi V, Roberts JD, Wong JA, Zhao R, Healey JS. Colchicine to Prevent Atrial Fibrillation Recurrence After Catheter Ablation: A Randomized, Placebo-Controlled Trial. Circ Arrhythm Electrophysiol 2024; 17:e01238. [PMID: 38126206 DOI: 10.1161/circep.123.012387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 11/22/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Inflammation may promote atrial fibrillation (AF) recurrence after catheter ablation. This study aimed to evaluate a short-term anti-inflammatory treatment with colchicine following ablation of AF. METHODS Patients scheduled for ablation were randomized to receive colchicine 0.6 mg twice daily or placebo for 10 days. The first dose of the study drug was administered within 4 hours before ablation. Atrial arrhythmia recurrence was defined as AF, atrial flutter, or atrial tachycardia >30 s on two 14-day Holters performed immediately and at 3 months following ablation. RESULTS The modified intention-to-treat population included 199 patients (median age, 61 years; 22% female; 70% first procedure) who underwent radiofrequency (79%) or cryoballoon ablation (21%) of AF. Antiarrhythmic drugs were prescribed at discharge in 149 (75%) patients. Colchicine did not prevent atrial arrhythmia recurrence at 2 weeks (31% versus 32%; hazard ratio [HR], 0.98 [95% CI, 0.59-1.61]; P=0.92) or at 3 months following ablation (14% versus 15%; HR, 0.95 [95% CI, 0.45-2.02]; P=0.89). Postablation chest pain consistent with pericarditis was reduced with colchicine (4% versus 15%; HR, 0.26 [95% CI, 0.09-0.77]; P=0.02) and colchicine increased diarrhea (26% versus 7%; HR, 4.74 [95% CI, 1.95-11.53]; P<0.001). During a median follow-up of 1.3 years, colchicine did not reduce a composite of emergency department visit, cardiovascular hospitalization, cardioversion, or repeat ablation (29 versus 25 per 100 patient-years; HR, 1.18 [95% CI, 0.69-1.99]; P=0.55). CONCLUSIONS Colchicine administered for 10 days following catheter ablation did not reduce atrial arrhythmia recurrence or AF-associated clinical events, but did reduce postablation chest pain and increase diarrhea.
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Affiliation(s)
- Alexander P Benz
- Population Health Research Institute (A.P.B., S.J.C., J.S., D.C., W.F.M., J.D.R., J.A.W., R.Z., J.S.H.), Hamilton, ON, Canada
- Department of Cardiology, University Medical Center Mainz, Johannes Gutenberg-University, Germany (A.P.B.)
| | - Guy Amit
- Cardiac Electrophysiology and Pacing, Division of Cardiology, Department of Medicine (G.A., J.G.A.-V., S.D., J.D.R., J.A.W., J.S.H.), Hamilton, ON, Canada
| | - Stuart J Connolly
- Population Health Research Institute (A.P.B., S.J.C., J.S., D.C., W.F.M., J.D.R., J.A.W., R.Z., J.S.H.), Hamilton, ON, Canada
| | - Jasrita Singh
- Population Health Research Institute (A.P.B., S.J.C., J.S., D.C., W.F.M., J.D.R., J.A.W., R.Z., J.S.H.), Hamilton, ON, Canada
- Cardiac Electrophysiology and Pacing, Division of Cardiology, Department of Medicine (G.A., J.G.A.-V., S.D., J.D.R., J.A.W., J.S.H.), Hamilton, ON, Canada
| | - Juan G Acosta-Vélez
- Cardiac Electrophysiology and Pacing, Division of Cardiology, Department of Medicine (G.A., J.G.A.-V., S.D., J.D.R., J.A.W., J.S.H.), Hamilton, ON, Canada
| | - David Conen
- Population Health Research Institute (A.P.B., S.J.C., J.S., D.C., W.F.M., J.D.R., J.A.W., R.Z., J.S.H.), Hamilton, ON, Canada
| | - Bishoy Deif
- Royal Victoria Hospital, Barrie, ON, Canada (B.D.)
| | - Syamkumar Divakaramenon
- Cardiac Electrophysiology and Pacing, Division of Cardiology, Department of Medicine (G.A., J.G.A.-V., S.D., J.D.R., J.A.W., J.S.H.), Hamilton, ON, Canada
| | - William F McIntyre
- Population Health Research Institute (A.P.B., S.J.C., J.S., D.C., W.F.M., J.D.R., J.A.W., R.Z., J.S.H.), Hamilton, ON, Canada
| | - Viwe Mtwesi
- Division of Cardiology, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa (V.M.)
| | - Jason D Roberts
- Population Health Research Institute (A.P.B., S.J.C., J.S., D.C., W.F.M., J.D.R., J.A.W., R.Z., J.S.H.), Hamilton, ON, Canada
- Cardiac Electrophysiology and Pacing, Division of Cardiology, Department of Medicine (G.A., J.G.A.-V., S.D., J.D.R., J.A.W., J.S.H.), Hamilton, ON, Canada
| | - Jorge A Wong
- Population Health Research Institute (A.P.B., S.J.C., J.S., D.C., W.F.M., J.D.R., J.A.W., R.Z., J.S.H.), Hamilton, ON, Canada
- Cardiac Electrophysiology and Pacing, Division of Cardiology, Department of Medicine (G.A., J.G.A.-V., S.D., J.D.R., J.A.W., J.S.H.), Hamilton, ON, Canada
| | - Robin Zhao
- Population Health Research Institute (A.P.B., S.J.C., J.S., D.C., W.F.M., J.D.R., J.A.W., R.Z., J.S.H.), Hamilton, ON, Canada
| | - Jeff S Healey
- Population Health Research Institute (A.P.B., S.J.C., J.S., D.C., W.F.M., J.D.R., J.A.W., R.Z., J.S.H.), Hamilton, ON, Canada
- Cardiac Electrophysiology and Pacing, Division of Cardiology, Department of Medicine (G.A., J.G.A.-V., S.D., J.D.R., J.A.W., J.S.H.), Hamilton, ON, Canada
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Johansson I, Benz AP, Kovalova T, Balasubramanian K, Fukakusa B, Lynn MJ, Nair N, Sikder O, Patel K, Gayathri S, Robinson M, Hardy C, Tyrwhitt J, Schulman S, Eikelboom JW, Connolly SJ. Outcomes of Patients with a Mechanical Heart Valve and Poor Anticoagulation Control on Warfarin. Thromb Haemost 2023. [PMID: 38158198 DOI: 10.1055/s-0043-1777827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
BACKGROUND Patients with a mechanical heart valve (MHV) require oral anticoagulation. Poor anticoagulation control is thought to be associated with adverse outcomes, but data are limited. OBJECTIVE To assess the risks of clinical outcomes in patients with a MHV and poor anticoagulation control on warfarin. PATIENTS/METHODS We conducted a retrospective study of consecutive patients undergoing MHV implantation at a tertiary care center (2010-2019). Primary outcome was a composite of ischemic stroke, systemic embolism, or prosthetic valve thrombosis. Major bleeding and death were key secondary outcomes. We constructed multivariable regression models to assess the association between time in therapeutic range (TTR) on warfarin beyond 90 days after surgery with outcomes. RESULTS We included 671 patients with a MHV (80.6% in aortic, 14.6% in mitral position; mean age 61 years, 30.3% female). Median follow-up was 4.9 years, mean TTR was 62.5% (14.5% TTR <40%, 24.6% TTR 40-60%, and 61.0% TTR >60%). Overall rates of the primary outcome, major bleeding, and death were 0.73, 1.41, and 1.44 per 100 patient-years. Corresponding rates for patients with TTR <40% were 1.31, 2.77, and 3.22 per 100 patient-years. In adjusted analyses, every 10% decrement in TTR was associated with a 31% increase in hazard for the primary outcome (hazard ratio [HR]: 1.31, 95% confidence interval [CI]: 1.13-1.52), 34% increase in major bleeding (HR: 1.34, 95% CI: 1.17-1.52), and 32% increase in death (HR: 1.32, 95% CI: 1.11-1.57). CONCLUSION In contemporary patients with a MHV, poor anticoagulation control on warfarin was associated with increased risks of thrombotic events, bleeding, and death.
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Affiliation(s)
- Isabelle Johansson
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Ontario, Canada
- Division of Cardiology, Department of Medicine K2, Karolinska University Hospital Solna, Karolinska Institutet, Stockholm, Sweden
| | - Alexander P Benz
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Ontario, Canada
- Department of Cardiology, University Medical Center Mainz, Johannes Gutenberg-University, Mainz, Germany
| | - Tanya Kovalova
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Ontario, Canada
| | - Kumar Balasubramanian
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Ontario, Canada
| | - Bianca Fukakusa
- Division of Cardiology, Department of Pediatrics, The University of British Columbia, Vancouver, Canada
| | - Matthew J Lynn
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Nikhil Nair
- Division of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Canada
| | - Omaike Sikder
- Division of Medicine, School of Nursing, McMaster University, Hamilton, Canada
| | - Kashyap Patel
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Sai Gayathri
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Canada
| | - Marlene Robinson
- Department of Medicine and Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Canada
| | - Colin Hardy
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Ontario, Canada
| | - Jessica Tyrwhitt
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Ontario, Canada
| | - Sam Schulman
- Department of Medicine and Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Canada
| | - John W Eikelboom
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Ontario, Canada
| | - Stuart J Connolly
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Ontario, Canada
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7
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Pandey A, Okaj I, Ichhpuniani S, Tao B, Kaur H, Spence JD, Young J, Healey JS, Devereaux PJ, Um KJ, Benz AP, Conen D, Whitlock RP, Belley-Cote EP, McIntyre WF. Risk Scores for Prediction of Postoperative Atrial Fibrillation After Cardiac Surgery: A Systematic Review and Meta-Analysis. Am J Cardiol 2023; 209:232-240. [PMID: 37922611 DOI: 10.1016/j.amjcard.2023.08.161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 08/22/2023] [Accepted: 08/23/2023] [Indexed: 11/07/2023]
Abstract
Postoperative atrial fibrillation (POAF) is a common complication after cardiac surgery and is associated with poor clinical outcomes. The objective of this systematic review and meta-analysis was to assess the performance of risk scores to predict POAF in cardiac surgery patients. We searched MEDLINE, Embase, and Cochrane CENTRAL for studies that developed/evaluated a POAF risk prediction model. Pairs of reviewers independently screened studies and extracted data. We pooled area under the receiver operating curves (AUCs), sensitivity and specificity, and adjusted odds ratios from multivariable regression analyses using the generic inverse variance method and random effects models. Forty-three studies (n = 63,847) were included in the quantitative synthesis. Most scores were originally developed for other purposes but evaluated for predicting POAF. Pooled AUC revealed moderate POAF discrimination for the EuroSCORE II (AUC 0.59, 95% confidence interval [CI] 0.54 to 0.65), Society of Thoracic Surgeons (AUC 0.60, 95% CI 0.56 to 0.63), EuroSCORE (AUC 0.63, 95% CI 0.58 to 0.68), CHADS2 (AUC 0.66, 95% CI 0.57 to 0.75), POAF Score (AUC 0.66, 95% CI 0.63 to 0.68), HATCH (AUC 0.67, 95% CI 0.57 to 0.75), CHA2DS2-VASc (AUC 0.68, 95% CI 0.60 to 0.75) and SYNTAX scores (AUC 0.74, 95% CI 0.71 to 0.78). Pooled analyses at specific cutoffs of the CHA2DS2-VASc, CHADS2, HATCH, and POAF scores demonstrated moderate-to-high sensitivity (range 46% to 87%) and low-to-moderate specificity (range 31% to 70%) for POAF prediction. In conclusion, existing clinical risk scores offer at best moderate prediction for POAF after cardiac surgery. Better models are needed to guide POAF risk stratification in cardiac surgery patients.
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Affiliation(s)
- Arjun Pandey
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Iva Okaj
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - Brendan Tao
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Hargun Kaur
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - Jack Young
- Health Sciences Library, McMaster University, Hamilton, Ontario, Canada
| | - Jeff S Healey
- Population Health Research Institute, Hamilton, Ontario, Canada; Division of Cardiology, McMaster University, Hamilton, Ontario, Canada
| | - P J Devereaux
- Population Health Research Institute, Hamilton, Ontario, Canada; Division of Cardiology, McMaster University, Hamilton, Ontario, Canada
| | - Kevin J Um
- Division of Cardiology, McMaster University, Hamilton, Ontario, Canada
| | | | - David Conen
- Population Health Research Institute, Hamilton, Ontario, Canada; Division of Cardiology, McMaster University, Hamilton, Ontario, Canada
| | | | - Emilie P Belley-Cote
- Population Health Research Institute, Hamilton, Ontario, Canada; Division of Cardiology, McMaster University, Hamilton, Ontario, Canada
| | - William F McIntyre
- Population Health Research Institute, Hamilton, Ontario, Canada; Division of Cardiology, McMaster University, Hamilton, Ontario, Canada.
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8
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Benz AP, Eikelboom JW. In DVT, oral DTIs and factor Xa inhibitors reduce major bleeding but not recurrent VTE vs. conventional anticoagulants. Ann Intern Med 2023; 176:JC92. [PMID: 37523702 DOI: 10.7326/j23-0053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/02/2023] Open
Abstract
SOURCE CITATION Wang X, Ma Y, Hui X, et al. Oral direct thrombin inhibitors or oral factor Xa inhibitors versus conventional anticoagulants for the treatment of deep vein thrombosis. Cochrane Database Syst Rev. 2023;4:CD010956. 37058421.
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Affiliation(s)
- Alexander P Benz
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada, University Medical Center Mainz, Johannes Gutenberg-University, Mainz, Germany (A.P.B.)
| | - John W Eikelboom
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada (J.W.E.)
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9
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Benz AP, Hijazi Z, Lindbäck J, Connolly SJ, Eikelboom JW, Kastner P, Ziegler A, Alexander JH, Granger CB, Lopes RD, Oldgren J, Siegbahn A, Wallentin L. Plasma angiopoietin-2 and its association with heart failure in patients with atrial fibrillation. Europace 2023; 25:euad200. [PMID: 37461214 PMCID: PMC10359110 DOI: 10.1093/europace/euad200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 05/24/2023] [Indexed: 07/22/2023] Open
Abstract
AIMS Several biomarkers are associated with clinical outcomes in patients with atrial fibrillation (AF), but a causal relationship has not been established. This study aimed to evaluate angiopoietin-2, a novel candidate biomarker of endothelial inflammation and vascular remodelling, in patients with AF. METHODS AND RESULTS Angiopoietin-2 was measured in plasma obtained from patients with AF treated with aspirin monotherapy (exploration cohort, n = 2987) or with oral anticoagulation (validation cohort, n = 13 079). Regression models were built to assess the associations between angiopoietin-2, clinical characteristics, and outcomes. In both cohorts, plasma angiopoietin-2 was independently associated with AF on the baseline electrocardiogram and persistent/permanent AF, age, history of heart failure, female sex, tobacco use/smoking, body mass index, renal dysfunction, diabetes, and N-terminal pro-B-type natriuretic peptide (NT-proBNP). Angiopoietin-2 was independently associated with subsequent hospitalization for heart failure after adjusting for age, creatinine, and clinical characteristics in the exploration cohort [c-index 0.79, 95% confidence interval (CI) 0.75-0.82; third vs. first quartile, hazard ratio (HR) 1.74, 95% CI 1.26-2.41] and in the validation cohort (c-index 0.76, 95% CI 0.74-0.78; HR 1.58, 95% CI 1.37-1.82). In both cohorts, the association persisted when also adjusting for NT-proBNP (P ≤ 0.001). In full multivariable models also adjusted for NT-proBNP, angiopoietin-2 did not show statistically significant associations with ischaemic stroke, cardiovascular and all-cause death, or major bleeding that were consistent across the two cohorts. CONCLUSIONS In patients with AF, plasma levels of angiopoietin-2 were independently associated with subsequent hospitalization for heart failure and provided incremental prognostic value to clinical risk factors and NT-proBNP.
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Affiliation(s)
- Alexander P Benz
- Population Health Research Institute, McMaster University, 237 Barton St. E., Hamilton, Ontario L8L 2X2, Canada
- Department of Cardiology, University Medical Center Mainz, Johannes Gutenberg-University, Langenbeckstr. 1, Mainz 55131, Germany
| | - Ziad Hijazi
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
| | - Johan Lindbäck
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Stuart J Connolly
- Population Health Research Institute, McMaster University, 237 Barton St. E., Hamilton, Ontario L8L 2X2, Canada
| | - John W Eikelboom
- Population Health Research Institute, McMaster University, 237 Barton St. E., Hamilton, Ontario L8L 2X2, Canada
| | | | | | - John H Alexander
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | | | - Renato D Lopes
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Jonas Oldgren
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
| | - Agneta Siegbahn
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
- Department of Medical Sciences, Clinical Chemistry, Uppsala University, Uppsala, Sweden
| | - Lars Wallentin
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
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10
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Hijazi Z, Lindbäck J, Oldgren J, Benz AP, Alexander JH, Connolly SJ, Eikelboom JW, Granger CB, Lopes RD, Siegbahn A, Wallentin L. Individual net clinical outcome with oral anticoagulation in atrial fibrillation using the ABC-AF risk scores. Am Heart J 2023; 261:55-63. [PMID: 36990261 DOI: 10.1016/j.ahj.2023.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 02/15/2023] [Accepted: 03/19/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND Decisions on stroke prevention strategies in patients with atrial fibrillation (AF) depend on the perceived risks of stroke and bleeding with different antithrombotic treatment strategies. The study objectives were to evaluate net clinical outcome with oral anticoagulation (OAC) for the individual patient with AF and to identify clinically relevant thresholds for OAC treatment. METHODS Patients with AF receiving OAC treatment in the randomized ARISTOTLE and RE-LY trials, with available biomarkers for calculation of ABC-AF scores at baseline, were included (n = 23,121). Observed 1-year risk on OAC was compared with predicted 1-year risk if the same patients would not have received OAC using the ABC-AF scores calibrated for aspirin. Net clinical outcome was defined as the sum of stroke and major bleeding risks. RESULTS The ratio between the 1-year incidence of major bleeding and stroke/systemic embolism events ranged from 1.4 to 10.6 according to different ABC-AF risk profiles. Net clinical outcome analyses showed that in patients with an ABC-AF-stroke risk >1% per year on OAC (>3% without OAC), treatment with OAC consistently provides larger net clinical benefit than no-OAC treatment. In patients with an ABC-AF-stroke risk <1.0% per year on OAC (<3% without OAC) an individualized balancing of risks regarding OAC or no-OAC treatment is needed. CONCLUSIONS In patients with AF, the ABC-AF risk scores allow an individual and continuous estimate of the balance between benefits and risks with OAC treatment. This precision medicine tool therefore seems useful as decision support and visualizes the net clinical benefit or harm with OAC treatment (http://www.abc-score.com/abcaf/). CLINICAL TRIAL REGISTRATION ClinicalTrials.gov identifier NCT00412984 (ARISTOTLE) and NCT00262600 (RE-LY).
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Affiliation(s)
- Ziad Hijazi
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden; Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden.
| | - Johan Lindbäck
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Jonas Oldgren
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden; Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Alexander P Benz
- Population Health Research Institute, Hamilton, Ontario, Canada; Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg-University, Mainz, Germany
| | | | | | | | | | - Renato D Lopes
- Duke Clinical Research Institute, Duke Medicine, Durham, NC
| | - Agneta Siegbahn
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden; Department of Medical Sciences, Clinical Chemistry, Uppsala University, Uppsala, Sweden
| | - Lars Wallentin
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden; Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
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11
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Benz AP, Hohnloser SH, Eikelboom JW, Carnicelli AP, Giugliano RP, Granger CB, Harrington J, Hijazi Z, Morrow DA, Patel MR, Seiffge DJ, Shoamanesh A, Wallentin L, Yi Q, Connolly SJ. Outcomes of patients with atrial fibrillation and ischemic stroke while on oral anticoagulation. Eur Heart J 2023; 44:1807-1814. [PMID: 37038327 PMCID: PMC10411934 DOI: 10.1093/eurheartj/ehad200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 02/08/2023] [Accepted: 03/20/2023] [Indexed: 04/12/2023] Open
Abstract
AIMS The prognosis of patients with atrial fibrillation (AF) and ischemic stroke while taking oral anticoagulation is poorly understood. This study aimed to characterize the outcomes of patients following a stroke event while on oral anticoagulation. METHODS AND RESULTS Individual participant data from five pivotal randomized trials of antithrombotic therapy in AF were used to assess the outcomes of patients with a post-randomization ischemic stroke while on study medication (warfarin, standard-, or lower-dose direct oral anticoagulant regimen) during trial follow-up. The primary outcome was recurrent ischemic stroke after the first post-randomization ischemic stroke. The primary analysis included 1163 patients with a first post-randomization ischemic stroke while on study medication (median age 73 years, 39.3% female, 35.4% history of stroke before trial enrollment). During a median continued follow-up of 337 days, 74 patients had a recurrent ischemic stroke [cumulative incidence at 1 year: 7.0%, 95% confidence interval (CI) 5.2%-8.7%]. The cumulative incidence of mortality at 3 months after stroke was 12.4% (95% CI 10.5%-14.4%). Consistent results for the incidence of recurrent ischemic stroke at 1 year were obtained in an analysis accounting for the competing risk of death (6.2%, 95% CI 4.8%-7.9%) and in a landmark analysis excluding the first 2 weeks after the index stroke and only including patients without permanent study drug discontinuation since then (6.8%, 95% CI 4.6%-8.9%). CONCLUSION Patients with AF and ischemic stroke while on oral anticoagulation are at increased risk of recurrent ischemic stroke and death. These patients currently have an unmet medical need.
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Affiliation(s)
- Alexander P Benz
- Population Health Research Institute, McMaster University, 237 Barton St. E., Hamilton, ON L8L 2X2, Canada
- Department of Cardiology, University Medical Center Mainz, Johannes Gutenberg University Mainz, Langenbeckstr. 1, Mainz 55131, Rhineland-Palatinate, Germany
| | | | - John W Eikelboom
- Population Health Research Institute, McMaster University, 237 Barton St. E., Hamilton, ON L8L 2X2, Canada
| | - Anthony P Carnicelli
- Duke Clinical Research Institute, Duke University, Durham, NC, United States
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC, United States
| | - Robert P Giugliano
- TIMI Study Group, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | | | | | - Ziad Hijazi
- Department of Medical Sciences, Cardiology, and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - David A Morrow
- TIMI Study Group, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Manesh R Patel
- Duke Clinical Research Institute, Duke University, Durham, NC, United States
| | - David J Seiffge
- Department of Neurology, Inselspital University Hospital and University of Bern, Bern, Switzerland
| | - Ashkan Shoamanesh
- Population Health Research Institute, McMaster University, 237 Barton St. E., Hamilton, ON L8L 2X2, Canada
| | - Lars Wallentin
- Department of Medical Sciences, Cardiology, and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Qilong Yi
- School of Epidemiology and Public Health, University of Ottawa, ON, Canada
| | - Stuart J Connolly
- Population Health Research Institute, McMaster University, 237 Barton St. E., Hamilton, ON L8L 2X2, Canada
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12
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Rostock T, Benz AP, Spittler R. What is atrial fibrillation? A RETRO-spective analysis. J Cardiovasc Electrophysiol 2023; 34:1127-1129. [PMID: 37070662 DOI: 10.1111/jce.15910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 04/09/2023] [Indexed: 04/19/2023]
Affiliation(s)
- Thomas Rostock
- Department of Cardiology II/Electrophysiology, Center for Cardiology, University Hospital Mainz, Mainz, Germany
| | - Alexander P Benz
- Department of Cardiology II/Electrophysiology, Center for Cardiology, University Hospital Mainz, Mainz, Germany
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Raphael Spittler
- Department of Cardiology II/Electrophysiology, Center for Cardiology, University Hospital Mainz, Mainz, Germany
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13
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Hijazi Z, Benz AP, Lindbäck J, Alexander JH, Connolly SJ, Eikelboom JW, Granger CB, Kastner P, Lopes RD, Ziegler A, Oldgren J, Siegbahn A, Wallentin L. Bone morphogenetic protein 10: a novel risk marker of ischaemic stroke in patients with atrial fibrillation. Eur Heart J 2023; 44:208-218. [PMID: 36380569 PMCID: PMC9839419 DOI: 10.1093/eurheartj/ehac632] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 08/31/2022] [Accepted: 10/24/2022] [Indexed: 11/17/2022] Open
Abstract
AIMS Biomarkers specifically related to atrial tissue may increase the understanding of the pathophysiology of atrial fibrillation (AF) and further improve risk prediction in this setting. Bone morphogenetic protein 10 (BMP10) is a protein expressed in the atrial myocardium. We evaluated the association between BMP10 and the risk of ischaemic stroke and other cardiovascular events in large cohorts of patients with AF, treated with and without oral anticoagulation (OAC). METHODS AND RESULTS BMP10 was measured in plasma samples collected at randomisation in patients with AF without OAC in the ACTIVE A and AVERROES trials (n = 2974), and with OAC in the ARISTOTLE trial (n = 13 079). BMP10 was analysed with a prototype Elecsys immunoassay. Associations with outcomes were evaluated by Cox-regression models adjusted for clinical characteristics, kidney function, and N-terminal pro-B-type natriuretic peptide (NT-proBNP). Median concentrations of BMP10 were 2.47 and 2.44 ng/mL, in the non-OAC and OAC cohort, respectively. Increasing BMP10 was associated with lower body mass index, older age, female sex, kidney dysfunction, and AF rhythm. BMP10 was consistently associated with ischaemic stroke. In the non-OAC cohort, BMP10 increased the concordance index of the multivariable model from 0.713 to 0.733 (P = 0.004) and in the OAC cohort from 0.673 to 0.694 (P < 0.001). Additionally, BMP10 maintained a significant prognostic value after additionally adjusting for NT-proBNP. BMP10 was not independently associated with bleeding or with death. CONCLUSION The novel atrial biomarker BMP10 was independently associated with ischaemic stroke in patients with AF irrespective of OAC treatment. BMP10 seems to be more specifically related to the risk of ischaemic stroke in AF. ONE-SENTENCE SUMMARY In this study, BMP10 may be a novel specific biomarker of ischaemic stroke in patients with atrial fibrillation, irrespective of oral anticoagulation.
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Affiliation(s)
- Ziad Hijazi
- Uppsala Clinical Research Center, Uppsala University, Dag Hammarskjölds väg 38, 751 85 Uppsala, Sweden.,Department of Medical Sciences, Cardiology, Uppsala University, Ingång 40, 751 85 Uppsala, Sweden
| | - Alexander P Benz
- Population Health Research Institute, McMaster University, 237 Barton Street East, Hamilton, Ontario L8L 2X2, Canada.,Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg-University, Langenbeckstraße 1, 55131 Mainz, Germany
| | - Johan Lindbäck
- Uppsala Clinical Research Center, Uppsala University, Dag Hammarskjölds väg 38, 751 85 Uppsala, Sweden
| | - John H Alexander
- Duke Clinical Research Institute, Duke University School of Medicine, 300 W. Morgan Street Durham, NC 27701, USA
| | - Stuart J Connolly
- Population Health Research Institute, McMaster University, 237 Barton Street East, Hamilton, Ontario L8L 2X2, Canada
| | - John W Eikelboom
- Population Health Research Institute, McMaster University, 237 Barton Street East, Hamilton, Ontario L8L 2X2, Canada
| | - Christopher B Granger
- Duke Clinical Research Institute, Duke University School of Medicine, 300 W. Morgan Street Durham, NC 27701, USA
| | - Peter Kastner
- Roche Diagnostics GmbH, Nonnenwald 2, DE-82377 Penzberg, Germany
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University School of Medicine, 300 W. Morgan Street Durham, NC 27701, USA
| | - André Ziegler
- Roche Diagnostics GmbH, Nonnenwald 2, DE-82377 Penzberg, Germany
| | - Jonas Oldgren
- Uppsala Clinical Research Center, Uppsala University, Dag Hammarskjölds väg 38, 751 85 Uppsala, Sweden.,Department of Medical Sciences, Cardiology, Uppsala University, Ingång 40, 751 85 Uppsala, Sweden
| | - Agneta Siegbahn
- Uppsala Clinical Research Center, Uppsala University, Dag Hammarskjölds väg 38, 751 85 Uppsala, Sweden.,Department of Medical Sciences, Clinical Chemistry, Uppsala University, Ingång 40, 751 85 Uppsala, Sweden
| | - Lars Wallentin
- Uppsala Clinical Research Center, Uppsala University, Dag Hammarskjölds väg 38, 751 85 Uppsala, Sweden.,Department of Medical Sciences, Cardiology, Uppsala University, Ingång 40, 751 85 Uppsala, Sweden
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14
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Vamos M, Erath JW, Benz AP, Duray GZ. Editorial: Developments in cardiac implantable electronic device therapy: how can we improve clinical implementation? Front Cardiovasc Med 2023; 10:1177882. [PMID: 37153463 PMCID: PMC10155095 DOI: 10.3389/fcvm.2023.1177882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 03/28/2023] [Indexed: 05/09/2023] Open
Abstract
CIED, cardiac implantable electronic devices; CRT, cardiac resynchronization therapy; CRT-D, cardiac resynchronization therapy defibrillator; EA, electroanatomical; ICD, implantable cardioverter defibrillator; LBB, left bundle branch; LBBAP, left bundle branch area pacing; LV, left ventricular; LVEF, left ventricular ejection fraction; NT-proBNP, N-terminal pro-B-type natriuretic peptide; MRI, cardiac magnetic resonance imaging; S-ICD, subcutaneous defibrillator.
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Affiliation(s)
- Mate Vamos
- Cardiac Electrophysiology Division, Department of Internal Medicine, University of Szeged, Szeged, Hungary
- Correspondence: Mate Vamos ;
| | - Julia W. Erath
- Dep. of Cardiology, University Hospital Frankfurt—Goethe University, Frankfurt am Main, Germany
| | - Alexander P. Benz
- Department of Cardiology, University Medical Center Mainz, Johannes Gutenberg-University, Mainz, Germany
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Gabor Z. Duray
- Department of Cardiology, Medical Centre, Hungarian Defence Forces, Budapest, Hungary
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15
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Nguyen ST, Belley-Côté EP, Ibrahim O, Um KJ, Lengyel A, Adli T, Qiu Y, Wong M, Sibilio S, Benz AP, Wolf A, Whitlock NJ, Gabriel Acosta J, Healey JS, Baranchuk A, McIntyre WF. Techniques improving electrical cardioversion success for patients with atrial fibrillation: a systematic review and meta-analysis. Europace 2022; 25:318-330. [PMID: 36503970 PMCID: PMC9935008 DOI: 10.1093/europace/euac199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 10/13/2022] [Indexed: 12/14/2022] Open
Abstract
AIMS Electrical cardioversion is commonly used to restore sinus rhythm in patients with atrial fibrillation (AF), but procedural technique and clinical success vary. We sought to identify techniques associated with electrical cardioversion success for AF patients. METHODS AND RESULTS We searched MEDLINE, EMBASE, CENTRAL, and the grey literature from inception to October 2022. We abstracted data on initial and cumulative cardioversion success. We pooled data using random-effects models. From 15 207 citations, we identified 45 randomized trials and 16 observational studies. In randomized trials, biphasic when compared with monophasic waveforms resulted in higher rates of initial [16 trials, risk ratio (RR) 1.71, 95% CI 1.29-2.28] and cumulative success (18 trials, RR 1.10, 95% CI 1.04-1.16). Fixed, high-energy (≥200 J) shocks when compared with escalating energy resulted in a higher rate of initial success (four trials, RR 1.62, 95% CI 1.33-1.98). Manual pressure when compared with no pressure resulted in higher rates of initial (two trials, RR 2.19, 95% CI 1.21-3.95) and cumulative success (two trials, RR 1.19, 95% CI 1.06-1.34). Cardioversion success did not differ significantly for other interventions, including: antero-apical/lateral vs. antero-posterior positioned pads (initial: 11 trials, RR 1.16, 95% CI 0.97-1.39; cumulative: 14 trials, RR 1.01, 95% CI 0.96-1.06); rectilinear/pulsed biphasic vs. biphasic truncated exponential waveform (initial: four trials, RR 1.11, 95% CI 0.91-1.34; cumulative: four trials, RR 0.98, 95% CI 0.89-1.08) and cathodal vs. anodal configuration (cumulative: two trials, RR 0.99, 95% CI 0.92-1.07). CONCLUSIONS Biphasic waveforms, high-energy shocks, and manual pressure increase the success of electrical cardioversion for AF. Other interventions, especially pad positioning, require further study.
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Affiliation(s)
- Stephanie T Nguyen
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario L8P 1H6, Canada,Department of Medicine, McMaster University, Hamilton, Ontario L8P 1H6, Canada
| | - Emilie P Belley-Côté
- Department of Medicine, McMaster University, Hamilton, Ontario L8P 1H6, Canada,Population Health Research Institute, McMaster University, Hamilton, Ontario L8L 2X2, Canada
| | - Omar Ibrahim
- Department of Medicine, McMaster University, Hamilton, Ontario L8P 1H6, Canada
| | - Kevin J Um
- Department of Medicine, McMaster University, Hamilton, Ontario L8P 1H6, Canada
| | - Alexandra Lengyel
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario L8P 1H6, Canada
| | - Taranah Adli
- Schulich School of Medicine and Dentistry, Western University, London, Ontario N6A 5C1, Canada
| | - Yuan Qiu
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario L8P 1H6, Canada,University of Ottawa, Ottawa, Ontario K1N 6N5, Canada
| | - Michael Wong
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario L8P 1H6, Canada
| | - Serena Sibilio
- Istituto Clinico Sant’Ambrogio, Università di Milano, Milano 20157, Italy
| | - Alexander P Benz
- Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg-University, Mainz 55131, Germany
| | - Alex Wolf
- University of Limerick School of Medicine, Limerick V94 T9PX, Ireland
| | - Nicola J Whitlock
- Bishop Tonnos Catholic Secondary School, Ancaster, Ontario L9G 5E3, Canada
| | - Juan Gabriel Acosta
- Department of Medicine, McMaster University, Hamilton, Ontario L8P 1H6, Canada
| | - Jeff S Healey
- Department of Medicine, McMaster University, Hamilton, Ontario L8P 1H6, Canada,Population Health Research Institute, McMaster University, Hamilton, Ontario L8L 2X2, Canada
| | - Adrian Baranchuk
- Queen’s University School of Medicine, Queen’s University, Kingston, Ontario K7L 3L4, Canada
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16
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Affiliation(s)
- Alexander P Benz
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Ontario, Canada (A.P.B., J.W.E.).,Department of Cardiology, University Medical Center Mainz, Johannes Gutenberg-University, Germany (A.P.B.)
| | - John W Eikelboom
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Ontario, Canada (A.P.B., J.W.E.)
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17
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Rostock T, Benz AP, Spittler R. Left atrial field isolation with pulsed field ablation: A new option for challenging left atrial tachycardias? J Cardiovasc Electrophysiol 2022; 33:2444-2446. [PMID: 36259722 DOI: 10.1111/jce.15712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 10/14/2022] [Indexed: 12/15/2022]
Affiliation(s)
- Thomas Rostock
- Department of Cardiology II/Electrophysiology, Center for Cardiology, University Hospital Mainz, Mainz, Germany
| | - Alexander P Benz
- Department of Cardiology II/Electrophysiology, Center for Cardiology, University Hospital Mainz, Mainz, Germany.,Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Raphael Spittler
- Department of Cardiology II/Electrophysiology, Center for Cardiology, University Hospital Mainz, Mainz, Germany
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18
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Oraii A, Healey JS, Benz AP, Pandey AK, Wong JA, Fonguh S, Wang J, Conen D, Gerstein HC, Connolly SJ, McIntyre WF. Association of Eligibility for a Sodium-Glucose Cotransporter 2 Inhibitor and Cardiovascular Events in Patients With Atrial Fibrillation. Can J Cardiol 2022; 38:1434-1441. [PMID: 35562018 DOI: 10.1016/j.cjca.2022.05.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 04/28/2022] [Accepted: 05/02/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Sodium-glucose cotransporter 2 inhibitors (SGLT2i) reduce heart failure (HF) in a broad range of populations, but they have not been studied specifically in patients with atrial fibrillation (AF). We aimed to examine the association between SGLT2i eligibility and cardiovascular events in patients with AF to evaluate the potential utility of SGLT2is for AF management. METHODS We pooled data from 2 randomized controlled trials (RCTs) of patients with AF (RE-LY and ACTIVE-W). Among patients assigned to anticoagulation arms, those meeting the enrollment criteria from at least 1 of the phase 3 SGLT2i RCTs were classified as "SGLT2i eligible" and the remainder as "SGLT2i ineligible." The primary outcome was the composite of HF hospitalization or cardiovascular death. RESULTS A total of 21,484 patients with AF (mean age: 71.2 ± 8.8, 36.1% women, median CHA2DS2-VASc Score = 3) were included. The proportion of patients with AF eligible for SGLT2i was 41.2%. SGLT2i-eligible patients had higher rates of cardiovascular death or hospitalization for HF (5.8 vs 3.2 per 100 person-years, Plog-rank < 0.001), cardiovascular death (3.9 vs 1.5 per 100 person-years, Plog-rank < 0.001), and hospitalization for HF (2.5 vs 1.9 per 100 person-years, Plog-rank < 0.001). The age- and sex-adjusted model showed that SGLT2i-eligible patients were at a higher risk of cardiovascular death and hospitalization for HF (hazard ratio [HR], 1.97; 95% confidence interval [CI], 1.79-2.17; P < 0.001), cardiovascular death (HR, 2.75; 95% CI, 2.41-3.13; P < 0.001), and hospitalization for HF (HR, 1.41; 95% CI, 1.23-1.62; P < 0.001) than ineligible patients. CONCLUSIONS Most patients with AF do not currently have indications for SGLT2is but still have substantial risk of cardiovascular events. Future randomized trials should evaluate the efficacy of SGLT2is in patients with AF.
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Affiliation(s)
- Alireza Oraii
- Population Health Research Institute, Hamilton, Ontario, Canada
| | - Jeff S Healey
- Population Health Research Institute, Hamilton, Ontario, Canada; Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - Arjun K Pandey
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jorge A Wong
- Population Health Research Institute, Hamilton, Ontario, Canada; Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Sylvanus Fonguh
- Population Health Research Institute, Hamilton, Ontario, Canada
| | - Jia Wang
- Population Health Research Institute, Hamilton, Ontario, Canada
| | - David Conen
- Population Health Research Institute, Hamilton, Ontario, Canada; Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Hertzel C Gerstein
- Population Health Research Institute, Hamilton, Ontario, Canada; Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Stuart J Connolly
- Population Health Research Institute, Hamilton, Ontario, Canada; Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - William F McIntyre
- Population Health Research Institute, Hamilton, Ontario, Canada; Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
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19
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Affiliation(s)
- William F McIntyre
- Population Health Research Institute, McMaster University, Hamilton, ON L8L 2X2, Canada.,Department of Medicine, McMaster University, 237 Barton Street East, Hamilton, ON L8L 2X2, Canada
| | - Alexander P Benz
- Population Health Research Institute, McMaster University, Hamilton, ON L8L 2X2, Canada.,Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg-University, 55131 Mainz, Germany
| | - Jeff S Healey
- Population Health Research Institute, McMaster University, Hamilton, ON L8L 2X2, Canada.,Department of Medicine, McMaster University, 237 Barton Street East, Hamilton, ON L8L 2X2, Canada
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20
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Carnicelli AP, Hong H, Connolly SJ, Eikelboom J, Giugliano RP, Morrow DA, Patel MR, Wallentin L, Alexander JH, Bahit MC, Benz AP, Bohula EA, Chao TF, Dyal L, Ezekowitz M, Fox KAA, Gencer B, Halperin JL, Hijazi Z, Hohnloser SH, Hua K, Hylek E, Kato ET, Kuder J, Lopes RD, Mahaffey KW, Oldgren J, Piccini JP, Ruff CT, Steffel J, Wojdyla D, Granger CB. Direct Oral Anticoagulants Versus Warfarin in Patients With Atrial Fibrillation: Patient-Level Network Meta-Analyses of Randomized Clinical Trials With Interaction Testing by Age and Sex. Circulation 2022; 145:242-255. [PMID: 34985309 PMCID: PMC8800560 DOI: 10.1161/circulationaha.121.056355] [Citation(s) in RCA: 97] [Impact Index Per Article: 48.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) are preferred over warfarin for stroke prevention in atrial fibrillation. Meta-analyses using individual patient data offer substantial advantages over study-level data. METHODS We used individual patient data from the COMBINE AF (A Collaboration Between Multiple Institutions to Better Investigate Non-Vitamin K Antagonist Oral Anticoagulant Use in Atrial Fibrillation) database, which includes all patients randomized in the 4 pivotal trials of DOACs versus warfarin in atrial fibrillation (RE-LY [Randomized Evaluation of Long-Term Anticoagulation Therapy], ROCKET AF [Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared With Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation], ARISTOTLE [Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation], and ENGAGE AF-TIMI 48 [Effective Anticoagulation With Factor Xa Next Generation in Atrial Fibrillation-Thrombolysis in Myocardial Infarction 48]), to perform network meta-analyses using a stratified Cox model with random effects comparing standard-dose DOAC, lower-dose DOAC, and warfarin. Hazard ratios (HRs [95% CIs]) were calculated for efficacy and safety outcomes. Covariate-by-treatment interaction was estimated for categorical covariates and for age as a continuous covariate, stratified by sex. RESULTS A total of 71 683 patients were included (29 362 on standard-dose DOAC, 13 049 on lower-dose DOAC, and 29 272 on warfarin). Compared with warfarin, standard-dose DOACs were associated with a significantly lower hazard of stroke or systemic embolism (883/29 312 [3.01%] versus 1080/29 229 [3.69%]; HR, 0.81 [95% CI, 0.74-0.89]), death (2276/29 312 [7.76%] versus 2460/29 229 [8.42%]; HR, 0.92 [95% CI, 0.87-0.97]), and intracranial bleeding (184/29 270 [0.63%] versus 409/29 187 [1.40%]; HR, 0.45 [95% CI, 0.37-0.56]), but no statistically different hazard of major bleeding (1479/29 270 [5.05%] versus 1733/29 187 [5.94%]; HR, 0.86 [95% CI, 0.74-1.01]), whereas lower-dose DOACs were associated with no statistically different hazard of stroke or systemic embolism (531/13 049 [3.96%] versus 1080/29 229 [3.69%]; HR, 1.06 [95% CI, 0.95-1.19]) but a lower hazard of intracranial bleeding (55/12 985 [0.42%] versus 409/29 187 [1.40%]; HR, 0.28 [95% CI, 0.21-0.37]), death (1082/13 049 [8.29%] versus 2460/29 229 [8.42%]; HR, 0.90 [95% CI, 0.83-0.97]), and major bleeding (564/12 985 [4.34%] versus 1733/29 187 [5.94%]; HR, 0.63 [95% CI, 0.45-0.88]). Treatment effects for standard- and lower-dose DOACs versus warfarin were consistent across age and sex for stroke or systemic embolism and death, whereas standard-dose DOACs were favored in patients with no history of vitamin K antagonist use (P=0.01) and lower creatinine clearance (P=0.09). For major bleeding, standard-dose DOACs were favored in patients with lower body weight (P=0.02). In the continuous covariate analysis, younger patients derived greater benefits from standard-dose (interaction P=0.02) and lower-dose DOACs (interaction P=0.01) versus warfarin. CONCLUSIONS Compared with warfarin, DOACs have more favorable efficacy and safety profiles among patients with atrial fibrillation.
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Affiliation(s)
- Anthony P. Carnicelli
- Division of Cardiology, Duke University, Durham, NC,Duke Clinical Research Institute, Duke University, Durham, NC
| | - Hwanhee Hong
- Duke Clinical Research Institute, Duke University, Durham, NC,Department of Biostatistics and Bioinformatics, Duke University, Durham, NC
| | - Stuart J. Connolly
- Department of Medicine, McMaster University, Ontario, Canada,Population Health Research Institute, Hamilton Health Sciences, Ontario, Canada
| | - John Eikelboom
- Department of Medicine, McMaster University, Ontario, Canada,Population Health Research Institute, Hamilton Health Sciences, Ontario, Canada
| | - Robert P. Giugliano
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA,Thrombolysis in Myocardial Infarction Study Group, Boston, MA
| | - David A. Morrow
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA,Thrombolysis in Myocardial Infarction Study Group, Boston, MA
| | - Manesh R. Patel
- Division of Cardiology, Duke University, Durham, NC,Duke Clinical Research Institute, Duke University, Durham, NC
| | - Lars Wallentin
- Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden,Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
| | - John H. Alexander
- Division of Cardiology, Duke University, Durham, NC,Duke Clinical Research Institute, Duke University, Durham, NC
| | - M Cecilia Bahit
- Department of Cardiology, INECO Neurociencias Oroño, Santa Fe, Argentina
| | - Alexander P. Benz
- Population Health Research Institute, Hamilton Health Sciences, Ontario, Canada
| | - Erin A. Bohula
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA,Thrombolysis in Myocardial Infarction Study Group, Boston, MA
| | - Tze-Fan Chao
- Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Leanne Dyal
- Population Health Research Institute, Hamilton Health Sciences, Ontario, Canada
| | | | - Keith AA Fox
- Center for Cardiovascular Science, University of Edinburgh, Edinburgh, Scotland
| | - Baris Gencer
- Division of Cardiology, Geneva University Hospitals, Geneva, Switzerland,Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | | | - Ziad Hijazi
- Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden,Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
| | | | - Kaiyuan Hua
- Duke Clinical Research Institute, Duke University, Durham, NC,Department of Biostatistics and Bioinformatics, Duke University, Durham, NC
| | - Elaine Hylek
- Department of Medicine, Boston University School of Medicine, Boston, MA
| | - Eri Toda Kato
- Department of Cardiology, Kyoto University, Kyoto, Japan
| | - Julia Kuder
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Renato D. Lopes
- Division of Cardiology, Duke University, Durham, NC,Duke Clinical Research Institute, Duke University, Durham, NC
| | - Kenneth W. Mahaffey
- Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Jonas Oldgren
- Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden,Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
| | - Jonathan P. Piccini
- Division of Cardiology, Duke University, Durham, NC,Duke Clinical Research Institute, Duke University, Durham, NC
| | - Christian T. Ruff
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA,Thrombolysis in Myocardial Infarction Study Group, Boston, MA
| | - Jan Steffel
- Department of Cardiology, University of Zurich, Zurich, Switzerland
| | - Daniel Wojdyla
- Duke Clinical Research Institute, Duke University, Durham, NC
| | - Christopher B. Granger
- Division of Cardiology, Duke University, Durham, NC,Duke Clinical Research Institute, Duke University, Durham, NC
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21
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McIntyre WF, Wang J, Benz AP, Johnson L, Connolly SJ, Van Gelder IC, Lopes RD, Gold MR, Hohnloser SH, Lau CP, Israel CW, Wong JA, Conen D, Healey JS. Estimated incidence of previously undetected atrial fibrillation on a 14-day continuous electrocardiographic monitor and associated risk of stroke. Europace 2022; 24:1058-1064. [DOI: 10.1093/europace/euab324] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 12/20/2021] [Indexed: 11/13/2022] Open
Abstract
Abstract
Aims
There is uncertainty about whether and how to perform screening for atrial fibrillation (AF). To estimate the incidence of previously undetected AF that would be captured using a continuous 14-day ECG monitor and the associated risk of stroke.
Methods and results
We analysed data from a cohort of patients >65 years old with hypertension and a pacemaker, but without known AF. For each participant, we simulated 1000 ECG monitors by randomly selecting 14-day windows in the 6 months following enrolment and calculated the average AF burden (total time in AF). We used Cox proportional hazards models adjusted for CHA2DS2-VASc score to estimate the risk of subsequent ischaemic stroke or systemic embolism (SSE) associated with burdens of AF > and <6 min. Among 2470 participants, the median CHA2DS2-VASc score was 4.0, and 44 patients experienced SSE after 6 months following enrolment. The proportion of participants with an AF burden >6 min was 3.10% (95% CI 2.53–3.72). This was consistent across strata of age and CHA2DS2-VASc scores. Over a mean follow-up of 2.4 years, the rate of SSE among patients with <6 min of AF was 0.70%/year, compared to 2.18%/year (adjusted HR 3.02; 95% CI 1.39–6.56) in those with >6 min of AF.
Conclusions
Approximately 3% of individuals aged >65 years with hypertension may have more than 6 min of AF detected by a 14-day ECG monitor. This is associated with a stroke risk of over 2% per year. Whether oral anticoagulation will reduce stroke in these patients is unknown.
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Affiliation(s)
- William F McIntyre
- Population Health Research Institute, 237 Barton St E C3-109, Hamilton, ON L8L 2X2, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Jia Wang
- Population Health Research Institute, 237 Barton St E C3-109, Hamilton, ON L8L 2X2, Canada
| | - Alexander P Benz
- Population Health Research Institute, 237 Barton St E C3-109, Hamilton, ON L8L 2X2, Canada
| | - Linda Johnson
- Population Health Research Institute, 237 Barton St E C3-109, Hamilton, ON L8L 2X2, Canada
| | - Stuart J Connolly
- Population Health Research Institute, 237 Barton St E C3-109, Hamilton, ON L8L 2X2, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Isabelle C Van Gelder
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke Medicine, Durham, NC, USA
| | - Michael R Gold
- Division of Cardiology, Medical University of South Carolina, Charleston, SC, USA
| | - Stefan H Hohnloser
- Department of Electrophysiology, J.W. Goetshe University, Frankfurt, Germany
| | - Chu-Pak Lau
- Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong, China
| | - Carsten W Israel
- Division of Cardiology, Department of Medicine, Evangelical Hospital Bielefeld, Bielefeld, Germany
| | - Jorge A Wong
- Population Health Research Institute, 237 Barton St E C3-109, Hamilton, ON L8L 2X2, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - David Conen
- Population Health Research Institute, 237 Barton St E C3-109, Hamilton, ON L8L 2X2, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Jeff S Healey
- Population Health Research Institute, 237 Barton St E C3-109, Hamilton, ON L8L 2X2, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
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22
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Benz AP, Xu L, Eikelboom JW, Middeldorp S, Milling TJ, Crowther M, Yue P, Conley P, Lu G, Connolly SJ. Andexanet Alfa for Specific Anticoagulation Reversal in Patients with Acute Bleeding during Treatment with Edoxaban. Thromb Haemost 2022; 122:998-1005. [PMID: 34996121 PMCID: PMC9251710 DOI: 10.1055/s-0041-1740180] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background
Andexanet alfa (andexanet) is approved for specific anticoagulation reversal in patients with life-threatening or uncontrolled bleeding during treatment with rivaroxaban or apixaban. There is limited experience with andexanet in patients with acute bleeding on edoxaban.
Methods
Patients with acute major bleeding within 18 hours of edoxaban intake were prospectively enrolled. Patients received a bolus and 2-hour follow-on infusion of andexanet. The co-primary efficacy outcomes were change in antifactor Xa activity and the percentage of patients achieving excellent or good hemostasis, 12 hours after andexanet treatment. Efficacy was analyzed in patients with confirmed major bleeding and baseline antifactor Xa activity ≥40 ng/mL. Safety was analyzed in all patients.
Results
Thirty-six patients (mean age: 82 years, 61.1% male and 91.7% with atrial fibrillation) with acute major bleeding on edoxaban received andexanet. The primary site of bleeding was intracranial in 29 patients (80.6%). In the efficacy population (
n
= 28), median antifactor Xa activity decreased from 121.1 (interquartile range [IQR]: 70.3–202.4) ng/mL at baseline to 24.0 (IQR: 77.7–83.7) ng/mL at the end of andexanet bolus (median decrease: 68.9%, 95% confidence interval [CI]: 56.1–77.7%). Excellent or good hemostasis at 12 hours was achieved in 78.6% (95% CI: 59.0–91.7%) of patients. Within 30 days, four patients (11.1%) experienced a thrombotic event and four others (11.1%) died.
Conclusion
In patients with acute major bleeding on edoxaban, andexanet significantly decreased antifactor Xa activity. Hemostatic efficacy was similar to that observed in patients with bleeding on rivaroxaban or apixaban. Thrombotic events occurred at a rate expected in such patients.
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Affiliation(s)
- Alexander P Benz
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Lizhen Xu
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - John W Eikelboom
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Saskia Middeldorp
- Department of Internal Medicine & Radboud Institute of Health Sciences (RIHS), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Truman J Milling
- Departments of Neurology and Surgery and Perioperative Care, Seton Dell Medical School Stroke Institute, Dell Medical School, University of Texas at Austin, Austin, Texas, United States
| | - Mark Crowther
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Patrick Yue
- Portola Pharmaceuticals Inc., now Alexion, AstraZeneca Rare Disease, Boston, Massachusetts, United States
| | - Pamela Conley
- Portola Pharmaceuticals Inc., now Alexion, AstraZeneca Rare Disease, Boston, Massachusetts, United States
| | - Genmin Lu
- Portola Pharmaceuticals Inc., now Alexion, AstraZeneca Rare Disease, Boston, Massachusetts, United States
| | - Stuart J Connolly
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
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23
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Benz AP, Hohnloser SH. Is there a role for verapamil beyond rate control in paroxysmal atrial fibrillation? Europace 2021; 24:355-356. [PMID: 34499716 DOI: 10.1093/europace/euab225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 08/06/2021] [Indexed: 11/15/2022] Open
Affiliation(s)
- Alexander P Benz
- Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg-University, Mainz, Germany.,Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | - Stefan H Hohnloser
- Department of Cardiology, J. W. Goethe University, Theodor Stern Kai 7, 60590 Frankfurt, Germany.,Center of Thrombosis and Hemostasis, Gutenberg-University Mainz, Mainz, Germany
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24
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Pandey AK, Okaj I, Kaur H, Belley-Cote EP, Wang J, Oraii A, Benz AP, Johnson LSB, Young J, Wong JA, Verma S, Conen D, Gerstein H, Healey JS, McIntyre WF. Sodium-Glucose Co-Transporter Inhibitors and Atrial Fibrillation: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Am Heart Assoc 2021; 10:e022222. [PMID: 34459238 PMCID: PMC8649253 DOI: 10.1161/jaha.121.022222] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Background Sodium‐glucose co‐transporter (SGLT) inhibitors reduce cardiovascular outcomes including mortality in several populations; however, their effect on atrial fibrillation/flutter (AF) remains unclear. Our objective was to determine whether SGLT inhibitors reduce AF and whether a history of AF modifies the effect of SGLT inhibitors on the composite of heart failure hospitalization or cardiovascular death. Methods and Results We searched MEDLINE, Embase, and CENTRAL to March 2021. Pairs of reviewers identified randomized controlled trials that compared an SGLT inhibitor with placebo or no therapy. We pooled data using RevMan 5.4.1, assessed risk of bias using the Cochrane tool, and determined the overall quality of evidence using Grades of Recommendation, Assessment, Development and Evaluation. Thirty‐one eligible trials reported on AF events (75 279 participants, mean age 62 years, 35.0% women). Moderate quality evidence supported a lower risk of serious AF events with SGLT inhibitors (1.1% versus 1.5%; risk ratio 0.75 [95% CI, 0.66–0.86]; I2=0%). A similar reduction in total AF events was also noted with SGLT inhibitors. Three trials reported on heart failure hospitalization/cardiovascular death stratified by a baseline history of AF (18 832 participants, mean age 66 years, 38.1% women); in patients with a history of AF, SGLT inhibitors resulted in a lower risk in the composite of heart failure hospitalization or cardiovascular death (hazard ratio, 0.70 [95% CI, 0.57–0.85]; I2=0%)—similar to the effect estimate for patients without AF, P value for interaction: 1.00. Conclusions SGLT inhibitors may reduce AF events and likely reduce heart failure hospitalization/cardiovascular death to a similar extent in patients with and without AF.
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Affiliation(s)
- Arjun K Pandey
- Michael G. DeGroote School of Medicine McMaster University Hamilton Ontario Canada
| | - Iva Okaj
- Michael G. DeGroote School of Medicine McMaster University Hamilton Ontario Canada
| | - Hargun Kaur
- Faculty of Health Sciences McMaster University Hamilton Ontario Canada
| | - Emilie P Belley-Cote
- Department of Health Research Methods, Evidence and Impact McMaster University Hamilton Ontario Canada.,Population Health Research Institute Hamilton Ontario Canada.,Division of Cardiology Department of Medicine McMaster University Hamilton Ontario Canada
| | - Jia Wang
- Population Health Research Institute Hamilton Ontario Canada
| | - Alireza Oraii
- Tehran Heart CenterTehran University of Medical Sciences Tehran Iran
| | | | | | - Jack Young
- Faculty of Health Sciences McMaster University Hamilton Ontario Canada
| | - Jorge A Wong
- Population Health Research Institute Hamilton Ontario Canada.,Department of Medicine Faculty of Health Sciences McMaster University Hamilton Ontario Canada
| | - Subodh Verma
- Division of Cardiac Surgery St Michael's Hospital University of Toronto Ontario Canada
| | - David Conen
- Faculty of Health Sciences McMaster University Hamilton Ontario Canada.,Department of Health Research Methods, Evidence and Impact McMaster University Hamilton Ontario Canada.,Population Health Research Institute Hamilton Ontario Canada
| | - Hertzel Gerstein
- Faculty of Health Sciences McMaster University Hamilton Ontario Canada.,Department of Health Research Methods, Evidence and Impact McMaster University Hamilton Ontario Canada.,Population Health Research Institute Hamilton Ontario Canada
| | - Jeff S Healey
- Population Health Research Institute Hamilton Ontario Canada.,Division of Cardiology Department of Medicine McMaster University Hamilton Ontario Canada
| | - William F McIntyre
- Department of Health Research Methods, Evidence and Impact McMaster University Hamilton Ontario Canada.,Population Health Research Institute Hamilton Ontario Canada.,Division of Cardiology Department of Medicine McMaster University Hamilton Ontario Canada
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25
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Mendoza PA, McIntyre WF, Belley-Côté EP, Wang J, Parkash R, Atzema CL, Benz AP, Oldgren J, Whitlock RP, Healey JS. Oral anticoagulation for patients with atrial fibrillation in the ED: RE-LY AF registry analysis. J Thromb Thrombolysis 2021; 53:74-82. [PMID: 34338944 DOI: 10.1007/s11239-021-02530-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/10/2021] [Indexed: 11/27/2022]
Abstract
Oral anticoagulation (OAC) reduces stroke risk in patients with atrial fibrillation (AF). We sought to determine predictors of OAC initiation in AF patients presenting to the emergency department (ED). Secondary analysis of the RE-LY AF registry which enrolled individuals from 47 countries between 2007 and 2011 who presented to an ED with AF and followed them for 1 year. A total of 4149 patients with AF as their primary diagnosis who were not already taking OAC and had a CHA2DS2-VASc ≥ 1 for men or ≥ 2 for women were included in this analysis. Of these individuals, 26.8% were started on OAC (99.2% vitamin K antagonists) in the ED and 29.8% were using OAC one year later. Factors associated with initiating OAC in the ED included: specialist consultation (relative risk [RR] 1.84, 95%CI 1.44-2.36), rheumatic heart disease (RR 1.60, 95%CI 1.29-1.99), persistence of AF at ED discharge (RR 1.33, 95%CI 1.18-1.50), diabetes mellitus (RR 1.32, 95%CI 1.19-1.47), and hospital admission (RR 1.30, 95%CI 1.14-1.47). Heart failure (RR 0.83, 95%CI 0.74-0.94), antiplatelet agents (RR 0.77, 95%CI 0.69-0.84), and dementia (RR 0.61, 95%CI 0.40-0.94) were inversely associated with OAC initiation. Patients taking OAC when they left the ED were more likely using OAC at 1-year (RR 2.81, 95%CI 2.55-3.09) and had lower rates of death (RR 0.55, 95%CI 0.38-0.79) and stroke (RR 0.59, 95%CI 0.37-0.96). In patients with AF presenting to the ED, prompt initiation of OAC and specialist involvement are associated with a greater use of OAC 1 year later and may result in improved clinical outcomes.
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Affiliation(s)
- Pablo A Mendoza
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, Hamilton, ON, Canada
| | - William F McIntyre
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Emilie P Belley-Côté
- Population Health Research Institute, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Jia Wang
- Population Health Research Institute, Hamilton, ON, Canada
| | - Ratika Parkash
- Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | | | | | - Jonas Oldgren
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Richard P Whitlock
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, Hamilton, ON, Canada
- Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Jeff S Healey
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
- Population Health Research Institute, Hamilton, ON, Canada.
- Department of Medicine, McMaster University, Hamilton, ON, Canada.
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26
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Benz AP, Johansson I, Dewilde WJM, Lopes RD, Mehran R, Sartori S, Sarafoff N, Yasuda S, McIntyre WF, Healey JS, Shoamanesh A, Eikelboom JW, Connolly SJ. Antiplatelet Therapy in Patients with Atrial Fibrillation: A Systematic Review and Metaanalysis of Randomized Trials. Eur Heart J Cardiovasc Pharmacother 2021; 8:648-659. [PMID: 34142118 DOI: 10.1093/ehjcvp/pvab044] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 05/26/2021] [Accepted: 06/14/2021] [Indexed: 11/13/2022]
Abstract
AIMS To systematically assess the effects of antiplatelets on clinical outcomes in patients with atrial fibrillation (AF), treated and not treated with oral anticoagulation. METHODS AND RESULTS We searched MEDLINE, Embase and CENTRAL from inception until September 2020. From 5,446 citations, we selected randomized trials allocating patients with AF to antiplatelet therapy vs. control. We applied random-effects models for meta-analysis and assessed potential effect modification with background anticoagulation use. Eighteen trials including 21,518 participants met our prespecified eligibility criteria. In 10 studies without background anticoagulation, antiplatelets reduced all-cause stroke (486/6,165 [events/patients] vs. 621/6,061; risk ratio [RR] 0.77, 95% confidence interval [CI] 0.69-0.86, I2=0%). In 8 studies with background anticoagulation, there was a signal for an increase in all-cause stroke with antiplatelets (97/4,608 vs. 72/4,684; RR 1.33, 95% CI 0.98-1.79, I2=0%), p-value for interaction < 0.001. A similar pattern emerged for ischaemic stroke. Irrespective of background anticoagulation use, antiplatelets increased major bleeding (509/10,402 vs. 328/10,496; RR 1.54, 95% CI 1.35-1.77, I2=0%) and intracranial Haemorrhage (107/10,221 vs. 65/10,232; RR 1.64, 95% CI 1.20-2.24, I2=0%), and reduced myocardial infarction (201/9,679 vs. 260/9,751; RR 0.79, 95% CI 0.65-0.94, I2=0%), all p-values for interaction ≥ 0.36. Antiplatelets did not affect mortality (1,221/10,299 vs. 1,211/10,287; RR 1.02, 95% CI 0.89-1.17, I2=29%), p-value for interaction = 0.23. CONCLUSIONS In patients with AF not receiving oral anticoagulation, antiplatelet therapy modestly reduced stroke. There was a corresponding signal for harm when used on top of anticoagulation. Irrespective of background anticoagulation use, antiplatelet therapy significantly increased bleeding, moderately reduced myocardial infarction and did not affect mortality.
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Affiliation(s)
- Alexander P Benz
- Population Health Research Institute, McMaster University, Hamilton, Canada.,Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg-University, Mainz, Germany
| | - Isabelle Johansson
- Population Health Research Institute, McMaster University, Hamilton, Canada
| | | | - Renato D Lopes
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, United States
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Samantha Sartori
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Nikolaus Sarafoff
- Deutsches Herzzentrum München, Klinik für Herz-und Kreislauferkrankungen, Technische Universität Munich, Germany
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - William F McIntyre
- Population Health Research Institute, McMaster University, Hamilton, Canada
| | - Jeff S Healey
- Population Health Research Institute, McMaster University, Hamilton, Canada
| | - Ashkan Shoamanesh
- Population Health Research Institute, McMaster University, Hamilton, Canada
| | - John W Eikelboom
- Population Health Research Institute, McMaster University, Hamilton, Canada
| | - Stuart J Connolly
- Population Health Research Institute, McMaster University, Hamilton, Canada
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27
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Benz AP, Eikelboom JW. What is the role of growth-differentiation factor-15 in biomarker-based prediction of mortality in patients with atrial fibrillation? Eur J Intern Med 2021; 88:23-24. [PMID: 33994061 DOI: 10.1016/j.ejim.2021.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 04/14/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Alexander P Benz
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, 20 Copeland Avenue, Hamilton, ON L8L 2 × 2, Canada; Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg-University, Mainz, Germany.
| | - John W Eikelboom
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, 20 Copeland Avenue, Hamilton, ON L8L 2 × 2, Canada.
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28
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Gladstone DJ, Wachter R, Schmalstieg-Bahr K, Quinn FR, Hummers E, Ivers N, Marsden T, Thornton A, Djuric A, Suerbaum J, von Grünhagen D, McIntyre WF, Benz AP, Wong JA, Merali F, Henein S, Nichol C, Connolly SJ, Healey JS. Screening for Atrial Fibrillation in the Older Population: A Randomized Clinical Trial. JAMA Cardiol 2021; 6:558-567. [PMID: 33625468 DOI: 10.1001/jamacardio.2021.0038] [Citation(s) in RCA: 83] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Importance Atrial fibrillation (AF) is a major cause of preventable strokes. Screening asymptomatic individuals for AF may increase anticoagulant use for stroke prevention. Objective To evaluate 2 home-based AF screening interventions. Design, Setting, and Participants This multicenter randomized clinical trial recruited individuals from primary care practices aged 75 years or older with hypertension and without known AF. From April 5, 2015, to March 26, 2019, 856 participants were enrolled from 48 practices. Interventions The control group received standard care (routine clinical follow-up plus a pulse check and heart auscultation at baseline and 6 months). The screening group received a 2-week continuous electrocardiographic (cECG) patch monitor to wear at baseline and at 3 months, in addition to standard care. The screening group also received automated home blood pressure (BP) machines with oscillometric AF screening capability to use twice-daily during the cECG monitoring periods. Main Outcomes and Measures With intention-to-screen analysis, the primary outcome was AF detected by cECG monitoring or clinically within 6 months. Secondary outcomes included anticoagulant use, device adherence, and AF detection by BP monitors. Results Of the 856 participants, 487 were women (56.9%); mean (SD) age was 80.0 (4.0) years. Median cECG wear time was 27.4 of 28 days (interquartile range [IQR], 18.4-28.0 days). In the primary analysis, AF was detected in 23 of 434 participants (5.3%) in the screening group vs 2 of 422 (0.5%) in the control group (relative risk, 11.2; 95% CI, 2.7-47.1; P = .001; absolute difference, 4.8%; 95% CI, 2.6%-7.0%; P < .001; number needed to screen, 21). Of those with cECG-detected AF, median total time spent in AF was 6.3 hours (IQR, 4.2-14.0 hours; range 1.3 hours-28 days), and median duration of the longest AF episode was 5.7 hours (IQR, 2.9-12.9 hours). Anticoagulation was initiated in 15 of 20 patients (75.0%) with cECG-detected AF. By 6 months, anticoagulant therapy had been prescribed for 18 of 434 participants (4.1%) in the screening group vs 4 of 422 (0.9%) in the control group (relative risk, 4.4; 95% CI, 1.5-12.8; P = .007; absolute difference, 3.2%; 95% CI, 1.1%-5.3%; P = .003). Twice-daily AF screening using the home BP monitor had a sensitivity of 35.0% (95% CI, 15.4%-59.2%), specificity of 81.0% (95% CI, 76.7%-84.8%), positive predictive value of 8.9% (95% CI, 4.9%-15.5%), and negative predictive value of 95.9% (95% CI, 94.5%-97.0%). Adverse skin reactions requiring premature discontinuation of cECG monitoring occurred in 5 of 434 participants (1.2%). Conclusions and Relevance In this randomized clinical trial, among older community-dwelling individuals with hypertension, AF screening with a wearable cECG monitor was well tolerated, increased AF detection 10-fold, and prompted initiation of anticoagulant therapy in most cases. Compared with continuous ECG, intermittent oscillometric screening with a BP monitor was an inferior strategy for detecting paroxysmal AF. Large trials with hard clinical outcomes are now needed to evaluate the potential benefits and harms of AF screening. Trial Registration ClinicalTrials.gov Identifier: NCT02392754.
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Affiliation(s)
- David J Gladstone
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, and Division of Neurology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Division of Neurology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Rolf Wachter
- Clinic and Policlinic for Cardiology, University Hospital, Leipzig, Germany.,Department of Cardiology, University Medical Center Göttingen, Göttingen, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Göttingen, Göttingen, Germany
| | - Katharina Schmalstieg-Bahr
- Department of General Practice, University Medical Center Göttingen, Göttingen, Germany.,Department of General Practice and Primary Care, University Medical Center Hamburg-Eppendorf, Hamburg-Eppendorf, Germany
| | - F Russell Quinn
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Eva Hummers
- DZHK (German Centre for Cardiovascular Research), partner site Göttingen, Göttingen, Germany.,Department of General Practice, University Medical Center Göttingen, Göttingen, Germany
| | - Noah Ivers
- Women's College Hospital, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Tamara Marsden
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Andrea Thornton
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Angie Djuric
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Johanna Suerbaum
- Department of Cardiology, University Medical Center Göttingen, Göttingen, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Göttingen, Göttingen, Germany
| | - Doris von Grünhagen
- Clinic for Cardiology and Pneumology, University Medicine Göttingen, Göttingen, Germany
| | - William F McIntyre
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Alexander P Benz
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Jorge A Wong
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | | | - Sam Henein
- Southlake Regional Health Centre, Newmarket, Ontario, Canada
| | - Chris Nichol
- Camrose Primary Care Network, Camrose, Alberta, Canada
| | - Stuart J Connolly
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Jeff S Healey
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
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29
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van Haaps TF, Benz AP, Xu L, Coppens M, Eikelboom JW, Milling TJ, Crowther M, Beyer-Westendorf J, Cohen AT, Yue P, Conley PB, Lu G, Connolly SJ, Middeldorp S. ANDEXANET ALFA FOR ACUTE BLEEDING DURING TREATMENT WITH ENOXAPARIN. J Am Coll Cardiol 2021. [DOI: 10.1016/s0735-1097(21)03212-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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30
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Huynh JT, Healey JS, Um KJ, Vadakken ME, Rai AS, Conen D, Meyre P, Butt JH, Kamel H, Reza SJ, Nguyen ST, Oqab Z, Devereaux P, Balasubramanian K, Benz AP, Belley-Cote EP, McIntyre WF. Association Between Perioperative Atrial Fibrillation and Long-term Risks of Stroke and Death in Noncardiac Surgery: Systematic Review and Meta-analysis. CJC Open 2021; 3:666-674. [PMID: 34027371 PMCID: PMC8134907 DOI: 10.1016/j.cjco.2020.12.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 12/20/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Atrial fibrillation (AF) is frequently reported as a complication of noncardiac surgery. It is unknown whether new-onset perioperative AF is associated with an increased risk of stroke and death beyond the perioperative period. We performed a systematic review and meta-analysis to assess the long-term risks of stroke and mortality associated with new-onset perioperative AF after noncardiac surgery. METHODS MEDLINE and EMBASE were searched from inception to March 2020 for studies reporting on the association between perioperative AF and the risk of stroke and death occurring beyond 30 days after noncardiac surgery. Reference screening, study selection, data extraction, and quality assessment were performed in duplicate. Data were pooled using inverse variance-weighted random-effects models and presented as risk ratios (RRs). RESULTS From 7344 citations, we included 31 studies (3,529,493 patients). The weighted mean incidence of perioperative AF was 0.7%. During a mean follow-up of 28.1 ± 9.4 months, perioperative AF was associated with an increased risk of stroke (1.5 vs 0.9 strokes per 100 patient-years; RR: 2.9, 95% confidence interval [CI]: 2.1-3.9, I2 = 78%). Perioperative AF was also associated with a significantly higher risk of all-cause mortality (21.0 vs 7.6 deaths per 100 patient-years; RR: 1.8, 95% CI: 1.5-2.2, I2 = 94%). The pooled adjusted hazard ratios for stroke and all-cause mortality were 1.9 (95% CI: 1.6-2.2, I2 = 31%) and 1.5 (95% CI: 1.3-1.7, I2 = 20%), respectively. CONCLUSIONS Patients who had perioperative AF after noncardiac surgery had a higher long-term risk of stroke and mortality compared with patients who did not. Whether this risk is modifiable with oral anticoagulation therapy should be investigated.
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Affiliation(s)
- Jessica T. Huynh
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jeff S. Healey
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Kevin J. Um
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Maria E. Vadakken
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Anand S. Rai
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - David Conen
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Pascal Meyre
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital of Basel, University of Basel, Basel, Switzerland
| | - Jawad H. Butt
- Department of Cardiology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Hooman Kamel
- Feil Family Brain and Mind Research Institute, Department of Neurology, Weill Cornell Medical College, New York, New York, USA
| | - Seleman J. Reza
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Stephanie T. Nguyen
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Zardasht Oqab
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - P.J. Devereaux
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Kumar Balasubramanian
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Alexander P. Benz
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Emilie P. Belley-Cote
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - William F. McIntyre
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
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31
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Moschovitis G, Johnson LSB, Blum S, Aeschbacher S, De Perna ML, Pagnamenta A, Mayer Melchiorre PA, Benz AP, Kobza R, Di Valentino M, Zuern CS, Auricchio A, Conte G, Rodondi N, Blum MR, Beer JH, Kühne M, Osswald S, Conen D. Heart rate and adverse outcomes in patients with prevalent atrial fibrillation. Open Heart 2021; 8:openhrt-2021-001606. [PMID: 33883229 PMCID: PMC8061854 DOI: 10.1136/openhrt-2021-001606] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/18/2021] [Accepted: 04/06/2021] [Indexed: 11/20/2022] Open
Abstract
Objective The optimal target heart rate in patients with prevalent atrial fibrillation (AF) is not well defined. The aim of this study was to analyse the associations between heart rate and adverse outcomes in a large contemporary cohort of patients with prevalent AF. Methods From two prospective cohort studies, we included stable AF outpatients who were in AF on the baseline ECG. The main outcome events assessed during prospective follow-up were heart failure hospitalisation, stroke or systemic embolism and death. The associations between heart rate and adverse outcomes were evaluated using multivariable Cox regression models. Results The study population consisted of 1679 patients who had prevalent AF at baseline. Mean age was 74 years, and 24.6% were women. The mean heart rate on the baseline ECG was 78 (±19) beats per minute (bpm). The median follow-up was 3.9 years (IQR 2.2–5.0). Heart rate was not significantly associated with heart failure hospitalisation (adjusted HR (aHR) per 10 bpm increase, 1.00, 95% CI 0.94 to 1.07, p=0.95), stroke or systemic embolism (aHR 0.95, 95% CI 0.84 to 1.07, p=0.38) or death (aHR 1.02, 95% CI 0.95 to 1.09, p=0.66). There was no evidence of a threshold effect for heart rates <60 bpm or >100 bpm. Conclusions In this large contemporary cohort of outpatients with prevalent AF, we found no association between heart rate and adverse outcome events. These data are in line with recommendations that strict heart rate control is not needed in otherwise stable outpatients with AF.
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Affiliation(s)
- Giorgio Moschovitis
- Division of Cardiology, Regional Hospital of Lugano, Repubblica e Cantone Ticino Ente Ospedaliero Cantonale, Lugano, Ticino, Switzerland.,Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Linda S B Johnson
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada.,Clinical Sciences, Lund University, Malmö, Sweden
| | - Steffen Blum
- Division of Cardiology, University Hospital Basel, Basel, Switzerland.,Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland
| | - Stefanie Aeschbacher
- Division of Cardiology, University Hospital Basel, Basel, Switzerland.,Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland
| | - Maria Luisa De Perna
- Division of Cardiology, Regional Hospital of Lugano, Repubblica e Cantone Ticino Ente Ospedaliero Cantonale, Lugano, Ticino, Switzerland
| | - Alberto Pagnamenta
- Unit of Clinical Epidemiology, Repubblica e Cantone Ticino Ente Ospedaliero Cantonale, Bellinzona, Ticino, Switzerland
| | - Patrizia Assunta Mayer Melchiorre
- Division of Cardiology, Regional Hospital of Lugano, Repubblica e Cantone Ticino Ente Ospedaliero Cantonale, Lugano, Ticino, Switzerland
| | - Alexander P Benz
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Richard Kobza
- Cardiology Division, Heart Center, Luzerner Kantonsspital, Luzern, Luzern, Switzerland
| | - Marcello Di Valentino
- Division of Cardiology, Ospedale San Giovanni, Repubblica e Cantone Ticino Ente Ospedaliero Cantonale, Bellinzona, Ticino, Switzerland.,Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Ticino, Switzerland
| | - Christine S Zuern
- Division of Cardiology, University Hospital Basel, Basel, Switzerland.,Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland
| | - Angelo Auricchio
- Division of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Ticino, Switzerland
| | - Giulio Conte
- Division of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Ticino, Switzerland
| | - Nicolas Rodondi
- Institute of Primary Health Care, University of Bern, Bern, Switzerland.,Department of General Medicine, Inselspital University Hospital Bern, Bern, Switzerland
| | - Manuel R Blum
- Institute of Primary Health Care, University of Bern, Bern, Switzerland.,Department of General Medicine, Inselspital University Hospital Bern, Bern, Switzerland
| | - Juerg H Beer
- Department of Medicine, Baden Cantonal Hospital, Baden, Aargau, Switzerland.,Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | - Michael Kühne
- Division of Cardiology, University Hospital Basel, Basel, Switzerland.,Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland
| | - Stefan Osswald
- Division of Cardiology, University Hospital Basel, Basel, Switzerland.,Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland
| | - David Conen
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
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32
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Benz AP, Hijazi Z, Lindbäck J, Connolly SJ, Eikelboom JW, Oldgren J, Siegbahn A, Wallentin L. Biomarker-Based Risk Prediction With the ABC-AF Scores in Patients With Atrial Fibrillation Not Receiving Oral Anticoagulation. Circulation 2021; 143:1863-1873. [PMID: 33849281 DOI: 10.1161/circulationaha.120.053100] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND The novel ABC (Age, Biomarkers, Clinical History) scores outperform traditional risk scores for stroke, major bleeding, and death in patients with atrial fibrillation (AF) receiving oral anticoagulation. To refine their utility, the ABC-AF scores needed to be validated in patients not receiving oral anticoagulation. METHODS We measured plasma levels of the ABC biomarkers (N-terminal pro-B-type natriuretic peptide, cardiac troponin-T, and growth-differentiation factor 15) to apply the previously developed ABC-AF scores in patients with AF receiving aspirin (n=3195) or aspirin and clopidogrel (n=1110) in 2 large clinical trials. Calibration was assessed by comparing estimated with observed 1-year risks. Cox regression models were used for recalibration. Discrimination was evaluated separately for the aspirin-only and the overall cohort (n=4305). RESULTS The ABC-AF-stroke score yielded a c-index of 0.70 (95% CI, 0.67-0.73) in both cohorts. The ABC-AF-bleeding score had a c-index of 0.76 (95% CI, 0.71-0.81) in the aspirin-only cohort and 0.73 (95% CI, 0.69-0.77) overall. Both scores were superior to risk scores recommended by current guidelines. The ABC-AF-death score yielded a c-index of 0.78 (95% CI, 0.76-0.80) overall. Calibrated in patients receiving oral anticoagulation, the ABC-AF-stroke score underestimated and the ABC-AF-bleeding score overestimated the risk of events in both cohorts. These scores were recalibrated for prediction of absolute event rates in the absence of oral anticoagulation. CONCLUSIONS The biomarker-based ABC-AF scores showed better discrimination than traditional risk scores and were recalibrated for precise risk estimation in patients not receiving oral anticoagulation. They can now provide improved decision support on treatment of an individual patient with AF.
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Affiliation(s)
- Alexander P Benz
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada (A.P.B., S.J.C., J.W.E.)
| | - Ziad Hijazi
- Uppsala Clinical Research Center (Z.H., J.L., J.O., A.S., L.W.), Uppsala University, Sweden.,Department of Medical Sciences, Cardiology (Z.H., J.O., L.W.), Uppsala University, Sweden
| | - Johan Lindbäck
- Uppsala Clinical Research Center (Z.H., J.L., J.O., A.S., L.W.), Uppsala University, Sweden
| | - Stuart J Connolly
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada (A.P.B., S.J.C., J.W.E.)
| | - John W Eikelboom
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada (A.P.B., S.J.C., J.W.E.)
| | - Jonas Oldgren
- Uppsala Clinical Research Center (Z.H., J.L., J.O., A.S., L.W.), Uppsala University, Sweden.,Department of Medical Sciences, Cardiology (Z.H., J.O., L.W.), Uppsala University, Sweden
| | - Agneta Siegbahn
- Uppsala Clinical Research Center (Z.H., J.L., J.O., A.S., L.W.), Uppsala University, Sweden.,Department of Medical Sciences, Clinical Chemistry (A.S.), Uppsala University, Sweden
| | - Lars Wallentin
- Uppsala Clinical Research Center (Z.H., J.L., J.O., A.S., L.W.), Uppsala University, Sweden.,Department of Medical Sciences, Cardiology (Z.H., J.O., L.W.), Uppsala University, Sweden
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33
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Benz AP, Aeschbacher S, Krisai P, Moschovitis G, Blum S, Meyre P, Blum MR, Rodondi N, Di Valentino M, Kobza R, De Perna ML, Bonati LH, Beer JH, Kühne M, Osswald S, Conen D. Biomarkers of Inflammation and Risk of Hospitalization for Heart Failure in Patients With Atrial Fibrillation. J Am Heart Assoc 2021; 10:e019168. [PMID: 33843247 PMCID: PMC8174180 DOI: 10.1161/jaha.120.019168] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background Hospitalization for heart failure (HF) is very common in patients with atrial fibrillation (AF). We hypothesized that biomarkers of inflammation can identify patients with AF at increased risk of this important complication. Methods and Results Patients with established AF were prospectively enrolled. Levels of hs‐CRP (high‐sensitivity C‐reactive protein) and interleukin‐6 were measured from plasma samples obtained at baseline. We calculated an inflammation score ranging from 0 to 4 (1 point for each biomarker between the 50th and 75th percentile, 2 points for each biomarker above the 75th percentile). Individual associations of biomarkers and the inflammation score with HF hospitalization were obtained from multivariable Cox proportional hazards models. A total of 3784 patients with AF (median age 72 years, 24% prior HF) were followed for a median of 4.0 years. The median (interquartile range) plasma levels of hs‐CRP and interleukin‐6 were 1.64 (0.81–3.69) mg/L and 3.42 (2.14–5.60) pg/mL, respectively. The overall incidence of HF hospitalization was 3.04 per 100 person‐years and increased from 1.34 to 7.31 per 100 person‐years across inflammation score categories. After multivariable adjustment, both biomarkers were significantly associated with the risk of HF hospitalization (per increase in 1 SD, adjusted hazard ratio [HR], 1.22; 95% CI, 1.11–1.34 for log‐transformed hs‐CRP; adjusted HR, 1.48; 95% CI, 1.35–1.62 for log‐transformed interleukin‐6). Similar results were obtained for the inflammation score (highest versus lowest score, adjusted HR, 2.43; 95% CI, 1.80–3.30; P value for trend <0.001). Conclusions Biomarkers of inflammation strongly predicted HF hospitalization in a large, contemporary sample of patients with AF. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02105844.
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Affiliation(s)
- Alexander P Benz
- Population Health Research Institute McMaster University Hamilton Canada
| | - Stefanie Aeschbacher
- Division of Cardiology Department of Medicine University Hospital Basel Basel Switzerland.,Cardiovascular Research Institute Basel University Hospital BaselUniversity of Basel Switzerland
| | - Philipp Krisai
- Cardiovascular Research Institute Basel University Hospital BaselUniversity of Basel Switzerland.,Electrophysiology and Ablation Unit and L'Institut de Rythmologie et Modélisation Cardiaque (LIRYC) Centre Hospitalier Universitaire de Bordeaux Bordeaux-Pessac France
| | - Giorgio Moschovitis
- Population Health Research Institute McMaster University Hamilton Canada.,Division of Cardiology Ente Ospedaliero Cantonale (EOC)Ospedale Regionale di Lugano Lugano Ticino Switzerland
| | - Steffen Blum
- Division of Cardiology Department of Medicine University Hospital Basel Basel Switzerland.,Cardiovascular Research Institute Basel University Hospital BaselUniversity of Basel Switzerland
| | - Pascal Meyre
- Division of Cardiology Department of Medicine University Hospital Basel Basel Switzerland.,Cardiovascular Research Institute Basel University Hospital BaselUniversity of Basel Switzerland
| | - Manuel R Blum
- Institute of Primary Health Care (BIHAM) University of Bern Switzerland.,Department of General Internal Medicine, Inselspital Bern University HospitalUniversity of Bern Switzerland
| | - Nicolas Rodondi
- Institute of Primary Health Care (BIHAM) University of Bern Switzerland.,Department of General Internal Medicine, Inselspital Bern University HospitalUniversity of Bern Switzerland
| | - Marcello Di Valentino
- Division of Cardiology Ente Ospedaliero Cantonale (EOC)Ospedale San Giovanni Bellinzona Bellinzona Ticino Switzerland.,Biomedical Sciences Università della Svizzera Italiana Lugano Switzerland
| | - Richard Kobza
- Division of Cardiology Luzerner Kantonsspital Luzern Switzerland
| | - Maria Luisa De Perna
- Division of Cardiology Ente Ospedaliero Cantonale (EOC)Ospedale Regionale di Lugano Lugano Ticino Switzerland
| | - Leo H Bonati
- Department of Neurology and Stroke Center University Hospital Basel Basel Switzerland
| | - Jürg H Beer
- Department of Medicine Cantonal Hospital of Baden Switzerland.,Center for Molecular Cardiology University of Zurich Switzerland
| | - Michael Kühne
- Division of Cardiology Department of Medicine University Hospital Basel Basel Switzerland.,Cardiovascular Research Institute Basel University Hospital BaselUniversity of Basel Switzerland
| | - Stefan Osswald
- Division of Cardiology Department of Medicine University Hospital Basel Basel Switzerland.,Cardiovascular Research Institute Basel University Hospital BaselUniversity of Basel Switzerland
| | - David Conen
- Population Health Research Institute McMaster University Hamilton Canada.,Cardiovascular Research Institute Basel University Hospital BaselUniversity of Basel Switzerland
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Ibrahim OA, Belley-Côté EP, Um KJ, Baranchuk A, Benz AP, Dalmia S, Wang CN, Alhazzani W, Conen D, Devereaux PJ, Whitlock RP, Healey JS, McIntyre WF. Single-dose oral anti-arrhythmic drugs for cardioversion of recent-onset atrial fibrillation: a systematic review and network meta-analysis of randomized controlled trials. Europace 2021; 23:1200-1210. [PMID: 33723602 DOI: 10.1093/europace/euab014] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 01/08/2021] [Indexed: 11/12/2022] Open
Abstract
AIMS Single oral dose anti-arrhythmic drugs (AADs) are used to cardiovert recent-onset atrial fibrillation (AF); however, the optimal agent is uncertain. METHODS We performed a systematic review and network meta-analysis of randomized trials testing single oral dose AADs vs. any comparator to cardiovert AF <7 days duration. We searched MEDLINE, Embase, and CENTRAL to April 2020. The primary outcome was successful cardioversion at timepoint nearest 8 h after administration. RESULTS From 12 712 citations, 22 trials (2320 patients) were included. Thirteen trials included patients with some degree of heart failure; 19 included patients with some degree of ischaemic heart disease vs. placebo or rate-control (32% success) at 8 h, flecainide [73%, network odds ratio (OR) 7.6, 95% credible interval (CrI) 4.4-14.0], propafenone (70%, OR 4.6, CrI 2.9-7.3), and pilsicainide (59%, OR 10.0, CrI 1.8-69.0), but not amiodarone (28%, OR 1.0, CrI 0.4-2.8) were superior. Flecainide (OR 7.5, CrI 2.6-24.0) and propafenone (OR 4.5, CrI 1.6-13.0) were superior to amiodarone; propafenone vs. flecainide did not statistically differ (OR 0.6, CrI 0.3-1.1). At longest follow-up, amiodarone was superior to placebo (OR 11.0, CrI 3.2-41.0), flecainide vs. amiodarone (OR 0.79, CrI 0.19-3.1), and propafenone vs. amiodarone (OR 0.36, CrI 0.092-1.4) were not statistically different, and flecainide was superior to propafenone (OR 2.2, CrI 1.1-4.8). Atrial and ventricular tachyarrhythmias, bradyarrhythmias, and hypotension were rare with PO AADs. CONCLUSION Single oral dose Class 1C AADs are effective and safe for cardioversion of recent-onset AF. Flecainide may be superior to propafenone. Amiodarone is a slower acting alternative.
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Affiliation(s)
- Omar A Ibrahim
- Population Health Research Institute, McMaster University, 20 Copeland Ave, Hamilton, ON, L8L2X2, Canada
| | - Emilie P Belley-Côté
- Population Health Research Institute, McMaster University, 20 Copeland Ave, Hamilton, ON, L8L2X2, Canada
| | - Kevin J Um
- Population Health Research Institute, McMaster University, 20 Copeland Ave, Hamilton, ON, L8L2X2, Canada
| | | | - Alexander P Benz
- Population Health Research Institute, McMaster University, 20 Copeland Ave, Hamilton, ON, L8L2X2, Canada
| | - Shreyash Dalmia
- Population Health Research Institute, McMaster University, 20 Copeland Ave, Hamilton, ON, L8L2X2, Canada
| | | | - Waleed Alhazzani
- Population Health Research Institute, McMaster University, 20 Copeland Ave, Hamilton, ON, L8L2X2, Canada
| | - David Conen
- Population Health Research Institute, McMaster University, 20 Copeland Ave, Hamilton, ON, L8L2X2, Canada
| | - P J Devereaux
- Population Health Research Institute, McMaster University, 20 Copeland Ave, Hamilton, ON, L8L2X2, Canada
| | - Richard P Whitlock
- Population Health Research Institute, McMaster University, 20 Copeland Ave, Hamilton, ON, L8L2X2, Canada
| | - Jeff S Healey
- Population Health Research Institute, McMaster University, 20 Copeland Ave, Hamilton, ON, L8L2X2, Canada
| | - William F McIntyre
- Population Health Research Institute, McMaster University, 20 Copeland Ave, Hamilton, ON, L8L2X2, Canada
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35
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Benz AP, Xu L, Eikelboom JW, Middeldorp S, Milling TJ, Crowther M, Yue P, Conley P, Lu G, Connolly SJ. Abstract P3: Andexanet Alfa for Acute Bleeding During Treatment With Edoxaban. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.p3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
We previously reported results of a prospective cohort study evaluating andexanet alfa (andexanet) for anticoagulation reversal in patients with acute bleeding on a factor Xa inhibitor. Study enrollment continued to accumulate additional data on patients on edoxaban, which are presented here.
Methods:
Patients with acute major bleeding within 18 hours of edoxaban intake were prospectively enrolled. Patients received a 400 or 800 mg bolus and a 480 or 960 mg 2-hour follow-on infusion of andexanet, depending on edoxaban dosage and time of last dose. The co-primary efficacy outcomes were change in anti-factor Xa activity and the rate of excellent or good hemostasis, 12 hours after andexanet treatment, as determined by an independent adjudication committee. Efficacy was analyzed in patients with confirmed major bleeding and baseline anti-factor Xa activity ≥75 ng/mL. Safety was analyzed in all patients.
Results:
A total of 36 patients (mean age 82 years, 61.1% male and 91.7% with atrial fibrillation) with acute major bleeding on edoxaban received andexanet. The primary site of bleeding was intracranial in 29 (80.6%) patients. In the efficacy population (n=20), median anti-factor Xa activity decreased from 160.5 (interquartile range [IQR] 106.2-222.2) ng/mL at baseline to 50.9 (IQR 19.9-119.4) ng/mL at the end of bolus (median decrease 69.2%, 95% confidence interval [CI] 25.5-80.2%). Excellent or good hemostasis at 12 hours was achieved in 75.0% (95% CI 50.9-91.3%) of patients overall and in 81.3% (95% CI 54.4-96.0%) of those with intracranial hemorrhage (ICH). Within 30 days, a total of 4 (11.1%) patients experienced at least one thrombotic event and 4 (11.1%) others died.
Conclusions:
In patients with acute bleeding on edoxaban, andexanet significantly decreased anti-factor Xa activity. Excellent or good hemostasis at 12 hours was observed in 75.0% of patients overall and 81.3% of those with ICH. Thrombotic events occurred at a rate expected in such patients.
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Affiliation(s)
| | - Lizhen Xu
- Population Health Rsch Institute, Hamilton, Canada
| | | | - Saskia Middeldorp
- Dept of Vascular Medicine, Amsterdam Univ Med Cntrs, Univ of Amsterdam, Amsterdam, Netherlands
| | - Truman J Milling
- Seton Dell Med Sch Stroke Institute, Dell Med Sch, Univ of Texas at Austin, Austin, TX
| | | | - Patrick Yue
- Portola Pharmaceuticals, a wholly owned subsidiary of Alexion Pharmaceuticals, South San Francisco, CA
| | - Pamela Conley
- Portola Pharmaceuticals, a wholly owned subsidiary of Alexion Pharmaceuticals, South San Francisco, CA
| | - Genmin Lu
- Portola Pharmaceuticals, a wholly owned subsidiary of Alexion Pharmaceuticals, South San Francisco, CA
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36
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McIntyre WF, Vadakken ME, Rai AS, Thach T, Syed W, Um KJ, Ibrahim O, Dalmia S, Bhatnagar A, Mendoza PA, Benz AP, Bangdiwala SI, Spence J, McClure GR, Huynh JT, Zhang T, Inami T, Conen D, Devereaux PJ, Whitlock RP, Healey JS, Belley-Côté EP. Incidence and recurrence of new-onset atrial fibrillation detected during hospitalization for non-cardiac surgery: a systematic review and meta-analysis. Can J Anaesth 2021; 68:1045-1056. [PMID: 33624255 DOI: 10.1007/s12630-021-01944-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 01/11/2021] [Accepted: 01/11/2021] [Indexed: 12/26/2022] Open
Abstract
PURPOSE This systematic review aimed to summarize reports of the incidence and long-term recurrence of new-onset atrial fibrillation (AF) associated with non-cardiac surgery. SOURCES We searched CENTRAL, MEDLINE and EMBASE from inception to November 2019. We included studies that reported on the incidence of new-onset perioperative AF during hospitalization for non-cardiac surgery and/or AF recurrence in such patients following discharge. Reviewers screened articles and abstracted data independently and in duplicate. We assessed study quality by appraising methodology for collecting AF history, incident AF during hospitalization, and AF recurrence after discharge. PRINCIPAL FINDINGS From 39,233 citations screened, 346 studies that enrolled a total of 5,829,758 patients met eligibility criteria. Only 27 studies used prospective, continuous inpatient electrocardiographic (ECG) monitoring to detect incident AF. Overall, the incidence of postoperative AF during hospitalization ranged from 0.004 to 50.3%, with a median [interquartile range] of 8.7 [3.8-15.0]%. Atrial fibrillation incidence varied with type of surgery. Prospective studies using continuous ECG monitoring reported significantly higher incidences of AF than those that did not (13.9% vs 1.9%, respectively; P < 0.001). A total of 13 studies (25,726 patients) with follow-up up to 5.4 years reported on AF recurrence following hospital discharge; only one study used a prospective systematic monitoring protocol. Recurrence rates ranged from 0 to 37.3%. CONCLUSIONS Rates of AF incidence first detected following non-cardiac surgery and long-term AF recurrence vary markedly. Differences in the intensity of ECG monitoring and type of surgery may account for this variation. TRIAL REGISTRATION PROSPERO (CRD42017068055); registered 1 September 2017.
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Affiliation(s)
- William F McIntyre
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada.
- Department of Medicine, McMaster University, Hamilton, ON, Canada.
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
| | - Maria E Vadakken
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Anand S Rai
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Terry Thach
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Wajahat Syed
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Kevin J Um
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Omar Ibrahim
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Shreyash Dalmia
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Akash Bhatnagar
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Pablo A Mendoza
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Alexander P Benz
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Shrikant I Bangdiwala
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Jessica Spence
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Graham R McClure
- Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Jessica T Huynh
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Tianyi Zhang
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Toru Inami
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - David Conen
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - P J Devereaux
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Richard P Whitlock
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Jeff S Healey
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Emilie P Belley-Côté
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
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37
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Benz AP, Healey JS, Chin A, Commerford P, Marsden T, Karthikeyan G, McIntyre WF, Wong JA, Damasceno A, Hohnloser SH, Oldgren J, Wallentin L, Ezekowitz MD, Eikelboom JW, Yusuf S, Connolly SJ. Stroke risk prediction in patients with atrial fibrillation with and without rheumatic heart disease. Cardiovasc Res 2021; 118:295-304. [PMID: 33386845 DOI: 10.1093/cvr/cvaa344] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 12/09/2020] [Indexed: 11/14/2022] Open
Abstract
AIMS Patients with atrial fibrillation (AF) and rheumatic heart disease (RHD), especially mitral stenosis, are assumed to be at high risk of stroke, irrespective of other factors. We aimed to re-evaluate stroke risk factors in a contemporary cohort of AF patients. METHODS AND RESULTS We analyzed data of 15,400 AF patients presenting to an emergency department and who were enrolled in the global RE-LY AF registry, representing 47 countries from all inhabited continents. Follow-up occurred at 1 year after enrollment. A total of 1,788 (11.6%) patients had RHD. These patients were younger (51.4 ± 15.7 vs. 67.8 ± 13.6 years), more likely to be female (66.2% vs. 44.7%) and had a lower mean CHA2DS2-VASc score (2.1 ± 1.7 vs. 3.7 ± 2.2) as compared to patients without RHD (all p < 0.001). Significant mitral stenosis (average mean transmitral gradient 11.5 ± 6.5 mmHg) was the predominant valve lesion in those with RHD (59.6%). Patients with RHD had a higher baseline rate of anticoagulation use (60.4% vs. 45.2%, p < 0.001). Unadjusted stroke rates at 1 year were 2.8% and 4.1% for patients with and without RHD, respectively. The performance of the CHA2DS2-VASc score was modest in both groups (stroke at 1 year, c-statistics 0.69, 95% confidence interval [CI] 0.60-0.78 and 0.63, 95% CI 0.61-0.66, respectively). In the overall cohort, advanced age, female sex, prior stroke, tobacco use and non-use of anticoagulation were predictors for stroke (all p < 0.05). Mitral stenosis was not associated with stroke risk (adjusted odds ratio 1.07, 95% CI 0.67-1.72, p = 0.764). CONCLUSIONS The performance of the CHA2DS2-VASc score was modest in AF patients both with and without RHD. In this cohort, moderate-to-severe mitral stenosis was not an independent risk factor for stroke. TRANSLATIONAL PERSPECTIVE Based on studies conducted several decades ago, the presence of moderate-to-severe mitral stenosis has been associated with a very high risk of stroke in patients with AF. Our results, based on a large, global sample of contemporary patients with AF that contained a significant proportion of individuals with RHD, challenge the assumption that mitral stenosis is a major, independent risk factor for stroke. The performance of the widely used CHA2DS2-VASc score was modest in both patients with and without RHD. At least one ongoing randomized trial is evaluating the optimal antithrombotic strategy in patients with AF and RHD.
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Affiliation(s)
- Alexander P Benz
- Population Health Research Institute, McMaster University, Hamilton, Canada
| | - Jeff S Healey
- Population Health Research Institute, McMaster University, Hamilton, Canada
| | - Ashley Chin
- The Cardiac Clinic, Department of Medicine, Groote Schuur Hospital, and University of Cape Town, South Africa
| | - Patrick Commerford
- The Cardiac Clinic, Department of Medicine, Groote Schuur Hospital, and University of Cape Town, South Africa
| | - Tamara Marsden
- Population Health Research Institute, McMaster University, Hamilton, Canada
| | - Ganesan Karthikeyan
- Department of Cardiology, All India, Institute of Medical Sciences, New Delhi, India
| | - William F McIntyre
- Population Health Research Institute, McMaster University, Hamilton, Canada
| | - Jorge A Wong
- Population Health Research Institute, McMaster University, Hamilton, Canada
| | | | - Stefan H Hohnloser
- Division Clinical Electrophysiology, Department of Cardiology, Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Jonas Oldgren
- Uppsala Clinical Research Center, and Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Lars Wallentin
- Uppsala Clinical Research Center, and Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Michael D Ezekowitz
- Sidney Kimmel Medical College, at Thomas Jefferson University and Lankenau and Bryn Mawr Hospitals, Philadelphia, Pennsylvania, United States
| | - John W Eikelboom
- Population Health Research Institute, McMaster University, Hamilton, Canada
| | - Salim Yusuf
- Population Health Research Institute, McMaster University, Hamilton, Canada
| | - Stuart J Connolly
- Population Health Research Institute, McMaster University, Hamilton, Canada
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McIntyre WF, Wang J, Benz AP, Belley-Côté EP, Conen D, Devereaux PJ, Wong JA, Hohnloser SH, Capucci A, Lau CP, Gold MR, Israel CW, Whitlock RP, Connolly SJ, Healey JS. Device-Detected Atrial Fibrillation Before and After Hospitalisation for Noncardiac Surgery or Medical Illness: Insights From ASSERT. Can J Cardiol 2020; 37:803-809. [PMID: 33271225 DOI: 10.1016/j.cjca.2020.11.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 11/23/2020] [Accepted: 11/24/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Atrial fibrillation (AF) is often detected during hospitalisation for surgery or medical illness and is often assumed to be due to the acute condition. METHODS The Asymptomatic Atrial Fibrillation and Stroke Evaluation in Pacemaker Patients and the Atrial Fibrillation Reduction Atrial Pacing Trial (ASSERT) study enrolled patients ≥ 65 years old without AF. Pacemakers or implantable cardioverter-defibrillators recorded device-detected AF. We identified participants who were hospitalised and compared the prevalence of AF before and after hospitalisation. RESULTS Among 2580 participants, 436 (16.9%) had a surgical or medical hospitalisation. In the 30 days following a first hospitalisation, 43 participants (9.9%, 95% confidence interval [CI] 7.2%-13.1%) had > 6 minutes of device-detected AF; 20 (4.6%, 95% CI 2.8%-7.0%) had > 6 hours. More participants had AF > 6 minutes in the 30 days following hospitalisation compared with the period 30-60 days before hospitalisation (9.9% vs 4.4%; P < 0.001). Similar results were observed for episodes > 6 hours (4.6% vs 2.3%, P = 0.03). Roughly half of participants with device-detected AF in the 30 days following hospitalisation had at least 1 episode of the same duration in the 6 months before (50% [95% CI 31.3%-68.7%] for > 6 min; 68.8% [95% CI 41.3%-89.0%] for > 6 h). Those with AF in the 30 days following hospitalisation were more likely to have had AF in the past (adjusted odds ratio [OR] 7.2, 95% CI 3.2-15.8 for > 6 min; adjusted OR 32.6, 95% CI 10.3-103.4 for > 6 h). CONCLUSIONS The prevalence of device-detected AF increases around the time of hospitalisation for noncardiac surgery or medical illness. About half of patients with AF around the time of hospitalisation previously had similar episodes.
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Affiliation(s)
- William F McIntyre
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada.
| | - Jia Wang
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Alexander P Benz
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Emilie P Belley-Côté
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - David Conen
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - P J Devereaux
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Jorge A Wong
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Stefan H Hohnloser
- Department of Electrophysiology, J.W. Goethe University, Frankfurt, Germany
| | - Alessandro Capucci
- Department of Cardiovascular Sciences, Università Politecnica delle Marche, Ancona, Italy
| | - Chu-Pak Lau
- Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong, People's Republic of China
| | - Michael R Gold
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Carsten W Israel
- Division of Cardiology, Department of Medicine, Evangelical Hospital Bielefeld, Bielefeld, Germany
| | - Richard P Whitlock
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Stuart J Connolly
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Jeff S Healey
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
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39
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Benz AP, Eikelboom JW, Yusuf S, Hohnloser SH, Kahl A, Beresh H, Balasubramanian K, Healey JS, Connolly SJ. Long-Term Treatment with Apixaban in Patients with Atrial Fibrillation: Outcomes during the Open-Label Extension following AVERROES. Thromb Haemost 2020; 121:518-528. [PMID: 33011964 PMCID: PMC7982299 DOI: 10.1055/s-0040-1717115] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND AVERROES, a randomized controlled trial in high-risk patients with atrial fibrillation, unsuitable for vitamin K antagonist therapy, demonstrated efficacy and safety of apixaban compared with aspirin. At the conclusion of the double-blind phase, an open-label extension was initiated to allow study participants to receive apixaban until it became locally available. This study reports outcomes of patients on apixaban during the open-label extension. METHODS Rates of stroke or systemic embolism, hemorrhagic stroke, major bleeding, and other outcomes during the open-label extension are reported. RESULTS Of the 5,599 participants enrolled in AVERROES, 3,275 (58.5%) received apixaban during the open-label extension. Median (interquartile range) follow-up in the open-label extension was 3.0 (2.5-3.5) years. The rate of stroke or systemic embolism during the open-label extension was 1.0% per year, and the annual rates of hemorrhagic stroke and major bleeding were 0.3 and 1.2%, respectively. After adjustment for imbalances in patient variables, event rates in patients on apixaban during the open-label extension were similar to those of patients receiving apixaban during AVERROES. Additional analyses in all patients who received apixaban, at any time from the start of AVERROES to the end of the open-label extension, were performed. This cohort (n = 4,414) showed annual event rates of 1.1% for stroke or systemic embolism, 0.3% for hemorrhagic stroke, and 1.2% for major bleeding. CONCLUSION During the open-label extension, annual rates of stroke or systemic embolism, hemorrhagic stroke, and major bleeding remained as low as those observed during apixaban treatment in AVERROES. These data support the long-term efficacy and safety of apixaban in patients with atrial fibrillation.
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Affiliation(s)
| | | | - Salim Yusuf
- Population Health Research Institute, Hamilton, Ontario, Canada
| | - Stefan H Hohnloser
- Division Clinical Electrophysiology, Department of Cardiology, Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Anja Kahl
- Bristol-Myers Squibb, Lawrenceville, New Jersey, Unites States
| | - Heather Beresh
- Population Health Research Institute, Hamilton, Ontario, Canada
| | | | - Jeff S Healey
- Population Health Research Institute, Hamilton, Ontario, Canada
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Benz AP, Eikelboom JW. Is aspirin safer than a direct oral anticoagulant for patients with atrial fibrillation at high risk of bleeding? Eur J Intern Med 2020; 79:25-26. [PMID: 32771271 DOI: 10.1016/j.ejim.2020.07.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 07/31/2020] [Indexed: 11/26/2022]
Affiliation(s)
- Alexander P Benz
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, L8L 2×2, Canada.
| | - John W Eikelboom
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, L8L 2×2, Canada
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Benz AP, Wang J, McIntyre WF, Wong JA, Crystal E, Shurrab M, Israel CW, Hohnloser SH, Gold MR, Connolly SJ, Healey JS. Active-Fixation Atrial Leads and the Risk of Atrial Fibrillation: Insights From ASSERT. Circ Arrhythm Electrophysiol 2020; 13:e008655. [PMID: 32701364 DOI: 10.1161/circep.120.008655] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Alexander P Benz
- Population Health Research Institute, Hamilton, Ontario, Canada (A.P.B., J.W., W.F.M., J.A.W., S.J.C., J.S.H.)
| | - Jia Wang
- Population Health Research Institute, Hamilton, Ontario, Canada (A.P.B., J.W., W.F.M., J.A.W., S.J.C., J.S.H.)
| | - William F McIntyre
- Population Health Research Institute, Hamilton, Ontario, Canada (A.P.B., J.W., W.F.M., J.A.W., S.J.C., J.S.H.)
| | - Jorge A Wong
- Population Health Research Institute, Hamilton, Ontario, Canada (A.P.B., J.W., W.F.M., J.A.W., S.J.C., J.S.H.)
| | - Eugene Crystal
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (E.C.)
| | - Mohammed Shurrab
- Cardiology Department, Health Sciences North, Sudbury, Ontario, Canada (M.S.)
| | - Carsten W Israel
- Klinik für Innere Medizin-Kardiologie, Diabetologie and Nephrologie, Evangelisches Klinikum Bethel, Bielefeld, Germany (C.W.I.)
| | - Stefan H Hohnloser
- Division of Clinical Electrophysiology, Department of Cardiology, Johann Wolfgang Goethe University, Frankfurt, Germany (S.H.H.)
| | - Michael R Gold
- Department of Medicine, Medical University of South Carolina, Charleston (M.R.G.)
| | - Stuart J Connolly
- Population Health Research Institute, Hamilton, Ontario, Canada (A.P.B., J.W., W.F.M., J.A.W., S.J.C., J.S.H.)
| | - Jeff S Healey
- Population Health Research Institute, Hamilton, Ontario, Canada (A.P.B., J.W., W.F.M., J.A.W., S.J.C., J.S.H.)
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Mcintyre W, Wang J, Connolly SJ, Benz AP, Conen D, Devereaux PJ, Wong JA, Belley-Cote EP, Hohnloser SH, Capucci A, Lau CP, Gold MR, Whitlock RP, Healey JS. 74Subclinical atrial fibrillation before and after acute medical illness or noncardiac surgery: insights from ASSERT. Europace 2020. [DOI: 10.1093/europace/euaa162.269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
OnBehalf
ASSERT Investigators
Background
Atrial fibrillation (AF) is frequently detected perioperatively or during acute medical illness. It is unclear if such AF is reversible and unlikely to recur, or is a manifestation of paroxysmal AF.
Objective
To compare the prevalence of pacemaker-detected, subclinical AF (atrial rate >190 bpm) before and after hospitalization for noncardiac surgery or medical illness in patients without a history of clinical AF.
Methods
ASSERT enrolled patients who were >65 years old and had hypertension but no known AF. Pacemakers and defibrillators recorded episodes of subclinical AF. We identified participants who were hospitalized for noncardiac surgery or medical illness, and created heart rhythm profiles, centred on the day of hospitalization. We compared the prevalence of subclinical AF before and after hospitalization. We blanked the 30 days before hospitalization, because of uncertainty in defining the precise onset of illness.
Results
Among 2580 patients, 436 had a documented surgical or medical hospitalization. In the 30 days following a first hospitalization, 43 patients (9.9%) had >1 episode of >6 minutes of subclinical AF; 20 (4.6%) had >6 hours and 13 (3%) had >24 hours.
A higher proportion of patients had >1 episode of subclinical AF >6 minutes in the 30 days following a first surgical or medical hospitalization, as compared to the period between 30 and 60 days before hospitalization (9.9% versus 4.4%, P < 0.001). There was no significant difference when comparing 0-90 days after hospitalization to 30-120 days before (13.7% versus 10.6%, P = 0.1). Similar results were observed for the same comparisons with episodes >6 hours (4.6% versus 2.3%, P = 0.03 and 5.9% versus 5.6%, P = 0.8, respectively).
The majority of patients with subclinical AF in the 30 days following hospitalization had at least one episode of subclinical AF of the same duration in the 6 months prior (50% for episodes >6 minutes; 69% for >6 hours and 60% for >24 hours). Those who did have subclinical AF in the 30 days following hospitalization were more likely to have had subclinical AF in the past 6 months than those who did not (OR 7.2 95%CI 3.2-15.8 for episodes >6 minutes; OR 32.6, 95%CI 10.3-103.4 for >6 hours and OR 36.3 95%CI 9.0-146.0 for >24 hours).
Conclusions
The prevalence of subclinical AF increased following hospitalization for noncardiac surgery or medical illness. However, most patients with subclinical AF following hospitalization had previously experienced similar episodes, particularly those with longer episodes of subclinical AF.
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Affiliation(s)
| | - J Wang
- McMaster University, Hamilton, Canada
| | | | - A P Benz
- McMaster University, Hamilton, Canada
| | - D Conen
- McMaster University, Hamilton, Canada
| | | | - J A Wong
- McMaster University, Hamilton, Canada
| | | | | | - A Capucci
- Marche Polytechnic University of Ancona, Ancona, Italy
| | - C P Lau
- The University of Hong Kong, Hong Kong, Hong Kong
| | - M R Gold
- Medical University of South Carolina, Charleston, United States of America
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Benz AP, Eikelboom JW. Prothrombin Complex Concentrates for Intracranial Hemorrhage on Factor Xa Inhibitors. Circulation 2020; 141:1690-1692. [PMID: 32453664 DOI: 10.1161/circulationaha.120.046932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Alexander P Benz
- Population Health Research Institute, Hamilton Health Sciences and McMaster University Hamilton, Ontario, Canada
| | - John W Eikelboom
- Population Health Research Institute, Hamilton Health Sciences and McMaster University Hamilton, Ontario, Canada
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McIntyre WF, Connolly SJ, Wang J, Masiero S, Benz AP, Conen D, Wong JA, Beresh H, Healey JS. Thromboembolic events around the time of cardioversion for atrial fibrillation in patients receiving antiplatelet treatment in the ACTIVE trials. Eur Heart J 2019; 40:3026-3032. [DOI: 10.1093/eurheartj/ehz521] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 06/18/2019] [Accepted: 07/27/2019] [Indexed: 11/13/2022] Open
Abstract
Abstract
Aims
It is unknown whether cardioversion of atrial fibrillation causes thromboembolic events or is a risk marker. To assess causality, we examined the temporal pattern of thromboembolism in patients having cardioversion.
Methods and results
We studied patients randomized to aspirin or aspirin plus clopidogrel in the ACTIVE trials, comparing the thromboembolic rate in the peri-cardioversion period (30 days before until 30 days after) to the rate during follow-up, remote from cardioversion. Among 962 patients, the 30-day thromboembolic rate remote from cardioversion was 0.16%; while it was 0.73% in the peri-cardioversion period [hazard ratio (HR) 4.1, 95% confidence interval (CI) 2.1–7.9]. The 30-day thromboembolic rates in the periods immediately before and after cardioversion were 0.47% and 0.96%, respectively (HR 2.2, 95% CI 0.7–7.1). Heart failure (HF) hospitalization increased in the peri-cardioversion period (HR 11.5, 95% CI 6.8–19.4). Compared to baseline, the thromboembolic rate in the 30 days following cardioversion was increased both in patients who received oral anticoagulation or a transoesophageal echocardiogram prior to cardioversion (HR 7.9, 95% CI 2.8–22.4) and in those who did not (HR 4.8, 95% CI 1.6–14.9) (interaction P = 0.2); the risk was also increased with successful (HR 4.5; 95% CI 2.0–10.5) and unsuccessful (HR 10.2; 95% CI 2.3–44.9) cardioversion.
Conclusions
Thromboembolic risk increased in the 30 days before cardioversion and persisted until 30 days post-cardioversion, in a pattern similar to HF hospitalization. These data suggest that the increased thromboembolic risk around the time of cardioversion may not be entirely causal, but confounded by the overall clinical deterioration of patients requiring cardioversion.
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Affiliation(s)
- William F McIntyre
- Population Health Research Institute, McMaster University, 30 Birge St. Room C3-121, Hamilton, Ontario, Canada
| | - Stuart J Connolly
- Population Health Research Institute, McMaster University, 30 Birge St. Room C3-121, Hamilton, Ontario, Canada
| | - Jia Wang
- Population Health Research Institute, McMaster University, 30 Birge St. Room C3-121, Hamilton, Ontario, Canada
| | - Simona Masiero
- Population Health Research Institute, McMaster University, 30 Birge St. Room C3-121, Hamilton, Ontario, Canada
- Clinica di Cardiologia ed Aritmologia, Ospedali Riuniti di Ancona, Via Conca, 71, Ancona, Italy
| | - Alexander P Benz
- Population Health Research Institute, McMaster University, 30 Birge St. Room C3-121, Hamilton, Ontario, Canada
| | - David Conen
- Population Health Research Institute, McMaster University, 30 Birge St. Room C3-121, Hamilton, Ontario, Canada
| | - Jorge A Wong
- Population Health Research Institute, McMaster University, 30 Birge St. Room C3-121, Hamilton, Ontario, Canada
| | - Heather Beresh
- Population Health Research Institute, McMaster University, 30 Birge St. Room C3-121, Hamilton, Ontario, Canada
| | - Jeff S Healey
- Population Health Research Institute, McMaster University, 30 Birge St. Room C3-121, Hamilton, Ontario, Canada
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Erath JW, Benz AP, Hohnloser SH, Vamos M. Clinical outcomes after implantation of quadripolar compared to bipolar left ventricular leads in patients undergoing cardiac resynchronization therapy: a systematic review and meta-analysis. Europace 2019; 21:1543-1549. [DOI: 10.1093/europace/euz196] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 06/26/2019] [Indexed: 11/13/2022] Open
Abstract
Abstract
Aims
Some retrospective and prospective studies in heart failure patients with indication for cardiac resynchronization therapy (CRT) suggest better clinical outcomes for quadripolar (QP) left ventricular (LV) leads over bipolar (BP) leads. Although, lead failure remains an important safety concern, when using these more complex, novel electrodes. To evaluate safety and efficacy outcomes for QP vs. BP LV leads in patients receiving CRT.
Methods and results
We performed a comprehensive literature search through 2018 in PubMed, Cochrane Library, and Google Scholar databases to identify studies comparing patients with QP and BP LV CRT leads. A total of 12 studies were selected for analysis comprising 31 403 patients (QP lead: 22 429 patients; BP lead: 8974 patients). Eight studies examined the effects of CRT on survival. In these studies, use of QP electrodes was associated with significantly better survival compared to patients with BP LV leads (OR 0.61, 95% CI 0.50–0.76; P < 0.01). Clinical improval measured in New York Heart Association functional class (OR 0.59, 95% CI 0.34–1.01; P = 0.05) and hospitalization rates (OR 0.67, 95% CI 0.55–0.83; P < 0.01) were also improved in patients receiving QP leads. Lead malfunctions defined as LV lead failure resulting in lead deactivation (OR 0.57, 95% CI 0.34–0.98; P = 0.04) or LV lead dislodgement requiring LV lead replacement/repositioning (OR 0.48; 95% CI 0.31–0.75; P < 0.01) were more often encountered among patients with BP leads compared to patients with QP leads.
Conclusion
Our meta-analysis suggests distinct benefits of QP over BP electrodes in patients undergoing CRT.
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Affiliation(s)
- Julia W Erath
- Division of Clinical Electrophysiology, Department of Cardiology, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, D Frankfurt, Germany
| | - Alexander P Benz
- Division of Clinical Electrophysiology, Department of Cardiology, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, D Frankfurt, Germany
| | - Stefan H Hohnloser
- Division of Clinical Electrophysiology, Department of Cardiology, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, D Frankfurt, Germany
| | - Mate Vamos
- Division of Clinical Electrophysiology, Department of Cardiology, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, D Frankfurt, Germany
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Vamos M, Erath JW, Benz AP, Hohnloser SH. P2777Accumulating evidence for deleterious effects of digoxin in heart failure and atrial fibrillation: an updated meta-analysis. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy565.p2777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- M Vamos
- JW Goethe University, Department of Cardiology, Division of Clinical Electrophysiology, Frankfurt am Main, Germany
| | - J W Erath
- JW Goethe University, Department of Cardiology, Division of Clinical Electrophysiology, Frankfurt am Main, Germany
| | - A P Benz
- JW Goethe University, Department of Cardiology, Division of Clinical Electrophysiology, Frankfurt am Main, Germany
| | - S H Hohnloser
- JW Goethe University, Department of Cardiology, Division of Clinical Electrophysiology, Frankfurt am Main, Germany
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Erath JW, Vamos M, Benz AP, Hohnloser SH. P5737Clinical performance of quadripolar left ventricular leads compared to biventricular leads. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy566.p5737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- J W Erath
- JW Goethe University, Cardiology/Electrophysiology, Frankfurt am Main, Germany
| | - M Vamos
- JW Goethe University, Cardiology/Electrophysiology, Frankfurt am Main, Germany
| | - A P Benz
- JW Goethe University, Cardiology/Electrophysiology, Frankfurt am Main, Germany
| | - S H Hohnloser
- JW Goethe University, Cardiology/Electrophysiology, Frankfurt am Main, Germany
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Benz AP, Vamos M, Erath JW, Hohnloser SH. Cephalic vs. subclavian lead implantation in cardiac implantable electronic devices: a systematic review and meta-analysis. Europace 2018; 21:121-129. [DOI: 10.1093/europace/euy165] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 06/18/2018] [Indexed: 12/22/2022] Open
Affiliation(s)
- Alexander P Benz
- Division Clinical Electrophysiology, Department of Cardiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, Frankfurt am Main, Germany
| | - Mate Vamos
- Division Clinical Electrophysiology, Department of Cardiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, Frankfurt am Main, Germany
| | - Julia W Erath
- Division Clinical Electrophysiology, Department of Cardiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, Frankfurt am Main, Germany
| | - Stefan H Hohnloser
- Division Clinical Electrophysiology, Department of Cardiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, Frankfurt am Main, Germany
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Rami A, Benz AP, Niquet J, Langhagen A. Axonal Accumulation of Lysosomal-Associated Membrane Protein 1 (LAMP1) Accompanying Alterations of Autophagy Dynamics in the Rat Hippocampus Upon Seizure-Induced Injury. Neurochem Res 2015; 41:53-63. [PMID: 26329516 DOI: 10.1007/s11064-015-1704-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Revised: 08/11/2015] [Accepted: 08/18/2015] [Indexed: 02/02/2023]
Abstract
We found a dramatic upregulation in the expression of LC3 in the hippocampus of rats upon status epilepticus (SE). However, the enhancement in LC3 expression might be caused by a reduction in lysosomal activity or by alterations in autophagosome-lysosome fusion leading to a cytosolic vesicular retention. In order to dissect this aspect, we monitored the spatial and temporal expression of LC3 and LAMP1 in the hippocampus of rats with SE. The Western blot analysis showed that the expression of LAMP1 was slightly increased in hippocampal cells at 6, 24, and 48 h post-SE. However, immunofluorescence analysis showed dramatic spatial changes in LAMP1 distribution within the hippocampus. LAMP1 in controls was localised only in cytosol as dot like staining, however at 24 h post-SE LAMP1 was not only highly expressed, but accumulated in mossy fibers of dentate gyrus. In parallel, we found few scattered LC3-positive-dots in neurites of dentate gyrus which co-localise with LAMP1-positive structures. We conclude that SE not only increased autophagosomal abundance, but also lysosomal activities and a massive accumulation of LAMP1 in axons of dentate gyrus. This could support the hypothesis that the marked increased autophagosomal abundance in cytosol reflects an increase in the autophagic activity more than an inhibition of autophagosomal clearance. Although LAMP1 may have contributed to cell damage in the selective vulnerable hippocampal CA1-subfield, it is also possible that lysosomal/autophagic mechanisms in mossy fibers were compensatory and reflected an attempt to survive the epileptic insult by breaking down non-essential components.
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Affiliation(s)
- A Rami
- Institut für Zelluläre und Molekulare Anatomie (Anatomie III), Klinikum der Johann Wolfgang von Goethe-Universität, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany.
| | - A P Benz
- Institut für Zelluläre und Molekulare Anatomie (Anatomie III), Klinikum der Johann Wolfgang von Goethe-Universität, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
| | - J Niquet
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, 90095, USA
| | - A Langhagen
- Institut für Zelluläre und Molekulare Anatomie (Anatomie III), Klinikum der Johann Wolfgang von Goethe-Universität, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
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