Mineralocorticoid receptor antagonists in heart failure with reduced ejection fraction: a systematic review and network meta-analysis of 32 randomized trials

INTRODUCTION

Several randomized controlled trials (RCTs) have examined mineralocorticoid receptor antagonists (MRAs) in heart failure (HF) with reduced ejection fraction (HFrEF). This systematic review and network meta-analysis (NMA) evaluated the comparative efficacy and safety of MRAs in HFrEF.

MATERIALS AND METHODS

MEDLINE(Pubmed), Scopus, Cochrane and ClinicalTrials.gov were searched until April 8, 2024 for RCTs examining the efficacy and/or safety of MRAs in HFrEF. Double-independent study selection, extraction and quality assessment were performed. Random-effects frequentist NMA models were used. Evidence certainty was assessed via Grading of Recommendations Assessment, Development and Evaluation (GRADE).

RESULTS

Totally, 32 RCTs (15685 patients) were analyzed. Eplerenone ranked above spironolactone in all-cause mortality (hazard ratio {HR}=0.78, 95% confidence interval {CI} [0.66,0.91], GRADE:"Moderate"), cardiovascular death (HR=0.74, 95%CI [0.53, 1.04], GRADE:"Low") and in all safety outcomes. Spironolactone was superior to eplerenone in the composite of cardiovascular death or hospitalization (HR=0.67, 95%CI [0.50,0.89], GRADE:"Moderate"), HF hospitalization (HR=0.61, 95%CI [0.43,0.86], GRADE:"Moderate"), all-cause hospitalization (HR=0.51, 95%CI [0.26,0.98], GRADE:"Moderate") and cardiovascular hospitalization (HR=0.56, 95%CI [0.37,0.84], GRADE:"Moderate"). Canrenone ranked first in all-cause mortality, the composite outcome and HF hospitalization. Finerenone ranked first in hyperkalemia (risk ratio [RR]=1.56, 95%CI [0.89,2.74], GRADE:"Moderate"), renal injury (RR=0.56, 95%CI [0.24,1.29]), any adverse event (RR=0.84, 95%CI [0.75,0.94], GRADE:"Moderate"), treatment discontinuation (RR=0.89, 95%CI [0.64,1.23]) and hypotension (RR=1.06, 95%CI [0.12,9.41]).

CONCLUSIONS

MRAs are effective in HFrEF with certain safety disparities. Spironolactone and eplerenone exhibited similar efficacy, however, eplerenone demonstrated superior safety. Finerenone was the safest MRA, while canrenone exhibited considerable efficacy, nonetheless, evidence for these MRAs were scarce.

Intracoronary Thrombolysis in ST-Segment Elevation Myocardial Infarction Patients Undergoing Primary Percutaneous Coronary Intervention: an Updated Meta-analysis of Randomized Controlled Trials

BACKGROUND

Primary percutaneous coronary intervention (PPCI) is the standard reperfusion treatment in ST-segment elevation myocardial infarction (STEMI). Intracoronary thrombolysis (ICT) may reduce thrombotic burden in the infarct-related artery, which is often responsible for microvascular obstruction and no-reflow.

METHODS

We conducted, according to the PRISMA statement, the largest meta-analysis to date of ICT as adjuvant therapy to PPCI. All relevant studies were identified by searching the PubMed, Scopus, Cochrane Library, and Web of Science.

RESULTS

Thirteen randomized controlled trials (RCTs) involving a total of 1876 patients were included. Compared to the control group, STEMI ICT-treated patients had fewer major adverse cardiac events (MACE) (OR 0.65, 95% CI, 0.48-0.86, P = 0.003) and an improved 6-month left ventricular ejection fraction (MD 3.78, 95% CI, 1.53-6.02, P = 0.0010). Indices of enhanced myocardial microcirculation were better with ICT (Post-PCI corrected thrombolysis in myocardial infarction (TIMI) frame count (MD - 3.57; 95% CI, - 5.00 to - 2.14, P < 0.00001); myocardial blush grade (MBG) 2/3 (OR 1.76; 95% CI, 1.16-2.69, P = 0.008), and complete ST-segment resolution (OR 1.97; 95% CI, 1.33-2.91, P = 0.0007)). The odds for major bleeding were comparable between the 2 groups (OR 1.27; 95% CI, 0.61-2.63, P = 0.53).

CONCLUSIONS

The present meta-analysis suggests that ICT was associated with improved MACE and myocardial microcirculation in STEMI patients undergoing PPCI, without significant increase in major bleeding. However, these findings necessitate confirmation in a contemporary large RCT.

Prognostic implications of thyroid disease in patients with atrial fibrillation

Atrial fibrillation (AF) is often accompanied by thyroid disease (THD). This study aimed to explore the relationship between THD and the occurrence of significant clinical outcomes in patients with AF. This post hoc analysis utilized data from the MISOAC-AF trial (NCT02941978), which enrolled hospitalized patients with AF. Patients were categorized based on their THD history into hyperthyroidism, hypothyroidism, or euthyroidism. Cox regression models were employed to calculate unadjusted and adjusted hazard ratios (aHRs). The primary outcomes of interest included all-cause mortality, cardiovascular death, and hospitalizations during the follow-up period. The study included 496 AF patients (mean age 73.09 ± 11.10 years) with available THD data, who were followed-up for a median duration of 31 months. Among them, 16 patients (3.2%) had hyperthyroidism, 141 (28.4%) had hypothyroidism, and 339 (68.4%) had no thyroid disease. Patients with hypothyroidism exhibited higher rates of hospitalization during follow-up (aHR: 1.57, 95% CI 1.12 to 2.20, p = 0.025) compared to the euthyroid group. Elevated levels of thyroid-stimulating hormone (TSH) were correlated with an increased risk of cardiovascular mortality (aHR: 1.03, 95% CI 1.01 to 1.05, p = 0.007) and hospitalizations (aHR: 1.06, 95% CI 1.01 to 1.12, p = 0.03). Conversely, lower levels of triiodothyronine (T3) were associated with higher risks of all-cause mortality (aHR: 0.51, 95% CI 0.31 to 0.82, p = 0.006) and cardiovascular mortality (aHR: 0.42, 95% CI 0.23 to 0.77, p = 0.005). Among patients with AF, hypothyroidism was associated with increased hospitalizations. Furthermore, elevated TSH levels and decreased T3 levels were linked to higher cardiovascular and all-cause mortality risks, respectively.

Residual leaks following percutaneous left atrial appendage occlusion and outcomes: a meta-analysis

BACKGROUND AND AIMS

Residual leaks are not infrequent after left atrial appendage occlusion. However, there is still uncertainty regarding their prognostic implications. The aim of this study is to evaluate the impact of residual leaks after left atrial appendage occlusion.

METHODS

A literature search was conducted until 19 February 2023. Residual leaks comprised peri-device leaks (PDLs) on transoesophageal echocardiography (TEE) or computed tomography (CT), as well as left atrial appendage patency on CT. Random-effects meta-analyses were performed to assess the clinical impact of residual leaks.

RESULTS

Overall 48 eligible studies (44 non-randomized/observational and 4 randomized studies) including 61 666 patients with atrial fibrillation who underwent left atrial appendage occlusion were analysed. Peri-device leak by TEE was present in 26.1% of patients. Computed tomography-based left atrial appendage patency and PDL were present in 54.9% and 57.3% of patients, respectively. Transoesophageal echocardiography-based PDL (i.e. any reported PDL regardless of its size) was significantly associated with a higher risk of thromboembolism [pooled odds ratio (pOR) 2.04, 95% confidence interval (CI): 1.52-2.74], all-cause mortality (pOR 1.16, 95% CI: 1.08-1.24), and major bleeding (pOR 1.12, 95% CI: 1.03-1.22), compared with no reported PDL. A positive graded association between PDL size and risk of thromboembolism was noted across TEE cut-offs. For any PDL of >0, >1, >3, and >5 mm, the pORs for thromboembolism were 1.82 (95% CI: 1.35-2.47), 2.13 (95% CI: 1.04-4.35), 4.14 (95% CI: 2.07-8.27), and 4.44 (95% CI: 2.09-9.43), respectively, compared with either no PDL or PDL smaller than each cut-off. Neither left atrial appendage patency, nor PDL by CT was associated with thromboembolism (pOR 1.45 and 1.04, 95% CI: 0.84-2.50 and 0.52-2.07, respectively).

CONCLUSIONS

Peri-device leak detected by TEE was associated with adverse events, primarily thromboembolism. Residual leaks detected by CT were more frequent but lacked prognostic significance.

Risk of arterial thromboembolism, bleeding and mortality in atrial fibrillation patients with comorbid cancer: A systematic review and meta-analysis

AIMS

Atrial fibrillation (AF) and cancer often co-exist. Each has been associated with an increased risk of morbidity and mortality. The aim of this meta-analysis was to synthesize available data regarding the incidence of arterial thromboembolism (TE), bleeding, and all-cause mortality in patients with AF with or without cancer.

METHODS

Literature search was conducted in PubMed, Ovid MEDLINE, WebOfScience, Scopus, CENTRAL, OpenGrey, and EThOS databases to identify studies that included patients with AF and accounted for cancer status with the incidence of TE (ischemic stroke, transient ischemic attack, or arterial thrombosis), major or clinically relevant non-major bleeding, and all-cause mortality. A random-effects meta-analysis was used.

RESULTS

Overall, 17 studies were included (3,149,547 patients). The risk of TE was similar in patients with AF with comorbid cancer compared with that in AF alone (pooled odds ratio [pOR] 0.97, 95% Confidence Interval [CI] 0.85-1.11, I2 = 87%). Major or clinically relevant non-major bleeding (pOR 1.65, 95% CI 1.35-2.02, I2 = 98%) and all-cause death (pOR 2.17, 95% CI 1.83-2.56, I2 = 98%) were significantly higher in patients with AF with cancer than in patients with AF only. The history of TE and hypertension and mean age were significant moderators of TE risk.

CONCLUSION

In patients with AF, the presence of cancer is associated with a similar risk of TE as well as an increased risk of bleeding and all-cause death compared with the absence of cancer.

Association of Length of Stay With the Clinical Trajectory of Hospitalized Patients With Atrial Fibrillation: Staying Less Is More?

Data predicting the length of stay (LOS) in patients with concurrent atrial fibrillation (AF) are scarce. This study aimed to investigate the potential predictors for prolonged LOS and its prognostic value. In this observational post hoc analysis of the MISOAC-AF (Motivational Interviewing to Support Oral AntiCoagulation adherence in patients with non-valvular Atrial Fibrillation) randomized trial logistic regression analyses were conducted to identify the parameters associated with prolonged LOS (defined as >7 days according to diagnostic accuracy analyses). Kaplan-Meier and Cox regression analyses were performed to generate survival curves and adjusted hazard ratios (aHRs) with 95% confidence intervals (CIs) for the primary end point of all-cause mortality and for the secondary end points during a median 3.7-year follow-up. Of the 1,057 patients studied, 462 (43.7%) were hospitalized for ≥7 days. Heart failure with reduced ejection fracture (aHR 1.75, 95% CI 1.17 to 2.63), permanent AF (aHR 1.72, 95% CI 1.29 to 2.31), history of coronary artery disease (aHR 2.32, 95% CI 1.59 to 3.39), and advanced or end-stage chronic kidney disease (aHR 1.54, 95% CI 1.15 to 2.06) were independently associated with prolonged hospitalization. Prolonged LOS was independently linked with increased all-cause mortality rates (aHR 1.68, 95% CI 1.25 to 2.26), cardiovascular mortality (aHR 1.92, 95% CI 1.36 to 2.72), major bleeding (aHR 3.07, 95% CI 1.07 to 8.78), and the composite outcome of cardiovascular death or rehospitalization (aHR 1.31, 95% CI 1.04 to 1.66). Each extra day of LOS was an independent predictor of all-cause mortality (aHR 1.03, 95% CI 1.02 to 1.04). Hospitalized patients with concurrent AF carry a substantial morbidity burden being prone to extended LOS. A jointed approach seems reasonable to reduce the LOS in patients with AF.

Changes in CHA2DS2-VASc score and risk of ischemic stroke among patients with atrial fibrillation

AIMS

The CHA2DS2-VASc score is fundamental to stroke risk assessment in atrial fibrillation. However, stroke-related risk factors can be modified later in life. This study aimed to assess the association of changes in CHA2DS2-VASc score over time (Delta CHA2DS2-VASc score) with the risk of ischemic stroke.

MATERIALS AND METHODS

This is an observational analysis of 1127 atrial fibrillation patients previously enrolled in the MISOAC-AF trial. After a median 2.6-year follow-up period, baseline and follow-up CHA2DS2-VASc scores were used to extract the Delta CHA2DS2-VASc score. The stroke predicting accuracies of the baseline, follow-up, and Delta CHA2DS2-VASc scores were assessed through regression analyses.

RESULTS

The mean baseline, follow-up, and Delta CHA2DS2-VASc scores were 4.2, 4.8, and 0.6 respectively. Ischemic stroke occurred in 54 (4.4%) patients, of which 83.3% had a Delta CHA2DS2-VASc score ≥1, contrary to 40.1% of the stroke-free group. The stroke risk per 1-point increase of the CHA2DS2-VASc score was not significantly associated with the baseline score (aHR=1.14; 95%CI: 0.93-1.41; p=0.201), whereas a significant association was observed with the follow-up (aHR=2.58; 95% CI: 2.07-3.21; p<0.001) and Delta (aHR=4.56; 95%CI: 3.50-5.94; p<0.001) scores. C-index assessment indicated that follow-up and Delta CHA2DS2-VASc scores were more potent predictors of ischemic stroke compared to baseline.

CONCLUSION

In atrial fibrillation patients, changes in CHA2DS2-VASc score over time were associated with the incidence of stroke. The improved predictability of follow-up and Delta CHA2DS2-VASc scores indicates that stroke risk is not a static parameter.

TRIAL REGISTRATION

This is an observational, post-hoc analysis of the MISOAC-AF randomized controlled trial, registered on ClinicalTrials.gov (identifier: NCT02941978; registered: October 21, 2016).

Diagnostic Puzzles and Cause-Targeted Treatment Strategies in Myocardial Infarction with Non-Obstructive Coronary Arteries: An Updated Review

Myocardial infarction with nonobstructive coronary arteries (MINOCA) is a distinct subtype of myocardial infarction (MI), occurring in about 8-10% of spontaneous MI cases referred for coronary angiography. Unlike MI with obstructive coronary artery disease, MINOCA's pathogenesis is more intricate and heterogeneous, involving mechanisms such as coronary thromboembolism, coronary vasospasm, microvascular dysfunction, dissection, or plaque rupture. Diagnosing MINOCA presents challenges and includes invasive and non-invasive strategies aiming to differentiate it from alternative diagnoses and confirm the criteria of elevated cardiac biomarkers, non-obstructive coronary arteries, and the absence of alternate explanations for the acute presentation. Tailored management strategies for MINOCA hinge on identifying the underlying cause of the infarction, necessitating systematic diagnostic approaches. Furthermore, determining the optimal post-MINOCA medication regimen remains uncertain. This review aims to comprehensively address the current state of knowledge, encompassing diagnostic and therapeutic approaches, in the context of MINOCA while also highlighting the evolving landscape and future directions for advancing our understanding and management of this intricate myocardial infarction subtype.

Oral anticoagulation challenges and therapeutic dilemmas in the very elderly: to treat and how to treat octogenarians and nonagenarians?

The proportion of very elderly patients, namely octogenarians and nonagenarians, is expected to rise substantially over the next decades. This population is more prone to age‑dependent diseases associated with higher thromboembolic and bleeding risks. The very elderly are under‑represented in oral anticoagulation (OAC) clinical trials. However, real‑world evidence is accumulating, in parallel with an increase in OAC coverage in this patient group. OAC treatment seems to be more beneficial in the oldest age spectrum. Direct oral anticoagulants (DOACs) have the dominant market share in most clinical scenarios necessitating OAC treatment, proving at least as safe and effective as conventional vitamin K antagonists. Dose adjustments due to age or renal function often need to be made in DOAC‑treated very elderly patients. When prescribing OAC in this population, an individualized, yet holistic, approach accounting for comorbidities, comedications, altered physiological function, pharmacovigilance, frailty, compliance, and risk of falls is useful. However, given the limited randomized‑level evidence on OAC treatment in the very elderly, there are still pending questions. This review will discuss recent evidence, important practical aspects, and future directions for anticoagulation treatment in atrial fibrillation, venous thromboembolism, and peripheral artery disease in octogenarians and nonagenarians.

Cardioselective versus Non-Cardioselective Beta-Blockers and Outcomes in Patients with Atrial Fibrillation and Chronic Obstructive Pulmonary Disease

Background: Atrial fibrillation (AF) and chronic obstructive pulmonary disease (COPD) have been independently associated with increased mortality; however, there is no evidence regarding beta-blocker cardioselectivity and long-term outcomes in patients with AF and concurrent COPD. Methods: This post hoc analysis of the MISOAC-AF randomized trial (NCT02941978) included patients hospitalized with comorbid AF. At discharge, all patients were classified according to the presence of COPD; patients with COPD on beta-blockers were classified according to beta-blocker cardioselectivity. Adjusted hazard ratios (aHRs) were calculated by using multivariable Cox regression models. The primary outcome was all-cause mortality, and the secondary outcomes were cardiovascular mortality and hospitalizations. Results: Of 1103 patients with AF, 145 (13%) had comorbid COPD. Comorbid COPD was associated with an increased risk of all-cause (aHR, 1.33; 95% confidence interval (CI), 1.02 to 1.73) and cardiovascular mortality (aHR 1.47; 95% CI, 1.10 to 1.99), but not with increased risk of hospitalizations (aHR 1.10; 95% CI, 0.82 to 1.48). The use of cardioselective versus non-cardioselective beta-blockers was associated with similar all-cause mortality (aHR 1.10; 95% CI, 0.63 to 1.94), cardiovascular mortality (aHR 1.33; 95% CI, 0.71 to 2.51), and hospitalizations (aHR 1.65; 95% CI 0.80 to 3.38). Conclusions: In recently hospitalized patients with AF, the presence of COPD was independently associated with increased risk of all-cause and cardiovascular mortality. No difference between cardioselective and non-cardioselective beta-blockers, regarding clinical outcomes, was identified.

A Systematic Review and Meta-Analysis of Basal and Post-Stress Circulating Cortisol Concentration in an Important Marine Aquaculture Fish Species, European Sea Bass, Dicentrarchus labrax

BACKGROUND

European sea bass is a species characterized by high and dispersed cortisol levels. The aim of the present study was to analyze all published data on basal and post-acute stress cortisol levels in this species.

METHODS

For this systematic review and meta-analysis the Web of Science and Scopus databases were searched for papers reporting plasma or serum cortisol levels in E. sea bass, without language or date restrictions. Data were extracted directly for the reported results and were analyzed separately for basal and post-acute stress levels, as well their standardized mean differences (SMD) using random-effects meta-analyses.

RESULTS

Of 407 unique records identified, 69 were eligible. Basal cortisol levels had a pooled effect of 88.7 ng mL^-1 (n = 57), while post-acute stress levels were 385.9 ng mL^-1 (n = 34). The average SMD between basal and post-stress was calculated to be 3.02 (n = 22). All analyses had a high between-study heterogeneity. Results for basal and post-stress levels were affected by the assay type and anesthesia prior to blood sampling.

CONCLUSIONS

Cortisol levels in E. sea bass are higher than most studied fish species and display large heterogeneity. Application of stress led to elevated cortisol levels in all studies examined. In all cases, sources of between-studies heterogeneity were identified.

Artificial intelligence-based mining of electronic health record data to accelerate the digital transformation of the national cardiovascular ecosystem: design protocol of the CardioMining study

INTRODUCTION

Mining of electronic health record (EHRs) data is increasingly being implemented all over the world but mainly focuses on structured data. The capabilities of artificial intelligence (AI) could reverse the underusage of unstructured EHR data and enhance the quality of medical research and clinical care. This study aims to develop an AI-based model to transform unstructured EHR data into an organised, interpretable dataset and form a national dataset of cardiac patients.

METHODS AND ANALYSIS

CardioMining is a retrospective, multicentre study based on large, longitudinal data obtained from unstructured EHRs of the largest tertiary hospitals in Greece. Demographics, hospital administrative data, medical history, medications, laboratory examinations, imaging reports, therapeutic interventions, in-hospital management and postdischarge instructions will be collected, coupled with structured prognostic data from the National Institute of Health. The target number of included patients is 100 000. Natural language processing techniques will facilitate data mining from the unstructured EHRs. The accuracy of the automated model will be compared with the manual data extraction by study investigators. Machine learning tools will provide data analytics. CardioMining aims to cultivate the digital transformation of the national cardiovascular system and fill the gap in medical recording and big data analysis using validated AI techniques.

ETHICS AND DISSEMINATION

This study will be conducted in keeping with the International Conference on Harmonisation Good Clinical Practice guidelines, the Declaration of Helsinki, the Data Protection Code of the European Data Protection Authority and the European General Data Protection Regulation. The Research Ethics Committee of the Aristotle University of Thessaloniki and Scientific and Ethics Council of the AHEPA University Hospital have approved this study. Study findings will be disseminated through peer-reviewed medical journals and international conferences. International collaborations with other cardiovascular registries will be attempted.

TRIAL REGISTRATION NUMBER

NCT05176769.

First-in-man transradial percutaneous closure of ventricular septal defect with an Amplatzer Duct Occluder IΙ in an adult patient: a case report

Background

Transcatheter closure of perimembranous ventricular septal defect (VSD) is a promising alternative to surgical closure but has been associated with conduction disorders. Vascular access via multiple large vessels is associated with procedure-related complications, undermining the benefit of percutaneous approaches. In this case, we present the first-in-man transcatheter closure of a perimembranous VSD with an Amplatzer Duct Occluder IΙ in an adult patient via a single transradial artery access.

Case summary

A 62-year-old female was admitted to the hospital due to gradually worsening fatigue and shortness of breath on exertion. Transoesophageal echocardiogram (TOE) revealed a VSD size of 4-6 mm and a left ventricular ampulla size of 12 mm. A percutaneous VSD closure with the Amplatzer Duct Occluder II was decided. The angiography and TOE showed successful device placement and excellent procedural results. The patient was discharged home the next day after the procedure. The patient did not report any post-procedural complications during the 8-month follow-up. Echocardiographic assessment showed a gradual decrease in left ventricular dimensions.

Discussion

Transcatheter closure of perimembranous VSD is a promising alternative to surgical closure, but it is not free of complications. Traditional VSD occluders rely on multivessel access and complex formation of arteriovenous loops. In this case, we report the feasibility of perimembranous VSD closure with an Amplatzer Duct Occluder IΙ via a single radial artery access in an adult patient. This approach is a much simpler technique with several potential advantages and should be considered in selected adult patients and in similar clinical scenarios.

Prognostic implications of adherence to oral anticoagulants among patients with atrial fibrillation: Insights from MISOAC-AF trial

OBJECTIVES

To explore the implications of adherence to oral anticoagulants (OACs) on all-cause mortality and cardiovascular outcomes in patients with atrial fibrillation (AF).

METHODS

This post-hoc analysis of the MISOAC-AF trial included recently hospitalized patients with AF. Adherence to OACs was assessed by the proportion of days covered (PDC). Good adherence was defined as PDC >80 %. Cox regression models were used to associate PDC with clinical outcomes of all-cause death, cardiovascular death (CVD), stroke, and bleeding. A sub-analysis was performed among adherent patients to compare outcomes between vitamin K antagonists (VKAs) and direct oral anticoagulants (DOACs).

RESULTS

During a median 31-month follow-up, 778 cardiac patients with comorbid AF who had been prescribed OACs upon hospital discharge were studied. The mean PDC was 0.78; 66 % of patients had good adherence (>80 %) which was associated with lower risk of all-cause death [adjusted hazard ratio (aHR): 0.64; 95 % confidence interval (CI): 0.46 to 0.84, p < 0.001] and CVD (aHR: 0.70; 95 % CI: 0.50 to 0.97, p = 0.03). The risk of stroke and major or non-major bleeding did not differ by adherence status. Among adherent patients to OACs, VKA use was associated with higher rates of all-cause death (p < 0.001), CVD (p < 0.001), and stroke (p = 0.01); no differences were found regarding major or non-major bleeding risk.

CONCLUSIONS

In recently hospitalized patients with AF, good adherence to OACs was associated with a reduced risk of all-cause death and CVD. The rates of stroke or bleeding events were not significantly different. VKAs were associated with more adverse events compared to DOACs.

Fish Scales Produce Cortisol upon Stimulation with ACTH

Cortisol concentration in fish scales is a novel and reliable indicator of chronic stress. However, until now cortisol in scales has been considered to be accumulated through the circulation and it has not yet been studied whether it can be de novo produced from cells found in the scales. In the current study, scales of European sea bass, Dicentrarchus labrax, were stimulated in-vitro with a range of concentrations of adrenocorticotropic hormone (ACTH) to investigate if they can produce and release cortisol. Moreover, scales were exposed to a combination of ACTH and metyrapone, an inhibitor of cortisol production, to examine whether cortisol was actually produced in the scales. Results from ACTH administration showed that scales increased their cortisol release in a dose-dependent manner. This effect was reversed when scales were co-incubated with ACTH and metyrapone, indicating that cortisol was produced de novo and not released only upon stimulation with ACTH.

Prognostic impact of secondary prevention medical therapy following myocardial infarction with non-obstructive coronary arteries: a Bayesian and frequentist meta-analysis

AIMS

Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a clinical entity with several causes and pathophysiologic mechanisms. Secondary prevention with medical therapy used in patients with obstructive coronary artery disease has unclear benefits in MINOCA patients.

METHODS AND RESULTS

A literature search was conducted until 8 March 2022. Random-effect frequentist and hierarchical Bayesian meta-analyses were performed to assess the clinical impact of medical therapy [renin-angiotensin-aldosterone system (RAAS) inhibitors, statins, dual antiplatelet therapy (DAPT), β-blockers] in MINOCA patients. Outcomes of interest were all-cause mortality and major adverse cardiovascular events (MACE). A total of 12 663 MINOCA patients among five observational studies were analysed. The mean follow-up ranged from 12 to 90 months across studies. In frequentist meta-analysis, statins and β-blockers were associated with a lower risk of all-cause mortality [pooled adjusted hazard ratios (aHRs) 0.53 and 0.81, with 95% confidence intervals (CIs) (0.37-0.76) and (0.67-0.97), respectively]. Only RAAS inhibitors were associated with a lower risk of MACE [pooled aHR: 0.69, with 95% CI (0.53-0.90)]. Bayesian meta-analysis based on informative prior assumptions offered strong evidence only for the benefit of statins on decreasing the risk of all-cause death [Bayes factor (BF): 33.2] and moderate evidence for the benefit of RAAS inhibitors on decreasing the risk of MACE (BF: 9); assigning less informative prior distributions did not affect the results, yet it downgraded the level of evidence to anecdotal.

CONCLUSION

In this meta-analysis, statins and RAAS inhibitors were consistently associated with a lower risk of all-cause mortality and MACE, respectively, in patients with MINOCA. Neutral prognostic evidence was demonstrated for β-blockers and DAPT.

Prognostic impact of secondary prevention treatment following myocardial infarction with non-obstructive coronary arteries: Bayesian versus frequentist meta-analysis

Background

Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a clinical entity with a plethora of causes and pathophysiologic mechanisms. Traditional secondary prevention medications may not offer benefit for patients with MINOCA, calling into question the routine use of such therapies in this population.

Material and methods

Literature search was conducted in MEDLINE (PubMed), Scopus by ELSEVIER and Cochrane Central Register of Controlled Trials (CENTRAL) databases until 08 March 2022. Random-effects frequentist and hierarchical Bayesian meta-analyses were performed to assess the prognostic impact of secondary prevention medications (β-blockers, RAAS inhibitors, statins, DAPT, ASA and P2Y12 inhibitors) on the occurrence of major adverse cardiovascular events (MACE) and all-cause mortality in MINOCA patients. Sensitivity analyses accounted for the effect of: i. small sample size, ii. limited study follow-up period, and iii. different ethnicity.

Results

Of 2,569 articles initially retrieved, 9 observational studies were deemed eligible for this analysis, encompassing a total of 14,003 patients suffering from MINOCA (mean follow-up range from 6 to 90 months, mean age = 64.9±10.4 years).Administration of ASA, DAPT and P2Y12 inhibitors was not significantly linked with MACE [pooled adjusted hazard ratios (aHRs) = 0.94, 0.88, and 0.97, with 95% confidence intervals (CIs): 0.56–1.59, 0.47–1.65, and 0.562–1.53, respectively]. RAAS inhibitors and statins were independently associated with lower risk of MACE (pooled aHRs = 0.61 and 0.55 with 95% Cis: 0.46–0.82, and 0.34–0.90, respectively) and all-cause mortality (pooled aHRs = 0.58 and 0.55 with 95% Cis: 0.37–0.91, and 0.43–0.72, respectively). B-blockers were associated with significantly lower risk of all-cause death according to the frequentist analysis (pooled aHR = 0.80, 95% CI: 0.67–0.96) and with non-significantly lower risk of MACE (pooled aHR = 0.81, 95% CI: 0.65–1.01) [Figure 1]. The results deriving from the Bayesian analyses were generally consistent with the frequentist analyses, with the exceptions of the Bayesian analyses on statin and β-blocker effects, which were affected by the pre-test probabilities set herein [Figure 2]. The overall heterogeneity observed in our analyses was relatively small, and there was not substantial publication bias. Furthermore, the performed sensitivity analyses supported the robustness of the observed outcomes.

Conclusion

In this meta-analysis, it appeared that predominantly RAAS inhibitors and statins across secondary prevention medications were consistently associated with lower risk of MACE or all-cause death during the follow-up period of patients that experienced MINOCA.

Funding Acknowledgement

Type of funding sources: None.

Clinical impact of peri-device leaks following percutaneous left atrial appendage occlusion: a systematic review and meta-analysis

Background

Peri-device leaks (PDL) are quite common after left-atrial appendage occlusion (LAAO) given the complex anatomy of LAA and surrounding structures. However, there is uncertainty regarding the prognostic implications of PDL.

Material and methods

Literature search was conducted in MEDLINE (PubMed), EMBASE, Scopus by ELSEVIER and Cochrane Central Register of Controlled Trials (CENTRAL) databases until 12 October 2021. A random-effects meta-analysis was performed to assess the effect of PDL presence on thromboembolism, all-cause mortality and major bleeding occurrence. Sensitivity analyses accounted for: i. the combined AF ablation performance, ii. the anticoagulation strategy followed after LAAO, iii. mean PDL size, and iv. mean female percentage.

Results

Of 699 articles initially retrieved, 46 were deemed eligible for this analysis (9,184 AF patients undergoing LAAO out of whom 1,446 had PDL). PDL presence was significantly associated with elevated odds of thromboembolism (FIgure 1) [pooled odds ratio (pOR) 3.05, 95% confidence interval (CI) 1.94–4.81; I2=37%]; yet PDL was not significantly linked with mortality (pOR=0.86, 95% CI: 0.25–2.95; I2=69%) and major bleeding rates (0.95, 95% CI: 0.27–3.35; I2=72%). AF-ablation did not significantly interact with the prognostic impact of PDL when performed in conjunction with LAAO (p for subgroup= 0.17). Antiplatelet discharge medication affected the prognostic value of PDL (p for subgroup &lt;0.01 and =0.04, respectively). The prognostic significance of mean PDL size [peri-procedural or at 1–3 months or D(mean size)/D(time of follow-up)] on the risk of thromboembolism did not yield any significant association (p values &gt;0.05). Meta-regression analysis of the mean female percentage demonstrated a non-significant trend towards a positive linear correlation between female percentage and risk of thromboembolism (p=0.10) (FIgure 2).

Conclusions

This is the first meta-analysis on the prognostic impact of PDL after LAAO. The findings highlighted a significant association between PDL and thromboembolic events, warranting careful post-LAAO device surveillance.

Funding Acknowledgement

Type of funding sources: None.

Risk of arterial thromboembolism in patients with concomitant atrial fibrillation and cancer: a systematic review and meta-analysis

Background/Introduction

Atrial fibrillation (AF) and cancer often co-exist and have been independently associated with increased risk of arterial thromboembolism (TE), all cause death and bleeding; however, no cumulative data exist regarding the clinical course of AF patients with comorbid cancer.

Purpose

The aim of this systematic review and meta-analysis is to synthesize the available data regarding the incidence of major adverse cardiovascular events in AF patients in association with concurrent cancer.

Methods

The composite outcome of any TE (ischemic stroke, transient ischemic attack, or arterial thrombosis) was defined as the primary study outcome, while all-cause mortality and major or clinically relevant non-major bleeding occurrence as the secondary ones. Literature search was conducted in PubMed (MEDLINE), WebOfScience, Scopus, CENTRAL, OpenGrey, and EThOS databases. A random-effects model meta-analysis was performed. Subgroup analyses were conducted assessing the effect of active cancer history and various cancer subtypes on the outcomes of interest. Meta-regression analyses were also performed to examine the relative impact of CHA2DS2VASC and HASBLED prognostic scores on the risk of TE and bleeding, respectively.

Results

Overall 17 studies were included in our analysis, encompassing a total of 3,151,861 AF patients. Comorbid cancer was non-significantly associated with lower odds of TE than AF alone (pooled odds ratio (pOR) = 0.85, 95% confidence interval (CI): 0.69–1.03, I2=87%). The likelihood for all-cause death and bleeding occurrence was significantly higher in AF patients with cancer (pOR = 2.27, 95% CI: 1.69–3.06, I2=99%); pOR = 1.58, 95% CI: 1.26–1.97, I2=97% respectively) compared to those without cancer. Subgroup analysis on active cancer status did not yield any substantial difference, marginally improving the heterogeneity of our analysis. The highest all-cause mortality likelihood was observed in Liver-Pancreas-Gallbladder category (pOR = 10.58, 95% CI: 4.69–23.88, I2=98%) while the highest bleeding likelihood was encountered in Genitourinary cancer (pOR = 1.90, 95% CI: 1.42–2.55, I2=71.9%). The performed meta-regression analyses did not yield any significant results.

Conclusions

Our meta-analysis of 17 eligible studies demonstrated that cancer does not seem to be associated with increased risk of TE, while with increased all-cause death and bleeding occurrence in AF patients. This correlation might be explained by higher cancer-driven mortality rates (competing risk), many cases of TE being left undiagnosed within the scope of palliative cancer care, misdiagnosed episodes of TE due to the presence of brain metastases, optimal cardio-oncology monitoring, and more frequent usage of prophylactic anticoagulation treatment for cancer-associated venous thromboembolism. Nonetheless, further competing-risk survival analyses are warranted before reaching definite conclusions.

Funding Acknowledgement

Type of funding sources: None.

The role of cardiac computed tomography in predicting adverse coronary events

Cardiac computed tomography (CCT) is now considered a first-line diagnostic test for suspected coronary artery disease (CAD) providing a non-invasive, qualitative, and quantitative assessment of the coronary arteries and pericoronary regions. CCT assesses vascular calcification and coronary lumen narrowing, measures total plaque burden, identifies plaque composition and high-risk plaque features and can even assist with hemodynamic evaluation of coronary lesions. Recent research focuses on computing coronary endothelial shear stress, a potent modulator in the development and progression of atherosclerosis, as well as differentiating an inflammatory from a non-inflammatory pericoronary artery environment using the simple measurement of pericoronary fat attenuation index. In the present review, we discuss the role of the above in the diagnosis of coronary atherosclerosis and the prediction of adverse cardiovascular events. Additionally, we review the current limitations of cardiac computed tomography as an imaging modality and highlight how rapid technological advancements can boost its capacity in predicting cardiovascular risk and guiding clinical decision-making.

Renal function and mortality in patients with atrial fibrillation

AIM

The aim of this study is to examine the association of the presence of chronic kidney disease (CKD) and estimated glomerular filtration rate (eGFR) values with mortality in patients with atrial fibrillation.

METHODS

This posthoc analysis of a randomized controlled trial consisted of hospitalized patients with atrial fibrillation who were followed up for a median of 2.7 years after discharge. Kaplan-Meier curves, multivariate Cox-regression and spline curves were utilized to assess the association of CKD, CKD stages 2-5 according to the KDOQI guidelines, and the continuum of eGFR values with the primary outcome of all-cause death, and the secondary outcome of cardiovascular mortality.

RESULTS

Out of 1064 hospitalized patients with atrial fibrillation, 465 (43.7%) had comorbid CKD. The presence of CKD was associated with an increased risk for both all-cause and cardiovascular mortality following hospitalization [adjusted hazard ratio (aHR): 1.60; 95% confidence intervals (95% CIs): 1.25-2.05 and aHR: 1.74; 95% CI: 1.30-2.33, respectively]. The aHRs for all-cause mortality in CKD stages 2-5, as compared with CKD stage 1 were 2.18, 2.62, 4.20 and 3.38, respectively (all P < 0.05). In spline curve analyses, eGFR values lower than 50 ml/min/1.73 m2 were independent predictors of higher all-cause and cardiovascular mortality.

CONCLUSION

In recently hospitalized patients with atrial fibrillation, the presence of CKD was independently associated with decreased survival, which was significant across CKD stages 2-5, as compared with CKD stage 1. Values of eGFR lower than 50 ml/min/1.73 m2 were incrementally associated with worse prognosis.

Glycemic control and atrial fibrillation: an intricate relationship, yet under investigation

Atrial fibrillation (AF) and diabetes mellitus (DM) constitute two major closely inter-related chronic cardiovascular disorders whose concurrent prevalence rates are steadily increasing. Although, the pathogenic mechanisms behind the AF and DM comorbidity are still vague, it is now clear that DM precipitates AF occurrence. DM also affects the clinical course of established AF; it is associated with significant increase in the incidence of stroke, AF recurrence, and cardiovascular mortality. The impact of DM on AF management and prognosis has been adequately investigated. However, evidence on the relative impact of glycemic control using glycated hemoglobin levels is scarce. This review assesses up-to-date literature on the association between DM and AF. It also highlights the usefulness of glycated hemoglobin measurement for the prediction of AF and AF-related adverse events. Additionally, this review evaluates current anti-hyperglycemic treatment in the context of AF, and discusses AF-related decision-making in comorbid DM. Finally, it quotes significant remaining questions and sets some future strategies with the potential to effectively deal with this prevalent comorbidity.

Role of cardiac CT in the diagnostic evaluation and risk stratification of patients with myocardial infarction and non-obstructive coronary arteries (MINOCA): rationale and design of the MINOCA-GR study

INTRODUCTION

Myocardial infarction with non-obstructive coronary arteries (MINOCA) occurs in 5%-15% of all patients with acute myocardial infarction. Cardiac MR (CMR) and optical coherence tomography have been used to identify the underlying pathophysiological mechanism in MINOCA. The role of cardiac CT angiography (CCTA) in patients with MINOCA, however, has not been well studied so far. CCTA can be used to assess atherosclerotic plaque volume, vulnerable plaque characteristics as well as pericoronary fat tissue attenuation, which has not been yet studied in MINOCA.

METHODS AND ANALYSIS

MINOCA-GR is a prospective, multicentre, observational cohort study based on a national registry that will use CCTA in combination with CMR and invasive coronary angiography (ICA) to evaluate the extent and characteristics of coronary atherosclerosis and its correlation with pericoronary fat attenuation in patients with MINOCA. A total of 60 consecutive adult patients across 4 participating study sites are expected to be enrolled. Following ICA and CMR, patients will undergo CCTA during index hospitalisation. The primary endpoints are quantification of extent and severity of coronary atherosclerosis, description of high-risk plaque features and attenuation profiling of pericoronary fat tissue around all three major epicardial coronary arteries in relation to CMR. Follow-up CCTA for the evaluation of changes in pericoronary fat attenuation will also be performed. MINOCA-GR aims to be the first study to explore the role of CCTA in combination with CMR and ICA in the underlying pathophysiological mechanisms and assisting in diagnostic evaluation and prognosis of patients with MINOCA.

ETHICS AND DISSEMINATION

The study protocol has been approved by the institutional review board/independent ethics committee at each site prior to study commencement. All patients will provide written informed consent. Results will be disseminated at national meetings and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT4186676.

Associations of Atrial Fibrillation Patterns With Mortality and Cardiovascular Events: Implications of the MISOAC-AF Trial

AIM

This retrospective cohort study aimed to evaluate the prognostic implications of the distinct atrial fibrillation (AF) temporal patterns: first diagnosed, paroxysmal, and persistent or permanent AF.

METHODS

In this post hoc analysis of the MISOAC-AF trial (NCT02941978), a total of 1052 patients with AF (median age 76 years), discharged from the cardiology ward between 2015 and 2018, were analyzed. Kaplan-Meier and Cox-regression analyses were performed to compare the primary outcome of all-cause mortality, the secondary outcomes of stroke, major bleeding and the composite outcome of cardiovascular (CV) mortality or hospitalization among AF patterns.

RESULTS

Of patients, 121 (11.2%) had first diagnosed, 356 (33%) paroxysmal, and 575 (53.2%) persistent or permanent AF. During a median follow-up of 31 months (interquartile range 10 to 52 months), 37.3% of patients died. Compared with paroxysmal AF, patients with persistent or permanent AF had higher mortality rates (adjusted hazard ratio (aHR), 1.37; 95% confidence interval [CI], 1.08-1.74, P = .009), but similar CV mortality or hospitalization rates (aHR, 1.09; 95% CI, 0.91-1.31, P = .35). Compared with first diagnosed AF, patients with persistent or permanent AF had similar mortality (aHR, 1.26; 95% CI, 0.87-1.82, P = .24), but higher CV mortality or hospitalization rates (aHR, 1.35; 95% CI, 1.01-1.8, P = .04). Stroke and major bleeding events did not differ across AF patterns (all P > .05).

CONCLUSIONS

In conclusion, in recently hospitalized patients with comorbid AF, the presence of persistent or permanent AF was associated with a higher incidence of mortality and morbidity compared with paroxysmal and first diagnosed AF.

Prognostic implications of valvular heart disease in patients with non-valvular atrial fibrillation

Background

Atrial fibrillation (AF) and valvular heart disease (VHD) are frequently encountered in clinical practice, and often coexist, especially in the elderly population. Both conditions are associated with increased mortality and morbidity. Recent guidelines suggest careful evaluation of patients with AF and VHD due to the puzzling nature of their coexistence.

Purpose

To evaluate the prognostic effect of significant valvular heart disease (sVHD) among patients with non-valvular AF.

Methods

This is a post-hoc analysis of the MISOAC-AF trial (NCT02941978). Consecutive inpatients with non-valvular AF who underwent echocardiography were included. sVHD was defined as the presence of at least moderate aortic stenosis (AS) or aortic/mitral/tricuspid regurgitation (AR/MR/TR). Cox regression analyses with covariate adjustments were used for outcome prediction.

Results

In total, 983 patients with non-valvular AF (median age 76 years) were analyzed over a median follow-up period of 32 months. sVHD was diagnosed in 575 (58.5%) AF patients. sVHD was associated with all-cause mortality (21.6%/yr vs. 1.6%/yr; adjusted HR [aHR] 1.55, 95% confidence interval [CI] 1.17–2.06; p=0.02), cardiovascular mortality (16%/yr vs. 4%/yr; aHR1.70, 95% CI 1.09–2.66; p=0.02) and heart failure-hospitalization (5.8%/yr vs. 1.8%/yr; aHR 2.53, 95% CI 1.35–4.63; p=0.02). The prognostic effect of sVHD was particularly evident in patients aged &lt;80 years and in those without history of heart failure (p for interaction &lt;0.05, in both subgroups) [Figure 1]. After multivariable adjustment, moderate/severe AS and TR were associated with mortality, while AS and MR with heart failure-hospitalization [Figure 2]. AS was the only independent predictor of valve intervention during follow-up (aHR 10.78, 95% CI 4.80–24.22; p&lt;0.001). Mixed aortic valve disease (AS+AR) had superior prognostic power across patterns of combined VHD.

Conclusions

Among patients with non-valvular AF, sVHD was highly prevalent, and beared high prognostic value across a wide spectrum of clinical outcomes. AS, MR, TR and mixed aortic valve disease were associated with worse prognosis.

Funding Acknowledgement

Type of funding sources: None. Subgroup analyses by VHD statusPrognostic impact of valve lesions

Indications for percutaneous left atrial appendage occlusion in hospitalized patients with atrial fibrillation

AIMS

Percutaneous left atrial appendage occlusion (LAAO) is an alternative nonpharmacological therapeutic option for stroke prevention in patients with NVAF. However, no data exist on potential LAAO candidates' prevalence among 'real-world' NVAF patients. This study aimed to investigate the indications for LAAO in hospitalized patients with comorbid nonvalvular atrial fibrillation (NVAF).

METHODS

This is a post-hoc analysis of the MISOAC-AF (Motivational Interviewing to Support OAC-AF, ClinicalTrials.gov: NCT02941978), randomized controlled trial, which enrolled NVAF patients hospitalized for any reason in a tertiary cardiology department. In this analysis, patients with a history of major bleeding or stroke under OAC therapy were considered to have a strong indication for LAAO.

RESULTS

A total of 980 patients with NVAF were studied (mean age 73.9 ± 10.9 years, 54.7% men). Prior major bleeding occurred in 134 (13.7%) patients (intracranial bleeding in 1%, upper and lower gastrointestinal bleeding in 6.4 and 8.9%, respectively). A total of 58 (5.9%) patients experienced an embolic stroke while being treated using OAC. Overall, either of these events was prevalent in 173 (17.7%) patients, denoting a strong indication for LAAO.

CONCLUSION

Almost one out of six patients hospitalized with comorbid NVAF may be considered eligible for percutaneous LAAO for stroke prevention.Trial Identification: NCT02941978, https://clinicaltrials.gov/ct2/show/NCT02941978.

Oral anticoagulation patterns and prognosis in octogenarian patients with atrial fibrillation

The relationship between oral anticoagulants (OACs) and prognosis in elderly patients with atrial fibrillation (AF) has not been adequately explored. In this retrospective cohort study, we identified subjects aged over 80 from a database of 1140 AF patients discharged from the cardiology ward of a single tertiary center between 2015 and 2018. We examined the OAC treatment of octogenarian patients at discharge [VKA (vitamin K antagonist), NOAC (non-vitamin K antagonist oral anticoagulant), no OAC treatment]. We analyzed follow-up data of patients on OAC at discharge. The primary endpoint was all-cause death. The secondary endpoint was the incidence of stroke and major bleeding. The association of NOAC versus VKA treatment with these endpoints was assessed with multivariable Cox regression, using the VKA group as reference. A total of 330 octogenarian patients with AF were included with a mean (± SD) age of 83.9 ± 3.5 years. At discharge, 53.3% received a NOAC, 30% a VKA, and 16.7% no OAC. Patients on OAC were followed-up over a median of 2.6-years . The adjusted risk of all-cause death was not different in the NOAC group, compared with the VKA group (hazard ratio [HR], 0.72; 95% confidence intervals [CI] 0.50-1.03; P = 0.07). The risk of stroke or major bleeding was not different either (all P > 0.05). In conclusion, in this cohort of post-discharge octogenarian patients with AF, the risk for all-cause death was similar in NOAC versus VKA users, after adjustment for baseline covariates. No differences in stroke and major bleeding events among these treatment groups were revealed.

Prognostic implications of valvular heart disease in patients with non-valvular atrial fibrillation

Background

Valvular heart disease (VHD) in non-valvular atrial fibrillation (AF) is a puzzling clinical entity. The aim of this study was to evaluate the prognostic effect of significant VHD (sVHD) among patients with non-valvular AF.

Methods

This is a post-hoc analysis of the MISOAC-AF trial (NCT02941978). Consecutive inpatients with non-valvular AF who underwent echocardiography were included. sVHD was defined as the presence of at least moderate aortic stenosis (AS) or aortic/mitral/tricuspid regurgitation (AR/MR/TR). Cox regression analyses with covariate adjustments were used for outcome prediction.

Results

In total, 983 patients with non-valvular AF (median age 76 [14] years) were analyzed over a median follow-up period of 32 [20] months. sVHD was diagnosed in 575 (58.5%) AF patients. sVHD was associated with all-cause mortality (21.6%/yr vs. 6.5%/yr; adjusted HR [aHR] 1.55, 95% confidence interval [CI] 1.17–2.06; p = 0.02), cardiovascular mortality (16%/yr vs. 4%/yr; aHR 1.70, 95% CI 1.09–2.66; p = 0.02) and heart failure-hospitalization (5.8%/yr vs. 1.8%/yr; aHR 2.53, 95% CI 1.35–4.63; p = 0.02). The prognostic effect of sVHD was particularly evident in patients aged < 80 years and in those without history of heart failure (p for interaction < 0.05, in both subgroups). After multivariable adjustment, moderate/severe AS and TR were associated with mortality, while AS and MR with heart failure-hospitalization.

Conclusion

Among patients with non-valvular AF, sVHD was highly prevalent and beared high prognostic value across a wide spectrum of clinical outcomes, especially in patients aged < 80 years or in the absence of heart failure. Predominantly AS, as well as MR and TR, were associated with worse prognosis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-021-02264-3.

Peridevice Leak Following Amplatzer Left Atrial Appendage Occlusion: Cardiac Computed Tomography Classification and Clinical Outcomes

OBJECTIVES

This study aimed to investigate cardiac computed tomography (CT) and transesophageal echocardiography (TEE) peridevice leak (PDL) assessments, and the clinical relevance of PDL.

BACKGROUND

PDL assessment is integral during follow-up after left atrial appendage (LAA) occlusion. Comparative studies of TEE and cardiac CT are sparse, and the clinical relevance of PDL is uncertain.

METHODS

This was a single-center observational study of consecutive patients undergoing LAA occlusion with Amplatzer devices (Amplatzer Cardiac Plug/Amulet) between 2010 and 2018 (N = 415). Patients with both 8-week CT and TEE were included for analysis (n = 346). Images were analyzed by blinded investigators (K.K. and A.S.). PDL on cardiac CT was classified from grade 1 to 3, based on PDL at the device disc, device lobe, and LAA contrast patency. Primary clinical outcome was a composite of ischemic stroke, transient ischemic attack, systemic embolism, or all-cause death.

RESULTS

PDL was present in 110 patients (32%) by TEE, with 29 (8%) >3 mm. By cardiac CT, 210 patients (61%) had PDL at the disc, with contrast patency in 204 patients (59%). A grade 3 PDL (gap at disc, lobe, and LAA contrast patency) was present in 63 patients (18%). Bland-Altman analysis showed poor agreement between CT and TEE for leak sizing. CT and TEE detected PDL was not significantly associated with worse outcome, hazard ratio: 1.82 (95 % confidence interval: 0.95 to 3.50); p = 0.07 and hazard ratio: 1.43 (95% confidence interval: 0.74 to 2.76); p = 0.28, respectively.

CONCLUSIONS

PDL occurrence is substantially higher with CT compared with TEE, with a large discrepancy between modalities in leak quantification. A novel CT-based classification is proposed, yet PDL was not associated with worse clinical outcome.

Comparative Analysis of Risk Stratification Scores in Atrial Fibrillation

BACKGROUND

Atrial Fibrillation (AF) has become a major global health concern and is associated with an increased risk of poor outcomes. Identifying risk factors in patients with AF can be challenging, given the high burden of comorbidities in these patients. Risk stratification schemes appear to facilitate accurate prediction of outcomes and assist therapeutic management decisions.

OBJECTIVE

To summarize current evidence on risk stratification scores for patients with AF.

RESULTS

Traditional risk models rely heavily on demographics and comorbidities, while newer tools have been gradually focusing on novel biomarkers and diagnostic imaging to facilitate more personalized risk assessment. Several studies have been conducted to compare existing risk schemes and identify specific patient populations in which the prognostic ability of each scheme excels. However, current guidelines do not appear to encourage the implementation of risk models in clinical practice, as they have not incorporated new ones in their recommendations for the management of patients with AF for almost a decade.

CONCLUSION

Further work is warranted to analyze new reliable risk stratification schemes and optimally implement them into routine clinical life.

Τhe association of heart failure across left ventricular ejection fraction with mortality in atrial fibrillation

Aims

The aim of this study is to investigate the prognostic implications of the presence of heart failure (HF) across the range of left ventricular ejection fraction (LVEF) in patients with comorbid atrial fibrillation (AF).

Methods and results

We conducted a retrospective cohort study of 1063 patients (median age 76 years), discharged from the cardiology ward with a primary or secondary diagnosis of AF between 2015 and 2018. We used Cox proportional‐hazards and spline models to examine the association of the presence of HF, across the range of LVEF, with the primary outcome of all‐cause mortality. HF was documented in 52.9% of patients at baseline. During a median follow‐up of 31 months (interquartile range 10 to 52 months), 37.3% of patients died. The presence of HF was associated with a significantly higher risk of mortality [adjusted hazard ratio (aHR) 2.17; 95% confidence interval (CI), 1.70 to 2.77; P < 0.001], which was evident across HF with reduced (aHR 3.03; 95% CI 2.41 to 4.52), mid‐range (aHR 2.08; 95% CI 1.47 to 2.94), and preserved LVEF (aHR 1.94; 95% CI 1.47 to 2.55). Among patients with HF, the spline curve depicted a non‐linear association between LVEF and the risk of death, in which there was a steep and progressive increase in mortality for every 5% reduction in LVEF below 25% (aHR 1.97, 95% CI 1.04 to 3.73, P = 0.04).

Conclusions

In patients with AF who were discharged from the hospital, the presence of HF at baseline was independently associated with a twofold risk of death, which was significant across LVEF‐classified HF subtypes. Among patients with AF and HF, the risk of death rose significantly as LVEF was reduced below 25%.

Left atrial appendage occlusion in chicken-wing anatomies: Imaging assessment, procedural, and clinical outcomes of the "sandwich technique"

OBJECTIVES

To describe imaging assessment, procedural and follow-up outcome of patients undergoing left atrial appendage (LAA) occlusion (LAAO) using a "sandwich" technique.

BACKGROUND

The presence of a LAA with chicken wing morphology constitutes a challenge that sometimes requires specific occlusion strategies like the "sandwich" technique. However, procedural and follow-up data focusing on this implanting strategy is scarce.

METHODS

This multicenter study collected individual data from eight centers between 2012 and 2019. Consecutive patients with chicken-wing LAAs defined as an early (<20 mm from the ostium) and severe bend (>90°) who underwent LAAO with Amplatzer devices and using the "sandwich" technique were included in the analysis.

RESULTS

Overall, 190 subjects were enrolled in the study. Procedures were done with the Amulet device (85%) and the Amplatzer Cardiac Plug (15%). Successful implantation was achieved in 99.5% with ≤1 partial recapture in 80% of cases. Single (46.2%) and dual antiplatelet therapy (39.4%) were the most used antithrombotic therapies after LAAO. In-hospital major adverse events rate was 1.5% with no deaths. One patient (0.5%) had cardiac tamponade requiring percutaneous drainage. With a mean follow-up of 19.6 ± 14.8 months, the mortality and stroke rates were 7.7%/year and 2.5%/year, respectively. Follow-up transesophageal echocardiography (TEE) at 2-3 months showed device-related thrombosis in 2.8% and peri-device leak ≥3 mm in 1.2% of patients.

CONCLUSIONS

In a large series of patients with chicken wing LAA anatomies undergoing LAAO, the use of the "sandwich" technique was feasible and safe. Preprocedural imaging was a key-factor to determine specific measurements.

Cardio-protective Effects of Glucagon-like Peptide-1 Receptor Agonists: An Overview of Systematic Reviews and Publication Overlap

BACKGROUND

Glucagon-like peptide-1 receptor agonists (GLP-1RAs) have emerged as a new antihyperglycemic class with the demonstrated advantage of reducing major adverse cardiovascular events (MACE) among individuals with type 2 diabetes (T2DM), atherosclerotic cardiovascular disease, or high cardiovascular risk.

OBJECTIVE

Τo summarize the evidence of systematic reviews (SRs) that assess MACE (cardiovascular mortality, nonfatal myocardial infarction, and stroke) and hospitalizations for heart failure in GLP-1RAs-treated patients and to evaluate possible overlap in pertinent SRs.

METHODS

We performed a comprehensive search via MEDLINE, Cochrane Library, and PROSPERO databases up to February 23, 2020, for SRs examining cardiovascular outcomes of GLP-1RAs in T2DM patients. Three independent authors extracted data and assessed the methodological quality of the included SRs using the ROBIS tool.

RESULTS

We found 37 SRs - published between 2009 and 2020 in English - of which 35 collected data only from randomized clinical trials while two from observational studies as well. The methodological quality of the 37 SRs ranged from low to high, while only 3 have evaluated the overall quality of evidence outcome using the Grading of Recommendations Assessments, Development and Evaluation (GRADE) approach. All the included SRs showed cardiovascular safety of GLP-1RAs while the latest ones demonstrated a reduction in composite MACE endpoint as well as its every individual component and heart failure hospitalizations.

CONCLUSION

In the first overview of SRs about cardiovascular outcomes of GLP-1RAs, they proved favorable effects on reducing cardiovascular events in T2DM patients. There are, however, many overlapping reviews based on relatively few cardiovascular outcomes trials.

Prognostic significance of diabetes mellitus in patients with atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

Background

Despite the plethora of studies on atrial fibrillation (AF) and diabetes mellitus (DM), there is still no sufficient data on the blood glucose regulation as a prognostic modifier in DM patients with AF.

Purpose

The purpose of this study was to investigate the association of DM and levels of glycated hemoglobin (HbA1c) with outcomes in patients with AF.

Methods

This retrospective cohort study included patients who were recently hospitalized with a primary or secondary diagnosis of AF from December 2015 through June 2018. Kaplan-Meier curves and Cox-regression adjusted hazard ratios (aHR) were calculated for the primary outcome of all-cause mortality and for the secondary outcomes of cardiovascular (CV) mortality, stroke and the composite outcome of CV death or hospitalization. Spline curve models were fitted to investigate associations of HbA1c values and mortality among patients with AF and DM.

Results

In total 1140 AF patients were included, of whom 373 (32.7%) had DM. During a median follow-up of 2.6 years, 414 (37.3%) patients died. The presence of DM was associated with a higher risk of all-cause mortality (aHR = 1.44, 95% confidence intervals [CI]: 1.12-1.85), CV mortality (aHR = 1.44, 95% CI: 1.08-1.93), stroke (aHR = 2.62, 95% CI: 1.24-5.53) and the composite outcome of hospitalization or CV death (aHR = 1.28, 95% CI: 1.06-1.54). In AF patients with comorbid DM, the spline curves showed a positive linear association between HbA1c levels and outcomes, with values &lt;6.2% predicting significantly decreased all-cause and CV mortality.

Conclusions

The presence of DM on top of AF was associated with a 1.5-fold increased risk for all-cause or CV mortality and excess morbidity. HbA1c levels lower than 6.2% were independently related to better survival rates. Follow-up outcomes by presence of DMOutcomeDMNon-DMAdjusted HR(95% CI)p-valueAll-cause death171/373 (45.8%)243/736 (33%)1.44 (1.12-1.85)&lt;0.001CV-death130/373 (34.9%)173/736 (23.5%)1.44 (1.08-1.93)&lt;0.001Major bleeding18/340 (5.3%)29/644 (4.5%)1.53 (0.71-3.28)0.291Stroke24/340 (7.1%)28/645 (4.3%)2.62 (1.24-5.53)0.013AF-related hospitalization59/340 (17.4%)115/645 (17.8%)1.20 (0.78-1.85)0.281HF-related hospitalization35/333 (10.5%)46/640 (7.2%)1.34 (0.83-2.19)0.235Hospitalization or CV-death243/373 (65.1%)399/736(54.2%)1.28 (1.06-1.54)&lt;0.001*Adjusted for: age, gender, smoking, BMI, history of hypertension, eGFR (CKD-EPI) and use of statin, ACEI-ARB, OAC and rate control medication after discharge.DM, diabetes mellitus; HR, hazard ratio; AF, atrial fibrillation; CV, cardiovascular; HF, heart failure.Abstract Figure. Visual overview of the study

Polypharmacy and major adverse events in atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

Background

Polypharmacy has been defined as the daily use of more than 4 drugs, by an individual, regardless of the condition(s) they have been prescribed for and their efficacy. The burden of polypharmacy pertains to adverse drug reactions, disability, frequent and longtime hospitalization and long-term mortality. The prevalence of polypharmacy exceeds 10% in most adult age groups and particularly in the elderly. At the same time, atrial fibrillation (AF) is the most prevalent sustained cardiac arrhythmia, afflicting more than 8% of the elderly and those with multiple comorbidities.

Purpose

The purpose of this study was to examine the association between the presence of polypharmacy and outcomes among AF patients.

Methods

This is a retrospective analysis among 1140 patients enrolled in the MISOAC-AF trial. All cause- and cardiovascular- mortality have been defined as primary endpoints. Independent clinical predictors of polypharmacy and of major adverse outcomes were identified via bootstrapped multivariate logistic and Cox regression analysis, respectively.

Results

The mean number of prescribed medications at patients’ discharge was 3.9 ± 1.6 and polypharmacy (use of more than 4 medications daily) was found in 36.9% of the patients. Smoking (p = 0.036), dyslipidemia (p &lt; 0.001), coronary artery disease (p &lt; 0.001), heart failure (HF; p = 0.003) and chronic kidney disease (p &lt; 0.001) were independent predictors of polypharmacy among AF paients. Kaplan–Meier survival analysis showed that AF patients with polypharmacy have significantly greater risk of CV death (p = 0.040), while Cox regression analysis indicated polypharmacy as an independent predictor for all-cause and CV- mortality [adjusted hazard ratios: 1.31(1.03 - 1.67) and 1.39(1.05 - 1.84), respectively] and for the composite outcome of AF- or HF- related hospitalization or CV death [adjusted hazard ratio: 1.31 (1.05 - 1.63)].

Conclusion

This study highlights the implications of polypharmacy in the context of AF, a prevalent, chronic, life-threatening condition. Investigating polypharmacy is quite relevant in the era of pharmacovigilance, contributing to rational pharmacotherapy with regard to cardiovascular conditions and beyond. Abstract Figure. Mortality rates by polypharmacy presence

Digoxin and association with mortality in patients discharged from hospital with atrial fibrillation, with or without heart failure

Funding Acknowledgements

Type of funding sources: None.

OnBehalf

MISOAC- AF study group

BACKGROUND

Digoxin is widely used in atrial fibrillation (AF) and heart failure (AF). However, established evidence is conflicting regarding its association with clinical outcomes.

AIM

To investigate the relation between digoxin and adverse outcomes in patients with AF, with or without HF, in a contemporary AF cohort.

METHODS

We performed a retrospective analysis of data from 698 patients, originating from the MISOAC- AF (Motivational Interviewing to Support Oral AntiCoagulation Adherence in patients with non-valvular Atrial Fibrillation) trial, and followed over a median of 2.5 years. HF was denoted at baseline. The primary outcome was all-cause mortality and the secondary outcome was all-cause hospitalization, in a time-to-event analysis. Propensity scores were used to derive matched populations, balanced on key baseline covariates. To limit potential confounding, we also implemented inverse probability of treatment weighting (IPTW) analysis.

RESULTS

Among patients with HF, 10.5% (n = 39) were administered digoxin at baseline, whereas 89.5% (n = 331) were not. Digoxin administration was not associated with an increased risk of death (hazard ratio (HR) in the digoxin group, 1.21; 95% Confidence Interval (CI), 0.69 to 2.13, p = 0.5) or hospitalization of any cause (HR 1.15; 95% CI, 0.67 to 1.96; p = 0.6). Among patients without HF, 3.5% (n = 11) were administered digoxin, with neutral effects on all-cause mortality (HR: 3.25; 95% CI, 0.98 to 10.70), p = 0.06) and all-cause hospitalization (HR, 1.15; 95% CI, 0.67 to 1.96, p = 0.60). Consistent qualitatively results were observed using IPTW.

CONCLUSIONS

Among patients with AF, digoxin administration was not associated with an increased risk of death and hospitalization of any cause, irrespective of HF status. Abstract Figure.

Prognostic significance of diabetes mellitus in patients with atrial fibrillation

Background

There are limited data on the association of diabetes mellitus (DM) and levels of glycated hemoglobin (HbA1c) with outcomes in patients with atrial fibrillation (AF).

Methods

This retrospective cohort study included patients who were recently hospitalized with a primary or secondary diagnosis of AF from December 2015 through June 2018. Kaplan–Meier curves and Cox-regression adjusted hazard ratios (aHR) were calculated for the primary outcome of all-cause mortality and for the secondary outcomes of cardiovascular (CV) mortality and the composite outcome of CV death or hospitalization. Competing-risk regression analyses were performed to calculate the cumulative risk of stroke, major bleeding, AF- or HF-hospitalizations adjusted for the competing risk of all-cause death. Spline curve models were fitted to investigate associations of HbA1c values and mortality among patients with AF and DM.

Results

In total 1109 AF patients were included, of whom 373 (33.6%) had DM. During a median follow-up of 2.6 years, 414 (37.3%) patients died. The presence of DM was associated with a higher risk of all-cause mortality (aHR = 1.40 95% confidence intervals [CI] 1.11–1.75), CV mortality (aHR = 1.39, 95% CI 1.07–1.81), sudden cardiac death (aHR = 1.73, 95% CI 1.19–2.52), stroke (aHR = 1.87, 95% CI 1.01–3.45) and the composite outcome of hospitalization or CV death (aHR = 1.27, 95% CI 1.06–1.53). In AF patients with comorbid DM, the spline curves showed a positive linear association between HbA1c levels and outcomes, with values 7.6–8.2% being independent predictors of increased all-cause mortality, and values < 6.2% predicting significantly decreased all-cause and CV mortality.

Conclusions

The presence of DM on top of AF was associated with substantially increased risk for all-cause or CV mortality, sudden cardiac death and excess morbidity. HbA1c levels lower than 6.2% were independently related to better survival rates suggesting that optimal DM control could be associated with better clinical outcomes in AF patients with DM.

Family-effects in the epigenomic response of red blood cells to a challenge test in the European sea bass (Dicentrarchus labrax, L.)

Abstract

Background

In fish, minimally invasive blood sampling is widely used to monitor physiological stress with blood plasma biomarkers. As fish blood cells are nucleated, they might be a source a potential new markers derived from ‘omics technologies. We modified the epiGBS (epiGenotyping By Sequencing) technique to explore changes in genome-wide cytosine methylation in the red blood cells (RBCs) of challenged European sea bass (Dicentrarchus labrax), a species widely studied in both natural and farmed environments.

Results

We retrieved 501,108,033 sequencing reads after trimming, with a mean mapping efficiency of 73.0% (unique best hits). Minor changes in RBC methylome appeared to manifest after the challenge test and a family-effect was detected. Only fifty-seven differentially methylated cytosines (DMCs) close to 51 distinct genes distributed on 17 of 24 linkage groups (LGs) were detected between RBCs of pre- and post-challenge individuals. Thirty-seven of these genes were previously reported as differentially expressed in the brain of zebrafish, most of them involved in stress coping differences. While further investigation remains necessary, few DMC-related genes associated to the Brain Derived Neurotrophic Factor, a protein that favors stress adaptation and fear memory, appear relevant to integrate a centrally produced stress response in RBCs.

Conclusion

Our modified epiGBS protocol was powerful to analyze patterns of cytosine methylation in RBCs of D. labrax and to evaluate the impact of a challenge using minimally invasive blood samples. This study is the first approximation to identify epigenetic biomarkers of exposure to stress in fish.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12864-021-07420-9.

A novel prognostic tool to predict mortality in patients with atrial fibrillation: The BASIC-AF risk score

BACKGROUND

This study sought to develop and validate a risk score to predict mortality in patients with atrial fibrillation (AF) after a hospitalization for cardiac reasons.

METHODS

The new risk score was derived from a prospective cohort of hospitalized patients with concurrent AF. The outcome measures were all-cause and cardiovascular mortality. Random forest was used for variable selection. A risk points model with predictor variables was developed by weighted Cox regression coefficients and was internally validated by bootstrapping.

RESULTS

In total, 1130 patients with AF were included. During a median follow-up of 2 years, 346 (30.6%) patients died and 250 patients had a cardiovascular cause of death. N-terminal pro-B-type natriuretic peptide and high-sensitivity troponin-T were the most important predictors of mortality, followed by indexed left atrial volume, history and type of heart failure, age, history of diabetes mellitus, and intraventricular conduction delay, all forming the BASIC-AF risk score (Biomarkers, Age, ultraSound, Intraventricular conduction delay, and Clinical history). The score had good discrimination for all-cause (c-index = 0.85 and 95% CI 0.82-0.88) and cardiovascular death (c-index = 0.84 and 95% CI 0.81-0.87). The predicted probability of mortality varied more than 50-fold across deciles and adjusted well to observed mortality rates. A decision curve analysis revealed a significant net benefit of using the BASIC-AF risk score to predict the risk of death, when compared with other existing risk schemes.

CONCLUSIONS

We developed and internally validated a well-performing novel risk score for predicting death in patients with AF. The BASIC-AF risk score included routinely assessed parameters, selected through machine-learning algorithms, and may assist in tailored risk stratification and management of these patients.

Mortality in patients with atrial fibrillation with or without heart failure following hospital discharge

Background

The association of heart failure (HF) with the prognosis of atrial fibrillation (AF) remains unclear.

OBJECTIVES

To assess all-cause mortality in patients following hospitalization with comorbid AF in relation to the presence of HF.

Methods

We performed a cross-sectional analysis of data from 977 patients discharged from the cardiology ward of a single tertiary center between 2015 and 2018 and followed for a median of 2 years. The association between HF and the primary endpoint of death from any cause was assessed using multivariable Cox regression.

Results

HF was documented in 505 (51.7%) of AF cases at discharge, including HFrEF (17.9%), HFmrEF (16.5%) and HFpEF (25.2%). A primary endpoint event occurred in 212 patients (42%) in the AF-HF group and in 86 patients (18.2%) in the AF-no HF group (adjusted hazard ratio [aHR] 2.27; 95% confidence interval [CI], 1.65 to 3.13; P&lt;0.001). HF was associated with a higher risk of the composite secondary endpoint of death from any cause, AF or HF-specific hospitalization (aHR 1.69; 95% CI 1.32 to 2.16 p&lt;0.001). The associations of HF with the primary and secondary endpoints were significant and similar for AF-HFrEF, AF-HFmrEF, AF-HFpEF.

Conclusions

HF was present in half of the patients discharged from the hospital with comorbid AF. The presence of HF on top of AF was independently associated with a significantly higher risk of all-cause mortality than did absence of HF, irrespective of HF subtype.

Funding Acknowledgement

Type of funding source: None

Motivational Interviewing to Support Oral AntiCoagulation adherence in patients with non-valvular Atrial Fibrillation (MISOAC-AF): a randomised clinical trial

Background

Oral anticoagulation (OAC) is paramount to effective thromboprophylaxis; yet adherence to OAC remains largely suboptimal in patients with atrial fibrillation (AF).

Purpose

We aimed to assess the impact of an educational, motivational intervention on the adherence to OAC in patients with non-valvular AF.

Methods

Hospitalised patients with non-valvular AF who received OAC were randomly assigned to usual medical care or a proactive intervention, comprising motivational interviewing and tailored counseling on medication adherence. The primary study outcome was adherence to OAC at 1-year, evaluated as Proportion of Days Covered (PDC) by OAC regimens and assessed through nationwide prescription registers. Secondary outcomes included the rate of persistence to OAC, gaps in treatment, proportion of VKA-takers with labile INR (defined as time to therapeutic range&lt;70%) and clinical events.

Results

A total of 1009 patients were randomised, 500 in the intervention group and 509 in the control group. At 1-year follow-up, 77.2% (386/500) of patients in the intervention group had good adherence (PDC&gt;80%), compared with 55% (280/509) in the control group (adjusted odds ratio 2.84, 95% confidence interval 2.14–3.75; p&lt;0.001). Mean PDC±SD was 0.85±0.26 and 0.75±0.31, respectively (p&lt;0.001). Patients that received the intervention were more likely to persist in their OAC therapy at 1 year, while usual medical care was associated with more major (≥3 months) treatment gaps [Figure]. Among 212 VKA-takers, patients in the intervention group were less likely to have labile INR compared with those in the control group [21/120 (17.1%) vs 34/92 (37.1%), OR 0.33 95% CI 1.15–0.72, p=0.005]. Clinical events over a median follow-up period of 2 years occurred at a numerically lower, yet non-significant, rate in the intervention group [Table].

Conclusions

In patients receiving OAC therapy for non-valvular AF, a motivational intervention significantly improved patterns of medication adherence, without significantly affecting clinical outcomes.

Primary and secondary outcomes

Funding Acknowledgement

Type of funding source: None

A Modified Protocol for Cortisol Analysis in Zebrafish (Danio rerio), Individual Embryos, and Larvae

A modified protocol for the extraction and analysis of cortisol in individual zebrafish, Danio rerio, embryo, and larva samples has been developed and evaluated. Recovery efficiency of the method was high, specifically calculated at 93.8% ± 6.5%. Dilution tests showed high parallelism, while increasing the number of individuals used in each extraction sample resulted in a linear, although slightly underestimated, increase of cortisol yield. Results of cortisol content from 0, 3, and 5 days postfertilization (dpf) fish using the proposed protocol were within the range of most published studies analyzing cortisol in pooled samples of 10-30 individuals. Moreover, 5 dpf larvae had significantly higher cortisol levels than embryos, a pattern commonly observed in literature. Finally, application of an osmotic stress in 5 dpf larvae led to a statistically significant increase in cortisol content.

QTL for Stress and Disease Resistance in European Sea Bass, Dicentrarhus labrax L

There is a growing interest in selective breeding in European sea bass (Dicentrarchus labrax), especially regarding family selection based on growth performance. In particular, quantitative trait loci (QTL) identification in sea bass enhances the application of marker-assisted breeding for the genetic improvement of the production traits. The aims of the study were to identify potential QTL affecting stress and immunological indicators, body weight, and mortality after vibriosis injection in sea bass as well as to estimate heritability and genetic/phenotypic correlations for the aforementioned traits. To this end, stress test was performed on 960 offspring and a sub-group of them (420) was selected to explore the mortality after vibrio injection. Selective genotyping was performed in 620 offspring for 35 microsatellite markers and distributed into 6 linkage groups. The length of the genetic linkage map was 283.6 cM and the mean distance between the markers was 8.1 cM. QTL affecting body weight in three different growth periods detected on linkage groups LG1, LG4, LG6, and LG14. A QTL associated with weight in early growth stages (290-306 days post-hatching) was also identified on LG3. QTL analysis confirmed the existence of QTL affecting cortisol levels, on LG3 and LG14. Moreover, new QTL affecting only cortisol and glucose levels were detected on LG1 and LG23. No QTL affecting hormonal or biochemical marks was found on LG4 and LG6. Heritability of cortisol, lysozyme levels, and mortality were high (0.36, 0.55, and 0.38, respectively).

Motivational Interviewing to Support Oral AntiCoagulation adherence in patients with non-valvular Atrial Fibrillation (MISOAC-AF): a randomized clinical trial

AIMS

We aimed to assess the impact of an educational, motivational intervention on the adherence to oral anticoagulation (OAC) in patients with non-valvular atrial fibrillation (AF).

METHODS AND RESULTS

Hospitalized patients with non-valvular AF who received OAC were randomly assigned to usual medical care or a proactive intervention, comprising motivational interviewing, and tailored counselling on medication adherence. The primary study outcome was adherence to OAC at 1 year, which was evaluated according to proportion of days covered (PDC) by OAC regimens and was assessed through nationwide registers of prescription claims. Secondary outcomes included the rate of persistence to OAC, gaps in treatment, and clinical events. A total of 1009 patients were randomized, 500 in the intervention group and 509 in the control group. At 1-year follow-up, 77.2% (386/500) of patients in the intervention group were adherent (PDC > 80%), compared with 55% (280/509) in the control group [adjusted odds ratio (aOR) 2.84, 95% confidence interval (CI) 2.14-3.75; P < 0.001]. Mean PDC ± standard deviation was 0.85 ± 0.26 and 0.75 ± 0.31, respectively (P < 0.001). Patients that received the intervention were more likely to persist in their OAC therapy at 1 year (aOR 2.42, 95% CI 1.71-3.41; P < 0.001). Usual medical care was associated with more major (≥3 months) treatment gaps (aOR 2.39, 95% CI 1.76-3.26; P < 0.001). Clinical events over a median follow-up period of 2 years did not differ among treatment groups.

CONCLUSION

In patients receiving OAC therapy for non-valvular AF, a multilevel motivational intervention significantly improved medication adherence and rate of therapy persistence, and reduced major gaps in treatment. No significant impact on clinical outcomes was observed.

TRIAL REGISTRATION NUMBER

NCT02941978.