Incidence of cardiovascular events in patients with atrial fibrillation anticoagulated with rivaroxaban after 2.5 years of follow-up: not all is stroke or bleeding

Introduction

Atrial fibrillation (AF) is not a benign arrhythmia, but is associated with an increase in mortality, above all related to the risk of suffering thromboembolic events, mainly stroke. The use of oral anticoagulants (OAC) reduces this risk, but increases the risk of serious bleeding. The DOACs have been shown to be superior to the classic vitamin K antagonists (VKAs). It is not as well known whether AF is associated with an increase in other serious cardiac events.

Purpose

The objective of this analysis was to assess the incidence of stroke, major bleeding, total mortality and major adverse cardiac events [MACE, defined as cardiac mortality (including death for coronary events, progressive heart failure death and sudden cardiac death), coronary revascularization, myocardial infarction] in a contemporary series of patients with AF anticoagulated with rivaroxaban.

Methods

To do this, we have analyzed a series of 1,433 patients with AF, anticoagulated with rivaroxaban for at least the previous 6 months, consecutively included in the first half of year 2017 in 79 Spanish centers (EMIR study), and followed for 2.5 years.

Results

Mean age was 74.2±9.7 years, 44.5% being women. Prevalence of diabetes was 27.1%, chronic renal failure 16.1%, coronary heart disease 16.4% and heart failure 22.7%. 2MACE score was 1.8±1.4, CHA2DS2-VASc was 3.5±1.5 and HAS-BLED 1.6±1.0. 77.1% of patients received 20 mg/ day of rivaroxaban and 22.9% 15 mg/day. After a follow-up of 2.5 years, the annual rate (events/100 patients/year) of myocardial infarction was 0.16 (all non-STEMI), coronary revascularization 0.28, cardiac death 0.63 (sudden 0.16, heart failure 0.41, other 0.06), overall MACE 1.07 and overall mortality 2.73, while the incidence of stroke was 0.57 / 100 patients / year (ischemic 0.35, haemorrhagic 0.22) and major bleeding 1.04 (gastrointestinal 0.63, intracranial 0.28).

Conclusion

In a current series of patients with AF anticoagulated with rivaroxaban, the incidence of embolic and hemorrhagic complications and mortality are low, while the incidence of serious cardiac events is significant, being overall similar to that of stroke and major bleeding. Attention must be paid to the prevention and diagnosis of these problems.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Bayer Hispania

The ESC ACCA EAPCI EORP acute coronary syndrome ST-elevation myocardial infarction registry

Aims 

The Acute Cardiac Care Association (ACCA)–European Association of Percutaneous Coronary Intervention (EAPCI) Registry on ST-elevation myocardial infarction (STEMI) of the EurObservational programme (EORP) of the European Society of Cardiology (ESC) registry aimed to determine the current state of the use of reperfusion therapy in ESC member and ESC affiliated countries and the adherence to ESC STEMI guidelines in patients with STEMI.

Methods and results 

Between 1 January 2015 and 31 March 2018, a total of 11 462 patients admitted with an initial diagnosis of STEMI according to the 2012 ESC STEMI guidelines were enrolled. Individual patient data were collected across 196 centres and 29 countries. Among the centres, there were 136 percutaneous coronary intervention centres and 91 with cardiac surgery on-site. The majority of centres (129/196) were part of a STEMI network. The main objective of this study was to describe the demographic, clinical, and angiographic characteristics of patients with STEMI. Other objectives include to assess management patterns and in particular the current use of reperfusion therapies and to evaluate how recommendations of most recent STEMI European guidelines regarding reperfusion therapies and adjunctive pharmacological and non-pharmacological treatments are adopted in clinical practice and how their application can impact on patients’ outcomes. Patients will be followed for 1 year after admission.

Conclusion 

The ESC ACCA-EAPCI EORP ACS STEMI registry is an international registry of care and outcomes of patients hospitalized with STEMI. It will provide insights into the contemporary patient profile, management patterns, and 1-year outcome of patients with STEMI.

Long-term results of the Spanish trial on treatment and survival of patients with predominantly mild heart failure

A randomized open-label clinical trial was conducted to determine whether mortality, readmission, or quality of life differed between heart failure patients managed with captopril plus diuretics and those with digoxin plus diuretics. A total of 345 heart failure patients in New York Heart Association functional classes 2 and 3 without atrial fibrillation, dyspnea of bronchopulmonary origin, or hypertension not controlled with diuretics was randomized for digoxin (n = 175) or captopril (n = 170) treatment and followed up for a median of 4.5 years. Socioeconomic, demographic, electrocardiographic, echocardiographic, spirometric, and chest radiograph data were obtained at the initial examination. In a random sample of half the patients, ergometric, echocardiographic, and Holter records were obtained at entry and at 3 and 18 months. Patients were followed up for > or = 3 years. The end points were mortality, hospitalization for cardiac events, deterioration in quality of life, worsening of functional class, and need for digoxin or captopril in the captopril and digoxin groups, respectively. The trial had to be terminated prematurely owing to the difficulty in finding candidates free of angiotensin-converting enzyme (ACE)-inhibitor treatment. Baseline patient characteristics were similar in both groups. From the clinical point of view, only the 48-month mortality was relevantly lower (20.9 vs. 31.9%, respectively) among patients treated with captopril than that in those receiving digoxin (log rank test, p = 0.07). No statistically or clinically relevant differences were found in other end points or adverse effects. The results suggest but do not confirm the hypothesis that captopril treatment in mild to moderate heart failure might provide better long-term survival than digoxin.

[Atherosclerotic coronary ectasia or a lymphomucocutaneous syndrome in an adult (Kawasaki's disease)?]

We report the case of a 42-year-old man, who was admitted to hospital with an inferior myocardial infarction. He was treated with tissue plasminogen activator without complications in the acute phase. The stress testing performed before discharge showed residual myocardial ischemia. A catheterization study was indicated. The coronary angiogram demonstrated diffuse three vessel coronary artery aneurysmal disease. Two years before the patient had an aneurysm of the right iliac artery being operated on. The differential diagnosis of adult aneurysmal coronary disease is discussed with emphasis on Kawasaki's disease and atherosclerotic coronary artery ectasia.

[Thrombus in the thoracic aorta as cause of peripheral embolism diagnosed using transesophageal echocardiography]

The authors report the cases of two patients, with no risk factors for thromboembolism, in whom a mobile thrombus of the thoracic aorta was diagnosed by transesophageal echocardiography, after an episode of systemic embolism. The outcomes of the two cases were very different. In one patient the thrombus was no longer present after anticoagulant treatment with no recurrent embolic event. The other patient had a new embolic event and the thrombus persisted while having anticoagulant therapy. This patient underwent surgery, and the thrombus was removed. These cases illustrate the value of transesophageal echocardiography in the detection of embolic source.

[The effect of antihypertensive therapy on left ventricular mass and diastolic filling in light and moderate hypertension]

BACKGROUND

To valorate the effect of four antihypertensive drugs on the regression of cardiac mass and diastolic function, by echocardiography-Doppler, in not treated hypertensive subjects.

METHODS

60 mild-moderate hypertensive subjects were studied randomized in four groups of 15 patients each one: enalapril (10-40 mg/d), atenolol (25-100 mg/d), verapamil-retard (120-240 mg/d), alphametildopa (250 mg/8h to 3 g/d). The active drug therapy phase was 6 months, performing echo-Doppler, evaluating posterior-wall and septal-wall thicknesses, ventricular mass index, ratio of early to atrial peak diastolic filling velocity (E/A), the first-third filling fraction and atrial filling fraction.

RESULTS

The cardiac mass index decreased with the four drugs: with enalapril from 178 +/- 28 to 155 +/- 29 g/m2 (p < 0.05), with atenolol from 170 +/- 23 to 154 +/- 19 g/m2 (p < 0.05), with verapamil from 180 +/- 27 to 159 +/- 22 g/m2 (p < 0.05) and with alphametildopa from 176 +/- 30 to 142 +/- 22 g/m2 (p < 0.01). The E/A ratio and first-third filling fraction only improved in the atenolol subgroup, from 0.79 +/- 0.13 to 0.97 +/- 0.16 (p < 0.01) and from 36 +/- 5 to 44 +/- 9% (p < 0.01), decreasing atrial filling fraction from 37 +/- 6 to 30 +/- 8% (p < 0.01), without modifying with enalapril (0.74 +/- 0.14 to 0.76 +/- 0.20, 35 +/- 5% to 36 +/- 7%, 38 +/- 5 to 39 +/- 7%, p = NS), verapamil (0.69 +/- 0.12 to 0.74 +/- 0.17, 35 +/- 6% to 36 +/- 8% to 40 +/- 12%, p = NS) neither alphametildopa (0.72 +/- 0.14 to 0.71 +/- 0.21, 34 +/- 5% to 35 +/- 7%, 40 +/- 6% to 41 +/- 9%, p = NS). The heart rate decreased more with atenolol than with the other drugs (61 +/- 15 vs 71 +/- 12, p < 0.01).

CONCLUSIONS

In hypertensive patients the decreasing of cardiac mass is not accompanied of improvement of the diastolic function except in patients treated with atenolol, probably due to bradycardia.

[The 2-dimensional and Doppler color echocardiographic study of a congenital aneurysm of the sinus of Valsalva with a fistula of the right atrium in an adult]

This report describe a 69-year old woman with a congenital aneurysm of the non-coronary sinus of Valsalva ruptured in the right atrium, causing severe hemodynamic derangement of the right ventricle. The site of the communication between the aneurysm and the receiving chamber was accurately diagnosed by two-dimensional color flow Doppler imaging which provided more valuable preoperative information than conventional aortography.

[Doppler analysis of mitral flow in mild to moderate hypertension]

We evaluate by Echo-Doppler the left ventricular relaxation disturbance produced by mild to moderate hypertension. It's a comparative study between 15 healthy and 40 patients with hypertension (diastolic blood pressure between 90-114 mmHg and/or systolic greater than 160 mmHg). Echocardiography was performed in all cases and diameters, thickness, volumes, ejection fraction, mass, transmitral flow by Doppler and cardiac output were evaluated . In hypertensive patients the septal and posterior wall thicknesses were significantly higher (1.39 +/- 0.2 cm vs 1.1 +/- 0.1, p less than 0.001 cm. and 1.26 +/- 0.12 cm vs 0.98 +/- 0.1 cm, p less than 0.001), and also the absolute mass and corrected according to corporal surface (339 +/- 58 g vs 203 +/- 44, p less than 0.001, and 185 +/- 34 g/m2 vs 115 +/- 16, p less than 0.001). In transmitral flow Doppler the higher isovolumetric period and lower diastolic filling in the first 1/3 (71 +/- 19 msec vs 53 +/- 20, p less than 0.05, and 35 +/- 5% vs 52 +/- 4%, p less than 0.001) are indicators of relaxation disturbance. A lower deceleration of early inflow and a higher deceleration time (265 +/- 98 cm/sec2/vs 454 +/- 139, p less than 0.001, and 226 +/- 38 msec vs 156 +/- 15, p less than 0.001) show compliance damage. The atrial filling was significantly higher in hypertensive patients (37 +/- 7% vs 20 +/- 8%, p less than 0.001). The E/A ratio, separate both groups but corrected by the age the signification was rather lower.(ABSTRACT TRUNCATED AT 250 WORDS)

In situ right gastroepiploic artery. A conduit for coronary revascularization

The internal mammary artery is widely recognized as the graft of choice for coronary artery bypass grafting at present. Alternative conduits have been investigated in order to find other adequate long-term grafts. The right gastroepiploic artery has been recently used as a graft to bypass distal coronary vessels. From November 1989 to June 1990, we have implanted this artery in 46 cases. Pedicled grafts were implanted in 20 patients to the main right coronary artery, in 21 patients we grafted the right distal branches, in 3 patients the left anterior descending, and in 2 the circumflex branches. Mean grafts per patient were 3 in this series, with a mean of 2.2 arterial grafts per patient. One patient died in the early postoperative period. The remaining patients had an uncomplicated postoperative evolution. Thirteen patients underwent graft and coronary angiography. Direct or indirect graft patency was confirmed in all cases. The final important issue concerning the long-term patency of this graft will be solved in the future, but short-term patency rates of the right gastroepiploic artery can be anticipated when proper techniques are used.

[Double outlet right ventricle with situs inversus. Surgical treatment of a case with interventricular communication and pulmonary stenosis]

A 4-year-old patient with situs inversus, double outlet right ventricle, septal defect, and pulmonary stenosis has been surgically corrected. During operation a tubular patch was used to communicate left ventricle with the aorta. Cross-sectional echocardiography was performed in order to test correct position of the graft.

[Prostaglandins in newborn infants with severe cardiopathy]

Between February 1983 and December 1985 authors have studied 26 newborn infants with severe congenital heart disease who received prostaglandin E1 infusion as therapy. Onset of therapy was before 5 days of age in 15 patients, between 5 and 7 days of age in 7 cases and after 14 days of age in the remaining ones. Initial dose was 0.05 mcg/kg/minutes and mean duration of infusion was 131.9 +/- 19.0 hours. Patients were divided into 3 groups according to pulmonary and systemic blood flows: Group I, with cyanosis and diminished pulmonary blood flow (12 cases); Group II, with diminished systemic blood flow (10 cases); and group III, with cyanosis and normal or increased pulmonary blood flow (4 cases). Most patients of groups I (10/12) and II (9/10) improved levels of blood PO2: mean increments of 17.8 +/- 7.4 and 17.5 +/- 13.3 torr respectively. Peripheral pulses also improved in four extremities in patients from group II; systolic and diastolic pressures increased 16 +/- 9.6 and 5 +/- 2.2 mmHg, respectively. No improvement was observed in patients from group III, with exception of patients with transposition of great vessels. Most frequent complication of prostaglandin infusion was hyperthermia, which was observed in 16 cases but disappeared in all with moderate reduction of doses. Appropriate surgery was performed in 19 patients, with an overall survival of 52.6%. In conclusion, prostaglandin infusion appears to be a very valued tool to improve the hemodynamic condition in newborn infants with severe congenital heart disease and thus allow the practice of corrective surgery during first month of life.

Direct communication between the right pulmonary artery and the left atrium

Images

[Mitral atresia. Anatomical study and surgical implications]

We present the pathological study of 17 cases of mitral atresia with patent aortic valve and their surgical implications. The study is based on the type of atrioventricular connection, presence or absence of ventricular septum, size of the left ventricle and relation of the aorta with the aforementioned ventricle. We have classified mitral atresia into two groups by assessing these data. Group A) Both ventricles and atrioventricular connections are present and there is ventricular septal defect. The aorta may connect with an either normal or hypoplastic left ventricle or it may emerge in double outlet from the right ventricle. Group B) Absent left ventricle and atrioventricular connection. The aorta emerges from the single ventricle or the rudimentary chamber. Thirteen cases belonged to group A and four to group B. The pathological structure of mitral atresia requires the decompression of the left atrium by atrioseptostomy during the neonatal period to enable survival. On a second stage a palliative correction should be carried out, which; depending on ventricular size and outlet of the vessels, will be a valvular prosthesis left atrium-left ventricle or the modified atriopulmonary technique connecting the new left atrium with the systemic ventricle and aorta after resecting the auricular septum and connecting the right atrium with the pulmonary artery.

[Isolated hypoplasia of the right ventricle. Study of 3 cases]

Right ventricular hypoplasia without additional congenital heart disease is an uncommon abnormality. It is characterized by partial absence of right ventricular inflow tract, both tricuspid and pulmonary valves being normally shaped. We report three cases; a newborn, an infant and a twelve years old boy. All of them had cyanosis and right atrial enlargement and both of the younger patients had electrocardiographic signs suggesting right ventricular hypoplasia. Right atrial mean pressure were raised. A differential diagnosis should be stablished with all sorts of right ventricular hypoplasia with cyanosis and with restrictive myocardiopathyes. Surgery for symptomatic patient should be palliative during first months of life and corrective from age one year onwards.

Persistent left sided fifth aortic arch in a neonate

A persistent left sided fifth aortic arch with coarctation of the aorta and persistence of the ductus arteriosus was recognised and treated surgically in a newborn infant. The fifth arch was used to repair the coarctation, and five years later the child had normal peripheral pulses and no residual murmurs.

Isolated atresia of the left pulmonary veins

Four cases of congenital isolated atresia of the left pulmonary veins were observed over a 12-year period. The diagnosis was established through radionuclide pulmonary perfusion studies together with cardiac catheterization and pulmonary arteriography. Both procedures showed an elevated pulmonary pressure wedge and decreased blood flow with late poor filling of the pulmonary capillary bed on the affected side. Arteriography revealed non-visualization of the left pulmonary veins. The possibility of congenital atresia of the pulmonary veins should be borne in mind when confronted by unexplained hemoptysis, recurrent lower respiratory infections with protracted infiltrates, or pulmonary arterial hypertension. Surgical treatment, though difficult, is feasible.