Antithrombotic therapy for stable coronary artery disease and atrial fibrillation in patients with and without revascularisation: the AFIRE trial

BACKGROUND

The Atrial Fibrillation and Ischemic Events with Rivaroxaban in Patients with Stable Coronary Artery Disease (AFIRE) trial demonstrated non-inferior efficacy endpoints for rivaroxaban monotherapy versus combination therapy (rivaroxaban plus a single antiplatelet) and superior safety endpoints in patients with atrial fibrillation and stable coronary artery disease.

AIMS

This post hoc analysis investigated whether the AFIRE trial results reflected the presence or absence of prior revascularisation.

METHODS

Among 2,215 patients, 1,697 (76.6%) had previously undergone revascularisation, and the remaining 518 (23.4%) had not undergone prior revascularisation. The primary efficacy endpoint was a composite of stroke, systemic embolism, myocardial infarction, unstable angina requiring revascularisation, or death from any cause, while the primary safety endpoint was major bleeding.

RESULTS

In 1,697 patients with prior revascularisation, the efficacy and safety endpoints were superior for monotherapy versus combination therapy (efficacy: hazard ratio [HR] 0.62, 95% confidence interval [CI]: 0.45-0.85; p=0.003; safety: HR 0.62, 95% CI: 0.39-0.98; p=0.042). Among 518 without prior revascularisation, there were no significant differences in endpoints (efficacy: HR 1.19, 95% CI: 0.67-2.12; p=0.554; safety: HR 0.47, 95% CI: 0.18-1.26; p=0.134). There was borderline interaction of the efficacy endpoints (p=0.055) between two treatments. The safety benefit of monotherapy on any bleeding was significant in patients without prior revascularisation (HR 0.59, 95% CI: 0.38-0.93; p=0.022).

CONCLUSIONS

In high-risk thrombosis patients with a history of prior revascularisation, rivaroxaban monotherapy versus combination therapy demonstrated favourable safety and efficacy outcomes.

Left Ventricular End-Systolic Diameter May Predict Persistent Heart Failure with Reduced Ejection Fraction

Patients with persistent heart failure (HF) with reduced ejection fraction (HFrEF) have a poorer prognosis than those with HF with improved ejection fraction (HFimpEF). However, data on the predictive value of echocardiographic parameters for persistent HFrEF are lacking. We retrospectively studied 443 patients who were diagnosed with HFrEF (EF ≤ 40%) during hospitalization and underwent echocardiography at the 1-year follow-up. We divided them into the 2 groups: HFimpEF (EF > 40%) and persistent HFrEF group at 1-year follow-up, and assessed the predictive value of echocardiographic parameters at discharge for persistent HFrEF. In total, 301/443 patients (68%) were diagnosed with persistent HFrEF and 142/443 (32%) with HFimpEF at the 1-year follow-up. Kaplan-Meier analysis revealed that the persistent HFrEF group had a poorer prognosis than the HFimpEF group (log-rank, P < 0.001). Receiver operating characteristic curve analysis revealed that left ventricular end-systolic diameter (LVESD) had the highest area under the curve (AUC) (0.70; 95% confidence interval [CI]: 0.64-0.75; cutoff value: 55 mm) among various echocardiographic parameters. LVESD was an independent predictor of persistent HFrEF at the 1-year follow-up (odds ratio: 1.07, 95%CI: 1.02-1.12) upon multivariable logistic regression analysis. The incidence of persistent HFrEF was higher in patients with an LVESD ≥ 55 mm than in those with an LVESD < 55 mm (81% versus 55%, Fisher's exact test, P < 0.001). In conclusion, an LVESD (≥ 55 mm) was associated with persistent HFrEF. Focusing on LVESD in daily practice may help clinicians with risk stratification for decision-making regarding management in patients with advanced HF refractory to guideline-directed medical therapy.

Direct Link Between Cardiac Failure and Global Cerebral Atrophy in a Young Adult: A Case Report on Reduced Cerebral Artery Blood Flow

BACKGROUND Heart failure is associated with structural brain abnormalities, including atrophy of multiple brain regions. Previous studies have reported brain atrophy in middle-aged patients with systolic heart failure. In this report, we present the case of a 21-year-old woman with idiopathic dilated cardiomyopathy, cardiac failure, and global cerebral atrophy due to reduced cerebral artery blood flow. We also discuss the impact of brain atrophy in this young adult patient with severe heart failure and no risk factors for atherosclerosis. CASE REPORT A 21-year-old woman with dyspnea and leg edema was admitted to our hospital. After several examinations, an endomyocardial biopsy led to a diagnosis of idiopathic dilated cardiomyopathy, and transthoracic ultrasound cardiography revealed that her left ventricular ejection fraction was 36%. One year after the first hospitalization, her heart failure was classified as New York Heart Association Class III. Magnetic resonance imaging showed severe global brain atrophy, and single-photon emission computed tomography combined with brain computed tomography showed reduced blood flow to the entire brain. She had no risk factors for atherosclerosis and no atherosclerotic changes to her brain or carotid arteries, but her neuropsychological and neurological findings indicated more pronounced brain and cognitive dysfunction. CONCLUSIONS This young adult patient with idiopathic dilated cardiomyopathy, cardiac failure, and global cerebral atrophy showed reduced cerebral artery blood flow and cognitive impairment. The findings of this report indicate that low cardiac output may directly cause brain atrophy in patients with systolic heart failure.

Thrombocytopenia as a Bleeding Risk Factor in Atrial Fibrillation and Coronary Artery Disease: Insights From the AFIRE Study

Background Thrombocytopenia poses a risk of bleeding in patients with chronic coronary syndrome after coronary intervention. However, whether thrombocytopenia also increases the bleeding risk in patients with atrial fibrillation and chronic coronary syndrome remains unclear. Methods and Results This study evaluated the AFIRE (Atrial Fibrillation and Ischemic Events With Rivaroxaban in Patients With Stable Coronary Artery Disease) trial. Thrombocytopenia was defined as platelet count <100 000/mm3 level at enrollment. Primary end points included incidence of major bleeding based on the International Society on Thrombosis and Hemostasis criterion and major adverse cardiovascular ischemic events (cardiac death, myocardial infarction, and stroke). A total of 2133 patients were classified into the thrombocytopenia (n=70) and nonthrombocytopenia (n=2063) groups. Major bleeding was significantly higher in the thrombocytopenia group than in the nonthrombocytopenia group (10.0% versus 4.1%, P=0.027). The thrombocytopenia group tended to have a higher risk of major adverse cardiovascular ischemic events (11.4% versus 6.2%, P=0.08). The bleeding incidence was significantly higher in patients with thrombocytopenia receiving combination therapy with rivaroxaban and a single antiplatelet drug (thrombocytopenia group, 14.3%, versus nonthrombocytopenia group, 5.0%; hazard ratio, 3.18 [95% CI, 1.27-7.97], P=0.014). Thrombocytopenia was an independent predictor of major bleeding (hazard ratio, 2.57 [95% CI, 1.19-5.56], P=0.017). Conclusions Among patients with atrial fibrillation and chronic coronary syndrome, thrombocytopenia was significantly associated with increased risk of major bleeding. Selecting drugs for patients with thrombocytopenia continuing antithrombotic therapy should be given special consideration. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02642419. https://www.umin.ac.jp/ctr/; Unique identifier: UMIN000016612.

[Emergent Transcatheter Aortic Valve Implantation for Degenerated Surgical Aortic Valve Under Local Anesthesia:Report of a Case]

An 89-year-old man who had undergone aortic valve replacement with a 21 mm Mosaic bioprosthetic valve at another hospital 14 years ago was admitted to the emergency room for a sudden respiratory distress two days prior and was diagnosed with severe aortic regurgitation( AR) caused by valve insufficiency and acute heart failure secondary to low cardiac function. Upon admission, he was found to have severe hypoxia with PaO2 of 40 mmHg range, and transcatheter aortic valve replacement (TAVI, TAV in SAV) with a 20 mm SAPIEN3 was performed under local anesthesia for fear of hypotension while under general anesthesia. After confirming that AR had completely disappeared, the patient was intubated and discharged from the operating room on a mechanical ventilator. The patient was weaned from the ventilator on the second postoperative day and was transferred to the other hospital for rehabilitation, 48 days postoperatively. Although there is no report on the comparative study of anesthesia methods for emergency transcatheter aortic valve implantation( TAVI), TAVI under regional anesthesia is minimally invasive with a lower risk for hypotension than general anesthesia. Therefore, we believe it is useful for patients with acute heart failure and hypotension. In addition, it is important to use a balloon expandable valve with excellent implantability to complete the procedure in a short time.

A randomized, double-blind, placebo-controlled pilot trial of low-intensity pulsed ultrasound therapy for refractory angina pectoris

BACKGROUND

Despite the advances in the treatment of cardiovascular diseases, effective treatment remains to be established to improve the quality of life and prognosis of patients with chronic coronary syndromes. This study was aimed to evaluate the effectiveness and safety of the low-intensity pulsed ultrasound (LIPUS) therapy, which we have developed as a novel non-invasive angiogenic therapy through upregulation of endothelial nitric oxide synthase (eNOS).

METHODS AND FINDINGS

We conducted a randomized, double-blind, placebo-controlled (RCT) pilot trial of the LIPUS therapy for patients with refractory angina pectoris. The patients who received optimal medical therapy without indication of PCI or CABG due to the lack of graftability or complexity of coronary lesions were enrolled. They were randomly divided into the LIPUS treatment group (N = 31) and the placebo group (N = 25) in a 1:1 fashion. The LIPUS therapy was performed in a transthoracic manner for 20 min for 3 sections each (mitral, papillary muscle, and apex levels) under the conditions that we identified; frequency 1.875 MHz, intensity 0.25 MPa, and 32 cycles. The primary endpoint was weekly use of nitroglycerin. Secondary endpoints included stress myocardial perfusion imaging and others. The average weekly nitroglycerin use (times/week) was decreased from 5.50 to 2.44 in the LIPUS group and from 5.94 to 2.83 in the placebo group. The changes in the average weekly nitroglycerin use were comparable; -3.06 (95% CI: -4.481 to -1.648) in the LIPUS group (P<0.01) and -3.10 (95% CI: -4.848 to -1.356) in the placebo group (P<0.01). No adverse effects were noted.

CONCLUSIONS

In the present study, the LIPUS therapy did not further ameliorate chest pain as compared with optimal medications alone in patients with refractory angina pectoris. The present findings need to be confirmed in another trial with a large number of patients. (Registration ID: UMIN000012369).

Risk prediction score for clinical outcome in atrial fibrillation and stable coronary artery disease

OBJECTIVE

Antithrombotic therapy is essential for patients with atrial fibrillation (AF) and stable coronary artery disease (CAD) because of the high risk of thrombosis, whereas a combination of antiplatelets and anticoagulants is associated with a high risk of bleeding. We sought to develop and validate a machine-learning-based model to predict future adverse events.

METHODS

Data from 2215 patients with AF and stable CAD enrolled in the Atrial Fibrillation and Ischaemic Events With Rivaroxaban in Patients With Stable Coronary Artery Disease trial were randomly assigned to the development and validation cohorts. Using the random survival forest (RSF) and Cox regression models, risk scores were developed for net adverse clinical events (NACE) defined as all-cause death, myocardial infarction, stroke or major bleeding.

RESULTS

Using variables selected by the Boruta algorithm, RSF and Cox models demonstrated acceptable discrimination and calibration in the validation cohort. Using the variables weighted by HR (age, sex, body mass index, systolic blood pressure, alcohol consumption, creatinine clearance, heart failure, diabetes, antiplatelet use and AF type), an integer-based risk score for NACE was developed and classified patients into three risk groups: low (0-4 points), intermediate (5-8) and high (≥9). In both cohorts, the integer-based risk score performed well, with acceptable discrimination (area under the curve 0.70 and 0.66, respectively) and calibration (p>0.40 for both). Decision curve analysis showed the superior net benefits of the risk score.

CONCLUSIONS

This risk score can predict the risk of NACE in patients with AF and stable CAD.

TRIAL REGISTRATION NUMBERS

UMIN000016612, NCT02642419.

Implication of modified MELD scores for postdischarge prognosis in hospitalized patients with heart failure

We evaluated whether modified Model for End-Stage Liver Disease (MELD) scores are useful for predicting the postdischarge prognosis in hospitalized patients with heart failure (HF) who are discharged alive. The MELD-XI and MELD-Na scores were calculated at discharge for a total of 1156 patients in the HIJ-HF II study. We also studied 3 groups on the basis of the left ventricular ejection fraction (LVEF): the HFrEF (LVEF < 40%), HFmrEF (LVEF 40-49%) and HFpEF (LVEF ≥ 50%) groups. The primary outcome was all-cause mortality, and the secondary outcome was rehospitalization due to worsening HF. The median MELD-XI and MELD-Na scores were 12 and 14, respectively. After a median follow-up of 19 months, there were significantly higher rates of all-cause mortality in patients with MELD-XI scores ≥ 12 than in those with MELD-XI scores < 12; there were also higher rates of all-cause mortality in patients with MELD-Na scores ≥ 14 than in those with MELD-Na scores < 14 (both log-rank p < 0.001). The cumulative incidence function based on a competing risks model showed a higher rate of rehospitalization due to worsening HF in patients with MELD-XI scores ≥ 12 than in those with MELD-XI scores < 12 and a higher rate of rehospitalization due to worsening HF in those with MELD-Na scores ≥ 14 than in those with MELD-Na scores < 14 (both Gray's test p < 0.001). The adjusted hazard ratios (HRs) of all-cause mortality for patients with MELD-XI scores ≥ 12 and those with MELD-Na scores ≥ 14 were 2.07 [95% confidence interval (CI) 1.25-3.44] and 2.79 [95% CI 1.63-4.79], respectively, in the HFrEF group; however, the HRs were not significant in the HFmrEF or HFpEF groups. Thus, MELD-XI and MELD-Na scores may be useful for predicting prognosis in hospitalized HF patients who are discharged alive, especially for those in the HFrEF group.

A case of descending aortic dissection in a patient with unrepaired tetralogy of Fallot and pulmonary atresia

The prognosis of tetralogy of Fallot with pulmonary atresia (TOF/PA) is mainly determined by the development of major aorto-pulmonary collateral arteries (MAPCAs) that provide pulmonary blood perfusion. TOF/PA can be managed conservatively until adulthood in patients with adequate, but not excessive perfusion via MAPCAs. To the best of our knowledge, this is the first report of a patient with unrepaired TOF/PA who eventually developed descending aortic dissection (AD), and survived with medical treatment. A 46-year-old woman was referred to our hospital by her local cardiologist with exertional dyspnea. A three-dimensional (3-D) computed tomography (CT) performed prior to presentation showed a dilated thoracic aorta, three well-developed MAPCAs, and a patent ductus arteriosus (PDA), whereas the 3-D CT performed at presentation revealed a descending AD with the entry site at the proximal part of the thoracic descending aorta, and neither the MAPCAs nor the PDA originated from the area of the AD. The patient was treated medically and was discharged thereafter. In this case, 3D-CT taken 9 months prior to the dissection showed no involvement of MAPCAs in the dissection area and was useful to make a decision of conservative therapy.

Learning objective

Few systematic studies have addressed patients with tetralogy of Fallot with pulmonary atresia (TOF/PA) who survived more than 20 years due to optimal control of pulmonary blood flow depending on the development of major aorto-pulmonary collateral arteries (MAPCAs). We report a patient with unrepaired TOF/PA who developed descending aortic dissection (AD) in her forties. Three-dimensional computed tomography was useful for diagnosing and choosing a treatment plan by identifying the involvement of MAPCAs within the region of the AD.

Adherence to CPAP in summer to autumn predicts self-reported common cold symptoms in patients with obstructive sleep apnea in winter: A prospective observational study

OBJECTIVE

We conducted a prospective observational study to determine the relationship between adherence to continuous positive airway pressure (CPAP) and susceptibility to the common cold in moderate-to-severe obstructive sleep apnea (OSA) patients.

METHODS

We prospectively investigated the number of days with common cold symptoms from November 2019 to February 2020. The rate of CPAP use for 4 h/night in the preceding four months (July to October 2019) was used as a measure of CPAP adherence. Multiple generalized linear models were used to evaluate the association to days of common cold symptoms after controlling for demographic variables, habitual short sleep duration, and insomnia severity.

RESULTS

We included 123 outpatients (median age 63 years) with moderate-to-severe OSA treated with CPAP. In the multivariate generalized linear model, better CPAP adherence was independently significantly associated with days with fewer common cold symptoms (β = -0.248, P = 0.031); meanwhile, the severity of insomnia and habitual short sleep duration was not significantly associated with it. Subgroup analyses revealed that the association between CPAP adherence and days with common cold symptoms was also significant in young to middle-aged (<65 years) participants (β = -0.407, P = 0.005). In contrast, the association was negligible in older (≥65 years) participants.

CONCLUSIONS

CPAP adherence may be protective against viral infections in patients with moderate-to-severe OSA. This effect appears to be more pronounced in young to middle-aged patients with OSA.

Antithrombotic monotherapy for stable coronary artery disease and atrial fibrillation patients with and without prior coronary artery revascularization: Insights from the AFIRE trial

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): The Japan Cardiovascular Research Foundation under a contract with Bayer Yakuhin

Background

The AFIRE (Atrial Fibrillation and Ischemic Events With Rivaroxaban in Patients With Stable Coronary Artery Disease) trial demonstrated that rivaroxaban monotherapy was noninferior to combination therapy with rivaroxaban plus a single antiplatelet therapy regarding efficacy and superior for safety endpoints in patients with atrial fibrillation and stable coronary artery disease including patients not requiring revascularization [prior percutaneous coronary intervention (PCI) or bypass grafting (CABG)].

Purpose

The aim of this post-hoc subgroup analysis was to investigate the efficacy and safety of rivaroxaban monotherapy compared to combination therapy in patients with and without prior revascularization.

Methods

Among 2,215 patients included in the modified intention-to-treat analysis in the AFIRE trial, 1445 patients (65.2%) had undergone previous PCI alone, and 252 (11.4%) had undergone previous CABG. The remaining 518 patients (23.4%) was categorized as a group without prior revascularization and then compared with a group with prior revascularization (PCI or CABG). The primary efficacy end point was a composite of stroke, systemic embolism, myocardial infarction, unstable angina requiring revascularization, or death from any cause. The primary safety end point was major bleeding, according to the criteria of the International Society on Thrombosis and Hemostasis.

Results

In 1697 patients with prior revascularization, efficacy and safety endpoints of rivaroxaban monotherapy were superior to combination therapy (efficacy: HR 0.62, 95%CI 0.45-0.85, p=0.003; safety: HR 0.62, 95%CI 0.39-0.98, p=0.040), whereas there were no significant differences in efficacy and safety endpoints among 518 patients without prior revascularization (efficacy: HR 1.19, 95%CI 0.67-2.11, p=0.553; safety: HR 0.47, 95%CI 0.18-1.26, p=0.125). There was a borderline interaction of efficacy endpoint (P for interaction=0.055) by randomized treatment assignment (Figure 1 and Figure 2). Compared with combination therapy, the safety benefit of rivaroxaban monotherapy on any bleeding was significant in patients without prior revascularization (HR 0.59, 95%CI 0.38-0.93, p=0.022).

Conclusions

In patients with prior PCI or CABG, rivaroxaban monotherapy resulted in more favorable safety and efficacy outcomes than combination therapy. There was a borderline interaction for primary efficacy outcome between prior revascularization and anti-thrombotic therapy.

Prognostic impact of guideline-directed medical therapy in patients with heart failure on regular hemodialysis

BACKGROUND

Renin-angiotensin system inhibitor (RASi) and β-blocker provide prognostic benefits as guideline-directed medical therapy (GDMT) in patients with heart failure and reduced ejection fraction (HFrEF). However, there is limited data for the favorable effects in such patients receiving regular hemodialysis. We aimed to evaluate the prognostic impact of RASi and β-blocker in patients with HFrEF who receive regular hemodialysis.

METHODS

In this retrospective, single-center, observational study, from 2110 consecutive patients hospitalized for HF and who survived to discharge, 97 with HFrEF who received regular hemodialysis were included for analysis. They were classified into three groups according to prescribed medication at discharge following index hospitalization: both RASi and β-blocker (Dual-GDMT group: n = 55), either RASi or β-blocker (Mono-GDMT group: n = 34), and neither RASi nor β-blocker (No-GDMT group: n = 8). The primary endpoint was a composite of all-cause death and rehospitalization for heart failure.

RESULTS

The mean age was 66 years and 79% of the patients were men. During the median follow-up of 501 days, the primary endpoint occurred in 43 patients (44%). Kaplan-Meier analysis revealed that the Dual-GDMT group had the lowest rates of the primary endpoint (log-rank test for trend: p < 0.001). Even after adjustment for diverse covariates (multivariate Cox regression), the Dual-GDMT (hazard ratio [HR]: 0.04, 95% confidence interval (CI): 0.005-0.32) and Mono-GDMT (HR: 0.08, 95% CI: 0.01-0.50) groups had better prognoses than the No-GDMT group.

CONCLUSIONS

The prescription of RASi and/or β-blocker was associated with a lower adverse-event rate after discharge in patients with HFrEF who were on regular hemodialysis.

Impact of the timing of first appropriate shock on outcomes in patients with an implantable cardioverter-defibrillator: Early versus late

BACKGROUND

Appropriate implantable cardioverter-defibrillator (ICD) shocks are associated with an increased risk of mortality and heart failure (HF) events. The first appropriate shock may occur late after implantation. However, whether the timing of the first appropriate shock influences prognosis is unknown. This study aimed to evaluate the clinical significance of the timing of the first appropriate shock in patients with ICD.

METHODS

This retrospective and observational study enrolled 565 consecutive ICD patients. Patients who received an appropriate shock were divided into the early group (first appropriate shock <1 year after ICD implantation) and late group (first appropriate shock ≥1 year after ICD implantation). All-cause mortality was compared between the two groups.

RESULTS

Over a median follow-up of 5.6 years, 112 (19.8%) patients received an appropriate shock, including 32 patients (28.6%) in the early group and 80 patients (71.4%) in the late group. Comparisons of baseline characteristics at ICD implantation revealed that the late group was more likely to receive cardiac resynchronization therapy (66.3% vs. 31.3%, p < 0.001), ICD for primary prevention (60.0% vs. 31.3%, p = 0.001), and angiotensin-converting enzyme inhibitor or angiotensin-receptor blocker treatment (88.8% vs. 71.9%, p = 0.028). Survival after shock was significantly worse in the late group than in the early group (p = 0.027). In multivariable Cox proportional hazards analysis, the late group had an increased risk of all-cause mortality compared with the early group (HR: 2.22; 95% CI 1.01-4.53; p = 0.029). In both groups, the most common cause of death was HF.

CONCLUSIONS

Late occurrence of the first appropriate ICD shock was associated with a worse prognosis compared with early occurrence of the first appropriate shock. Cardiac death was the most common cause of death in patients who experienced late occurrence of the first appropriate ICD shock, resulting from HF in most cases.

Prognostic significance of cardiorenal dysfunction within 1 year after atrial fibrillation ablation in patients with systolic dysfunction

Atrial fibrillation (AF) ablation can improve left ventricular ejection fraction (LVEF) and renal function and can even reduce mortality in patients with impaired LVEF. However, the effect of post-ablation cardiorenal dysfunction on the prognosis of patients with impaired LVEF who underwent AF ablation remains unclear. Of the 1243 consecutive patients undergoing AF ablation, the prognosis of 163 non-dialysis patients who underwent AF ablation with < 50% LVEF was evaluated. The primary outcome was a composite of all-cause mortality, heart failure hospitalization, and a need for modification of the treatment for heart failure. During the median follow-up of 4.2 years after the first AF ablation procedure, the primary outcome occurred in 30 of 163 patients (18%). The receiver operating characteristic curve analysis demonstrated that the post-LVEF (LVEF within 1 year after the procedure, and before the occurrence of primary outcome) had larger areas under the curve (0.70) than the pre-LVEF (LVEF before the procedure), and the most optimal cutoff value was LVEF ≤ 42%. Multivariate analysis demonstrated that patients with post-LVEF ≤ 42% and worsening renal function (WRF; an absolute increase in serum creatinine [SCr] ≥ 0.3 mg/dL compared with the SCr at baseline within 1 year after the procedure and before the occurrence of primary outcome) had a 3.4- to 4.3-fold and 3.4- to 3.7-fold higher risk of the primary outcome compared with those without these predictors, respectively. Patients were categorized using post-LVEF ≤ 42% and WRF as follows: group 1 (post-LVEF > 42% without WRF), group 2 (post-LVEF ≤ 42% without WRF), group 3 (post-LVEF > 42% with WRF), and group 4 (post-LVEF ≤ 42% with WRF). Group 4 had a 15.8-fold (P = 0.0001) higher risk of the primary outcome compared with group 1 after adjusting for pre-procedural factors. In patients with impaired LVEF undergoing AF ablation, post-LVEF ≤ 42% and WRF were independent predictors of poor prognosis. The combination of post-LVEF ≤ 42% and WRF is strongly associated with a poor prognosis in patients with AF undergoing ablation, who with these post-ablation cardiorenal dysfunction may have to be treated more intensively after AF ablation.

Prognostic Impact of Landiolol in Patients with Acute Heart Failure and Atrial Fibrillation with Rapid Ventricular Rates: A Pilot Observational Study

<b><i>Introduction:</i></b> Guidelines recommend ventricular rate control to &#x3c;130 bpm during atrial fibrillation (AF) in patients with acute decompensated heart failure (ADHF) to avoid aggravating deteriorations in cardiac outputs. We aimed to evaluate the prognostic impact of landiolol in patients with ADHF and AF. <b><i>Methods:</i></b> This observational study included 60 patients who were urgently hospitalized with ADHF and presented with AF and a heart rate (HR) ≥130 bpm at admission. The patients were assigned to the landiolol group (<i>n</i> = 37) or the reference group (<i>n</i> = 23) based on their intravenous landiolol use within 24 h after admission. The primary endpoint was death from any cause. <b><i>Results:</i></b> The groups’ baseline characteristics were similar. A significant HR reduction occurred in the landiolol group at 2 h after admission. Compared with the reference group, the HR was significantly lower (111.6 vs. 97.9 bpm, <i>p</i> = 0.02) and the absolute HR reduction was greater (−32.2 vs. −50.0 bpm, <i>p</i> = 0.006) in the landiolol group at 48 h after admission. The landiolol group’s mortality rate was significantly lower than that in the reference group (log-rank test, <i>p</i> = 0.032). landiolol use within 24 h after admission was independently associated with lower all-cause mortality (adjusted hazard ratio: 0.15, 95% confidence interval: 0.02–0.92). <b><i>Conclusion:</i></b> Patients with ADHF and AF who received landiolol for rate control during the acute phase had better prognoses than those who did not receive landiolol.

Effect of rivaroxaban monotherapy vs. combination with anti-platelet therapy in patients with atrial fibrillation and stable coronary artery disease across different body mass index categories

Background

The AFIRE (Atrial Fibrillation and Ischemic Events With Rivaroxaban in Patients With Stable Coronary Artery Disease) trial showed both noninferiority for efficacy and superiority for safety endpoints of rivaroxaban monotherapy compared to rivaroxaban plus antiplatelet therapy (combination therapy) in patients with atrial fibrillation (AF) and stable coronary artery disease (CAD). However, no accumulating evidence regarding efficacy and safety of these fixed-dose direct oral anticoagulant therapy was available in underweight and obese patients.

Purpose

The aim of this post-hoc analysis of the AFIRE trial was to evaluate outcomes of rivaroxaban monotherapy (vs. combination therapy) in patients with AF and stable CAD across body mass index (BMI) categories.

Methods

Patients were categorized into groups 1 (underweight: BMI of &lt;18.5 kg/m2), 2 (normal: BMI of 18.5 to &lt;25 kg/m2), 3 (overweight: BMI of 25 to &lt;30 kg/m2), and 4 (obesity: BMI of ≥30 kg/m2). Efficacy (a composite of all-cause death, myocardial infarction, unstable angina requiring revascularization, stroke, or systemic embolism) and safety (major bleeding defined according to International Society on Thrombosis and Haemostasis criteria) were compared between rivaroxaban monotherapy and combination therapy across BMI categories.

Results

We analyzed 2,054 patients with a median age of 75.0 (interquartile range [IQR], 69 to 80)) years old and CHA2DS2-VASc of 4 (IQR, 3 to 5). Group 1 through 4 included 72 (3.5%), 1,158 (56.4%), 680 (33.1%), 144 (7.0%) patients and 62.3%, 52.3%, 36.2%, and 30.3% were received reduced dose of rivaroxaban, respectively. Although the sample sizes for group 1 and 4 were limited, monotherapy was superior to combination therapy for efficacy in group 2 (hazard ratio [HR], 0.64; 95% CI, 0.44 to 0.95) and safety in group 3 (HR, 0.25; 95% CI, 0.10 to 0.62), whereas a significant difference in the endpoints was not observed in the other BMI categories. Impact of monotherapy on endpoints did not have a significant interaction in BMI.

Conclusions

Rivaroxaban monotherapy had similar effect on prognosis across all BMI categories in patients with AF and stable CAD.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): The Japan Cardiovascular Research Foundation based on a contract with Bayer Yakuhin, Ltd

Stratification of Destination Therapy Candidates by J-HeartMate Risk Score Among Elderly Non-Responders to Cardiac Resynchronization Therapy

Background: For elderly patients with refractory heart failure (HF), destination therapy (DT) with a continuous-flow left ventricular assist device (LVAD) is a possible treatment. The aim of DT is for long-term, satisfying quality of life on LVAD support. Previously, elderly non-responders to cardiac resynchronization therapy (CRT) were primarily destined for palliative care, but DT has been available in Japan since April 30, 2021. This study investigated the prognosis of elderly CRT non-responders and assessed the feasibility of DT in these patients based on the J-HeartMate Risk Score (J-HMRS).

Methods and Results: Of the 559 patients who underwent CRT at Tokyo Women’s Medical University between 2000 and 2018, 198 were aged 65–75 years. Among these, 76 were identified as non-responders based on echocardiographic data, and were included in this study. We calculated patients’ J-HMRS and investigated associations between the J-HMRS and cardiac events after CRT. Patients were divided into 3 groups according to the J-HMRS: low (n=23), medium (n=29), and high (n=24) risk. Patients in the low-risk group experienced as many HF rehospitalizations and ventricular arrhythmia events as those in the other groups. However, survival analysis revealed that, after CRT, survival was higher for patients in the low- compared with high-risk group (P=0.04).

Conclusions: The J-HMRS classified 30% of elderly CRT non-responders as low risk and as suitable candidates for DT in Japan.

Long-term outcomes regarding arterial stiffness and carotid artery atherosclerosis in female patients with rapid eye movement obstructive sleep apnea

Objective

Rapid eye movement (REM) obstructive sleep apnea (OSA) is associated with the risk of cardiovascular events. Arterial stiffness and carotid artery intima-media thickness (IMT) predict these events, but few relevant studies have been conducted. We compared long-term changes in arterial stiffness and IMT between patients with REM OSA and non-REM (NREM) OSA receiving continuous positive airway pressure (CPAP) or oral appliance (OA) therapy.

Methods

Newly diagnosed female patients with OSA received CPAP (n = 6) or OA (n = 7). Pulse wave velocity (PWV) and carotid artery ultrasound were performed before and 60 months after treatment.

Results

There were no differences in baseline characteristics (mean age: 56.0 vs. 61.3 years; mean body mass index: 22.6 vs. 21.7 kg/m²) between the REM OSA and non-REM OSA groups. The median apnea-hypopnea index was lower in the REM OSA group than in the non-REM OSA group. Increased PWV (12.92 ± 1.64 to 14.56 ± 2.73 m/s) and deteriorated glucose metabolism were observed in the REM OSA group after treatment. PWV, IMT, and cardiovascular risk factors were unaffected in the non-REM OSA group.

Conclusion

Arterial stiffness and glucose metabolism are deteriorated in patients with REM OSA compared with these parameters in patients with non-REM OSA after CPAP or OA treatment.

Rivaroxaban Monotherapy in Atrial Fibrillation and Stable Coronary Artery Disease Across Body Mass Index Categories

Background

The AFIRE (Atrial Fibrillation and Ischemic Events With Rivaroxaban in Patients With Stable Coronary Artery Disease) trial showed both noninferiority for efficacy and superiority for safety endpoints of rivaroxaban monotherapy compared with those of rivaroxaban plus antiplatelet therapy (combination therapy) in patients with atrial fibrillation and stable coronary artery disease.

Objectives

This study sought to evaluate outcomes of rivaroxaban monotherapy in those patients across body mass index (BMI) categories.

Methods

Patients were categorized into 4 groups: underweight (BMI <18.5 kg/m²), normal weight (BMI 18.5 to <25 kg/m²), overweight (BMI 25 to <30 kg/m²), and obesity (BMI ≥30 kg/m²). Efficacy (a composite of all-cause death, myocardial infarction, unstable angina requiring revascularization, stroke, or systemic embolism) and safety (major bleeding defined according to International Society on Thrombosis and Haemostasis criteria) were compared between rivaroxaban monotherapy and combination therapy across BMI categories.

Results

This study analyzed 2,054 patients with a median age of 75.0 years and CHA₂DS₂-VASc score of 4. A significant interaction was not observed between BMI categories and effect of monotherapy for efficacy (P = 0.83) and safety (P = 0.07), although monotherapy was superior to combination therapy for efficacy in normal weight (HR: 0.64; 95% CI: 0.44-0.95) and safety in overweight (HR: 0.25; 95% CI: 0.10-0.62), whereas a significant difference in the endpoints was not observed in the other BMI categories.

Conclusions

Rivaroxaban monotherapy had a similar effect on prognosis across all BMI categories in patients with atrial fibrillation and stable coronary artery disease. (Atrial Fibrillation and Ischemic Events With Rivaroxaban in Patients With Stable Coronary Artery Disease [AFIRE]; UMIN000016612, NCT02642419).

Impact of signal-averaged electrocardiography findings on appropriate shocks in prophylactic implantable cardioverter defibrillator patients with nonischemic systolic heart failure

BACKGROUND

Appropriate shock therapy is associated with subsequent all-cause death in heart failure (HF) patients who receive an implantable cardioverter defibrillator (ICD) for the primary prevention of sudden cardiac death. To evaluate the impact of signal-averaged electrocardiography (SAECG) findings on appropriate shocks in prophylactic ICD patients with nonischemic systolic HF.

METHODS

We studied 86 patients with nonischemic HF and a left ventricular ejection fraction ≤ 35% who underwent new ICD implantation for the primary prevention of sudden cardiac death. We excluded patients who had a previously implanted permanent pacemaker and patients who received cardiac resynchronization therapy with an ICD. SAECG was performed before implantation. Abnormal SAECG findings were defined if 2 of the following 3 conditions were identified: filtered QRS duration (fQRS) ≥ 114 ms, root-mean-square voltage during the last 40 ms of the fQRS (RMS 40) < 20 μV, and duration of the low-amplitude potentials < 40 μV (LAS 40) > 38 ms; additionally, patients with a QRS complex ≥ 120 ms who met both the RMS 40 and LAS 40 criteria were also considered to have abnormal SAECG findings. The primary outcome was the first occurrence of appropriate shock after implantation of the ICD. The secondary outcomes were the first occurrence of inappropriate shock and all-cause mortality.

RESULTS

Forty-two patients met the criteria for abnormal SAECG findings (49%). During a median follow-up period of 61 months, 17 patients (20%) died, 24 (28%) received appropriate shock therapy, and 19 (22%) received inappropriate shock therapy. There was a significantly higher incidence of appropriate shocks in patients with abnormal SAECG findings than in those with normal SAECG findings (log-rank test, p = 0.025). Multivariate analysis revealed that abnormal SAECG findings were independently associated with the occurrence of appropriate shock (hazard ratio 2.67, 95% confidential interval 1.14-6.26). However, abnormal SAECG findings were not related to inappropriate shock. There was no difference in the incidence of all-cause death between patients with abnormal and normal SAECG findings.

CONCLUSIONS

Our results suggest that abnormal SAECG findings are associated with a high probability of appropriate shocks in prophylactic ICD patients with nonischemic systolic HF.

Prognostic significance of diastolic dysfunction in patients with systolic dysfunction undergoing atrial fibrillation ablation

Background

The relationship between pre-ablation left ventricular diastolic dysfunction (LVDD) and prognosis in patients with left ventricular systolic dysfunction (LVSD) undergoing atrial fibrillation (AF) ablation remains unclear.

Methods

The prognosis of 173 patients with impaired left ventricular ejection fraction (<50%) who underwent AF ablation was examined. The primary outcome was a composite of all-cause mortality, heart failure (HF) hospitalization, and worsening HF symptoms requiring unplanned outpatient intensification of decongestive therapy.

Results

During the follow-up period (median, 3.5 years), the primary outcome after AF ablation occurred in 28 patients (16%). The receiver operating characteristic curve analysis showed that early septal diastolic mitral annular velocity (e′) had a larger area under the curve (0.70) than other LVDD parameters, and optimal cut-off values of LVDD, represented by e′, septal E (early diastolic left ventricular filling velocity)/e′, and peak tricuspid valve regurgitation velocity (TRV), were 5.0 cm/s, 13.2, and 2.5 m/s, respectively. Multivariate analysis revealed that e′ ≤5.0 cm/s (standard hazard ratio [HR], 3.87; 95% confidence interval [CI], 1.73–8.69; p = 0.001), septal E/e′ ≥13.2 (HR, 3.62; 95% CI, 1.60–8.21; p = 0.002), and peak TRV ≥ 2.5 m/s (HR, 2.42; 95% CI, 1.13–5.16; p = 0.02) independently predicted the outcome. Patients with New York Heart Association functional status ≥ III had a 3.3–4.5-fold higher risk of the outcome.

Conclusions

LVDD or severe HF symptoms predict poor outcomes in patients with LVSD undergoing AF ablation. Therefore, patients with LVDD or severe HF symptoms should receive more intensive treatment even after AF ablation.

Left ventricular systolic function affects right atrial pressure as prognosticator in patients with heart failure

The effect of the left ventricular ejection fraction (LVEF) on the prognostic impact of the right atrial pressure (RAP) in patients with heart failure (HF) requires clarification. We aimed to investigate whether LVEF affects the prognostic impact of RAP estimated from inferior vena cava (IVC) measurements in patients hospitalized with HF. Initially, this observational study included 1349 consecutive patients urgently hospitalized with HF. After patient exclusions, 506 and 484 patients with reduced (< 40%) and with non-reduced (≥ 40%) LVEF, respectively, were assigned according to maximum IVC diameter and its collapsibility, to the Normal-RAP (diameter ≤ 2.1 cm; collapsibility ≥ 50%), High-RAP (diameter > 2.1 cm; collapsibility < 50%), and Intermediate-RAP (others) groups. The endpoint comprised cardiovascular death after discharge and hospitalization for HF recurrence. During the observation period, 247 (49%) patients with LVEF < 40% and 178 (37%) patients with LVEF ≥ 40% experienced the endpoint. The patient subgroups with LVEF < 40% had comparable event rates (ptrend = 0.10). The High-RAP subgroup with LVEF ≥40% had a higher event rate than the other subgroups (p < 0.001). The RAP independently predicted the endpoint in patients with LVEF ≥ 40% (hazard ratio: 1.26; 95% confidence interval: 1.01-1.59). The interaction between the RAP groups and LVEF regarding the primary endpoint was significant (pinteraction = 0.007). Stratifying patients with HF according to IVC measurements may predict the post-discharge cardiovascular prognoses of patients with non-reduced LVEF, but not that of patients with reduced LVEF.

Clinical outcomes of endovascular therapy with vascular stents for central venous obstruction in hemodialysis patients

BACKGROUND

Symptomatic central venous obstruction (CVO) is sometimes observed in patients undergoing hemodialysis. Angioplasty is generally performed for salvage purposes, and stent implantation is performed as a last resort to prevent permanent venous occlusion. However, published reports about the clinical outcomes of stenting for CVO have been limited by the small number of included patients and the relatively old generation of analyzed stents. This study aimed to clarify the safety and efficacy of endovascular therapy (EVT) using stents for symptomatic CVO in contemporary practice.

METHODS

This retrospective review was performed between May 2012 and August 2021. We retrospectively analyzed consecutive 31 lesions (31 patients, 64 ± 10.7 years old) treated with a vascular stent for elastic recoil after balloon angioplasty or recurrent stenosis <3 months after angioplasty. The primary outcome was primary patency, defined as freedom from target lesion revascularization. The secondary outcome was assisted primary patency, defined as freedom from permanent occlusion of the target stents.

RESULTS

In all cases, stents were successfully deployed on the target lesions. No EVT-related complications were observed. Self-expandable and balloon-expandable stents were used in 26 and 5 lesions, respectively. The median follow-up period was 18 months (interquartile range, 7-40). Kaplan-Meier analysis revealed that the primary patency rates were 66.1 % at 6 months, 61.7 % at 12 months, and 38.4 % at 24 months after EVT. The assisted primary patency rate was 70.3 % 24 months after EVT. In the multivariate analysis, younger age was the only independent predictor of target lesion revascularization (hazard ratio: 0.92, 95 % CI: 0.85-0.99, p = 0.04).

CONCLUSIONS

Stent implantation for CVO that is resistant to standard angioplasty seems safe and effective.

Rivaroxaban Monotherapy vs Combination Therapy With Antiplatelets on Total Thrombotic and Bleeding Events in Atrial Fibrillation With Stable Coronary Artery Disease: A Post Hoc Secondary Analysis of the AFIRE Trial

Importance

Appropriate regimens of antithrombotic therapy for patients with atrial fibrillation (AF) and coronary artery disease (CAD) have not yet been established.

Objective

To compare the total number of thrombotic and/or bleeding events between rivaroxaban monotherapy and combined rivaroxaban and antiplatelet therapy in such patients.

Design, Setting, and Participants

This was a post hoc secondary analysis of the Atrial Fibrillation and Ischemic Events With Rivaroxaban in Patients With Stable Coronary Artery Disease (AFIRE) open-label, randomized clinical trial. This multicenter analysis was conducted from February 23, 2015, to July 31, 2018. Patients with AF and stable CAD who had undergone percutaneous coronary intervention or coronary artery bypass grafting 1 or more years earlier or who had angiographically confirmed CAD not requiring revascularization were enrolled. Data were analyzed from September 1, 2020, to March 26, 2021.

Interventions

Rivaroxaban monotherapy or combined rivaroxaban and antiplatelet therapy.

Main Outcomes and Measures

The total incidence of thrombotic, bleeding, and fatal events was compared between the groups. Cox regression analyses were used to estimate the risk of subsequent events in the 2 groups, with the status of thrombotic or bleeding events that had occurred by the time of death used as a time-dependent variable.

Results

A total of 2215 patients (mean [SD] age, 74 [8.2] years; 1751 men [79.1%]) were included in the modified intention-to-treat analysis. The total event rates for the rivaroxaban monotherapy group (1107 [50.0%]) and the combination-therapy group (1108 [50.0%]) were 12.2% (135 of 1107) and 19.2% (213 of 1108), respectively, during a median follow-up of 24.1 (IQR, 17.3-31.5) months. The mortality rate was 3.7% (41 of 1107) in the monotherapy group and 6.6% (73 of 1108) in the combination-therapy group. Rivaroxaban monotherapy was associated with a lower risk of total events compared with combination therapy (hazard ratio, 0.62; 95% CI, 0.48-0.80; P < .001). Monotherapy was an independent factor associated with a lower risk of subsequent events compared with combination therapy. The mortality risk after a bleeding event (monotherapy, 75% [6 of 8]; combination therapy, 62.1% [18 of 29]) was higher than that after a thrombotic event (monotherapy, 25% [2 of 8]; combination therapy, 37.9% [11 of 29]).

Conclusions and Relevance

Rivaroxaban monotherapy was associated with lower risks of total thrombotic and/or bleeding events than combination therapy in patients with AF and stable CAD. Tapered antithrombotic therapy with a sole anticoagulant should be considered in these patients.

Trial Registration

ClinicalTrials.gov Identifier: NCT02642419.

Rivaroxaban Underdose for Atrial Fibrillation with Stable Coronary Disease: The AFIRE Trial Findings

Background  Rivaroxaban monotherapy was noninferior to combination therapy (rivaroxaban plus antiplatelet therapy) in efficacy but superior in safety in the Atrial Fibrillation and Ischemic Events with Rivaroxaban in Patients with Stable Coronary Artery Disease (AFIRE) trial. Among 2,215 patients with atrial fibrillation (AF) and stable coronary artery disease (CAD), 1,378 had baseline creatinine clearance (CrCl) ≥50 mL/min and received 10 (underdose) or 15 mg/d (standard-dose) rivaroxaban. We aimed to assess the effects of rivaroxaban underdose on clinical outcomes.

Methods  We assessed efficacy endpoint (a composite of stroke, systemic embolism, myocardial infarction, unstable angina requiring revascularization, and death from any cause) and major bleeding in the subgroup of patients with preserved renal function in the AFIRE trial.

Results  Age ≥75 years, female sex, lower CrCl, heart failure, and percutaneous coronary intervention history were associated with the underdose prescription. The underdose group had a similar incidence of the efficacy endpoint (3.62 vs. 3.51% per patient-year; p  = 0.871) and significantly lower incidence of major bleeding (0.82 vs. 2.17% per patient-year; p  = 0.022) than the standard-dose group. In patients receiving monotherapy, the incidences of efficacy endpoint and major bleeding were similar between the groups, whereas in those receiving combination therapy, the incidence of major bleeding was significantly lower in the underdose group than that in the standard-dose group.

Conclusion  In patients with AF, stable CAD, and preserved renal function, rivaroxaban underdose was associated with similar rates of thrombotic events but a lower incidence of hemorrhagic events than the standard dose.

Clinical Trial Registration  AFIRE UMIN Clinical Trials Registry ( https://www.umin.ac.jp/ctr/ ), number UMIN000016612, and ClinicalTrials.gov, number NCT02642419.

Prognosis and diastolic dysfunction predictors in patients with heart failure and recovered ejection fraction

There is limited data on whether diastolic dysfunction in patients with heart failure (HF) and recovered ejection fraction (HFrecEF) is associated with worse prognosis. We retrospectively assessed 96 patients diagnosed with HFrecEF and created ROC curve of their diastolic function at the 1-year follow-up for the composite endpoint of cardiovascular death and HF readmission after the follow-up. Eligible patients were divided into two groups according to the cutoff value of E/e′ ratio (12.1) with the highest AUC (0.70). Kaplan–Meier analysis showed that HFrecEF with high E/e′ group had a significantly poorer prognosis than the low E/e′ group (log-rank, p = 0.01). Multivariate Cox regression analysis revealed that the high E/e′ group was significantly related to the composite endpoint (hazard ratio 5.45, 95% confidence interval [CI] 1.23–24.1). The independent predictors at discharge for high E/e′ ratio at the 1-year follow-up were older age and female sex after adjustment for covariates (odds ratio [OR] 1.07, 95% CI 1.01–1.13 and OR 4.70, 95% CI 1.08–20.5). In conclusion, HFrecEF with high E/e′ ratio might be associated with a poor prognosis. Older age and female sex were independent predictors for a sustained high E/e′ ratio in patients with HFrecEF.

Impact of atrial fibrillation ablation on long‐term outcomes in patients with tachycardia‐bradycardia syndrome

Background

Methods

Results

Conclusions

Acute myocardial infarction and sudden cardiac arrest caused by anomalous left coronary artery arising from the noncoronary cusp

Anomalous left coronary artery arising from the noncoronary cusp (LCANCC) is a rare congenital disorder. We herein describe a 17-year-old female patient with sudden cardiac arrest followed by refractory cardiogenic shock. LCANCC-induced acute myocardial infarction with left main coronary artery involvement was subsequently diagnosed, and the patient required a durable left ventricular assist device. .

Portopulmonary hypertension and the risk of high right ventricular systolic pressure in liver transplant candidates

Aim

Portopulmonary hypertension (PoPH) is a rare and serious complication of liver cirrhosis and portal hypertension that can interfere with liver transplantation (LT). We evaluated the prevalence of PoPH and the clinical features of right ventricular systolic pressure (RVSP), which is equivalent to pulmonary artery systolic pressure, in LT candidates.

Methods

This was a single-center retrospective study. A total of 157 Japanese patients with decompensated liver cirrhosis or portal hypertension (76 men, median age = 52 years [range: 18–68 years]) were enrolled. The relationships between RVSP and clinical parameters, and the prevalence of PoPH in LT candidates, were evaluated.

Results

The cardiological parameters were as follows: brain natriuretic peptide (BNP), 39.1 (4.0–780.5) pg/mL; RVSP, 31.2 (16.0–122.4) mmHg; ejection fraction, 58% (28–72%); and mean peak tricuspid regurgitation velocity, 2.3 (1.5–5.3) m/s. The RVSP was significantly higher in females (p = 0.02) and primary biliary cholangitis (PBC) patients (p = 0.01), and was weakly correlated with the BNP level (r = 0.40, p = 0.01). For RVSPs of < 36 and ≥ 36 mmHg, the 5-year survival rates were 36.1% versus 34.1%, and 85.4% versus 85.3%, in non-LT and LT cases, respectively (p = 0.47 and 0.69, respectively). Among six patients with an RVSP ≥ 50 mmHg, three (1.9%) were diagnosed with PoPH and treated with vasodilators.

Conclusions

PoPH was observed in 3 cases (1.9%) in 157 LT candidates. In patients with suspected mild pulmonary hypertension (RVSP, 36 - 50 mmHg), LT was successfully performed.

First Validation of Myocardial Flow Reserve Derived from Dynamic 99mTc-Sestamibi CZT-SPECT Camera Compared with 13N-Ammonia PET

¹³N-ammonia positron emission tomography (NH₃-PET) can evaluate myocardial blood flow (MBF) at rest, stress, and myocardial flow reserve (MFR) as well as the ratio of MBF at stress to that at rest. MFR is useful in predicting the prognoses of patients with various heart diseases. Cadmium-zinc-telluride single photon emission computed tomography (CZT-SPECT) enables us to acquire dynamic images of radiotracer kinetics and measure original MBF and MFR using ^99mTc-sestamibi. This study aimed to investigate the utility of CZT-SPECT for quantitative assessment of MBF compared to NH₃-PET. We validated the correlation of MBF and MFR between CZT-SPECT and NH₃-PET. Fourteen patients using one-day rest/stress CZT-SPECT, D-SPECT followed by NH₃-PET within 1 month were enrolled and analyzed prospectively. The reproducibility of the MBF and MFR obtained with these two methods was examined using Spearman's correlation coefficient and Bland-Altman plot analysis. The diagnostic value of D-SPECT for abnormal MFR defined using NH₃-PET results as MFR < 2.0 was assessed using receiver-operating characteristic (ROC) analysis. The median duration between D-SPECT and NH₃-PET was 20 days. Although MBF was overestimated by D-SPECT compared to NH₃-PET at high value (mean difference, 0.43 [0.34-0.53]), MBF and MFR were correlated with the two modalities (MBF: r = 0.71, P < 0.0001, MFR: r = 0.60, P < 0.0001). The ROC curve analysis demonstrated a cutoff of 1.6 for detecting abnormal MFR with D-SPECT (sensitivity, 68%; specificity, 91%; AUC, 0.75). MBF and MFR obtained using D-SPECT and NH₃-PET had a good correlation, suggesting that the quantitative MFR evaluation by CZT-SPECT may help understand the trend of NH₃-PET MFR.

Myocardial Flow Reserve in Coronary Artery Disease with Low Attenuation Plaque: Coronary CTA and 13N-ammonia PET Assessments

RATIONALE AND OBJECTIVES

Physiological measurements from coronary angiography show that coronary stenosis with necrotic core plaque reduces coronary flow reserve (CFR). Myocardial flow reserve (MFR) estimated by ¹³N-ammonia PET (NH₃-PET) is a different index from CFR. Low attenuation plaque (LAP) on coronary CTA (CCTA) contains necrotic core, but the link between LAP and MFR has not been elucidated. We aimed to investigate the influence of LAP on MFR in coronary artery disease (CAD).

MATERIALS AND METHODS

The study included 105 consecutive patients who underwent NH₃-PET and CCTA within 3 months. Nonevaluable coronary arteries due to severe calcification and stent implants were excluded. Finally, 290 major vessels were retrospectively analyzed. Coronary arteries were divided into mild (1%-49%), moderate (50%-69% stenosis), and severe (≥70% stenosis) groups. Coronary plaques were classified either LAP (including soft tissue CT value <30 HU) or completely classified plaques. MFR for the major vessels were calculated and MFR <2.0 was considered a significant decrease. Comparison of MFR between territories with and without LAP, and the effect of plaque characteristics on MFR was analyzed.

RESULTS

MFR was significantly lower for territories with LAP than with calcified plaques or no plaque (2.1 ± 0.7, 2.4 ± 0.7, and 2.3 ± 0.7; p < 0.05). There was no difference between calcified plaque and no plaque territories (p = 0.79). Multivariate logistic analysis for plaque characteristics and stenosis severity revealed that LAP and severe stenosis were independent predictors for territories with MFR <2.0 with odds ratios of 3.1 (95% confidence interval, 1.2-8.1) and 3.0 (95% confidence interval, 1.7-5.3).

CONCLUSION

LAP reduced MFR compared with calcified plaque or no plaque in CAD. LAP is an independent predictor of the territory with MFR <2.0.

Functional Evaluation of Human Bioengineered Cardiac Tissue Using iPS Cells Derived from a Patient with Lamin Variant Dilated Cardiomyopathy

Dilated cardiomyopathy (DCM) is caused by various gene variants and characterized by systolic dysfunction. Lamin variants have been reported to have a poor prognosis. Medical and device therapies are not sufficient to improve the prognosis of DCM with the lamin variants. Recently, induced pluripotent stem (iPS) cells have been used for research on genetic disorders. However, few studies have evaluated the contractile function of cardiac tissue with lamin variants. The aim of this study was to elucidate the function of cardiac cell sheet tissue derived from patients with lamin variant DCM. iPS cells were generated from a patient with lamin A/C (LMNA) -mutant DCM (LMNA p.R225X mutation). After cardiac differentiation and purification, cardiac cell sheets that were fabricated through cultivation on a temperature-responsive culture dish were transferred to the surface of the fibrin gel, and the contractile force was measured. The contractile force and maximum contraction velocity, but not the maximum relaxation velocity, were significantly decreased in cardiac cell sheet tissue with the lamin variant. A qRT-PCR analysis revealed that mRNA expression of some contractile proteins, cardiac transcription factors, Ca²⁺-handling genes, and ion channels were downregulated in cardiac tissue with the lamin variant.Human iPS-derived bioengineered cardiac tissue with the LMNA p.R225X mutation has the functional properties of systolic dysfunction and may be a promising tissue model for understanding the underlying mechanisms of DCM.

Utility of dobutamine stress echocardiography in aortic valve regurgitation and reduced left ventricular function

OBJECTIVE

Predictors for post-operative reverse remodeling in patients with severe aortic regurgitation (AR) and reduced left ventricular ejection fraction (LVEF) are unknown. We performed low-dose dobutamine stress echocardiography (DSE) in patients with severe AR and reduced LVEF to evaluate the relationship between contractile reserve (CR) and reverse remodeling after surgery.

METHODS

In 31 patients with chronic severe AR and reduced LVEF (LVEF < 50%), we performed pre-operative DSE, assessed CR, and examined whether changes in preoperative DSE were associated with improvement of post-operative LVEF after aortic valve surgery.

RESULTS

The pre-operative echocardiographic findings were as follows: left ventricular (LV) end-diastolic dimension: 67 ± 10 mm, LV end-systolic dimension: 52 ± 13 mm, and LVEF: 42 ± 8%. All patients underwent aortic valve surgery. Patients with pre-operative LVEF of ≥45% exhibited a significant increase in LVEF; however, patients with pre-operative LVEF of <45% showed no significant change. When we examined the results of DSE performed in patients with pre-operative LVEF of <45%, ΔLVEF of ≥6% (with CR) during DSE was related to an improvement in post-operative LVEF; ΔLVEF of ≥6% during DSE predicted an improvement in post-operative LVEF, with sensitivity 100%; specificity 78%; and area under curve (AUC) .92.

CONCLUSIONS

DSE might be a helpful tool for predicting post-operative reverse remodeling in patients with severe AR and moderately reduced LVEF.

A novel optimized adaptive servo-ventilation setting for a patient with severe heart failure based on the echocardiogram: a case report

Background

Adaptive servo-ventilation (ASV) is a non-invasive positive-pressure ventilation therapy considered beneficial for treating heart failure (HF) in patients with central sleep apnoea. However, to the best of our knowledge, there is no evidence indicating that this therapy increases the mortality in HF patients. We hypothesized that ASV settings are important for HF patients with reduced ejection fraction. Therefore, to determine the suitable ASV setting for such patients, we optimized these settings to improve the left ventricular (LV) output during the therapy.

Case summary

We present a case of HF caused by dilated cardiomyopathy in a 45-year-old man. He was hospitalized due to HF; his LV ejection fraction was ∼20%, and haemodynamics analysis revealed his HF grade was Forrester subset IV. During hospitalization, he was diagnosed with sleep apnoea; therefore, we induced ASV with our optimized setting using an echocardiogram evaluating stroke volume (SV). Using this method, we could determine the appropriate setting that increased his SV and improved his apnoea–hypopnoea index. At the 5th-year follow-up, he had no dyspnoea on effort (New York Heart Association Functional Classification I). He continued using the ASV with good adherence, and no hospitalization for ventricular arrhythmia and HF was reported.

Discussion

Our ASV optimized setting showed beneficial effects in an HF patient with reduced ejection fraction. This method improved the patient’s SV and apnoea–hypopnoea index, indicating that this novel method should be considered for HF patients with reduced ejection fraction.

Relation of Left Atrial Flow, Volume, and Strain to Paroxysmal Atrial Fibrillation in Patients With Hypertrophic Cardiomyopathy

This study aims to characterize flow, volume, and strain of the left atrium in hypertrophic cardiomyopathy (HC) with atrial fibrillation (AF) using cine cardiovascular magnetic resonance (CMR) imaging. Cine CMR data for 144 patients with HC, including 29 patients with episodes of paroxysmal AF and 13 patients with persistent AF, were retrospectively analyzed. The vortex flow of the left atrial (LA, %) was measured using a vortex flow map and was used as an estimate of flow. The LA end-systolic volume index (ml/m²), LA ejection fraction (%) and global peak longitudinal LA strain (%) derived from a feature-tracking method were used as estimates of volume and strain. Vortex flow of the LA in patients with paroxysmal AF was significantly smaller than in patients without AF (vertical long-axis view; 26.7 ± 10.8% vs 33.2 ± 12.2%, p <0.005). The patients with paroxysmal AF had greater LA end-systolic volume index and global peak longitudinal LA strain and lower LA ejection fraction compared with those without AF. In conclusion, patients with HC with paroxysmal AF are characterized by small vortex flow, large volume, and decreased strain of LA on cine CMR.

The impact of kidney function in patients on antithrombotic therapy: a post hoc subgroup analysis focusing on recurrent bleeding events from the AFIRE trial

BACKGROUND

The success of antithrombotic therapies is assessed based on thrombotic and bleeding events. Simultaneously assessing both kinds of events might be challenging, and recurrent bleeding events are often ignored. We tried to confirm the effects of kidney function on outcome events in patients undergoing antithrombotic therapy.

METHODS

As a post hoc subgroup analysis of the Atrial Fibrillation and Ischemic Events with Rivaroxaban in Patients with Stable Coronary Artery Disease (AFIRE) trial, a randomized clinical trial with a median follow-up of 36 months, patients were divided into high and low estimated glomerular filtration rate (eGFR) groups with a cutoff value of 50 mL/min. The cumulative incidence of bleeding and crude incidence of recurrent bleeding per 100 patient-years were calculated. We used the Cox regression model with multiple failure time data for recurrent bleeding events.

RESULTS

Among 2092 patients, 1386 (66.3%) showed high eGFR. The cumulative bleeding events per 100 patients at 1 year were 5.4 and 6.2 in the high and low eGFR groups, respectively. The difference continued to increase over time. The hazard ratio for time to the first bleeding event in the high eGFR group was 0.875 (95% confidence interval 0.701-1.090, p = .234) and that for the first composite event was 0.723 (95% confidence interval 0.603-0.867, p < .000). The recurrent bleeding events per 100 person-years were 11.3 and 15.3 in the high and low eGFR groups, respectively, with a rate ratio of 0.738 (95% confidence interval 0.615-0.886, p = .001). During the observation period, the risk of bleeding changed with time. It peaked soon after the study enrollment in both groups. It decreased continuously in the high eGFR group but remained high in the low eGFR group.

CONCLUSIONS

We reaffirmed that kidney function affects bleeding events in patients on antithrombotic therapy, considering recurrent events. Patients should have detailed discussions with physicians regarding the possible bleeding events when continuing antithrombotic therapy, especially in patients with decreased kidney function.

TRIAL REGISTRATION

UMIN Clinical Trials Registry, UMIN000016612 . ClinicalTrials.gov, NCT02642419 . Registered on 21 October 2015.

Population pharmacokinetic analysis and dosage recommendations for digoxin in Japanese patients with atrial fibrillation and heart failure using real-world data

BACKGROUND

Digoxin is an important treatment option for reducing the ventricular rate in patients with atrial fibrillation (AF) and heart failure (HF). Digoxin has a narrow therapeutic window and large interindividual variability. A low target blood concentration, especially ≤0.9 ng/mL, is recommended for patients with HF who are taking digoxin. This study aimed to develop a population pharmacokinetic model and to identify clinical factors that affect digoxin exposure and an optimal digoxin dosing regimen in Japanese patients with AF and HF.

METHODS

A population pharmacokinetic analysis was performed by using a nonlinear mixed effects model based on 3465 concentration points from 391 patients (>18 years) who were receiving oral digoxin. Using trough serum digoxin concentrations and clinical data, a population pharmacokinetic model was developed for determining covariates of clearance. A 1-compartment model was used to examine the interindividual variability of the oral clearance (CL/F) of digoxin. An appropriate dosage of digoxin was identified using Monte Carlo simulation.

RESULTS

The final model demonstrated that creatinine clearance (CL_CR) and the use of amiodarone were factors that contributed to the CL/F of digoxin. Monte Carlo simulation results showed that with a daily maintenance dose of 0.25 mg, the intoxication risk window of a trough serum concentration of ≥0.9 ng/mL could be reached in more than half of patients regardless of renal function category or concurrent use of amiodarone. The appropriate maintenance dosage was 0.125 mg daily for most Japanese patients with AF and HF. However, with a daily dose of 0.125 mg, a trough serum concentration of ≥0.9 ng/mL could be reached in more than half of patients with renal impairments (CL_CR 30 mL/min) or concurrent use of amiodarone. A daily maintenance dose of 0.0625 mg was acceptable for these patients.

CONCLUSIONS

CL_CR and the use of amiodaron were found to contribute to digoxin clearance using a population pharmacokinetic methodology. For Japanese patients with AF and HF, 0.125 mg is an appropriate daily digoxin maintenance dose, but a dose reduction is required for patients with CL_CR <30 mL/min or concurrent amiodarone use.

Elevated cystatin-C levels are associated with increased mortality in acute coronary syndrome patients: An HIJ-PROPER Sub-Analysis

BACKGROUND AND AIMS

We investigated the association between serum cystatin-C levels and cardiovascular events in patients with acute coronary syndrome.

METHODS

Data of 1,100 patients from the prospective parent study were included. Patients hospitalized for acute coronary syndrome were divided into four groups based on quartiles (Q) of cystatin-C levels (mg/L) within 24-hours of admission: Q1, ≤0.82; Q2, 0.82<estimated level≤0.95; Q3, 0.95<estimated level≤1.12, and Q4, >1.12. The primary endpoint of this study was all-cause mortality and secondary endpoint was composite of all-cause mortality, non-fatal myocardial infarction, non-fatal stroke, unstable angina pectoris, or ischemia-driven revascularization.

RESULTS

During a median observation period of 4.0 years, the primary endpoint was noted in 5, 12, 18, and 36 patients in Q1, Q2, Q3, and Q4, respectively, with corresponding incidence rates of 1.8%, 4.4%, 6.5%, and 13.5%, respectively (p<0.0001 for difference among four groups). This association persisted even after adjusting for patient characteristics and other laboratory results at baseline (p=0.04). A stepwise increase in the incidence rate of the secondary endpoint with an incline in cystatin-C levels was observed in the non-adjusted model (26.6%, 33.3%, 32.3%, and 39.1% in Q1, Q2, Q3, and Q4, respectively; p=0.01), but not in the adjusted model (p=0.3). No difference was observed in the incidence rate of non-fatal myocardial infarction (p=0.89), non-fatal stroke (p=0.3), unstable angina pectoris (p=0.49), and ischemia-driven revascularization (p=0.47) with an incline in cystatin-C levels.

CONCLUSION

Elevated cystatin-C levels were associated with increased all-cause mortality but not cardiovascular events other than mortality in acute coronary syndrome patients.

Systemic sclerosis complicated by chronic thromboembolic pulmonary hypertension treated with balloon pulmonary angioplasty: a case report

Background

Systemic sclerosis (SSc) is known to induce pulmonary hypertension (PH), resulting in poor prognosis. Pulmonary hypertension secondary to connective tissue disease is usually classified as Group 1. In patients with SSc, PH owing to left heart failure (Group 2) and interstitial pneumonia (Group 3) are also known; however, there have been limited reports on chronic thromboembolic PH (CTEPH), which corresponds to Group 4.

Case summary

A 39-year-old female with SSc was admitted with shortness of breath on exertion for the past 4 months. Right heart catheterization revealed severe PH. Group 1 PH secondary to collagen tissue disease was suspected; however, thoracic computed tomography and lung perfusion scan led to the diagnosis of CTEPH of Group 4. We treated the PH with several medications and balloon pulmonary angioplasty (BPA), which improved the PH and right heart failure. Consequently, her overall condition also improved.

Discussion

This is a rare case report of SSc complicated by CTEPH, which was treated with BPA. Patients with SSc are prone to complications of various type of PH. Thus, it is important to distinguish CTEPH in terms of treatment choice and prognosis.

Papillary muscle ischemia on high-resolution cine imaging of nitrogen-13 ammonia positron emission tomography: Association with myocardial flow reserve and prognosis in coronary artery disease

BACKGROUND

The evaluation of papillary muscle (PM) perfusion through existing perfusion imaging, including single-photon emission computed tomography and magnetic resonance imaging, is not possible. Therefore, this study sought to investigate the detection of PM ischemia in coronary artery disease (CAD) using nitrogen-13 (N-13) ammonia positron emission tomography (NH3 PET) and its association with global myocardial flow reserve (MFR) and major adverse cardiac events (MACE).

METHODS

Data of adenosine-stress NH3 PET for 263 consecutive patients with known or suspected CAD were retrospectively analyzed. PM ischemia was defined as the absence of PM accumulation under stress conditions and PM presence at rest on high-resolution cine imaging derived from PET-computed tomography scanner with time-of-flight technology. The primary outcome was MACE.

RESULTS

Of 263 patients, 30 experienced mean follow-up period of 910 days (MACE), while 31 (11.8%) presented PM ischemia. Compared to patients without PM ischemia, those with PM ischemia reported a significantly lower global MFR and a significantly higher rate of MACE (P < .0001).

CONCLUSION

NH3 PET enables the detection of PM ischemia in approximately 10% of patients with known or suspected CAD. PM ischemia is associated with reduced global MFR and is an important sign in predicting prognosis.

Increased left atrial volume index is associated with more cardiovascular events in patients with acute coronary syndrome: HIJ-PROPER study findings

AIM

To investigate the association between the left atrial volume index (LAVI) and the incidence of cardiovascular events in patients with acute coronary syndrome (ACS) who did not have atrial fibrillation (AF).

METHODS

In this sub-analysis of the HIJ-PROPER study, 226 ACS patients who did not have a history of AF were enrolled. Participants were divided into two groups according to the LAVI cut-off level calculated by receiver operating characteristic (ROC) curve analysis to predict the primary endpoint, and cardiovascular events were compared between groups. The primary endpoint was the first occurrence of all-cause death, non-fatal myocardial infarction, non-fatal stroke, and hospitalization for heart failure.

RESULTS

ROC curve analysis for the occurrence of composite of cardiovascular events indicated a LAVI cut-off point of 34 mL/m² . Based on this, 131 patients (58.0%) were in the LAVI < 34 mL/m² group and 95 (42.0%) were in the LAVI ≥ 34 mL/m² group. Over a median follow-up period of 4.0 years [interquartile range: 3.2, 5.1], cardiovascular events were noted in 7 and 15 patients in the LAVI < 34 mL/m² and LAVI ≥ 34 mL/m² groups, corresponding to an incidence rate of 5.3% and 15.8%, respectively. Patients with a LAVI value ≥ 34 mL/m² had a significantly higher risk of cardiovascular events than those with a LAVI value < 34 mL/m² (hazard ratio: 2.93; 95% confidence interval: 1.19-7.22; P = .014). The tendency was similar after adjusting for several confounders (P = .025).

CONCLUSION

In ACS patients without AF, elevated LAVI was associated with increased cardiovascular events.

CLINICAL TRIAL REGISTRATION

International standard randomized controlled trial (URL: https://www.umin.ac.jp; UMIN000002742).