2020 Vol. 17, No. 12
Catheter ablation for atrial fibrillation is associated with reduced risk of mortality in the elderly: a prospective cohort study and propensity score analysis
2020, 17(12): 740-749. doi: 10.11909/j.issn.1671-5411.2020.12.008
Background It is unclear whether catheter ablation (CA) for atrial fibrillation (AF) affects the long-term prognosis in the elderly. This study aims to evaluate the relationship between CA and long-term outcomes in elderly patients with AF. Methods Patients more than 75 years old with non-valvular AF were prospectively enrolled between August 2011 and December 2017 in the Chinese Atrial Fibrillation Registry Study. Participants who underwent CA at baseline were propensity score matched (1:1) with those who did not receive CA. The outcome events included all-cause mortality, cardiovascular mortality, stroke/transient ischemic attack (TIA), and cardiovascular hospitalization. Results Overall, this cohort included 571 ablated patients and 571 non-ablated patients with similar characteristics on 18 dimensions. During a mean follow-up of 39.75 ± 19.98 months (minimum six months), 24 patients died in the ablation group, compared with 60 deaths in the non-ablation group [hazard ratio (HR) = 0.49, 95% confidence interval (CI): 0.30-0.79, P = 0.0024]. Besides, 6 ablated and 29 non-ablated subjects died of cardiovascular disease (HR = 0.25, 95% CI: 0.11–0.61, P = 0.0022). A total of 27 ablated and 40 non-ablated patients suffered stroke/TIA (HR = 0.79, 95% CI: 0.48–1.28, P = 0.3431). In addition, 140 ablated and 194 non-ablated participants suffered cardiovascular hospitalization (HR = 0.84, 95% CI: 0.67–1.04, P = 0.1084). Subgroup analyses according to gender, type of AF, time since onset of AF, and anticoagulants exposure in initiation did not show significant heterogeneity. Conclusions In elderly patients with AF, CA may be associated with a lower incidence of all-cause and cardiovascular mortality.
Effects of angiotensin-converting enzyme inhibitor and angiotensin II receptor blocker on one-year outcomes of patients with atrial fibrillation: insights from a multicenter registry study in China
2020, 17(12): 750-758. doi: 10.11909/j.issn.1671-5411.2020.12.005
Objective To evaluate the effect of angiotensin-converting enzyme inhibitor (ACEI)/angiotensin II receptor blocker (ARB) therapy on the prognosis of patients with atrial fibrillation (AF). Methods A total of 1, 991 AF patients from the AF registry were divided into two groups according to whether they were treated with ACEI/ARB at recruitment. Baseline characteristics were carefully collected and analyzed. Logistic regression was utilized to identify the predictors of ACEI/ARB therapy. The primary endpoint was all-cause mortality, while the secondary endpoints included cardiovascular mortality, stroke and major adverse events (MAEs) during the one-year follow-up period. Univariable and multivariable Cox regression were performed to identify the association between ACEI/ARB therapy and the one-year outcomes. Results In total, 759 AF patients (38.1%) were treated with ACEI/ARB. Compared with AF patients without ACEI/ARB therapy, patients treated with ACEI/ARB tended to be older and had a higher rate of permanent AF, hypertension, diabetes mellitus, heart failure (HF), left ventricular ejection fraction (LVEF) < 40%, coronary artery disease (CAD), prior myocardial infarction (MI), left ventricular hypertrophy, tobacco use and concomitant medications (all P < 0.05). Hypertension, HF, LVEF < 40%, CAD, prior MI and tobacco use were determined to be predictors of ACEI/ARB treatment. Multivariable analysis showed that ACEI/ARB therapy was associated with a significantly lower risk of one-year all-cause mortality [hazard ratio (HR) (95% CI): 0.682 (0.527-0.882), P = 0.003], cardiovascular mortality [HR (95% CI): 0.713 (0.514-0.988), P = 0.042] and MAEs [HR (95% CI): 0.698 (0.568-0.859), P = 0.001]. The association between ACEI/ARB therapy and reduced mortality was consistent in the subgroup analysis. Conclusions In patients with AF, ACEI/ARB was related to significantly reduced one-year all-cause mortality, cardiovascular mortality and MAEs despite the high burden of cardiovascular comorbidities.
2020, 17(12): 759-765. doi: 10.11909/j.issn.1671-5411.2020.12.003
Background The relationship between parity and atherosclerosis has been reported in some ethnic populations. However, results regarding Chinese women are still lacking. This study aimed to investigate the association of parity and carotid atherosclerosis, which has a predictive value of subsequent atherosclerotic events in elderly Chinese women. Methods A total of 2, 052 participants from the medical examination center of the Third Xiangya Hospital were enrolled in the study. A standardized, structured questionnaire was administered to collect information on subjects' demographic characteristics, socioeconomic status, and cardiovascular risk factors. High-resolution ultrasound was used to examine carotid plaques and carotid intima-media thickness (IMT). Results The mean age of participants was 66.1 ± 5.5 years. Women with more birth appeared to have a higher risk of carotid artery plaques. A multivariate-adjusted model yielded an odds ratio of 1.38 (95% CI: 12%-70%, P = 0.003) per birth. A positive association was observed between parity and common carotid IMT (β ± SE: 0.029 ± 0.006, P < 0.001), and internal carotid IMT (β ± SE: 0.011 ± 0.005, P = 0.03) in a univariate model; however, these associations became non-significant in multivariate-adjusted models. When common carotid IMT was classified into an IMT ≥ 1 mm group and an IMT < 1 mm group, higher parity was associated with more obvious thickening both in the unadjusted model (OR = 1.61, 95% CI: 1.29-2.00, P < 0.001) and in the fully adjusted model (OR = 1.43, 95% CI: 1.09-1.88, P = 0.01). Conclusions There is a positive association between parity and risk of carotid plaques, as well as between parity and risk of obvious thickening for common carotid IMT in elderly Chinese women, indicating multiparous women might experience more atherosclerotic challenges.
Validation of methods for effective orifice area measurement of prosthetic valves by two-dimensional and Doppler echocardiography following transcatheter self-expanding aortic valve implantation
2020, 17(12): 766-774. doi: 10.11909/j.issn.1671-5411.2020.12.006
Background The effective orifice area (EOA) is utilized to characterize the hemodynamic performance of the transcatheter heart valve (THV). However, there is no consensus on EOA measurement of self-expanding THV. We aimed to compare two echocardiographic methods for EOA measurement following transcatheter self-expanding aortic valve implantation. Methods EOA was calculated according to the continuity equation. Two methods were constructed. In Method 1 and Method 2, the left ventricular outflow tract diameter (LVOTd) was measured at the entry of the prosthesis (from trailing-to-leading edge) and proximal to the prosthetic valve leaflets (from trailing-to- leading edge), respectively. The velocity-time integral (VTI) of the LVOT (VTILVOT) was recorded by pulsed-wave Doppler (PW) from apical windows. The region of the PW sampling should match that of the LVOTd measurement with precise localization. The mean transvalvular pressure gradient (MG) and VTI of THV was measured by Continuous wave Doppler. Results A total of 113 consecutive patients were recruited. The mean age was 77.2 ± 5.5 years, and 72 patients (63.7%) were male. EOA1 with the use of Method 1 was larger than EOA2 (1.56 ± 0.39 cm2 vs. 1.48 ± 0.41 cm2, P = 0.001). MG correlated better with the indexed EOA1 (EOAI1) (r = -0.701, P < 0.001) than EOAI2 (r = -0.645, P < 0.001). According to EOAI (EOAI ≤ 0.65 cm2/m2, respectively), the proportion of sever prosthesis-patient mismatch with the use of EOA1 was lower than EOA2 (12.4% vs. 21.2%, P < 0.05). Compared with EOA2, EOA1 had lower interobserver and intra-observer variability (intra: 0.5% ± 17% vs. 3.8% ± 22%, P < 0.001; inter: 1.0% ± 9% vs. 3.5% ± 11%, P < 0.001). Conclusions For transcatheter self-expanding valve EOA measurement, LVOTd should be measured in the entry of the prosthesis stent (from trailing-to-leading edge), and VTILVOT should match that of the LVOTd measurement with precise localization.
Venous thromboembolism prophylaxis-prescribing patterns among elderly medical patients in a Saudi tertiary care center: success or failure?
2020, 17(12): 775-781. doi: 10.11909/j.issn.1671-5411.2020.12.004
Background Hospitalized elderly patients are at high risk of venous thromboembolism (VTE), and the appropriate use of thromboprophylaxis can significantly reduce the incidence of VTE in high-risk patients. We investigated the pattern of VTE prophylaxis administration among elderly medical patients and assessed its appropriateness based on the American College of Chest Physicians (ACCP) recommendations. Methods A cross-sectional single-center study was conducted between October 2019 and March 2020, including hospitalized (> 48 h), elderly (≥ 60 years), medical patients, and excluding patients receiving anticoagulant for other reason, having contraindication to thromboprophylaxis, or had VTE diagnosed within 48 h. The Padua prediction score was used to determine the patients' risk for VTE, and thromboprophylaxis use was assessed against the ACCP recommendations. Results The study included 396 patients with an average age of 75.0 ± 9.01 years, and most patients (71.7%) were classified as high risk for VTE development (Padua score ≥ 4 points). Thromboprophylaxis use was inappropriate in 27.3% of patients, of whom 85.2% were ineligible but still received thromboprophylaxis. Patients who were classified as low risk of VTE were more likely to receive inappropriate thromboprophylaxis (AOR = 76.5, 95% CI: 16.1-363.2), whereas patients with acute infection or rheumatologic disorder were less likely to receive inappropriate thromboprophylaxis (AOR = 0.46, 95% CI: 0.22-0.96). Conclusions Although the use of thromboprophylaxis among high-risk elderly patients was reasonably adequate, a large proportion of low-risk patients were exposed to unnecessary risk through inappropriate overutilization of thromboprophylaxis. Thus, healthcare providers should accurately assess patients' risk before prescribing thromboprophylaxis to ensure patient safety.