ISSN 1671-5411 CN 11-5329/R

2021 Vol. 18, No. 5

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RESEACH ARTICLE
The impact of post-operative atrial fibrillation on outcomes in coronary artery bypass graft and combined procedures
Yau-Lam Alex Chau, Ji Won Yoo, Ho Chuen Yuen, Khalid Bin Waleed, Dong Chang, Tong Liu, Fang Zhou Liu, Gary Tse, Sharen Lee, Ka Hou Christien Li
2021, 18(5): 319-326. doi: 10.11909/j.issn.1671-5411.2021.05.005
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 BACKGROUND Post-operative atrial fibrillation (POAF) is a common yet understudied clinical issue after coronary artery bypass graft (CABG) leading to higher mortality rates and stroke. This systematic review and meta-analysis evaluated the rates of adverse outcomes between patients with and without POAF in patients treated with CABG or combined procedures.  METHODS The search period was from the beginning of PubMed and Embase to May 18th, 2020 with no language restrictions. The inclusion criteria were: (1) studies comparing new onset atrial fibrillation before or after revascularization vs. no new onset AF before or after revascularization. The outcomes assessed included all-cause mortality, cardiac death, cerebral vascular accident (CVA), myocardial infarction (MI), repeated revascularization, major adverse cardiac event (MACE), and major adverse cardiac and cerebrovascular events (MACCEs).  RESULTS Of the 7,279 entries screened, 11 studies comprising of 57,384 patients were included. Compared to non-POAF, POAF was significantly associated with higher risk of all-cause mortality (Risk Ratio (RR) = 1.58; 95% Confidence Interval (CI): 1.42−1.76, P < 0.00001) with accompanying high level of heterogeneity (I2 = 62%).  Conclusions Patients with POAF after CABG or combined procedures are at an increased risk of all-cause mortality or CVAs. Therefore, POAF after such procedures should be closely monitored and treated judiciously to minimize risk of further complications. While there are studies on POAF versus no POAF on outcomes, the heterogeneity suggests that further studies are needed.
Potentially inappropriate prescribing of cardiovascular system and antiplatelet/anticoagulant drugs among elderly patients: a Korean population-based national study
Jongyeon Kim, Euna Han, Hee-Jin Hwang, Hyeonseok Cho, Young-Sang Kim, Hyejin Chun, Jinkwon Kim, Yon Chul Park, Hye-Young Kang
2021, 18(5): 327-337. doi: 10.11909/j.issn.1671-5411.2021.05.010
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 OBJECTIVES  To investigate the prevalence of potentially inappropriate prescribing (PIP) for cardiovascular system (CVS) and antiplatelet/anticoagulant (AP/AC) drugs among Korean elderly patients, using the Screening Tool of Older Persons’ Prescriptions (STOPP) criteria version 2 and to identify the risk factors related to PIP.  METHODS  The 2016 National Aged Patient Sample data, comprising National Health Insurance claim records for a random sample of 20% of patients aged ≥ 65 years, were used to calculate PIP prevalence of outpatient prescriptions. For criteria including drug-disease interactions, PIP prevalence per indication was estimated.  RESULTS  Among 1,274,148 elderly patients and 27,062,307 outpatient prescription claims, 100,085 patients (7.85%) and 341,664 claims (1.27%) had one or more PIP. The most frequent PIP was “non-steroidal anti-inflammatory drug with concurrent antiplatelet agent (s) without proton-pump inhibitor prophylaxis” in the claim-level (0.97%) and patient-level (6.33%) analyses. “Beta-blocker with bradycardia” (16.47% of claims) and “angiotensin receptor blockers in patients with hyperkalaemia” (23.89% of claims) showed the highest PIP prevalence per indication. Logistic regression analysis revealed that, among the patient and health care provider characteristics, female, older age, more severe comorbidities, polypharmacy, higher level of healthcare organization, and specialty of prescriber were significantly associated with a higher risk of PIP.  CONCLUSIONS  Our findings of a high prevalence of PIP for CVS and AP/AC drugs among the elderly suggest that an effective strategy is urgently needed to improve the prescription practices of these drugs.
Prevalence and prognostic value of cardiac troponin in elderly patients hospitalized for COVID-19
Vincenzo De Marzo, Antonio Di Biagio, Roberta Della Bona, Antonio Vena, Eleonora Arboscello, Harusha Emirjona, Sara Mora, Mauro Giacomini, Giorgio Da Rin, Paolo Pelosi, Matteo Bassetti, Pietro Ameri, Italo Porto,   GECOVID study group
2021, 18(5): 338-345. doi: 10.11909/j.issn.1671-5411.2021.05.004
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 BACKGROUND Increases in cardiac troponin (cTn) in coronavirus disease 2019 (COVID-19) have been associated with worse prognosis. Nonetheless, data about the significance of cTn in elderly subjects with COVID-19 are lacking. METHODS From a registry of consecutive patients with COVID-19 admitted to a hub hospital in Italy from 25/02/2020 to 03/07/2020, we selected those ≥ 60 year-old and with cTnI measured within three days from the molecular diagnosis of SARS-CoV-2 infection. When available, a second cTnI value within 48 h was also extracted. The relationship between increased cTnI and all-cause in-hospital mortality was evaluated by a Cox regression model and restricted cubic spline functions with three knots. RESULTS Of 343 included patients (median age: 75.0 (68.0−83.0) years, 34.7% men), 88 (25.7%) had cTnI above the upper-reference limit (0.046 µg/L). Patients with increased cTnI had more comorbidities, greater impaired respiratory exchange and higher inflammatory markers on admission than those with normal cTnI. Furthermore, they died more (73.9% vs. 37.3%, P < 0.001) over 15 (6−25) days of hospitalization. The association of elevated cTnI with mortality was confirmed by the adjusted Cox regression model (HR = 1.61, 95%CI: 1.06−2.52, P = 0.039) and was linear until 0.3 µg/L, with a subsequent plateau. Of 191 (55.7%) patients with a second cTnI measurement, 49 (25.7%) had an increasing trend, which was not associated with mortality (univariate HR = 1.39, 95%CI: 0.87−2.22, P = 0.265). CONCLUSIONS In elderly COVID-19 patients, an initial increase in cTn is common and predicts a higher risk of death. Serial cTn testing may not confer additional prognostic information.
REVIEW
Cardiac papillary fibroelastoma
Dominika M Zoltowska, Edin Sadic, Kyeesha Becoats, Shreya Ghetiya, Aleem Azal Ali, Srinivasan Sattiraju, Emil Missov
2021, 18(5): 346-351. doi: 10.11909/j.issn.1671-5411.2021.05.009
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Papillary fibroelastoma (PFE) is a primary, histologically benign endocardial neoplasm. Though PFE has long been reported as the second most common primary cardiac neoplasm, it has since pulled ahead of cardiac myxomas, largely due to evolving cardiac imaging modalities. While PFEs are benign histologically, they have the potential for devastating clinical consequences, transient ischemic attack, stroke, myocardial infarction, syncope, pulmonary, and peripheral embolism. Despite increased detection rate, there remains uncertainty regarding etiology, exact prevalence, and clinical management of PFEs. This paucity of information is reflected by the lack of official guidelines on this matter. In this article, we aim to summarize the current state of understanding regarding PFE and discuss areas of ongoing controversy.
Anticoagulation for atrial fibrillation in heart failure patients: balancing between Scylla and Charybdis
Grigorios Tsigkas, Anastasiοs Apostolos, Stefanos Despotopoulos, Georgios Vasilagkos, Angeliki Papageorgiou, Eleftherios Kallergis, Georgios Leventopoulos, Virginia Mplani, Ioanna Koniari, Dimitrios Velissaris, John Parissis
2021, 18(5): 352-361. doi: 10.11909/j.issn.1671-5411.2021.05.006
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The management of heart failure (HF) and atrial fibrillation (AF) in real-world practice remains a debating issue, while the number of HF patients with AF increase dramatically. While it is unclear if rhythm or rate control therapy is more beneficial and under which circumstances, anticoagulation therapy is the cornerstone of the AF-HF patients’ approach. Vitamin-K antagonists were the gold-standard during the past, but currently their usage is limited in specific conditions. Non-vitamin K oral anticoagulants (NOACs) have gained ground during the last ten years and considered as gold-standard of a wide spectrum of HF phenotypes. The current manuscript aims to review the current literature regarding the indications and the optimal choice and usage of NOACs in HF patients with AF.
Beta-blocker treatment in heart failure patients with atrial fibrillation: challenges and perspectives
Emmanouil Chourdakis, Ioanna Koniari, Dimitrios Velissaris, Grigorios Tsigkas, Nikolaos G Kounis, Neriman Osman
2021, 18(5): 362-375. doi: 10.11909/j.issn.1671-5411.2021.05.008
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Heart failure (HF) and atrial fibrillation (AF) are common conditions that share similar clinical phenotype and frequently coexist. The classification of HF in patients with preserved ejection fraction (> 50%, HFpEF), mid-range reduced EF (40%−49%, HFmrEF) and reduced EF (< 40%, HFrEF) are crucial for optimising the therapeutic approach, as each subgroup responds differently. Beta-blocker constitute an important component of our pharmacological regimen for chronic HF. Beta-blocker administration is reccomended in patients with HF with reduced ejection fraction in stable sinus rhythm, due to improvement of symptoms, the better long term-outcome and survival. The beneficial role of beta-blocker use in patients with preserved EF still remain unclear, as no treatment showed a positive impact, regarding morbidity or mortality reduction. The presence of AF in HF patients increases as the disease severity evolves and is associated with a higher rate of cardiovascular morbidity and mortality. But more question is the use of betablocker in HF patients irrespective of EF and concomitant AF. There are many conflicting data and publications, regarding the beta blocker benefit in this population. Generally, it is supported an attenuation of beta-blockers beneficial effect in HF patients with AF. A design of more randomised trials/studies with HF patients and concomitant AF may improve our clinical approach of beta-blockers use and identify the patients with HF, who mostly profit from an invasive approach.
Atrial fibrillation in patients with systolic heart failure: pathophysiology mechanisms and management
Ioanna Koniari, Eleni Artopoulou, Dimitrios Velissaris, Nicholas Kounis, Grigorios Tsigkas
2021, 18(5): 376-397. doi: 10.11909/j.issn.1671-5411.2021.05.003
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Heart failure (HF) and atrial fibrillation (AF) demonstrate a constantly increasing prevalence during the 21st century worldwide, as a result of the aging population and the successful interventions of the clinical practice in the deterioration of adverse cardiovascular outcomes. HF and AF share common risk factors and pathophysiological mechanisms, creating the base of a constant interrelation. AF impairs systolic and diastolic function, resulting in the increasing incidence of HF, whereas the structural and neurohormonal changes in HF with preserved or reduced ejection fraction increase the possibility of the AF development. The temporal relationship of the development of either condition affects the diagnostic algorithms, the prognosis and the ideal therapeutic strategy that leads to euvolaemia, management of non-cardiovascular comorbidities, control of heart rate or restoration of sinus rate, ventricular synchronization, prevention of sudden death, stroke, embolism, or major bleeding and maintenance of a sustainable quality of life. The indicated treatment for the concomitant HF and AF includes rate or/and rhythm control as well as thromboembolism prophylaxis, while the progress in the understanding of their pathophysiological interdependence and the introduction of the genetic profiling, create new paths in the diagnosis, the prognosis and the prevention of these diseases.
LETTER TO THE EDITOR
Coronary artery disease presenting as intractable hiccups: an unclear mechanism
Alor Sahoo, Sarabjeet Singh
2021, 18(5): 398-399. doi: 10.11909/j.issn.1671-5411.2021.05.007
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A valve-in-valve approach to manage severe bioprosthetic tricuspid valve stenosis
Dominika M Zoltowska, Naji Maaliki, Bashar Al-Turk, Andres M Pineda Maldonado, Srinivasan Sattiraju
2021, 18(5): 400-402. doi: 10.11909/j.issn.1671-5411.2021.05.002
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A case series of precipitous cardiac tamponade from suspected perimyocarditis in COVID-19 patients
William Kogler, Michael Omar, Naji Maaliki, Shaorinkumar Patel, Sam Foldy, Jose Ruiz
2021, 18(5): 403-406. doi: 10.11909/j.issn.1671-5411.2021.05.001
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