bluuebunny/crossref_metadata_2025_split huggingface dataset:
Vitamin K antagonists versus direct oral anticoagulants after cardiac surgery: a 31-country cohort study
Authors: Whitlock R , Belley-Cote E.P , Healey J , Devereaux P.J , Eikelboom J , Lamy A , Brady K , Marsella B , Tagarakis G.I , Paparella D , Reents W , Punjabi P , Connolly S 
Published: November 2020

Abstract

Background
About 10% of patients undergoing cardiac surgery have a history of atrial fibrillation (AF). Among these patients, uncertainty exists regarding the safest and most effective oral anticoagulant (OAC) during the postoperative period.

Purpose
To evaluate practice patterns regarding OAC early after cardiac surgery in patients with a preoperative history of AF and to compare the safety and effectiveness of direct oral anticoagulants (DOACs) versus vitamin K antagonists (VKAs).

Methods
We conducted a nested cohort study within the Left Atrial Appendage Occlusion Study (LAAOS) III (NCT01561651). LAAOS III included patients with AF undergoing cardiac surgery with a CHA2DS2-VASC ≥2. In this substudy, we examined patients without end-stage renal dysfunction (eGFR &gt;30 mL/min/1.73m2) who were discharged on OAC. We evaluated bleeding and thromboembolism within 90 days postoperatively using logistic regression adjusting for CHA2DS2-VASC score.

Results
Recruitment started in 2012 and completed in 2018 in 113 centres in 31 countries. Of the 4811 patients enrolled in LAAOS III, 3725 (77%) were included in this substudy. Preoperatively, 58% of patients received OAC: 56% DOACs and 44% VKAs. At hospital discharge 23% received DOACs and 77% VKAs; 55% of patients on a DOAC at baseline were switched to a VKA while 5% of patients on a VKA were switched to a DOAC. Patients discharged on a DOAC were older, had a higher CHA2DS2-VASC, and were more likely to be male. Patients having undergone an isolated coronary bypass procedure were more likely prescribed DOACs than VKAs (41% vs 23%, p&lt;0.001) whereas isolated non-mechanical valve patients were more likely to be prescribed VKAs (43% vs 28%, p&lt;0.001). Switching from a DOAC to a VKA postoperatively occurred in 42% of patients In Australia/New Zealand, 49% in Europe, and 63% in North America. Major bleeding between 48 hours postoperatively and 30 days occurred in 1.5% in the DOAC group and 1.3% in the VKA group (aOR 1.14, 95% CI 0.60–2.15, p=0.69) while between 48 hours and 90 days, it occurred in 1.8% of patients in both groups (aOR 0.97, 95% CI, 0.54–1.17, p=0.91). Cardiac tamponade, the composite of stroke and systemic arterial embolism, and the composite of stroke, systemic arterial embolism and death did not differ significantly at 30 and 90 days between the DOAC and VKA groups.

Conclusions
VKAs was the dominant OAC used early after cardiac surgery, but postoperative OAC practices varied by region. After adjustment for CHA2DS2-VASC score, the early postoperative incidence of major bleeding and of the composite of stroke and systemic arterial embolism did not differ significantly when DOACs were compared with VKAs.

Funding Acknowledgement
Type of funding source: Public grant(s) – National budget only. Main funding source(s): CIHR, Heart and Stroke Foundation
Effectiveness and safety of non-vitamin K antagonist oral anticoagulants in atrial fibrillation patients with antiphospholipid syndrome: a nationwide cohort study
Authors: Yang P.S , Shim M , Kang S.H , Kim S.H , Kim W.J , Moon J.Y , Sung J.H , Kim I.J , Lim S.W , Cha D.H , Lip G.Y.H , Joung B 
Published: November 2020

Abstract

Background and objectives
Non-vitamin K antagonist oral anticoagulants (NOACs) are an effective and safe alternative to warfarin in atrial fibrillation (AF) patients, but there is not enough evidence that NOACs can offer sufficient protection in AF patients concomitantly diagnosed with antiphospholipid syndrome (APS). Use of rivaroxaban has been associated with an increased risk of thrombotic events compared with warfarin in results of the TRAPS trial, but the TRAPS trial is not for AF patients and included only very high-risk APS patients with triple-positive for all 3 antiphospholipid antibodies. We sought to compare thromboembolic events, bleeding, and mortality between NOAC and warfarin in patients with both AF and APS.

Methods
From the Korean National Health Insurance Service (NHIS) database during the period from January 1, 2011 to December 31, 2016, we identified an warfarin-treated group of patients with AF and APS (n=1,237) who were compared with a 1:1 propensity-matched NOAC treated group (n=1,237).

Results
After a median follow-up period of 17 months, NOAC-treated patients had lower incidence rates for ischemic stroke (5.9 and 10.5 events per 100 person-years for the NOAC and warfarin groups), major bleeding (4.1 and 8.3 events per 100 person-years, respectively), and all-cause mortality (3.4 and 15.6 events per 100 person-years, respectively) compared with warfarin in patients with AF and APS. Compared with warfarin, NOAC significantly decreased the risk of ischemic stroke (hazard ratio [HR]: 0.60, 95% confidence interval [CI]: 0.47–0.77, p&lt;0.001), major bleeding (HR: 0.54, 95% CI: 0.41–0.72, p&lt;0.001) and all-cause mortality (HR: 0.32, 95% CI: 0.27–0.40, p&lt;0.001) with considering competing risk of death.

Conclusions
Compared with warfarin, AF patients with APS on NOACs had lower ischemic stroke, major bleeding, and all-cause mortality. Our data suggest that AF patients with APS can be safely and effectively treated with NOACs.

Funding Acknowledgement
Type of funding source: None
Effect of continuous positive airway pressure therapy in patients with paroxysmal atrial fibrillation and obstructive sleep apnea: a randomized controlled trial
Authors: Traaen G.M , Aakeroy L , Hunt T.E , Overland B , Bendz C , Sande L.O , Aakhus S , Zare H , Fagerland M , Steinshamn S , Bredesen N , Anfinsen O.G , Akre H , Loennechen J.P , Gullestad L 
Published: November 2020

Abstract

Background
There is strong evidence for an association between atrial fibrillation (AF) and sleep apnea (SA).

Purpose
We aimed to examine the effect of treatment with continuous positive airway pressure (CPAP) on the burden of AF.

Methods
After a run-in period for CPAP-tolerance, we randomly assigned 108 eligible patients between 18–75 years, who had paroxysmal AF and moderate-to-severe obstructive SA (apnea-hypopnea index (AHI)≥15), to receive either CPAP treatment (n=54) plus usual care or usual care alone (n=54) for five months. An implanted loop recorder measured time in AF continuously. The primary endpoint was the difference in change of AF burden (% of time in AF) between CPAP treatment and usual care from baseline (one month prior to randomization) to the last three months of the intervention period. Secondary endpoints were changes in quality of life assessed by the Short Form-36 (SF-36), Epworth Sleepiness Scale (ESS), and the Functional Outcomes of Sleep Questionnaire (FOSQ).

Results
Mean (SD) age was 62.4 (7.7) years, BMI 29.4 (4.2) kg/m2, ESS 7.9 (3.2), and 76.1% were men. In the intervention group, the mean duration of adherence to CPAP therapy was 4.3 hours/night. During treatment mean AHI decreased from 27.6 events/hour at baseline to 2.3 events/hour during follow-up. Mean time in AF decreased from 5.0%-4.3% in the control group and from 5.6%-4.1% in the CPAP group, but the difference in change was not significant (p=0.52). Sub-analysis of those using CPAP&gt;&lt;4 hours/night also showed no difference, neither did the quality of life questionnaires.

Conclusion
This is the first randomized controlled trial to assess the effect of treatment of SA on the burden of AF, and did not detect a difference between those treated with CPAP compared to usual care alone.

Funding Acknowledgement
Type of funding source: Public hospital(s). Main funding source(s): Oslo University Hospital is the main funding Source. ResMed Science Center provided an unrestricted grant.
Sinus heart rate post pulmonary vein ablation and long-term risk of recurrences
Authors: Von Olshausen G , Saluveer O , Schwieler J , Drca N , Bastani H , Tapanainen J , Bourke T , Paul-Nordin A , Kenneback G , Insulander P , Jensen-Urstad M , Braunschweig F 
Published: November 2020

Abstract

Aim
To investigate the association of sinus heart rate pre- and post-ablation and recurrence rates in patients undergoing catheter ablation for atrial fibrillation.

Methods
Between January 2012 and December 2017, data of 482 patients undergoing their first pulmonary vein isolation (PVI) were included. All patients were followed-up for 12 months and were screened for any atrial tachyarrhythmia. Sinus heart rate measurements were recorded before (PRE), directly post ablation (POST) and 3 months post ablation (3M).

Results
In the total study population, the mean resting sinus heart rate at PRE (mean 57.9 bpm (95% CI, 57.1–58.7 bpm)) increased by over 10 bpm to POST (mean 69.4 bpm (95% CI, 68.5–70.3 bpm); p&lt;0.001) followed by a slight decrease at 3M (mean 67.3 bpm (95% CI, 66.4–68.2 bpm)) but still remaining higher compared to PRE (p&lt;0.001). This pattern was observed in patients with and without recurrences at PRE, POST and 3M respectively (both p&lt;0.001). However, only at 3M, there was a significant difference in mean heart rate being lower in patients with compared to patients without recurrences (p=0.031). In this regard, patients with a heart rate ≥60 bpm at 3M and a heart rate change ≥11 bpm (PRE to 3M) had a favorable outcome in terms of recurrences compared to the remaining patients (HR 0.61 (95% CI, 0.44–0.84), p=0.002 and HR 0.55 (95% CI, 0.40–0.76), p&lt;0.001, respectively). These variables remained independently associated in multivariable analysis.

Conclusion
Our study confirms the impact of PVI on cardiac autonomic function with a significant heart increase post-ablation. A heart rate ≥60bpm at 3M and a heart rate change ≥11 bpm (PRE to 3M) are associated with a favorable outcome in terms of recurrences.

Funding Acknowledgement
Type of funding source: Foundation. Main funding source(s): German Research Foundation
Prevention of long-lasting atrial fibrillation through antitachycardia pacing in 584 dual-chamber pacemaker patients
Authors: Boriani G , Sakamoto Y , Iacopino S , Komura S , Pieragnoli P , Minamiguchi H , Infusino T , Noma T , De Rosa F , Takahashi Y , Biffi M 
Published: November 2020

Abstract

Background
Atrial fibrillation (AF) is a frequent arrhythmia in pacemaker patients and is associated with poor quality of life and increased risks of heart failure, dementia, stroke, and death. The MINERVA trial has shown that the combination of 3 pacing algorithms – 1) atrial antitachycardia pacing (aATP), 2) atrial preventive pacing and 3) managed ventricular pacing (MVP) - delays progression to persistent and permanent AF, compared with standard DDDR pacing mode and with MVP mode, in pacemaker patients with AF history.

Purpose
We performed a comparative non randomized evaluation to confirm the hypothesis that aATP is the main driver of persistent/permanent AF reduction independently on the effect of preventive atrial pacing.

Methods
Thirty-one Italian and Japanese Cardiology centers included consecutive dual-chamber pacemaker patients with AF history. aATP was programmed in all patients while preventive atrial pacing was not enabled. Comparison was made with all the 3 groups in MINERVA randomized trial. The main endpoint was incidence of AF longer than 7 consecutive days, as detected by device diagnostics.

Results
A total of 146 patients (73 years old, 54% male) were included and followed for a median observation period of 31 months. The 2-year incidence of AF&gt;7 days was 12% in the aATP group, very similar to that found in the arm of the MINERVA trial with aATP enabled (13.8%, p=0.732) and significantly lower than AF incidence found in the MINERVA Control DDDR arm (25.8%, p=0.012) and in the MINERVA MVP arm (25.9%, p=0.025).

Conclusions
In a real-world population of dual-chamber pacemaker patients with AF history, use of aATP was associated with low incidence of persistent AF during follow up, highlighting that the positive results of the MINERVA trial are related to the effectiveness of aATP rather than to the effects of preventive atrial pacing.

Funding Acknowledgement
Type of funding source: None
Role of tilt-table testing in syncope diagnosis and management: analysis of patients referred to a syncope unit
Authors: Castelo A , Laranjo S , Lousinha A , Cunha P , Brandao C , Alves S , Silva A , Ferreira V , Bras P , Mano T , Oliveira M , Ferreira R 
Published: November 2020

Abstract

Introduction
Head-up tilt-testing (HUT) enables the reproduction of reflex syncope in a laboratory setting. Despite being used to confirm the diagnosis of this syncope, there is some concerns regarding the best protocol to use and recent studies with implantable loop recorders have called the value of HUT into question.

Aim
To characterize the population undergoing HUT according to the modified Italian protocol, type of response to HUT and subsequent management at our center in the last 4 years.

Methods
Retrospective analysis of consecutive P who underwent HUT between 2015 and 2018. Descriptive analysis of patients (P) demographics and medical history, indication for HUT, type of response to HUT and management.

Results
A total of 419P (55.1% female) were included with a mean age of 62 years. The majority (n=302, 72.1%) had comorbidities (structural heart disease – 55%, cardiac dysrhythmias – 57.6%, hypertension – 48.3%, diabetes – 15.6%, depression – 15.9%, cerebrovascular disease –10.6%) or was under medication (n=220, 52.5%) with a potential hypotensive or bradycardic effect (44.1% ACEI/ARA, 29.1% beta-blocker, 27.7% diuretic, 23.6% antidepressant, 22.7% calcium channel blocker, 19.1% benzodiazepines). Syncope/presyncope episodes accounted for 56.1% of the HUT, with falls and disequilibrium accounting for 52%. In 21 cases (5%) suspected dysautonomia or other non-specified reasons were the indication for HUT. HUT were ordered according to the guidelines in 136P (84.6% – indication level I, 3.6% – level IIa, 11.8% – level IIb). HUT was positive in 292P (69.7%) – 77.1% after nitroglycerin administration (vasodepressor – 170P, cardioinhibitory – 53P, mixed – 62P and dysautonomic – 7P). Cardioinhibitory (CI) response predominated in the younger, and vasodepressor in the older P. Of the P with CI response, 41.5% had asystole (median of 41.4s, minimum 7.5s, maximum 115s). All P were instructed in the need to avoid triggering factors and perform counterpressure maneuvers. A pacemaker was implanted in 24P (5.7% of all population, due to long sinus pauses and asystole). Twenty-four P (5.7%) completed a tilt training program.

Conclusion
Most of the HUT were requested for syncope/presyncope, frequently according to the guidelines. There was a high rate of positive tests, with a predominance of vasodepressive response, particularly in the elderly.

Funding Acknowledgement
Type of funding source: None
Efficiency and safety of his bundle pacing in patients with newly-acquired heart failure after long-term right ventricular pacing, results from China mainland
Authors: Yiheng Y.A.N.G , Kexin W.A.N.G , Yunlong X.I.A , Yingxue D.O.N.G 
Published: November 2020

Abstract

Background
Clinical outcomes of his bundle pacing (HBP) lead implantation in patients with pacing induced cardiomyopathy (PICM) are unknown. We aim to investigate the efficiency and safety of HBP upgrade in a single center.

Methods and results
Patients with PICM and indication of resynchronization therapy were selected during 2018.1–2019.12. Clinical data including parameters of echocardiographic examination, ECG measurements, New York Heart Association (NYHA) classification were assessed before and after HBP upgrade. HBP upgrade was fulfilled in 38 of 40 (95%) patients. During a mean of 9.36±5.63 months follow-up, 28 patients completed the follow-up of clinical data. The mean age was 67.86±12.85 years and men account for 67.9%. Mean of H-V interval was 56.86±7.11ms. Left ventricular ejection fraction (LVEF) significantly increased from baseline 32.75% to 44.19% (P&lt;0.01). QRS duration decreased from 184.67±27.35 ms at baseline to 123.28±15.82ms with HBP (P&lt;0.01). LVEDD remodeled reversed from 60.85 mm at right ventricular pacing (RVP) implantation to 53.16mm. NYHA functional class improved to 1.96 from 2.64 at baseline during follow-up (P&lt;0.01). Over a median follow-up period of 3.03 (0.9–19.4) months, threshold of his bundle lead decreased from baseline 1.35±0.89mv to 1.2±0.89mv but no significance (P=0.308&gt;0.05).

Conclusion
HBP significantly improved echocardiographic measurements and NYHA classification for those with PICM. The threshold of his bundle lead is relatively stable in our follow-up period, reminding that the HBP upgrade is safe and effective for PICM patients.

Funding Acknowledgement
Type of funding source: Public hospital(s). Main funding source(s): This study was supported by grants from Liaoning Clinical Capacity Construction Funding (LNCCC-D-20-2015).
Application of the ESC and AHA guidelines for admission of syncope patients presenting to the ED
Authors: Du Fay De Lavallaz J , Zimmermann T , Badertscher P , Flores D , Widmer V , Walter J , Strebel I , Lopez-Ayala P , Wussler D , Koechlin L , Di Somma S , Keller D , Kuehne M , Mueller C 
Published: November 2020

Abstract

Background
Syncope in the ED is linked with high diagnostic and prognostic uncertainty, leading to an extremely high rate of admissions. These often inappropriate admissions are costly and expose patients to unnecessary testing. The recent ESC and AHA guidelines aim at reducing these admissions by stratifying patients in high- and low-risk groups.

Methods
The BASEL IX Syncope study is a large prospective international multicenter study recruiting patients 40 years presenting to the ED with syncope within the last 12 hours in eight countries on three continents. Cardiac syncope was centrally adjudicated by two physicians using all data collected up to 1-y follow-up. We classified patients as requiring admission or being judged safe for discharge according to the ESC and AHA guidelines criteria and compared these with the physician's decision regarding hospitalization. We assessed the consequence of these decisions on 30-day serious cardiac events and mortality. We validated our findings in a large American cohort recruiting syncope patients &gt;60 years in 11 EDs.

Results
1977 patients were eligible for this analysis. 215 (10.8%) experienced 30-day Major Adverse Cardiovascular Events (MACE). The ESC and AHA guidelines would have admitted a largely different number of patients (75.9% vs 29.6%) and provided different safety regarding adverse events and death at 30 days (Figure). The validation in the US cohort provided similar results, however US ED physicians decided to admit more patients (84%) as compared with the international derivation cohort (46.6%).

Conclusion
The AHA and ESC syncope guidelines recommend admission based on very different criteria and for a largely different number of patients. While the most recent ESC guidelines were written with the aim to limit the number of patients admitted, they still classify a large majority of an ED syncope cohort as high risk and warranting admission. The large discrepancy between the two guidelines is based on the criteria used for the classification: While the ESC guidelines consider risk factors, previous cardiac history, physical examination and ECG criteria, the AHA guidelines focus on serious conditions previously known or diagnosed in the ED. Figure: Percentage of the overall cohort admitted (green) or discharged (red) according to the AHA and ESC guidelines and to the decision of the physician in the BASEL-IX cohort. Patients experiencing a cardiac syncope, a 30-day MACE or death are represented for both the discharged and admitted groups.
Figure 1

Funding Acknowledgement
Type of funding source: Public hospital(s). Main funding source(s): University hospital Basel
Usefulness of late gadolinium enhancement cardiac magnetic resonance to predict appropriate therapies in implantable cardioverter defibrillator patients in primary prevention
Authors: Sanchez Somonte P , Quinto L , Zarakett F , Garre P , Alarcon F , Tolosana J.M , Guasch E , Arbelo E , Pujol M , Caixal G , Ortiz J.M , Jauregui B , Berruezo A , Mont L , Roca I 
Published: November 2020

Abstract

Background
The scar and the amount of border zone measured by late gadolinium enhancement cardiac magnetic resonance (LGE-CMR) has been proposed as an independent predictor of ventricular arrhythmias in patients with ischemic and non-ischemic cardiomyopathy. However, at the present time, the guidelines are based only on the ejection fraction to recommend an implantable cardioverter defibrillator (ICD) in primary prevention, and only a minority of these patients receive appropriate therapies. So, prevention needs to be improved.

Purpose
To identify predictors of appropriate therapies in patients with a primary prevention ICD using cardiac magnetic resonance imaging and a dedicated software (ADAS-3D) to characterize the scar.

Methods
Patients who underwent a LGE-MR prior to ICD implantation in primary prevention were retrospectively included. Clinical and cardiac imaging characteristics were collected. The myocardium was segmented with ADAS-3D software in 10 layers (from endocardium to epicardium). The scar, border zone, core and conducting channels were automatically measured in grams by the software.

Results
Since 2008 to 2017, 206 patients were included. Mean age was 67±28 years, 80% men, mean ejection fraction 26%±9, 52% with ischemic cardiomyopathy and 48% non-ischemic. The primary endpoint was appropriate therapies and/or sudden cardiac death (SCD). Median follow-up was 46.33 months. 46 patients (22%) reached the primary endpoint. Greater scar mass (36.05 grams vs 21.5 grams; HR 1.04; 95% CI (1.03–1-05), p&lt;0.001), core mass (9.8 grams vs 5.6 grams; HR 1.06; 95% CI (1.04–1-09), p&lt;0.001), border zone mass (26.2 grams vs 15.9 grams; HR 1.05; 95% CI (1.04–1-09), p&lt;0.001) and channel mass (3.0 grams vs 1.6 grams; HR 1.15 95% CI (1.06–1.25), p&lt;0.001) were associated with appropriate therapies and SCD. A border zone mass &gt;5.3 grams was independently associated with the primary endpoint (HR: 4.77; 95% CI (1.15–19.73), p=0.03).

Conclusions
The amount of border zone, core and channel mass measured by LGE-MR and ADAS software are independent predictors of appropriate therapies and SCD in patients with ICD in primary prevention.
Scar characterization

Funding Acknowledgement
Type of funding source: None