Clinical Cardiology最新文献

We would like to thank Dr Candemir and Kızıltunç for their follow-up letter in response to our manuscript. They have raised several very important questions. Regarding their first question as to whether there was a statistically significant difference in the diagnosis duration between patients who did and did not develop AF? Unfortunately, we did not collect data on the duration of diagnoses for the cardiovascular risk factors studied and hence will not be able to address this question. We agree this would be an interesting area for future research. It is worth noting that, in addition to duration (which can often be difficult to confirm), the severity of an associated AF risk factor, such as left ventricular ejection fraction (LVEF) in patients with heart failure (HF), is also important. In our manuscript, we observed that the patients who went on to develop AF had a significantly lower LVEF, eGFR, and blood pressure dipping than the non-AF group, suggesting relatively more severe cardiac and renal dysfunction and poorer hypertension control.

In response to their second point, we have repeated our Cox regression analyses with the additional inclusion of background diagnoses of HF and stroke, both of which were noted to be of greater prevalence in patients who developed AF compared to those who did not. In the full multivariable model, a 1-SD increase in AASI (HR 1.34; 95% CI 1.04–1.72; p = 0.21) and HF (HR 3.47; 95% CI 1.80–6.68; p < 0.001) was significantly associated with newly diagnosed AF, along with a history of previous AF, diastolic blood pressure (DBP), but not stroke and hypertension. Repeating the analysis using categorical AASI (above vs. ≤ median), the result was very similar; however, AASI was just above the significance cut-off (HR 1.65; 95% CI 0.99–2.74; p = 0.053).

On their final point regarding additional adjustment for beta-blocker (BB) use and other medications, repeating the full multivariable analysis with the additional adjustment for background BB use, as well as a 1-SD increase in AASI, HF, stroke, DBP, sex, previous AF, and hypertension, showed that the independent predictors of new AF were again male, sex, previous AF, lower DBP, HF, AASI (HR 1.36; 95% CI 1.06–1.75; p = 0.017), but not previous stroke, hypertension, and BB use. Repeating this analysis using categorical AASI (above vs. ≤ median) rather than continuous AASI revealed comparable results (AASI HR 1.69; 95% CI 1.02–2.81; p = 0.043).

Even further analyses with adjustment for the use of calcium channel blockers, ACE inhibitors/angiotensin II receptor blockers, statin use, and mineral corticoid antagonists, in addition to the factors above, revealed equivalent results for both continuous and categorical AASI.

In summary, the results of this manuscript have shown that AASI is a robust and independent predictor of new-onset AF in a cohort of adults investigated or managed for hypertension.

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The use of cardiac implantable electronic devices (CIRDs) has seen a significant rise in recent years. The European Heart Rhythm Association (EHRA) reported a 20% increase in pacemaker (PM) implantations and a 44% increase in implantable cardioverter-defibrillator (ICD) over a 10-year period in its member countries, prompting the need for safe, efficient, and simple-to-master techniques for establishing venous access [1]. The latest guidelines from the EHRA recommend cephalic vein access, commonly done via cephalic vein cut-down (CVC), for CIRD implantation. However, the greater skill and training required for CVC, coupled with anatomical challenges, often lead to the usage of alternative subclavian venous access (SVC) in patients initially approached via CVC, increasing adverse events [2]. To address this, a modified Seldinger technique has been described recently, offering the potential for an easier-to-learn method with decreased complexity, promising higher success rates and fewer adverse events.

To assess the efficacy and safety of cephalic venous puncture (CVP) compared to SVP for CIED implantation, Weidauer et al. conducted a study [3]. In a setting where most surgeons lacked prior training in cephalic vein access, CVP was mandated for all procedures. The researchers employed the modified Seldinger technique for CVP, involving initial cephalic vein puncture followed by guidewire-facilitated catheter or sheath insertion. This less invasive approach avoided the need for direct subclavian vein puncture using a large-bore needle. The study involved 229 consecutive patients receiving a CIED. Among these patients, 61 were implanted using primary or bail-out SVP, while 168 patients underwent primary cephalic vein preparation with CVP when feasible. Results showed successful implantation of at least one lead in 90% of CVP patients, with complete lead implantation in 72.6%. There were no significant differences in procedure time, fluoroscopy use, or radiation dose between the two groups. Importantly, none of the 122 patients with solely CVP lead implantation developed pneumothorax, compared to 7.5% in the SVP group with at least one lead through SVP. Hence, showing that changing the mandatory primary venous access for CIED from a subclavian puncture to the cephalic vein can be achieved without compromising procedure times or success rates.

The study's robust design and consistent findings significantly contribute to establishing CVP as a potential standard procedure for CIED implantation. In this context, the axillary vein puncture (AVP) approach has emerged as a viable alternative, demonstrating high success rates, low complication rates, reduced procedural times, and lower radiation exposure [4]. Direct visualization of the vessel during puncture is facilitated by the axillary approach. Furthermore, ultrasound-guided axillary access (USAA) proves advantageous for patients with cha