European Heart Journal - Quality of Care and Clinical Outcomes最新文献

Background and aims: Long-term data on atrial fibrillation (AF) impact on tricuspid regurgitation (TR) progression and its relation to pulmonary pressure are scant. We investigated this association in a study spanning over a decade.

Methods and results: Adults with echocardiographic evaluation before 2014, free of significant TR, were included. Patients were dichotomized by baseline AF, followed by stratification according to systolic pulmonary artery pressure (sPAP). The development of new significant TR and its impact on mortality were studied. Study population included 21 502 patients (median age 65, 40% female), 13% had baseline AF. During a median follow-up of 12 years, 11% developed significant TR. Compared with patients free of AF, patients with baseline AF were 3.5 and 1.3 times more likely to develop significant TR in univariate and multivariate models, respectively (95% CI 3.27-3.91, 1.18-1.44, P < 0.001 for both). The risk of TR progression was higher in patients with permanent AF and those treated with rate control strategy (hazard ratio 1.95 and 2.01, respectively; P < 0.001 for both). The association of AF with TR progression was sPAP-related, being more pronounced among patients with normal sPAP than among those with elevated sPAP (HR 1.5 vs. 1.18; P for interaction <0.001). TR progression was independently linked to a two-fold higher mortality risk, consistent regardless of baseline AF (P < 0.001).

Conclusion: AF is an independent predictor of TR progression, especially in patients with normal sPAP. Subsequent research on strategies to prevent TR progression in this patient population is warranted.

Aims: To analyse the temporal trends of oral anticoagulant (OAC) prescription, direct oral anticoagulant (DOAC) dose, clinical outcomes, and factors associated with non-anticoagulation in patients with incident atrial fibrillation (AF).

Methods and results: During 1 January 2011-31 December 2020, a total of 249 107 patients with newly diagnosed AF were identified, and the 1-year risks of ischaemic stroke, intracranial haemorrhage (ICH), and all-cause mortality were analysed. OAC prescription increased from 22.1% in 2011 to 57.7% in 2020 with DOAC accounting for 91.0% of overall OAC prescriptions. Compared to patients with incident AF diagnosed in 2011, there were increasing trends for a greater decrease in the risks of ischaemic stroke during 2012-2020 and mortality during 2014-2020, while the risk of ICH did not change significantly. For DOAC users, higher dose use increased from 11.04% in 2012 to 44.29% in 2019-2020 temporally associated with a lower risk of ischaemic stroke in the years 2015-2017 and 2018-2020 compared to 2012-2014. Determining factors refraining from OAC use included some 'patient-related factors' and 'non-patient' factors (AF diagnosed at clinics by physicians other than cardiologist/neurologist/internal medicine and citizens outside municipalities).

Conclusion: There was an increasing trend of OAC prescription, temporally associated with a decreased risk of ischaemic stroke and mortality. Among DOACs users, the risk of ischaemic stroke declined gradually, partly explained by the increasing prescriptions of higher dose DOACs. Both patient and non-patient factors were associated with non-anticoagulation. Further efforts are required to increase OAC prescription.

Aims: Patients surviving acute pulmonary embolism (PE) necessitate long-term treatment and follow-up. We estimated, the chronic economic impact of PE on the German healthcare system.

Methods and results: We calculated the direct cost of illness during the first year after discharge for the index PE, analysing data from a multicentre prospective cohort study in Germany. Main and accompanying readmission diagnoses were used to calculate DRG-based hospital reimbursements; anticoagulation costs were estimated from the exact treatment duration and each drug's unique national identifier; and outpatient post-PE care costs from guidelines-recommended algorithms and national reimbursement catalogues. Of 1017 patients enrolled at 17 centres, 958 (94%) completed ≥3-month follow-up; of those, 24% were rehospitalized (0.34 [95% CI 0.30-0.39] readmissions per PE survivor). Age, coronary artery, pulmonary and kidney disease, diabetes, and (in the sensitivity analysis of 837 patients with complete 12-month follow-up) cancer, but not recurrent PE, were independent cost predictors by hurdle gamma regression accounting for zero readmissions. The estimated rehospitalization cost was €1138 (95% CI 896-1420) per patient. Anticoagulation duration was 329 (IQR 142-365) days, with estimated average per-patient costs of €1050 (median 972; IQR 458-1197); costs of scheduled ambulatory follow-up visits amounted to €181. Total estimated direct per-patient costs during the first year after PE ranged from €2369 (primary analysis) to €2542 (sensitivity analysis).

Conclusion: By estimating per-patient costs and identifying cost drivers of post-PE care, our study may inform decisions concerning implementation and reimbursement of follow-up programmes aiming at improved cardiovascular prevention.

Aims: The Atrial fibrillation Better Care (ABC) pathway provides a framework for holistic care management of atrial fibrillation (AF) patients. This study aimed to determine the impact of changes in compliance to ABC pathway management on clinical outcomes.

Methods and results: This is a prospective multicenter AF registry. Patients with non-valvular AF were enrolled and followed-up for 3 years. Baseline and follow-up compliance to the ABC pathway was assessed. The main outcomes were all-cause death, ischaemic stroke/systemic embolism, major bleeding, and heart failure. There studied 3096 patients (mean age 67.6 ± 11.1 years, 41.8% female). Patients were categorized into four groups: Group 1: ABC compliant at baseline and 1 year [n = 1022 (33.0%)]; Group 2: ABC non-compliant at baseline but compliant at 1 year [n = 307 (9.9%)]; Group 3: ABC compliant at baseline and non-compliant at 1 year [n = 312 (10.1%)]; and Group 4: ABC non-compliant at baseline and also at 1 year [n = 1455 (47.0%)]. The incidence rates [95% confidence intervals (CI)] of the composite outcome for Group 1-4 were 5.56 (4.54-6.74), 7.42 (5.35-10.03), 9.74 (7.31-12.70), and 11.57 (10.28-12.97), respectively. With Group 1 as a reference, Group 2-4 had hazard ratios (95% CI) of the composite outcome of 1.32 (0.92-1.89), 1.75 (1.26-2.43), and 2.07 (1.65-2.59), respectively.

Conclusion: Re-evaluation of compliance status of the ABC pathway management is needed to optimize integrated care management and improve clinical outcomes. AF patients who were ABC pathway compliant at baseline and also at follow-up had the best clinical outcomes.

Background and aims: This study evaluated the safety and efficacy of catheter ablation in treating atrial fibrillation (AF) among the elderly population.

Methods and results: A total of 170 017 AF ablation procedures prospectively enrolled from 482 facilities between 2017 and 2020 were analysed. They were stratified into six age groups, ranging from <65 to ≥85 years, in 5-year increments. A cut-off of 80 years was set for dividing participants into two groups. The primary endpoints included procedure-related complications and 1-year arrhythmia recurrence after a 3-month blanking period. Patients ≥80 years constituted 7.2% of procedures in 2017, which significantly increased to 9.6% by 2020 (P < 0.001). This older group predominantly comprised women with smaller stature and body mass index, a higher prevalence of paroxysmal AF, and a higher rate of initial ablation procedures. The overall complication rate was 2.8%, showing a positive correlation with age (P < 0.001), peaking at 4.3% for patients ≥85 years. Older age remained a significant independent risk factor for complications (odds ratio: 1.36 [1.24, 1.49], P < 0.001). Cardiac tamponade, ischaemic stroke, and sick sinus syndrome were more common in the elderly. The recurrence rate in the total population was 16.0% and did not differ significantly between age groups (log-rank P = 0.473), remaining consistent even after adjusting for multiple variables.

Conclusion: Although age increases complication risk, recurrence rates remained steady across age groups, suggesting that AF ablation is a reasonable option for elderly individuals, contingent on careful patient selection for safety.

Background: Despite evidence supporting use of fractional flow reserve (FFR) and instantaneous waves-free ratio (iFR) to improve outcome of patients undergoing coronary angiography (CA) and percutaneous coronary intervention, such techniques are still underused in clinical practice due to economic and logistic issues.

Objectives: We aimed to develop an artificial intelligence (AI)-based application to compute FFR and iFR from plain CA.

Methods and results: Consecutive patients performing FFR or iFR or both were enrolled. A specific multi-task deep network exploiting 2 projections of the coronary of interest from standard CA was appraised. Accuracy of prediction of FFR/iFR of the AI model was the primary endpoint, along with sensitivity and specificity. Prediction was tested both for continuous values and for dichotomous classification (positive/negative) for FFR or iFR. Subgroup analyses were performed for FFR and iFR.A total of 389 patients from 5 centers were enrolled. Mean age was 67.9 ± 9.6 and 39.2% of patients were admitted for acute coronary syndrome. Overall, the accuracy was 87.3% (81.2-93.4%), with a sensitivity of 82.4% (71.9-96.4%) and a specificity of 92.2% (90.4-93.9%). For FFR, accuracy was 84.8% (77.8-91.8%), with a sensitivity of 81.9% (69.4-94.4%) and a specificity of 87.7% (85.5-89.9%), while for iFR accuracy was 90.2% (86.0-94.6%), with a sensitivity of 87.2% (76.6-97.8%) and a specificity of 93.2% (91.7-94.7%, all confidence intervals 95%).

Conclusion: The presented machine-learning based tool showed high accuracy in prediction of wire-based FFR and iFR.

Background: Supraventricular ectopic activity (SVEA) is a marker of foci that may initiate atrial fibrillation (AF) and is associated with worse survival. The types and frequencies of SVEA for predicting postoperative AF (POAF), new-onset AF, and clinical outcomes in obstructive hypertrophic cardiomyopathy (oHCM) remain unknown.

Methods and results: Our study consecutively recruited 961 patients with oHCM. All patients underwent a 24-h Holter monitor before surgery. POAF incidence was 20.7% and increased with the burden of premature atrial contractions (PACs). Multivariable analysis showed that supraventricular tachycardia (SVT) was independently associated with POAF, with the model including SVT yielding the largest area under the curve (AUC) [0.710, 95% CI 0.670-0.750] for predicting POAF. During a median follow-up of 2.9 years, 12 deaths, 60 new-onset AF, and 139 composite endpoints were observed. A Spearman correlation indicated a linear relationship between the incidence of new-onset AF and composite endpoints with PAC frequency. The Kaplan-Meier survival curves demonstrated that patients with PACs >200 beats/day had significantly higher cumulative rates of new-onset AF [HR 3.13, (95% CI 1.74-5.62), P < 0.001] and composite endpoints [HR 2.00, (95% CI 1.30-3.06), P = 0.002] than their counterparts. Adding PACs >200 beats/day to the multivariable model significantly improved net reclassification improvement (NRI) and integrated discrimination improvement (IDI) for predicting new-onset AF (NRI = 0.264, IDI = 0.033) and composite endpoints (NRI = 0.233, IDI = 0.014).

Conclusion: The incidence of POAF was 20.7%, increasing with PACs severity. Furthermore, PACs burden was positively associated with a higher incidence of adverse events. Specially, PACs >200 beats/day may best predict a higher incidence of new-onset AF and worse survival.

Background: Major emergency abdominal surgery is associated with postoperative complications and high mortality. Long-term outcomes in patients with perioperative atrial fibrillation (POAF) have recently received increased attention, especially POAF in non-thoracic surgery.

Purpose: This study aimed to compare long-term AF related hospitalization and stroke in patients with POAF in relation to major emergency abdominal surgery and in patients with non-perioperative AF.

Methods and results: We crosslinked data from Danish nationwide registries and identified all patients who underwent major emergency abdominal surgery (2000-2018) and were diagnosed with POAF, and patients who developed AF in a non-perioperative setting. Patients with POAF were matched in a 1:5 ratio on age, sex, year of AF diagnosis, and oral anticoagulation (OAC) status at the beginning of follow-up with patients with non-perioperative AF. From discharge, we examined adjusted hazard ratios (HRs) of stroke using multivariable Cox regression analysis. The study population comprised 1041 (out of 42 021 who underwent major emergency abdominal surgery) patients with POAF and 5205 patients with non-perioperative AF. The median age was 78 years [interquartile range: 71-84] for those initiated on OAC therapy and 78 years [interquartile range: 71-85] for those not initiated on OAC therapy. During the first year of follow up, POAF was associated with similar rates of stroke as non-perioperative AF {patients initiated on OAC: HR 0.96 [95% confidence interval (CI) 0.52-1.77] and patients not initiated on OAC: HR 0.69 (95% CI 0.41-1.15)}.

Conclusion: POAF in relation to major emergency abdominal surgery was associated with similar rates of stroke as non-perioperative AF. These results suggest that POAF not only carry an acute burden but also a long-term burden in patients undergoing major emergency abdominal surgery.