Heart rhythm最新文献

Background: There are conflicting published data on the optimal timing of non-vitamin K antagonist oral anticoagulants (NOACs) in atrial fibrillation (AF) patients with acute ischemic stroke.

Objective: To compare the efficacy and safety of early initiation of NOACs with later initiation of NOACs in those patients, we conducted a meta-analysis of phase 3 or phase 4 randomized controlled trials.

Methods: We systematically searched the Cochrane Library, PubMed, and Embase databases. A random effects model was selected to pool the effect measurement estimates (risk ratios [RRs] and 95% confidence intervals [CIs]).

Results: Three randomized controlled trials with 6442 enrolled patients with AF and acute ischemic stroke were included. Compared with later NOAC therapy, early NOAC therapy was associated with nonsignificant reductions in the risk of primary outcomes (RR, 0.82; 95% CI, 0.65-1.05). Subgroup analysis found that in reducing risk of primary outcomes, early anticoagulation may benefit female patients more than male patients (0.54 [0.35-0.83] vs 0.97 [0.63-1.50]; P for interaction, .06). Numerically lower rates of recurrent ischemic stroke (RR, 0.80; 95% CI, 0.56-1.15), death (RR, 0.96; 95% CI, 0.81-1.15), and systemic embolism (RR, 0.43; 95% CI, 0.16-1.11) were observed in early initiation of NOACs in comparison with later initiation of NOACs. There was no difference in major bleeding (RR, 0.98; 95% CI, 0.55-1.74), symptomatic intracranial hemorrhage (RR, 0.93; 95% CI, 0.43-1.96), or major extracranial bleeding (RR, 0.73; 95% CI, 0.28-1.95) between groups.

Conclusion: In AF patients with acute ischemic stroke, early initiation of NOACs is not inferior to later initiation of NOACs in reducing composite events, without increased hazard of bleeding, especially in female patients.

Background: Either dual antiplatelet therapy or oral anticoagulation in combination with aspirin represent recommended treatment regimens following left atrial appendage closure (LAAC). As the majority of patients receiving LAAC have high bleeding risk, less aggressive antithrombotic treatments are needed, such as single antiplatelet therapy.

Objectives: To compare both ischemic and bleeding outcomes in patients receiving single (SAPT) or dual antiplatelet therapy (DAPT) after successful LAAC.

Methods: Data on consecutive patients undergoing percutaneous LAAC between 2009 and 2023 were prospectively collected including one-year follow-up. A propensity score matching was performed among patients discharged under SAPT and DAPT. The primary endpoint was the one-year composite of cardiovascular death, stroke, systemic embolism or device related thrombosis (DRT). The secondary endpoints included major bleeding and DRT.

Results: Among 1033 patients discharged with antiplatelet therapy, 154 patients receiving SAPT were compared to 230 matched patients receiving DAPT. The primary endpoint was similar between the two study groups (SAPT 11.0% vs. DAPT 8.3%; Rate Ratio [RR]: 1.14; 95% Confidence Interval [CI]: 0.83-1.55; p=0.420). Consistently, we found no difference in terms of both major bleedings (SAPT 9.7% vs. DAPT 12.6%; Hazard Ratio: [HR]: 0.77; 95% CI: 0.43-1.39; p=0.387) and DRT (2.6% vs. 1.1%; RR:1.47; 95% CI: 0.89-2.43; p=0.130) between SAPT and DAPT groups.

Conclusions: In this propensity score analysis of a single-center LAAC cohort, both ischemic and bleeding outcomes did not differ at 1 year between patients discharged with SAPT or DAPT. These results have to be confirmed in an adequately powered randomized clinical trial.

Background: Hypertrophic cardiomyopathy (HCM) with tachyarrhythmias has been extensively studied in recent years. The characteristics of primary bradycardia in HCM remain largely unknown.

Objective: This study aimed to comprehensively investigate the prevalence, clinical features, and prognosis of primary bradycardia in patients with HCM in a large cohort.

Methods: A total of 1055 HCM patients with electrocardiogram results were recruited by Fuwai Hospital between 1999 and 2019. The study end points were all-cause death, cardiovascular death, and heart failure (HF)-related death.

Results: The final analysis included 1003 HCM patients, of whom 86 were identified as having primary bradycardia. Of those, 54 patients had sinus node dysfunction (SND) and 43 patients had atrioventricular block (AVB); 11 patients had both SND and AVB. Fibrosis was more severe in patients with primary bradycardia in HCM, and the patterns of fibrosis were different. Median follow-up was 6.8 years. SND only and AVB only were significantly associated with an increased risk of all-cause death (SND only: adjusted hazard ratio [aHR], 2.219, P = .012; AVB only: aHR, 2.425, P = .007), cardiovascular death (SND only: aHR, 2.737, P = .019; AVB only: aHR, 3.853, P < .001), and HF-related death (SND only: aHR, 4.217, P = .027; AVB only: aHR, 9.367, P < .001). The coexistence of SND and AVB was associated with an even worse prognosis than with SND or AVB alone.

Conclusion: Primary bradycardia, including SND and AVB, independently increases the risk of all-cause death, cardiovascular death, and HF-related death in patients with HCM. Our study provides an important reference for understanding the full picture of HCM patients with primary bradycardia.

Background: The long-term effects of catheter ablation (CA) compared with medical therapy on cardiovascular outcomes for atrial fibrillation (AF) remain undetermined.

Objective: Using a population-based cohort, we sought to determine what the association between CA and medical therapy was on these outcomes.

Methods: By use of Alberta administrative data, patients with AF as the primary diagnosis during hospitalization, emergency department visit, or physician visit were included between October 1, 2008, and March 31, 2018. Based on therapy received, patients were assigned to categories of CA, rate control, or rhythm control with medication. The association of treatment with the primary composite outcome of all-cause death, hospitalization for heart failure, or stroke was examined after adjustment for age, sex, comorbidities, and baseline medications.

Results: Of 39,966 treated AF patients, 2077 (5.2%), 29,467 (73.7%), and 8422 (21.1%) were treated with CA, rate control, and rhythm control with medication, respectively. Patients in the CA group had a lower incidence of the primary outcome (4.0/100 person-years) compared with the rate control group (8.7/100 person-years) or the rhythm control with medication group (6.8/100 person-years) during a median follow-up of 6.3 years. In multivariable analysis, compared with CA, both rate control (hazard ratio, 1.28; 95% confidence interval, 1.09-1.50) and rhythm control with medication (hazard ratio, 1.21; 95% confidence interval, 1.03-1.43) were associated with a higher risk of the primary outcome.

Conclusion: In this cohort study, patients who received CA demonstrated a reduction in the risk of long-term adverse cardiovascular outcomes compared with medical therapy in patients with AF, providing some data to indicate the effects of CA in the long-term.

Background: Pacemaker and implantable cardioverter-defibrillator (ICD) lead placement traditionally uses fluoroscopy, often with inaccurate lead placement on the free wall rather than on the ventricular septum, with associated longer QRS duration and pacemaker-induced cardiomyopathy while exposing staff and patients to radiation.

Objective: We sought to determine whether transesophageal 3-dimensional echocardiography (3DE) guidance improves lead placement accuracy in the ventricular septum, results in shorter paced QRS durations, and reduces fluoroscopy exposure.

Methods: In a single-center case-control study, 3DE guided right ventricular or atrial pacemaker and ICD leads to the desired location, with fluoroscopy used per operator preference. Ventricular lead location, paced QRS duration, and fluoroscopy times were recorded and compared with historical controls that used only fluoroscopy during procedures.

Results: In 59 patients, 3DE guidance substantially improved ventricular lead placement in the septum (78.4% vs 29.8%; P < .001) rather than in the free wall (3.9% vs 57.4%; P < .001) compared with 72 historical controls; this difference was more pronounced when only pacemaker leads were considered (90.2% vs 39.4% [P < .001] for septal and 2.4% vs 45.5% [P < .001] for free wall locations). Compared with controls, 3DE guidance reduced fluoroscopy times (6.6 vs 11.2 minutes for all leads [P = .005] and 4.7 vs 9.5 minutes for right ventricular leads [P = .014]) and trended toward shorter paced QRS durations (133 ms vs 141.5 ms; P = .084).

Conclusion: For pacemaker and ICD lead placement, 3DE guidance substantially improves the accuracy of lead placement in the septum, with a shorter QRS duration, while reducing fluoroscopy exposure.

Background: There are limited data on the effects of therapeutic anticoagulation (AC) on stroke and bleeding risk in patients with sepsis-induced atrial fibrillation (AF).

Objective: This study aimed to determine the effect of therapeutic AC on the development of inpatient strokes and significant bleeding in hospitalized patients with septic shock and AF.

Methods: This single-center, retrospective study examined 604 patients with septic shock and AF. The total AF population was further subdivided into new-onset AF. Propensity score matching was used to match patients with similar comorbidities who received and did not receive AC. The risks of bleeding, in-hospital stroke, increased length of stay, and mortality were compared between propensity score-matched cohorts.

Results: Bleeding Academic Research Consortium 2 and 3a bleeding events were the most common. After propensity score matching, the relative risk of bleeding on AC was not significantly higher in either group (AF, 1.33 [95% confidence interval, 0.81-2.17]; new-onset AF, 1.60 [95% confidence interval, 0.72-3.54]). AC also did not decrease the number of ischemic strokes (AF, 1.34% with AC vs 1.34% without AC [P = 1]; new-onset AF, 0.89% with AC vs 1.79% without AC [P = .56]). There was significantly reduced mortality of patients who received AC (AF, 52.35% with AC vs 66.44% without AC [P = .01]; new-onset AF, 46.43% with AC vs 66.07% without AC [P = .04]).

Conclusion: In patients with septic shock and AF, AC was not associated with a higher incidence of bleeding or lowering of in-hospital strokes but was associated with decreased mortality, potentially protecting against disseminated intravascular coagulopathy or other embolic phenomena.

Background: Patients with chronic kidney disease (CKD) on renal replacement therapy (RRT) are at high risk for cardiovascular implantable electronic device (CIED) infections. Although device extraction is standard management, it is often avoided in these patients because of high procedural risks.

Objectives: Evaluate the outcomes of CIED extraction in CKD on RRT patients with device infection.

Methods: This study used data from the TriNetX research network. The International Classification of Diseases-10^th Revision-Clinical Modification coding system was used to identify patients. Adults with a history of CKD on RRT and CIED infection were included. Patients with renal transplantation and prosthetic heart valves were excluded. Patients were stratified by device extraction. The primary outcome was mortality at 1 year.

Results: A total of 530 patients were identified, of whom 30% (n = 159) underwent device extraction. After propensity score matching (PSM), 302 patients remained, with 151 in each group. Kaplan-Meier survival analysis demonstrated a significant 1-year survival benefit for patients in the device extraction group (59.2%) compared with the no-extraction group (48.8%, P = .043; hazard ratio [HR], 0.696; 95% confidence interval [CI], 0.489-0.991). Freedom from complications such as pericardial effusion was similar between groups. Sensitivity analysis using Cox proportional hazards, adjusted for baseline confounders, confirmed the survival benefit of extraction, with a reduced mortality risk (HR, 0.581; 95% CI, 0.382-0.883; P = .011).

Conclusion: In CKD on RRT patients with CIED infection, device extraction is associated with a reduction in all-cause mortality at 1 year. However, the rate of device extraction is low in this group.