VASc Score Research Articles

Anticoagulation status and left atrial appendage occlusion indications in hospitalized cardiology patients with atrial fibrillation: a Hellenic Cardiorenal Morbidity Snapshot (HECMOS) sub-study

Abstract Background Proper use of oral anticoagulants is crucial in the management of non-valvular atrial fibrillation (NVAF) patients. Left atrial appendage occlusion (LAAC) may be considered for stroke prevention in patients with NVAF and contraindications for long-term anticoagulant treatment. Purpose We aimed to assess the anticoagulation status and LAAC indications in patients with NVAF from HECMOS (Hellenic Cardiorenal Morbidity Snapshot) survey. Methods HECMOS was a nationwide snapshot survey of cardiorenal morbidity in hospitalized cardiology patients. HECMOS used an electronic platform to collect demographic and clinically relevant information from all patients hospitalized on March 3, 2022, in 55 different cardiology departments. In this substudy, we included patients with known AF without mechanical prosthetic valves and moderate to severe mitral valve stenosis. Patients with poor adherence to anticoagulants, high bleeding risk, previous major bleeding, and previous stroke were considered candidates for LAAC. Results Two hundred fifty-six patients (mean age 76.6±11.7, 148 males) were included in our analysis. Most of them (n=159; 62%) suffered from persistent AF. Mean CHA 2 DS 2 - VASc score was 4.28±1.7, while mean HAS-BLED score was 1.47±0.9. Three out of 3 patients with a CHA 2 DS 2 -VASc 0 or 1 (female) received improperly anticoagulants. Sixteen out of 18 patients with a CHA 2 DS 2 -VASc 1 or 2 (female) received anticoagulants. Thirty-three out of 235 patients with a CHA 2 DS 2 -VASc > 1 or 2 (for female) did not receive improperly anticoagulants. Among 221 under anticoagulant therapy, 191 (86.4%) received non-vitamin K antagonist oral anticoagulants (NOACs) and 30 (13.6%) received vitamin K antagonists. Relative indications for LAAC were present in 77 patients with NVAF (53 had only one risk factor, while 22 had two and 2 patients had three concurrent risk factors). In detail, 15 reported poor or no adherence to the anticoagulant therapy, 17 patients had a history of major bleeding, 36 had a prior stroke and 35 had a HAS-BLED score ≥3. No LAAC treatment was recorded. Conclusion Αnticoagulation status was nearly optimal in a high thromboembolic risk population of cardiology patients, mainly treated with NOACs. Three out of ten AF patients should be screened for LAAC.Anticoagulation by thrombotic riskPotential LAAC candidates

Impact of real-world off-label dose of Apixaban on long-term clinical outcomes in patients with atrial fibrillation and chronic kidney disease

Abstract Background Apixaban represent one of the cornerstone treatments to prevent cardioembolic events in patients with nonvalvular atrial fibrillation (NVAF). However, the choices of Apixaban dose guided by the decision-making process of the physician, which considers specific according to kidney functions are inconsistent in the real-world practice. Objective The objective of the present study is to evaluate the effects of real-world Off-label dose of Apixaban on long-term clinical outcomes in NVAF patients with chronic kidney disease (CKD). Methods Our database of AF patients diagnosed with CKD from 2018 to 2023 was used to obtain laboratory, echocardiography, electrocardiogram (ECG), and clinical outcomes data. Inclusion criteria were all AF patients with CKD using Apixaban. And we compared bleeding, systemic thrombotic events including stroke/systemic embolism and death according to off-label real -world dose of Apixaban. Results Among 635 patients with AF and CKD (76.9±10.4 years), 335 (52.8%) patients took off-label underdosed Apixaban. Difference in the baseline characteristics was not observed among patients including CHA2DS2 VASc score and HASBLED score. During the median 18-month follow-up, a lower incidence of bleeding events (P=0.001) was observed in the off-label underdosed Apixaban group compared to those with standard dose or off-label overdosed Apixaban. However, there was no significant difference of systemic thrombotic events including stroke/systemic embolism and death according to off-label real-world dose of Apixaban (off-label underdose vs. standard dose, P=1.000; off-label overdose vs. standard dose, P=1.000; off-label underdose vs. off-label overdose, P=0.609). In multivariate analysis, HASBLED score was independent risk factors for bleeding events (OR 9.650; CI 1.998-46.622; P=0.005). Conclusions Compared with standard or off-label overdose of Apixaban, off-label underdose of Apixaban was associated with a lower risk of bleeding in patients with AF and CKD, with no difference in the risk of stroke/systemic embolism or death, supporting the apixaban dosing tailored to specific clinical features and drug pharmacokinetics of the Asian patients.

Right atrial strain: the hidden proof of bi-atrial cardiomyopathy in AF patients?

Abstract Background Although assessment of left atrium (LA) abnormalities has been extensively studied in atrial fibrillation (AF), structural and functional changes in the right atrium (RA) have remained almost unexplored in this context. Purpose We investigated the role of bi-atrial strain in patients with AF undergoing catheter ablation (CA). Methods Fifty-six consecutive patients undergoing catheter ablation of AF were prospectively studied with speckle-tracking echocardiography and electrophysiological study, before and after CA (median follow-up: 7±3 months). A group of 32 subjects undergoing CA of paroxysmal atrioventricular node-reentrant tachycardia, without structural heart disease, served as control group. Results Patients with AF had worse LA, but also RA strain indexes compared to controls [RA strain parameters: peak RAS reservoir (pRASr): 22.1±12.6 vs 29.8±12.7%, p=0.009; RA dispersion: SD-regional-RA-time-to-peak (SD-regional-RA-TTP): 0.048±0.015 vs 0.038±0.009, p=0.020)]. Patients with persistent AF showed similar LA strain values, but worse RA strain indexes, compared to patients with paroxysmal AF (pRASr: 24.8±12.1 vs 15.9±11.7%,p=0.017; SD-regional-RA-TTP:0.043±0.023 vs 0.062±0.030, p=0.016). RA function showed a significant relation with both LA strain and volume indexes and with abnormal LA electroanatomical substrate (pRASr and pLASr, Pearson correlation: r 0.594, p< 0.001; pRASr and low-voltage LA area: -0.316, p=0.018). RA, but not LA, parameters were found significantly reduced in patients with AF recurrence post-CA compared to those who maintain sinus rhythm (pRASr: 14.1±11.7 vs 24.6±13.5, p=0.039; SD-regional-RA-TTP: 0.054±0.031 vs 0.032±0.010, p=0.002), while the only independent clinical predictor of AF recurrence remained cardiovascular risk profile (CHA2DS2 VASc Score: HR 1.47,CI 1.003-2.158, p= 0.048). Conclusion RA function, as assessed by strain imaging, resulted progressively impaired in worse subtypes of AF, showing a strong correlation with bi-atrial mechanical and electroanatomical parameters, and associated with AF recurrences post-ablation.Graphical Abstract

The long-term usage of statin prevents adverse events in patients with atrial fibrillation

Abstract Background The effectiveness of statins in preventing adverse cardiovascular events in individuals with atrial fibrillation (AF) has remained uncertain. This study aimed to assess whether statin use could lead to better outcomes among individuals with AF. Purpose Our study aimed to investigate the relationship between statin use and cardiovascular outcomes in patients with newly-diagnosed AF. Methods This study used the National Health Insurance Research Database (NHIRD) in Taiwan. We enrolled 397,787 patients with AF from January 1st, 2012, to December 31st, 2020. Patients with AF were divided into 2 groups (statin user and statin non-user), and the risks of composite outcomes (ischemic stroke, hemorrhagic stroke and transient ischemic attack [TIA]), all-cause death and major adverse cardiovascular events (MACEs, which encompassed cardiovascular death, non-fatal myocardial infarction and heart failure hospitalization) were analyzed. Propensity score matching with time-dependent analysis was examined. Results We analyzed 288,958 patients with newly diagnosed AF (mean age, 73 years; 44% women; mean CHA2DS2-VASc score, 3.5). Compared with patients without statin use, statin user had a lower risk of composite endpoint, which included ischemic stroke, hemorrhagic stroke and TIA. (adjusted hazard ratio, 0.92; 95% confidence interval, 0.88-0.95; p < 0.01) after adjusting for patients’ age, gender, CHA2DS2-VASc score, cardiovascular medications, and comorbidities. In regard to all-cause mortality, statin users exhibited a 62% risk reduction compared to statin non-users (hazard ratio, 0.38; 95% confidence interval, 0.37-0.39; p < 0.01). Statin use was also associated with reduced incidence of MACEs (hazard ratio, 0.70, 95% confidence interval, 0.68-0.71; p < 0.01). In the subgroups stratified by CHA2DS2 VASc score, statin therapy was particularly effective for patients with CHA2DS2-VASc scores 0-3 for composite endpoints but consistently reduced all-cause mortality and MACEs across all score categories. Conclusions Among patients with newly diagnosed AF, statin use was associated with a lower risk of ischemic stroke, hemorrhagic stroke, TIA, all-cause mortality and MACEs.

Voltage-Guided and Non-Voltage-Guided Superior Vena Cava Isolation in Patients With Atrial Fibrillation.

In addition to the pulmonary vein, the superior vena cava (SVC) is an important focus of atrial fibrillation (AF). However, SVC isolation may cause serious complications, and appropriate settings and techniques for SVC isolation are lacking. This study enrolled 86 consecutive patients with AF who underwent SVC isolation. Voltage mapping using a multi-electrode catheter and ablation were performed under the guidance of an electro-anatomical mapping system. The lines encircling the SVC were divided into eight anatomic segments on the SVC geometry, and each segment was subjected to voltage-guided (VG) ablation in decreasing order of voltage (starting from the segment with the highest voltage). Non-VG (NVG) ablation was performed anatomically from the anterior wall toward the septum with one-round cautery. A total of 86 cases (66 males, mean age 69 [60, 74], mean CHA2DS2 VASc score 2 [1, 3], 58 paroxysmal AF) with AF were included for ablation. Electrical SVC isolation was successfully achieved in all patients. The length of the myocardial sleeves, as measured from the SVC-RA junction to the end of the local signal, was 37 [28, 45]mm. Major axis of the RA-SVC junction was 15 [13, 17] and minor axis of the RA-SVC junction was 11 [9, 13]. The number of ablation points with VG SVC isolation was fewer than that for NVG SVC isolation (8 [5, 11.5] vs. 11.5 [8.8, 13.3]; p=0.001). The procedure time of VG SVC isolation was greater than that of NVG SVC isolation (259s [154, 379] vs. 167s [115, 222]; p=0.012). There were no significant differences in the complication rates. VG SVC isolation reduced the number of ablation points compared with NVG SVC isolation.

Management of Patients Treated With Oral Anticoagulant Therapy Undergoing Percutaneous Coronary Intervention With Stent Implantation: The PERSEO Registry.

In patients on oral anticoagulant (OAC) therapy undergoing percutaneous coronary intervention (PCI) with stent, international guidelines endorse the use of direct oral anticoagulants (DOAC) rather than vitamin K antagonists (VKA) and dual antithrombotic therapy (DAT) rather than triple antithrombotic therapy (TAT). The aim of this study was to evaluate contemporary real-world data on antithrombotic regimens and outcome in patients on OAC undergoing PCI with stent. Consecutive patients on OAC undergoing PCI were enrolled in the multicenter, prospective, observational PERSEO registry (NCT03392948). Primary end point was net adverse clinical events (NACE) with VKA versus DOAC, whereas a secondary prespecified end point was NACE with DAT versus TAT both at 1-year follow-up. From February 2018 to February 2022; in total, 1234 consecutive patients were included. The main indication for OAC was atrial fibrillation (86%), and the mean CHA 2 DS 2 VASc and HAS-BLED scores were 4 ± 2 and 3.6 ± 1, respectively. Of the 1228 patients discharged alive, 222 (18%) were on VKA and 1006 (82%) on DOAC ( P < 0.01). DAT was employed in 197 patients whereas TAT in 1028. At follow-up, NACE rate was significantly higher than VKA compared with DOAC (23% vs. 16%, P = 0.013) and confirmed after propensity score adjustment. TAT and DAT did not differ as regards NACE rate (17% vs. 19%, P = 0.864) although, compared with TAT, DAT was associated with less major bleedings (2% vs. 5%, P = 0.014), confirmed after propensity score adjustment. In conclusion, in patients on OAC undergoing PCI, DOAC, compared with VKA, was associated with a significantly lower occurrence of NACE and DAT reduced bleedings compared with TAT.

Efficacy of CHA2DS2-VASc scores in predicting chronic kidney disease risk in patients treated in cardiac intensive care units

The CHA2DS2 -VASc score is a vital clinical tool for evaluating thromboembolic risk in patients with atrial fibrillation (AF). This study investigated the efficacy of the CHA2DS2 -VASc score in a cohort of 737 heterogeneous patients (mean age: 63 years) receiving care in cardiac intensive care units (CICUs), with a creatinine-based estimated glomerular filtration rate (eGFR) of ≥60 mL/min/1.73 m2 upon admission and discharge. Incident chronic kidney disease (CKD) was defined as the emergence of a new-onset eGFR<60 mL/min/1.73 m2, accompanied by a decline of >5 mL/min/1.73 m2 compared to that at discharge. The primary endpoint was the incidence of CKD, and the secondary endpoints included all-cause mortality, cardiovascular events, and progression to end-stage kidney disease. In this cohort, 210 (28 %) patients developed CKD. Multivariate analyses revealed that CHA2DS2 -VASc score was a significant independent predictor of incident CKD, regardless of the presence of AF. Integration of CHA2DS2 -VASc scores with eGFR enhanced the predictive accuracy of incident CKD, as evidenced by the improved C-index, net reclassification improvement, and integrated discrimination improvement values (all p < 0.05). Over the 12-month follow-up period, a composite endpoint was observed in 61 patients (8.3 %), with elevated CHA2DS2 -VASc scores being independently associated with this endpoint. In conclusion, CHA2DS2-VASc scores have emerged as robust predictors of both CKD incidence and adverse outcomes. Their inclusion substantially refined the 12-month risk stratification of patients with preserved renal function hospitalized in the CICUs.

Stroke risk assessment in different atrial fibrillation subtypes: CHA2DS2-VASc score and beyond

Abstract Background Patients with atrial fibrillation (AF) have been known to have an inhomogeneous risk of stroke, with several well-documented risk factors including hypertension, history of stroke, and diabetes mellitus that have been incorporated into the CHA2DS2–VASc score to stratify risk levels. Accumulating evidence has suggested that AF subtype, namely persistent AF and paroxysmal AF, also have an impact on stroke development. Purpose This study focused on the impact of AF subtype on stroke risk in a large, long-term follow-up cohort as to provide insight of the impact on ischemic stroke risks. Such findings may play a role in future ischemic stroke risk stratification in selected patients. Methods A total of 7346 AF patients were followed up for 10 years from January 2010 to December 2020 (mean follow-up time 2.74 years). Among these patients, 2460 (33.5%) had persistent or permanent AF (PerAF) and 4886 (66.5%) had paroxysmal AF (PAF). The study evaluated the risk of ischemic stroke between the two groups using Cox models adjusting for all components of the CHA2DS2–VASc score. Analyses were further stratified into the usage of oral anticoagulation (OAC) or no OAC. Results Comparing AF patients based on subtype, it was found that PerAF patients were older, had a higher prevalence of previous stroke, congestive heart failure, PAD, DM, and were more often prescribed anticoagulants. Univariate analysis found patients with PerAF at a higher risk for ischemic stroke (HR 1.262, p&amp;lt;0.001). The results remained significant after multivariate analysis with factors of the CHA2DS2–VASc score (HR 1.234, p&amp;lt;0.001). After stratifying patients according to anticoagulation prescription, PerAF and PAF patients were found to have similar rates of developing ischemic stroke in patients under DOAC. Conclusions Patients with PerAF have a higher risk of stroke during follow-up independent of components of the CHA2DS2VASc score. In patients with OAC use, there was no difference in stroke risk between AF subtypes.Stroke Risk in OAC-naive patientsStroke Risk in OAC-experienced patients

#606 Impact of real-world off-label dose of apixaban on long-term clinical outcomes in patients with atrial fibrillation and chronic kidney disease

Abstract Background and Aims Apixaban represent one of the cornerstone treatments to prevent cardioembolic events in patients with nonvalvular atrial fibrillation (NVAF). However, the choices of Apixaban dose guided by the decision-making process of the physician, which considers specific according to kidney functions are inconsistent in the real-world practice. The objective of the present study is to evaluate the effects of real-world Off-label dose of Apixaban on long-term clinical outcomes in NVAF patients with chronic kidney disease (CKD). Method Our database of AF patients diagnosed with CKD from 2018 to 2023 was used to obtain laboratory, echocardiography, electrocardiogram (ECG), and clinical outcomes data. Inclusion criteria were all AF patients with CKD using Apixaban. And we compared bleeding, systemic thrombotic events including stroke/systemic embolism and death according to off-label real -world dose of Apixaban. Results Among 635 patients with AF and CKD (76.9 ± 10.4 years), 335 (52.8%) patients took off-label underdosed Apixaban. Difference in the baseline characteristics was not observed among patients including CHA2DS2 VASc score and HASBLED score. During the median 18-month follow-up, a lower incidence of bleeding events (P = 0.001) was observed in the off-label underdosed Apixaban group compared to those with standard dose or off-label overdosed Apixaban. However, there was no significant difference of systemic thrombotic events including stroke/systemic embolism and death according to off-label real-world dose of Apixaban (off-label underdose vs. standard dose, P = 1.000; off-label overdose vs. standard dose, P = 1.000; off-label underdose vs. off-label overdose, P = 0.609). In multivariate analysis, HASBLED score was independent risk factors for bleeding events (OR 9.650; CI 1.998-46.622; P = 0.005). Conclusion Compared with standard or off-label overdose of Apixaban, off-label underdose of Apixaban was associated with a lower risk of bleeding in patients with AF and CKD, with no difference in the risk of stroke/systemic embolism or death, supporting the apixaban dosing tailored to specific clinical features and drug pharmacokinetics of the Asian patients.

ATRIAL FIBRILLATION IN A CIED POPULATION: RESULTS FROM A TELEMONITORING FOLLOW–UP

Abstract Background Telemedicine has emerged as a crucial tool in managing patients with Cardiac Implantable Electronic Devices (CIED), addressing the common challenge of the Atrial Fibrillation (AF) in cardiology. The incidence of AF in CIED recipients varies widely (30–70%), influenced by implant indication, device type, and population characteristics. This study aims to evaluate AF in an unselected, real–world CIED population, considering patients’ characteristics and the remote follow–up. Methods and Results 808 consecutive CIED recipients were evaluated between 2021 and 2023 in two Italian Division of Cardiology by collecting patients’ baseline characteristics and the scheduled remote follow–up data. Mean age was 75.6±12.6 years, 42% were females. 16.7% of the population was working actively and 73% of individuals were assisted by at least one caregiver, reflecting a diminished quality of life (EQ–5D score 8.9±4.3). Over a median follow–up of 20.6 months, 8.9% of patients died. 68.8% of the patients received a pacemaker, 19.3% an ICD and 11.9% a loop recorder. History of AF was present in 40.1% of the population, with a prevalence of permanent AF (46.6%). Ongoing anticoagulant therapy was documented in 303 patients (37.5%), 71% of whom were taking direct oral anticoagulants. Baseline CHA2DS2–VASC score was ≥3 in 79.7%, and the median HAS–BLED score was 1. During the observation period, scheduled remote transmissions revealed 719 AF episodes (15.7 episodes/patient/year), causing 21% of the overall remote alarms. Among patients without AF history, 69 (14.3%) experienced AF episodes (4.8 episodes/patient/year). Notably, 21.8% of the AF episodes lasted less than 10 minutes. Conclusions The wide spreading of heart rhythm monitoring technologies reveals the challenge of the subclinical AF in healthcare systems. This study, encompassing an unselected CIED population of elderly and frail patients with high AF prevalence, highlights AF as a primary cause of remote alerts and a substantial burden in telemonitoring controls. Telemedicine facilitated new AF diagnoses in 14.3% of individuals without a prior AF history and resulted a valuable tool considering the significant cardioembolic risk in these patients. However, the initiation of anticoagulation therapy remains debatable, especially for episodes of brief duration which in our experience exceeded 20% of the cases.

BETWEEN SCYLLA AND CHARYBDIS: MULTIPLE LEFT ATRIAL THROMBI DESPITE ORAL ANTICOAGULATION AND ANTIPLATELET THERAPY IN A PATIENT CANDIDATE FOR LEFT ATRIAL APPENDAGE OCCLUSION

Abstract Introduction Left atrial (LA) thrombosis usually occurs in patients affected by atrial fibrillation (AF), generally involving the left atrial appendage (LAA). We present the unexpected echocardiographic finding of multiple LA thrombi despite an adequate antithrombotic strategy. Case Presentation A 76–year–old lady underwent transesophageal echocardiographic examination (TOE) to assess eligibility for percutaneous LAA occlusion (LAAO) procedure due to high bleeding risk. Her medical history included AF and a recent percutaneous coronary revascularization; therefore, her antithrombotic therapy included apixaban 2.5 mg bid and clopidogrel 75 mg od. The TOE showed LA structural and functional remodeling with spontaneous echo contrast and multiple thrombi involving the LAA (one [12 x 9 mm] overflowing the orifice and attached to the Coumadin Ridge and the second [12 x 7 mm] attached and arising from the tunnel of patent foramen ovale). Mitral valve stenosis was excluded (Fig.1). Due to TOE findings, the patient was not considered eligible for percutaneous LAAO. Due to the concomitant very high thromboembolic risk, despite the previous intracranial bleeding, we decided to stop apixaban and to start parenteral anticoagulation for 3 weeks with low–molecular weight heparin (100 UI/kg bid) followed by the switch to a vitamin k antagonist (VKA). We also prescribed a hematological evaluation to exclude a hypercoagulability disorder. Our patient’s daughter was a carrier of a mutation in both the methylenetetrahydrofolatereductase and Thrombin genes. A TOE after 30 days showed the persistence of LA thrombi, although with significantly reduced size and mobility (Fig.2). The follow–up was clinically uneventful. We suggested to continue anticoagulation therapy with VKA, and we planned a new TOE after 4 weeks. Discussion Although proper anticoagulation decreases cardioembolic risk in patients with AF, atrial thrombosis may occur due to LA remodeling, high CHA2DS2–VASc score and other factors, including hypercoagulability disorders. The presence of multiple LA thrombi represents a challenge for clinicians, especially in case of concomitant high thromboembolic and bleeding risk. However, the best treatment strategies for these extreme conditions are not defined, so far. Therefore, the therapeutic choice is often tailored to the single patient and based on the clinical judgment, bearing in mind that avoiding Charybdis means passing to close to Scylla and vice versa.

NURSING COUNSELING FOR THE OPTIMIZATION OF THE REMOTE MANAGEMENT OF PATIENTS WITH ILR AFTER CRYPTOGENIC STROKE

Abstract Background ILR is a device used to diagnose and document cardiac rhythm disorders in various clinical contexts including syncope and CS. The ILRs can be remotely monitored through a dedicated system consisting of a fully automatic home monitor or, in the latest generation devices, throughan APP that can be downloaded by the patient on his mobile phone. ILR remote monitoring can be performed by the nurse after acquiring the necessary skills on system functioning and knowledge about heart rhythm disorders. Methods Since 2017, a collaboration between Cardiologists and Neurologists has been established at our hospital providing a shared protocol for the management of patients with CS implanted with an ILR to detect asymptomatic AF. All CS patients referred for ILR implantation at our center received a MEDTRONIC ILR and were equipped with a remote monitoring system. ILR management protocol includes a first phase after the implant, where the nurse carries out patient training and counseling; enters all data in the Medtronic Carelink website, provides the patient with the home monitor, clearly explaining its use at home and, finally, obtains patient informed. Second phase of the protocol includes patient FU management, where the nurse reviews all remote transmissions, identifies any arrhythmic events and contacts by phone the patient to evaluate symptoms and, in case,establish the date for FU. Results Since 2017, 70 pz with CS (mean age:65±9 years,67.24% with CHADS2–VASc Score &amp;gt;=4) underwent ILR implantation.ILR remote monitoring allowed the diagnosis of AF in 27% pz (asymptomatic in 72%), of bradyarrhythmia in 4% and VT in 2%. Patients with arrhythmic diagnoses were contacted for FU in H to set up appropriate intervention. In described care pathway, the training and counselling carried out by nurses after the implant was crucial to establish the relationship of trust between patient and nurse, which significantly improved patient compliance. Conclusions The use of ILR has allowed to detect arrhythmias, even when asymptomatic, in patients affected by CS. In our experience, remote monitoring managed by trained nurses was crucial for the early diagnosis of AF. However, since technology is rapidly evolving, training updates to nurse staff regarding remote monitoring systems are essential to improve the counselling. Teamwork and constant cardiologist–nurse communication proved to be fundamental in offering the best care to these patients.

The Relationship Between CHA2DS2-VASc Scores and The Degree of TIMI Flow in Patients with Acute ST-Segment Elevation Myocardial Infarction Who Underwent Primary Percutaneous Coronary Intervention at Dr. Saiful Anwar Malang

Background: Suboptimal reperfusion of the compromised myocardium in the area of the culprit coronary arteries is one of the main problems associated with primary PCI that need reliable risk stratification methods to accurately predict the occurrence of decreased TIMI flow given its complex pathophysiology. Some parameters are included CHA2DS2-VASc score. Objective: To understand the relationship between CHA2DS2-VASc and the decreased TIMI flow in STE-ACS patients who had underwent primary PCI at RSUD dr. Saiful Anwar Malang. Material and Methods: The study was cohort retrospective with the inclusion criteria being all STE-ACS patients who underwent primary PCI in RSUD Dr. Saiful Anwar Malang from January 2018 – August 2023. Patients were assigned to TIMI flow grade &lt;3 group (N =169) and TIMI flow grade 3 (N = 677) according to TIMI Flow degree after primary PCI. All the patient’s angiogram were evaluated for TIMI score and CHA2DS2-VASc score is based on a guideline. We concluded data in SPSS program and used the Spearman test and p value of .05 was considered as significant. Result: From a total sample of 846 patients, the correlation between STE-ACS onset and TIMI flow indicates that a higher number of patients with STE-ACS onset &lt;12 hours was found in the TIMI flow &lt;3 and 3 groups (p=0.000). The cutoff CHA2DS2 VASC score's sensitivity and specificity values were ascertained using ROC analysis with cut off value 2.5. The incidence of decreased TIMI flow rate was more significant in the CHA2DS2-VASc ≥3 group with DM (+) and age ≥64 (OR value 0.156, p=0.000) than in the CHA2DS2-VASc ≥3 group without DM and age &lt; 64. With an OR value of 2.94 (p=0.000), Killip class &gt; 2 is another powerful predictor of lower TIMI flow. Conclusion: The only variables in the CHA2DS2-VASc score component that are most strongly associated with the risk of reducing the degree of TIMI flow are DM, age, and Killip class. Keyword: Acute Coronary Syndrome, CHA2DS2-VASc Score, Intervention, Percutaneous Coronary Slow Flow- No Reflow Phenomena, TIMI Flow Degree.

Long-term follow-up of symptom and quality of life changes in patients with narcolepsy during and after the COVID-19 pandemic.

The COVID-19 pandemic may have a significant impact on patients with narcolepsy, yet a long-term follow-up study is currently lacking. This study aims to investigate changes in symptom severity and the quality of life of patients with narcolepsy during and after the pandemic. Patients with type 1 or type 2 narcolepsy (NT1, NT2) were retrospectively recruited and prospectively followed from 2020 to 2023. They received evaluations including the Epworth Sleepiness Scale (ESS), the visual analog scale (VAS) for hypersomnolence, the VAS for cataplexy, the Short-form 36 Health Survey questionnaire (SF-36), and a sleep diary. We compared the differences between the pre-lockdown, the lockdown, the post-lockdown, and the post-pandemic periods byrepeated measures ANOVAor the Friedman test, with the Bonferroni test for post hoc analysis. A total of 100 patients completed the 4-year study (mean age, 24.06 ± 7.00years; 55% male). We observed significant differences in the ESS (p = 0.037), total nighttime sleep (p = 0.03), total sleep time (p = 0.035), and sleep efficiency (p = 0.035) during the study period. There was also significantly worse physical role functioning in the post-pandemic period (p = 0.014). In particular, the NT1 group had significantly decreased VAS-C scores (p < 0.001) but experienced worse physical role functioning in the post-pandemic period (p = 0.009). Patients with narcolepsy continue to face challenges after the pandemic. A more flexible lifestyle with an adequate sleep time may be beneficial, and medication adherence should be emphasized.

The Intersection of Atrial Fibrillation and Coronary Artery Disease in Middle Eastern Patients. Analysis from the Jordan Atrial Fibrillation Study.

There is a scarcity of clinical studies which evaluate the association of atrial fibrillation (AF) and coronary artery disease (CAD) in the Middle East. The aim of this study was to evaluate the impact of CAD on baseline clinical profiles and one-year outcomes in a Middle Eastern cohort with AF. Consecutive AF patients evaluated in 29 hospitals and cardiology clinics were enrolled in the Jordan AF Study (May 2019-December 2020). Clinical and echocardiographic features, use of medications and one-year outcomes in patients with AF/CAD were compared to AF/no CAD patients. Of 2020 AF patients enrolled, 216 (10.7%) had CAD. Patients with AF/CAD were more likely to be men and had significantly higher prevalence of hypertension, diabetes, dyslipidemia, heart failure and chronic kidney disease compared to the AF/no CAD patients. They also had lower mean left ventricular ejection fraction and larger left atrial size. Mean CHA2DS2 VASc and HAS-BLED scores were higher in AF/CAD patients than those with AF/no CAD (4.3 ± 1.7 vs. 3.6 ± 1.8, p < 0.0001) and (2.0 ± 1.1 vs. 1.6 ± 1.1, p < 0.0001), respectively. Oral anticoagulant agents were used in similar rates in the two groups (83.8% vs. 82.9%, p = 0.81), but more patients with AF/CAD were prescribed additional antiplatelet agents compared to patients with AF/no CAD (73.7% vs. 41.5%, p < 0.0001). At one year, AF/CAD patients, compared to AF/no CAD patients had significantly higher hospitalization rate (39.4% vs. 29.2%, p = 0.003), more acute coronary syndrome and coronary revascularization (6.9% vs. 2.4%, p = 0.004), and higher all-cause mortality (18.5% vs. 10.9%, p = 0.002). In this cohort of Middle Eastern patients with AF, one in 10 patients had CAD. The coexistence of AF and CAD was associated with a worse baseline clinical profile and one-year outcomes. Clinical study registration: the study is registered on clinicaltrials.gov (unique identifier number NCT03917992).

Gender Differences in Patients with Atrial Fibrillation Receiving Oral Anticoagulants.

Gender is a well-recognized risk factor in atrial fibrillation (AF)-related ischemic stroke. The association of gender with the use of oral anticoagulants (OACs) and prognosis remains unknown. The National Health Insurance Research Database in Taiwan identified 203,775 patients with AF aged 20 years from 2012 to 2018, with 55.4% of males. Our main study cohort included 67,426 patients using OACs. The study endpoints include death, ischemic stroke, intracranial hemorrhage, major bleeding, and composite adverse events. Significant differences were found in baseline characteristics between sexes. Female patients with AF were older and had higher -VASc and HAS-BLED scores. Non-vitamin K antagonist oral anticoagulant (NOAC) use was more prominent in females while the use of warfarin was similar in both sexes. The distribution of baseline characteristics between the warfarin and NOAC groups in both sexes was much alike. Among the whole study cohort, NOAC was associated with a decreased risk of clinical endpoints compared to warfarin, which remained the same in subgroup analyses of both sexes. Additionally, a greater risk reduction of ischemic stroke with NOAC was observed in female patients compared to male patients (adjusted hazard ratio: 0.517 in males, 0.425 in females, interaction p = 0.040). This nationwide cohort demonstrated the differences between male and female patients with AF, including baseline characteristics, risk profiles, and medication use. Despite great differences in baseline demographic data, NOAC was associated with better clinical outcomes compared to warfarin in both sexes, and females benefited more than males in preventing ischemic stroke using NOACs.

A zero-exchange approach for left atrial access in pulmonary vein isolation with pulsed field ablation.

Pulsed field ablation (PFA) has emerged as an innovative technique for pulmonary vein isolation (PVI). Typically, a transeptal puncture (TSP) with a standard sheath precedes a switch to the larger diameter sheath in the left atrium. This study aimed to describe the safety and feasibility of direct TSP using the large diameter Faradrive sheath before performing PVI with PFA. We prospectively enrolled 166 consecutive patients with paroxysmal or persistent atrial fibrillation (AF) undergoing PVI with PFA at our institution. TSP was performed in all cases with transesophageal echocardiography guidance, using the Faradrive sheath and a 98 cm matched Brockenbrough needle. The primary endpoint was the occurrence of pericardial tamponade during or within the first 48 h after the procedure. The secondary endpoint was the occurrence of any major complication. All 166 patients were included into the final analysis (44% female): 64% of patients had paroxysmal AF and 36% persistent AF (68 ± 11 years old, median CHA2DS2Vasc Score 3, median left atrial volume index 31). The median duration of the procedure was 60 min, median time to TSP was 15 min, and the median fluoroscopy dose was 595 cGy × cm2. The primary endpoint occurred in one patient: a non-TSP related pericardial tamponade, which was managed with pericardial puncture. Direct TSP with skipping sheath exchange using the large diameter Faradrive sheath for PVI with PFA was safe, feasible, and reduced costs in all patients. Large scale studies and registries are needed to verify this workflow.

Value of CHA2DS2-VASC Score as Predictor of Contrast-Induced Nephropathy in Patients with Non-ST Elevation Myocardial Infarction Undergoing Percutaneous Coronary Intervention

Background: PCI necessitates the usage of iodinated contrast agent which in some cases is accompanied by CIN and the potential for worse outcomes. The current study aimed to use the CHA2DS2-VASc score with its simple and available components as a predictor of risk of developing CIN in NSTEMI cases who will undergo PCI.&#x0D; Methods: This single center observational study was conducted on 200 cases diagnosed with NSTEMI who were subjected to primary PCI. The basic level of serum Cr was detected at time of admission followed by monitoring for 48 h, and seven days following the approach to detect the occurrence of CIN. Electrocardiogram (ECG) and transthoracic echocardiography are assessed to all patients.&#x0D; Results: At cut off ≥2 (area under curve (AUC)=0.649), CHA2DS2-VASc could be used as a predictor for post-PCI CIN with sensitivity and specificity, PPV, NPV and accuracy of 77.6%, 52.3%, 34.5%, 87.8% and 58.5% respectively. There was a statistically significant correlation between occurrence of CIN and all the studied factors (female sex, HTN, DM, anemia, CHF, hemoglobin (HBG), pre-existing renal disease, previous stroke, pre-creatinine, 48hrs and 7 days post-creatinine, pre glomerular filtration rate (GFR) and cha2ds-vasc score and dehydration) with exception of age and vascular disease (p&gt;0.05) being non-significant. Contrast volume, CHA2DS VASC score, metformin use, eGFR after 48h and ACEI /ARB II antagonists ’inhibitor use were significant independent predictors for CIN.&#x0D; Conclusions: In NSTEMI cases who are subjected to PCI, CHADS2 VASC score ≥ 2 is accompanied by a high risk for CIN and in hospital morbidity and mortality. CHA2DS2-VASC score is considered a useful novel, easy, and reliable method to anticipate CIN in NSTEMI cases undergoing urgent P.

Left atrial appendage occlusion in patients suffering from advanced chronic kidney disease (stage 4 and 5). Long-term follow-up.

Advanced chronic kidney disease (A-CKD) combined with atrial fibrillation increases the risk of both thrombogenic and bleeding events. Left atrial appendage occlusion (LAAO) may be an alternative to oral anticoagulation to prevent thromboembolic events. We aimed to evaluate the outcomes of LAAO in patients with A-CKD. Comparison at long-term follow-up of patients diagnosed with and without A-CKD (eGFR<30 mL/min/1.73 m2 ) who underwent LAAO between 2009 and May 2022. Five hundred seventy-three patients were included. Eighty-one (14%) were diagnosed with A-CKD. There were no differences in sex, age, and cardiovascular risk factors, except for diabetes which was more frequent in patients with A-CKD. The control group had higher rates of stroke, both ischemic and hemorrhagic. There were no differences in the CHA2 DS2 -VASc score, although A-CKD patients had a higher bleeding risk according to the HASBLED scale. Global procedural success was 99.1%. At follow-up, there were no differences in stroke rate: at 1-year (HR: 1.22, IC-95%: 0.14-10.42, p = 0.861); at 5-years (HR: 0.60, IC-95%: 0.08-4.58, p = 0.594). Although bleeding events were higher in the A-CKD group, no differences were found in major bleeding (defined BARC ≥ 3) at 1-year (HR: 1.34, IC-95%: 0.63-2.88, p = 0.464) or at 5-years follow-up (HR: 1.30, IC-95%: 0.69-2.48, p = 0.434). Mortality rate at 5 years was higher in the A-CKD patients (HR: 1.84, IC-95%: 1.18-2.87, p = 0.012). LAAO is an effective and safe treatment in A-CKD patients to prevent ischemic events and bleeding. This strategy could be an alternative to oral anticoagulation in this high-risk group of patients.

Risk Profiles and Treatment Patterns in Atrial Fibrillation Patients with Chronic Kidney Disease Receiving or not Receiving Anticoagulation Therapy.

Background Patients with atrial fibrillation (AF) and chronic kidney disease (CKD) are at high risk for both thromboembolism and bleeding events. The latter induces a potential reason for withholding oral anticoagulation (OAC) despite an indication for prophylaxis of thromboembolic events. Methods AF patients with CKD (estimated glomerular filtration [eGFR] rate between 15 and 49 mL/min per 1.73 m 2 ) were included in a prospective international registry in Europe between 2016 and 2020, that is, XARENO (factor XA inhibition in renal patients with nonvalvular atrial fibrillation observational registry). The study enrolled adult patients treated at the discretion of physicians with rivaroxaban, vitamin K antagonists (VKA), or without OAC (w/oOAC). Here, we report a prespecified explorative baseline comparison between patients receiving OAC or no OAC within XARENO. Results In total, 1,544 patients (mean age: 78.2 years, mean eGFR: 36.2 mL/min) were studied (rivaroxaban n = 764, VKA n = 691, w/oOAC n = 89). Patients in the w/oOAC group were older and had a similar stroke (mean CHA 2 DS 2 -VASc score 4.0) but higher bleeding risk (mean modified Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile INR, Elderly, Drugs/Alcohol Concomitantly score 2.5 vs. 1.8) compared with the OAC groups. The distribution of comorbidities including hypertension, diabetes, and heart failure was similar. Treatment with antiplatelet drugs was fivefold more frequent in the w/oOAC group. Conclusion Only 5.8% of the overall population of AF patients with advanced CKD received no OAC. These patients were older and had a higher bleeding risk, which might explain this decision, but which contrasts with the more frequent use of antiplatelet drugs in this vulnerable group of patients.