The Editor's Roundtable: Medical Management of Atrial Fibrillation.

Am J Cardiol. 2012 Feb 15;109(4):563-9

Authors: Friedewald VE, Kowal RC, Olshansky B, Yancy CW, Roberts WC

PMID: 22293222 [PubMed - in process]

Red Blood Cell Indices and Development of Hospital-Acquired Anemia During Acute Myocardial Infarction.

Am J Cardiol. 2012 Jan 18;

Authors: Salisbury AC, Amin AP, Reid KJ, Wang TY, Alexander KP, Chan PS, Masoudi FA, Spertus JA, Kosiborod M

Abstract
Hospital-acquired anemia (HAA) is common, often develops in the absence of bleeding, and is associated with poor outcomes in patients with acute myocardial infarction (AMI). It is unknown whether red cell distribution width (RDW) and mean corpuscular volume (MCV), which are routinely available markers of iron deficiency, are associated with development of HAA during AMI. We studied 15,133 patients with AMI without anemia at admission. HAA was defined by nadir hemoglobin levels below age-, gender-, and race-specific thresholds and moderate-severe HAA was defined as nadir hemoglobin ?11 g/dl. We examined the association between low MCV (<80 fL) and/or increased RDW (>15%) on patients' initial complete blood cell count and moderate-severe HAA using multivariable modified Poisson regression. Moderate-severe HAA was more common in patients with high RDW and low MCV (45.5%), high RDW and MCV ?80 fL (33.0%), and normal RDW and low MCV (28.0%) than in those with normal RDW and MCV (18.3%, p <0.001). Compared to patients with normal RDW and MCV, those with increased RDW and low MCV (relative risk 1.72, 95% confidence interval 1.57 to 1.87), increased RDW and MCV ?80 fL (relative risk 1.28, 95% confidence interval 1.16 to 1.42), or normal RDW and low MCV (relative risk 1.34, 95% confidence interval 1.08 to 1.65) were independently more likely to develop moderate-severe HAA. In conclusion, increased RDW and low MCV were independent predictors of moderate-severe HAA.

PMID: 22264598 [PubMed - as supplied by publisher]

Midregional Pro-A-Type Natriuretic Peptide for Diagnosis and Prognosis in Patients With Suspected Acute Myocardial Infarction.

Am J Cardiol. 2012 Jan 16;

Authors: Meune C, Twerenbold R, Drexler B, Balmelli C, Wolf C, Haaf P, Reichlin T, Irfan A, Reiter M, Zellweger C, Meissner J, Stelzig C, Freese M, Capodarve I, Mueller C

Abstract
We hypothesized that midregional pro-A-type natriuretic peptide (MR-proANP), the stable midregional epitope of proANP, might be useful in the early diagnosis and risk stratification of patients with suspected acute myocardial infarction (AMI). In this multicenter study we measured MR-proANP, cardiac troponin T (cTnT), and high-sensitive cTnT (hs-cTnT) at presentation in 675 consecutive patients presenting to the emergency department with suspected AMI. The final diagnosis was adjudicated by 2 independent cardiologists. Patients were followed 360 days for mortality and AMI. AMI was the final diagnosis in 119 patients (18%). Median MR-proANP levels at presentation were significantly higher in patients with AMI (189 pmol/L, interquartile range 97 to 341) versus patients with another final diagnosis (83 pmol/L, 49 to 144, p <0.001). However, neither the combination of MR-proANP with cTnT nor its combination with hs-cTnT significantly improved diagnostic accuracy as quantified by area under the receiver operating characteristic curve (0.91 vs 0.89 for cTnT alone, p = 0.086; 0.95 vs 0.96 for hs-cTnT, respectively, p = 0.02). Cumulative 360-day mortality/AMI rates were 2.4% in the first, 3.6% in the second, 9.5% in the third, and 18.8% in the fourth quartiles of MR-proANP (p <0.001). MR-proANP (area under the curve 0.76) predicted mortality/AMI independently of and more accurately than cTnT (area under the curve 0.62), hs-cTnT (area under the curve 0.71), and Thrombolysis In Myocardial Infarction risk score (area under the curve 0.72). Net reclassification improvements offered by the additional use of MR-proANP were 0.388 (p <0.001), 0.425 (p <0.001), and 0.217 (p = 0.007), respectively. In conclusion, MR-proANP improves risk prediction for 360-day mortality/AMI but does not seem to help in the early diagnosis of AMI.

PMID: 22257708 [PubMed - as supplied by publisher]

Age-Specific Gender Differences in In-Hospital Mortality by Type of Acute Myocardial Infarction.

Am J Cardiol. 2012 Jan 13;

Authors: Zhang Z, Fang J, Gillespie C, Wang G, Hong Y, Yoon PW

Abstract
Younger women hospitalized with an acute myocardial infarction (MI) have a poorer prognosis than men. Whether this is true for patients with acute ST-segment elevation MI (STEMI) and non-STEMI (NSTEMI) is not extensively studied. Using the MarketScan 2004 to 2007 Commercial and Medicare supplemental admission databases, we assessed gender differences in in-hospital mortality according to age in 91,088 patients (35,899 with STEMI, 55,189 with NSTEMI) who were 18 to 89 years old and had acute MI as their primary diagnosis. Patients with STEMI had significantly higher in-hospital mortality than those with NSTEMI (4.35% vs 3.53%, p <0.0001). Compared to men women were older, had higher co-morbidity scores, and were less likely to undergo revascularization during hospitalization in the STEMI and NSTEMI populations. In patients with STEMI the unadjusted women-to-men odds ratio for in-hospital mortality was 2.29 (95% confidence interval 1.48 to 3.55) for the 18- to 49-year age group, 1.68 (1.28 to 2.21) for 50 to 59, 1.48 (1.17 to 1.88) for 60 to 69, 1.28 (1.06 to 1.57) for 70 to 79, and 1.01 (0.83 to 1.23) for 80 to 89. Corresponding unadjusted odds ratios were 1.51 (0.87 to 2.61), 1.46 (1.11 to 1.92), 1.29 (1.04 to 1.61), 0.83 (0.70 to 0.99) and 0.82 (0.70 to 0.94) for patients with NSTEMI. After adjustment for potential confounding factors, excess risk for in-hospital mortality in younger women versus their men counterparts (<60 years old) persisted in STEMI. In patients with NSTEMI the difference between younger women and younger men was not statistically significant; however, older women (?70 years old) had better survival than men. In conclusion, higher risk of in-hospital mortality in younger women compared to younger men is more evident in patients with STEMI.

PMID: 22245410 [PubMed - as supplied by publisher]

Meta-Analysis of Long-Term Outcomes for Drug-Eluting Stents Versus Bare-Metal Stents in Primary Percutaneous Coronary Interventions for ST-Segment Elevation Myocardial Infarction.

Am J Cardiol. 2012 Jan 3;

Authors: Wallace EL, Abdel-Latif A, Charnigo R, Moliterno DJ, Brodie B, Matnani R, Ziada KM

Abstract
The use of drug-eluting stents (DESs) in primary percutaneous coronary intervention (PPCI) has shown early benefit over bare-metal stents (BMSs) in decreasing adverse cardiac events. However, there are concerns regarding the increased risk of late and very late stent thrombosis (ST) after DES use. With the paucity of ST events individual trials may have been underpowered to detect significant differences. We sought to perform a meta-analysis to evaluate the available literature examining the outcomes of DESs and BMSs in PPCI after ?3 years of follow-up. We analyzed 8 randomized clinical trials (RCTs) and 5 observational studies comparing DESs to BMSs in PPCI. Clinical end-point data were analyzed for RCTs and observational studies separately using random-effect models. RCTs included 5,797 patients in whom first-generation DESs (sirolimus- or paclitaxel-eluting stents) were compared to BMS control arms. Patients receiving DESs had a significantly lower risk of target lesion revascularization (odds ratio [OR] 0.48, confidence interval [CI] 0.37 to 0.61), target vessel revascularization (OR 0.53, CI 0.42 to 0.66), and accordingly major adverse cardiac events (OR 0.69; CI 0.56 to 0.84). Incidence of ST was not different between groups (OR 1.02, CI 0.76 to 1.37). There was no significant difference in mortality (OR 0.88, CI 0.68 to 1.12) or recurrent myocardial infarction (OR 0.97; CI 0.61 to 1.54). Among observational studies (n = 4,650) fewer studies reported on target lesion revascularization and target vessel revascularization, but the trend remained in favor of DESs. A small but statistically significant increase in ST was noted with DES use (OR 1.62, CI 1.18 to 2.21) at ?3 years of follow up, without evidence of recurrent myocardial infarction. Those receiving DESs had a significantly lower mortality compared to those receiving BMSs (OR, 0.65, 95% CI 0.53 to 0.80, p <0.001). In conclusion, this meta-analysis of RCTs examining the long-term outcomes of first-generation DESs versus BMSs in PPCI, DES use resulted in decreased repeat revascularization with no increase in ST, mortality, or recurrent myocardial infarction.

PMID: 22221949 [PubMed - as supplied by publisher]

Comparison of Bleeding and In-Hospital Mortality in Asian-Americans Versus Caucasian-Americans With ST-Elevation Myocardial Infarction Receiving Reperfusion Therapy.

Am J Cardiol. 2012 Jan 3;

Authors: Mehta RH, Parsons L, Peterson ED,

Abstract
Concern has been raised that Asian-Americans may have a higher bleeding risk than Caucasian-Americans when treated with fibrinolytic and antithrombotic agents. To date there is limited evidence to support or refute this hypothesis or evaluate bleeding risk and its related outcomes in Caucasian-Americans versus Asian-Americans with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary interventions (PPCI). We evaluated Asian-Americans and Caucasian-Americans with STEMI receiving reperfusion therapy in the National Registry of Myocardial Infarction (NRMI) 4 and 5 (n = 90,317). We studied risk-adjusted major bleeding and in-hospital mortality. Major bleeding rates after fibrinolysis were similar in Asian-Americans (n = 705) and Caucasian-Americans (n = 42,243, 11.1% vs 10.3%, adjusted odds ratio [OR] 0.97, 95% confidence interval [CI] 0.69 to 1.36, p = 0.5002). Although the observed major bleeding rate was higher in Asian-Americans (n = 1,037) compared to Caucasian-Americans (n = 46,332) treated with PPCI (10.3% vs 7.8%, p = 0.0036), these rates differed only marginally after adjusting for baseline clinical variables (OR 1.24, 95% CI 0.97 to 1.59). Overall adjusted mortality was similar in Asian-Americans and Caucasian-Americans when treated with fibrinolysis (OR 0.96, 95% CI 0.56 to 1.65) or with PPCI (OR 1.35, 95% CI 0.85 to 2.13). Major bleeding after PPCI or fibrinolysis was associated with similar increased risks for mortality in these ethic groups. In conclusion, despite suggestions to the contrary, Asian-Americans with STEMI treated with fibrinolysis or PPCI had similar bleeding and bleeding-related mortality risks compared to Caucasian-Americans. Given the genotypic and phenotypic differences between the 2 cohorts, similar studies in the rapidly growing Asian-American population are needed to confirm our findings and to understand the safety and effectiveness of newer potent antiplatelet and antithrombotic agents in patients with coronary syndromes.

PMID: 22221945 [PubMed - as supplied by publisher]

Cost-Effectiveness of Clopidogrel Plus Aspirin for Stroke Prevention in Patients With Atrial Fibrillation in Whom Warfarin Is Unsuitable.

Am J Cardiol. 2012 Jan 3;

Authors: Coleman CI, Straznitskas AD, Sobieraj DM, Kluger J, Anglade MW

Abstract
Guidelines for atrial fibrillation (AF) recommend clopidogrel plus aspirin as an alternative stroke prevention strategy in patients in whom warfarin is unsuitable. A Markov model was conducted from a Medicare prospective using data from the Atrial Fibrillation Clopidogrel Trial with Irbesartan for Prevention of Vascular Events-A (ACTIVE-A) trial and other published studies. Base-case analysis evaluated patients 65 years old with AF, a CHADS(2) (congestive heart failure, 1 point; hypertension defined as blood pressure consistently >140/90 mm Hg or antihypertension medication, 1 point; age ?75 years, 1 point; diabetes mellitus, 1 point; previous stroke or transient ishemic attack, 2 points) score of 2, and a lower risk for major bleeding. Patients received clopidogrel 75 mg/day plus aspirin or aspirin alone. Patients were followed for up to 35 years. Outcomes included quality-adjusted life-years (QALYs), costs (in 2011 American dollars), and incremental cost-effectiveness ratios. Quality-adjusted life expectancy and costs were 9.37 QALYs and $88,751 with clopidogrel plus aspirin and 9.01 QALYs and $79,057 with aspirin alone. Incremental cost-effectiveness ratio for clopidogrel plus aspirin was $26,928/QALY. With 1-way sensitivity analysis using a willingness-to-pay threshold of $50,000/QALY, clopidogrel plus aspirin was no longer cost effective when the CHADS(2) score was ?1, major bleeding risk with aspirin was ?2.50%/patient-year, the relative risk decrease for ischemic stroke with clopidogrel plus aspirin versus aspirin alone was <25%, and the utility of being healthy with AF on combination therapy decreased to 0.95. Monte Carlo simulation demonstrated that clopidogrel plus aspirin was cost effective in 55% and 73% of 10,000 iterations assuming willingness-to-pay thresholds of $50,000 and $100,000/QALY. In conclusion, clopidogrel plus aspirin appears cost-effective compared to aspirin alone for stroke prevention in patients with AF with a CHADS(2) of ?2 and a lower risk of bleeding.

PMID: 22221944 [PubMed - as supplied by publisher]

Effect of Timing of Chronic Preoperative Aspirin Discontinuation on Morbidity and Mortality in Patients Having Combined Coronary Artery Bypass Grafting and Valve Surgery.

Am J Cardiol. 2011 Dec 21;

Authors: Jacob M, Smedira N, Blackstone E, Williams S, Cho L

Abstract
The objective of this study was to determine if late use of aspirin before coronary artery bypass grafting (CABG) with valve surgery affects bleeding events and major adverse cardiovascular events. Aspirin has been shown to decrease postoperative CABG mortality and ischemic events. There are no data on the time of aspirin discontinuation and its effect on CABG with valve surgery and bleeding complications. From January 1, 2002 to January 31, 2008, 1,963 patients undergoing nonurgent plus valve surgery at the Cleveland Clinic were on preoperative aspirin; 1,404 (72%) discontinued aspirin ?6 days before surgery (early discontinuation) and 559 (28%) continued aspirin within 5 days of surgery (late use). Propensity-score analysis and matching were employed for fair comparison of outcomes. There was no difference between early-discontinuation and late-use groups in the composite outcome of in-hospital mortality, myocardial infarction, and stroke (5.3% in the 2 groups). More patients in the late-use group received postoperative transfusions (49% vs 42%, p = 0.02). There was a trend toward increased reoperation for bleeding (6.1% vs 3.7%, p = 0.08) in the late-use group. In conclusion, in patients undergoing CABG with valve surgery, there was an increased use of postoperative red blood cell transfusion and a trend toward increased reoperation for bleeding in the late-use group. There was no difference in major adverse cardiac events between groups. Late use of aspirin in CABG with valve surgery must be weighed against an increased risk of bleeding.

PMID: 22196776 [PubMed - as supplied by publisher]

Outcomes of Patients Treated With Triple Antithrombotic Therapy After Primary Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction (from the Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction [HORIZONS-AMI] Trial).

Am J Cardiol. 2011 Dec 21;

Authors: Nikolsky E, Mehran R, Dangas GD, Yu J, Parise H, Xu K, Pocock SJ, Stone GW

Abstract
In the setting of ST-segment elevation myocardial infarction (STEMI), patients at high risk of systemic emboli who undergo primary percutaneous coronary intervention (PCI) using stents might require triple antithrombotic therapy (a combination of aspirin, thienopyridine, and vitamin K antagonist [VKA]). The risks and benefits of such therapy in the setting of STEMI have been incompletely characterized. We, therefore, assessed the outcomes of patients who received triple therapy after primary PCI in the large-scale, contemporary Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction [HORIZONS-AMI] trial. Among the 3,320 patients triaged to primary PCI, 126 (3.8%) were prescribed triple therapy and 3,194 (96.2%) were prescribed dual antiplatelet therapy. The most frequent indications for VKA treatment were a severely reduced left ventricular ejection fraction with a large akinetic area, atrial fibrillation (23.8% each), and mural thrombus (23.0%). The assignment to triple therapy was associated with older age, female gender, rhythm disturbances, Killip class >1 on admission, lower left ventricular ejection fraction, left anterior descending artery territory infarcts, and Final Thrombolysis In Myocardial Infarction flow grade <3. Patients treated with triple versus dual therapy had comparable short- and long-term ischemic outcomes but had significantly increased rates of major bleeding during the index hospitalization (17.1% vs 6.5%, p <0.0001), resulting in premature VKA discontinuation in 14.3% of those patients. In conclusion, in the setting of STEMI treated with primary PCI, the combination of aspirin, thienopyridine, and VKA results in an excess of bleeding complications and premature discontinuation of VKA. The risk of adding oral anticoagulation to patients admitted for STEMI should be carefully considered before choosing drug-eluting or bare metal stents.

PMID: 22196778 [PubMed - as supplied by publisher]

Sex Differences in Management and Mortality of Patients With ST-Elevation Myocardial Infarction (from the Korean Acute Myocardial Infarction National Registry).

Am J Cardiol. 2011 Dec 21;

Authors: Kang SH, Suh JW, Yoon CH, Cho MC, Kim YJ, Chae SC, Yoon JH, Gwon HC, Han KR, Kim JH, Ahn YK, Jeong MH, Kim HS, Choi DJ,

Abstract
There has been controversy over the disparity between men and women with regard to the management and prognosis of acute myocardial infarction. Analyzing nationwide multicenter prospective registries in Korea, the aim of this study was to determine whether female gender independently imposes a risk for mortality. Data from 14,253 patients who were hospitalized for ST-segment elevation myocardial infarction from November 2005 to September 2010 were extracted from registries. Compared to men, women were older (mean age 56 ± 12 vs 67 ± 10 years, p <0.001), and female gender was associated with a higher frequency of co-morbidities, including hypertension, diabetes, and dyslipidemia. Women had longer pain-to-door time and more severe hemodynamic status than men. All-cause mortality rates were 13.6% in women and 7.0% in men at 1 year after the index admission (hazard ratio for women 2.01, 95% confidence interval 1.80 to 2.25, p <0.001). The risk for death after ST-segment elevation myocardial infarction corresponded highly with age. Although the risk remained high after adjusting for age, further analyses adjusting for medical history, clinical performance, and hemodynamic status diminished the gender effect (hazard ratio 1.00, 95% confidence interval 0.86 to 1.17, p = 0.821). Propensity score matching, as a sensitivity analysis, corroborated the results. In conclusion, this study shows that women have a comparable risk for death after ST-segment elevation myocardial infarction as men. The gender effect was accounted for mostly by the women's older age, complex co-morbidities, and severe hemodynamic conditions at presentation.

PMID: 22196789 [PubMed - as supplied by publisher]

Comparison of Late Results of Percutaneous Coronary Intervention Among Stable Patients ?65 Versus >65 Years of Age With an Occluded Infarct Related Artery (from the Occluded Artery Trial).

Am J Cardiol. 2011 Dec 13;

Authors: Skolnick AH, Reynolds HR, White HD, Menon V, Carvalho AC, Maggioni AP, Pearte CA, Gruberg L, Azevedo RE, Schroeder E, Forman SA, Lamas GA, Hochman JS, Džavík V

Abstract
Although opening an occluded infarct-related artery >24 hours after myocardial infarction in stable patients in the Occluded Artery Trial (OAT) did not reduce events over 7 years, there was a suggestion that the effect of treatment might differ by patient age. Baseline characteristics and outcomes by treatment with percutaneous coronary intervention (PCI) versus optimal medical therapy alone were compared by prespecified stratification at age 65 years. A p value <0.01 was prespecified as significant for OAT secondary analyses. The primary outcome was death, myocardial infarction, or New York Heart Association class IV heart failure. Patients aged >65 years (n = 641) were more likely to be female, to be nonsmokers, and to have hypertension, lower estimated glomerular filtration rates, and multivessel disease compared to younger patients (aged ?65 years, n = 1,560) (p <0.001). There was no significant observed interaction between treatment assignment and age for the primary outcome after adjustment (p = 0.10), and there was no difference between PCI and optimal medical therapy observed in either age group. At 7-year follow-up, younger patients tended to have angina more often compared to the older group (hazard ratio 1.21, 99% confidence interval 1.00 to 1.46, p = 0.01). The 7-year composite primary outcome was more common in older patients (p <0.001), and age remained significant after covariate adjustment (hazard ratio 1.42, 99% confidence interval 1.09 to 1.84). The rate of early PCI complications was low in the 2 age groups. The trend toward a differential effect of PCI in the young versus the old for the primary outcome was likely driven by measured and unmeasured confounders and by chance. PCI reduces angina to a similar degree in the young and old. In conclusion, there is no indication for routine PCI to open a persistently occluded infarct-related artery in stable patients after myocardial infarction, regardless of age.

PMID: 22172242 [PubMed - as supplied by publisher]

Usefulness of Transesophageal Echocardiography to Confirm Clinical Utility of CHA(2)DS(2)-VASc and CHADS(2) Scores in Atrial Flutter.

Am J Cardiol. 2011 Nov 29;

Authors: Parikh MG, Aziz Z, Krishnan K, Madias C, Trohman RG

Abstract
The CHA(2)DS(2)-VASc and CHADS(2) risk stratification schemes are used to predict thromboembolism and ischemic stroke in patients with atrial fibrillation. However, limited data are available regarding the utility of these risk stratification schemes for stroke in patients with atrial flutter. A retrospective analysis of 455 transesophageal echocardiographic studies in patients with atrial flutter was performed to identify left atrial (LA) thrombi and/or spontaneous echocardiographic contrast (SEC). The CHA(2)DS(2)-VASc (Congestive heart failure, Hypertension, Age ?75 years [doubled risk weight], Diabetes mellitus, previous Stroke/transient ischemic attack [doubled risk weight], Vascular disease, Age 65 to 74 years, Sex) and CHADS(2) (Congestive heart failure, Hypertension, Age ?75 years, Diabetes mellitus, previous Stroke/transient ischemic attack [double risk weight]) scores were calculated to stratify the risk of stroke or transient cerebrovascular ischemic events. Transesophageal echocardiography revealed LA thrombi in 5.3% and SEC in 25.9% of patients. Using CHADS(2), LA thrombus was found in 2.2% of the low-intermediate-risk group and 8.3% of the high-risk group (p = 0.005). SEC was found in 19.8% of the low-intermediate-risk group and 32% of the high-risk group (p = 0.004). Using CHA(2)DS(2)-VASc, LA thrombus was found in 1.7% of the low-intermediate-risk group and 6.5% of the high-risk group (p = 0.053). SEC was found in 11.8% of the low-intermediate-risk group versus 30.9% of the high-risk group (p = 0.004). The sensitivity for LA thrombus/SEC with a high CHADS(2) and CHA(2)DS(2)-VASc score was 64.8% and 88.7%, respectively (p = 0.0001). The specificity for LA thrombus/SEC with high CHADS(2) and CHA(2)DS(2)-VASc scores was 52.6% and 28.9%, respectively (p = 0.0001). In conclusion, both CHA(2)DS(2)-VASc and CHADS(2) scores are useful for stroke risk stratification in patients with atrial flutter. CHA(2)DS(2)-VASc had greater sensitivity for LA thrombus and SEC detection at the cost of reduced specificity.

PMID: 22133753 [PubMed - as supplied by publisher]

Rates and Implications for Hospitalization of Patients ?65 Years of Age With Atrial Fibrillation/Flutter.

Am J Cardiol. 2011 Nov 23;

Authors: Naccarelli GV, Johnston SS, Dalal M, Lin J, Patel PP

Abstract
The responsibility of managing atrial fibrillation (AF) and atrial flutter (AFL) falls predominantly on the Medicare system. Patients with AF or AFL often have a range of cardiovascular (CV) co-morbidities and are frequently hospitalized for AF and other CV causes. The present retrospective cohort study used medical claims data to evaluate the rates of hospitalization and inpatient mortality in elderly (aged ?65 years) patients with AF or AFL with Medicare supplemental insurance. The data were extracted from the United States Thomson Reuters MarketScan Medicare Supplemental and Coordination of Benefits Database (January 2004 to December 2007). Patients aged ?65 years with ?1 inpatient or ?2 outpatient nondiagnostic claims for AF or AFL and ?12 months of continuous enrollment before their index AF or AFL diagnoses were identified. The frequencies of hospitalization and inpatient death were evaluated over the postindex study period (mean 24.3 months). Of an eligible study population of 55,774 patients with AF or AFL (mean age 77.9 years, 52.2% men), 28,939 patients (51.9%) were hospitalized (all causes) with nonfatal outcomes, 12,652 (22.7%) were rehospitalized, and 1,592 (2.9%) died in the hospital. Higher proportions of patients were hospitalized for non-CV than for CV causes (35.6% vs 27.2%). For CV hospitalizations culminating in inpatient death (n = 516), the most common admission diagnoses were major bleeding, stroke or transient ischemic attack, and congestive heart failure. In conclusion, elderly patients with AF or AFL undergo frequent hospitalization for CV and non-CV causes. Measures that lower inpatient admission rates, particularly readmission rates, may reduce the increasing cost of treating patients with AF or AFL with Medicare supplemental insurance.

PMID: 22118826 [PubMed - as supplied by publisher]

Effect of Warfarin on Outcomes in Septuagenarian Patients With Atrial Fibrillation.

Am J Cardiol. 2011 Nov 23;

Authors: Roy B, Desai RV, Mujib M, Epstein AE, Zhang Y, Guichard J, Jones LG, Feller MA, Ahmed MI, Aban IB, Love TE, Levesque R, White M, Aronow WS, Fonarow GC, Ahmed A

Abstract
Anticoagulation has been shown to decrease ischemic stroke in atrial fibrillation (AF). However, concerns remain regarding their safety and efficacy in those ?70 years of age who constitute most patients with AF. Of the 4,060 patients (mean age 65 years, range 49 to 80) in the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) trial, 2,248 (55% of 4,060) were 70 to 80 years of age, 1,901 of whom were receiving warfarin. Propensity score for warfarin use, estimated for each of the 2,248 patients, was used to match 227 of the 347 patients not on warfarin (in 1:1, 1:2, or 1:3 sets) to 616 patients on warfarin who were balanced in 45 baseline characteristics. All-cause mortality occurred in 18% and 33% of matched patients receiving and not receiving warfarin, respectively, during up to 6 years (mean 3.4) of follow-up (hazard ratio [HR] when warfarin use was compared to its nonuse 0.58, 95% confidence interval [CI] 0.43 to 0.77, p <0.001). All-cause hospitalization occurred in 64% and 67% of matched patients receiving and not receiving warfarin, respectively (HR associated with warfarin use 0.93, 95% CI 0.77 to 1.12, p = 0.423). Ischemic stroke occurred in 4% and 8% of matched patients receiving and not receiving warfarin, respectively (HR associated with warfarin use 0.57, 95% CI 0.31 to 1.04, p = 0.068). Major bleeding occurred in 7% and 10% of matched patients receiving and not receiving warfarin, respectively (HR associated with warfarin use 0.73, 95% CI 0.44 to 1.22, p = 0.229). In conclusion, warfarin use was associated with decreased mortality in septuagenarian patients with AF but had no association with hospitalization or major bleeding.

PMID: 22118824 [PubMed - as supplied by publisher]

Outcomes of Drug-Eluting Stents for Protected Left Main Coronary Artery Disease (from the Multicenter, United States DEScover Registry).

Am J Cardiol. 2011 Nov 23;

Authors: Leitner J, Vlachos HA, Selzer F, Jamal SM, Kip KE, Williams DO, Abbott JD

Abstract
Percutaneous coronary intervention (PCI) for protected left main coronary artery (PLM) disease is complex because of patient and lesion factors; however, limited data exist on the outcomes of drug-eluting stent (DES) use for this indication. DEScover is a prospective observational study that enrolled consecutive patients with PCI in 2005. In-hospital and 1-year statuses were analyzed for 6,172 patients treated with DES according to LM and coronary artery bypass grafting (CABG) statuses (PLM, n = 93; previous CABG native vessel non-LM, n = 722; no previous CABG, n = 5,357). Cumulative event rates were calculated by the Kaplan-Meier method. Cox proportional hazards regression was used for multivariable analysis of adverse events. Baseline clinical, angiographic, and procedural variables differed significantly among groups, with patients with previous CABG, PLM, and non-LM having higher risk characteristics. In patients with previous CABG, after adjustment with CABG non-LM as a reference group, there were no significant differences in 1-year risk of any adverse event except a trend toward a greater risk of myocardial infarction (MI) in patients with PLM (adjusted hazard ratio 2.4, confidence interval 0.95 to 6.2, p = 0.06). However, patients after CABG (PLM and non-LM) compared to patients without previous CABG had a similar adjusted risk of death, MI, and stent thrombosis; an increased risk of target lesion revascularization (adjusted hazard ratio 1.79, confidence interval 1.2 to 2.6, p = 0.003), target vessel revascularization and death/MI/target vessel revascularization; and a lower risk of CABG (adjusted hazard ratio 0.25, confidence interval 0.09 to 0.67, p = 0.006). In conclusion, status after CABG rather than PLM location increases the risk of repeat revascularization with PCI in DES-treated patients.

PMID: 22118825 [PubMed - as supplied by publisher]