Abstract The 2MACE score was specifically developed as a risk-stratification tool in atrial fibrillation (AF) to predict cardiovascular outcomes. We evaluated the predictive ability of the 2MACE score in the GLORIA-AF registry. All eligible patients from phase II/III of the prospective global GLORIA-AF registry were included. Major adverse cardiac events (MACEs) were defined as the composite outcome of stroke, myocardial infarction and cardiovascular death. Cox proportional hazards were used to examine the relationship between the 2MACE score and study outcomes. Predictive capability of the 2MACE score was investigated using receiver-operating characteristic curves. A total of 25,696 patients were included (mean age 71 years, female 44.9%). Over 3 years, 1583 MACEs were recorded. Patients who had MACE were older, with more cardiovascular risk factors and were less likely to be managed using a rhythm-control strategy. The median 2MACE score in the MACE and non-MACE groups were 2 (IQR 1–3) and 1 (IQR 0–2), respectively (p < 0.001). The 2MACE score was positively associated with an increase in the risk of MACE, with a score of ≥ 2 providing the best combination of sensitivity (69.6%) and specificity (51.6%), HR 2.47 (95% CI, 2.21–2.77). The 2MACE score had modest predictive performance for MACE in patients with AF (AUC 0.655 (95% CI, 0.641–0.669)). Our analysis in this prospective global registry demonstrates that the 2MACE score can adequately predict the risk of MACE (defined as myocardial infarction, CV death and stroke) in patients with AF. Clinical trial registration: http://www.clinicaltrials.gov . Unique identifiers: NCT01468701, NCT01671007 and NCT01937377
Abstract Aims Women are less likely to receive lipid-lowering therapy (LLT) after acute myocardial infarction (AMI). We analysed whether this under-prescription currently persists and has an impact on long-term outcomes. Methods and results The FAST-MI programme consists of nationwide registries including all patients admitted for AMI ≤ 48 h from onset over a 1 month period in 2005, 2010, and 2015, with long-term follow-up. This analysis focused on high-intensity LLT (atorvastatin ≥ 40 mg or equivalent, or any combination of statin and ezetimibe) in women and men. Women accounted for 28% (N = 3547) of the 12 659 patients. At discharge, high-intensity LLT was significantly less prescribed in women [54 vs. 68% in men, P < 0.001, adjusted odds ratio (OR) 0.78(95% confidence interval (CI) 0.71–0.87)], a trend that did not improve over time: 2005, 25 vs. 35% (P = 0.14); 2010, 66 vs. 79% (P < 0.001); 2015, 67 vs. 79.5% (P = 0.001). In contrast, female sex was not associated with a lack of other recommended treatments at discharge: beta-blockers [adjusted OR 0.98(95% CI 0.88–1.10), P = 0.78], or renin–angiotensin blockers [adjusted OR 0.94(95% CI 0.85–1.03), P = 0.18]. High-intensity LLT at discharge was significantly associated with improved 5 year survival and infarct- and stroke-free survival in women [adjusted hazard ratios (HR) 0.74(95% CI 0.64–0.86), P < 0.001 and adjusted HR: 0.81(95% CI: 0.74–0.89); P < 0.001, respectively]. Similar results were found using a propensity score-matched analysis [HR for 5 year survival in women with high-intensity LLT: 0.82(95% CI 0.70–0.98), P = 0.03]. Conclusion Women suffer from a bias regarding the prescription of high-intensity LLT after AMI, which did not attenuate between 2005 and 2015, with potential consequences on both survival and risk of cardiovascular events.
Abstract Aims Chronic Obstructive Pulmonary Disease (COPD) may influence management and prognosis of Atrial Fibrillation (AF), but this relationship has been scarcely explored in contemporary global cohorts. We aimed to investigate the association between AF and COPD, in relation to treatment patterns and major outcomes. Methods From the prospective, global GLORIA-AF Registry, we analysed factors associated with COPD diagnosis, as well as treatment patterns and risk of major outcomes in relation to COPD. Primary outcome was the composite of all-cause death and major adverse cardiovascular events (MACEs). Results 36,263 patients (mean age 70.1±10.5 years, 45.2% females) were included; 2,261 (6.2%) had COPD. Prevalence of COPD was lower in Asia, and higher in North America. Age, female sex, smoking, BMI, and cardiovascular comorbidities were associated with presence of COPD. COPD was associated with higher use of OAC (adjusted Odds Ratio [aOR] and 95% Confidence Interval [CI]: 1.29 [1.13-1.47]), and higher OAC discontinuation (adjusted Hazard Ratio [aHR] and 95%CI: 1.12 [1.01-1.25]). COPD was associated with less use of beta-blocker (aOR [95%CI]: 0.79 [0.72-0.87]), amiodarone and propafenone, and higher use of digoxin and verapamil/diltiazem. Patients with COPD had higher hazard of primary composite outcome (aHR [95%CI]: 1.78 [1.58-2.00]); no interaction was observed regarding beta-blocker use. COPD was also associated with all-cause death (aHR [95%CI]: 2.01 [1.77-2.28]), MACEs (aHR [95%CI]: 1.41 [1.18-1.68]) and major bleeding (aHR [95%CI]: 1.48 [1.16-1.88]). Conclusions In AF patients, COPD was associated with differences in OAC treatment and use of drugs. AF/COPD patients had worse outcomes, including higher mortality, MACE and major bleeding.
Background and aim The clinical utility of transesophageal echocardiography ( TEE ) after brain ischemia ( BI ) remains a matter of debate. We aimed to evaluate the clinical impact of TEE and to build a score that could help physicians to identify which patients should better benefit from TEE . Methods This prospective, multicenter, observational study included patients over 18 years old, hospitalized for BI . TEE findings were judged discriminant if the results showed important information leading to major changes in the management of patients. Most patients with patent foramen ovale were excluded. Variables independently associated with a discriminant TEE were used to build the prediction model. Results Of the entire population (1479 patients), 255 patients (17%) were classified in the discriminant TEE group. Five parameters were selected as predictors of a discriminant TEE . Accordingly, the ADAM ‐C score could be calculated as follows: Score = 4 (if age ≥60) + 2 (if diabetes) + 2 (if aortic stenosis from any degrees) + 1 (if multi‐territory stroke) + 2 (if history of coronary artery disease). At a threshold lower than 3, the sensitivity, specificity, positive predictive value, and negative predictive value ( NPV ) of detecting discriminant TEE were 88% (95% CI 85–90), 44% (95% CI 41–47), 21% (95% CI 19–27), and 95% (95% CI 94–97), respectively. Conclusion A simple score based on clinical and transthoracic echocardiographic parameters can help physicians to identify patients who might not benefit from TEE . Indeed, a score lower than 3 has an interesting NPV of 95% (95% CI 94–97).
Abstract: Acute aortic dissection is an uncommon but potentially catastrophic vascular emergency. Assessment of risk factors is important for the diagnosis. These include chest pain features, blood pressure differential more than 20 mmHg and aortic enlargement on chest X-ray. Physical examination, electrocardiogram, chest X-ray, transthoracic echocardiography are readily available in emergency departments but typically are not sufficient to rule out the diagnosis. CT angiography, transesophageal or magnetic resonance angiography must be performed to confirm diagnosis. D-dimer testing has been identified in prior studies as a biomarker helpful for screening of patients, with cut-off values similar to pulmonary embolism. D-dimer may help triage patients with low or intermediate risk.
Abstract Background and purpose Prospectively collected data comparing the safety and effectiveness of individual non-vitamin K antagonists (NOACs) are lacking. Our objective was to directly compare the effectiveness and safety of NOACs in patients with newly diagnosed atrial fibrillation (AF). Methods In GLORIA-AF, a large, prospective, global registry program, consecutive patients with newly diagnosed AF were followed for 3 years. The comparative analyses for (1) dabigatran vs rivaroxaban or apixaban and (2) rivaroxaban vs apixaban were performed on propensity score (PS)-matched patient sets. Proportional hazards regression was used to estimate hazard ratios (HRs) for outcomes of interest. Results The GLORIA-AF Phase III registry enrolled 21,300 patients between January 2014 and December 2016. Of these, 3839 were prescribed dabigatran, 4015 rivaroxaban and 4505 apixaban, with median ages of 71.0, 71.0, and 73.0 years, respectively. In the PS-matched set, the adjusted HRs and 95% confidence intervals (CIs) for dabigatran vs rivaroxaban were, for stroke: 1.27 (0.79–2.03), major bleeding 0.59 (0.40–0.88), myocardial infarction 0.68 (0.40–1.16), and all-cause death 0.86 (0.67–1.10). For the comparison of dabigatran vs apixaban, in the PS-matched set, the adjusted HRs were, for stroke 1.16 (0.76–1.78), myocardial infarction 0.84 (0.48–1.46), major bleeding 0.98 (0.63–1.52) and all-cause death 1.01 (0.79–1.29). For the comparison of rivaroxaban vs apixaban, in the PS-matched set, the adjusted HRs were, for stroke 0.78 (0.52–1.19), myocardial infarction 0.96 (0.63–1.45), major bleeding 1.54 (1.14–2.08), and all-cause death 0.97 (0.80–1.19). Conclusions Patients treated with dabigatran had a 41% lower risk of major bleeding compared with rivaroxaban, but similar risks of stroke, MI, and death. Relative to apixaban, patients treated with dabigatran had similar risks of stroke, major bleeding, MI, and death. Rivaroxaban relative to apixaban had increased risk for major bleeding, but similar risks for stroke, MI, and death. Registration URL: https://www.clinicaltrials.gov . Unique identifiers: NCT01468701, NCT01671007. Date of registration: September 2013. Graphical abstract
'%3e%3cpath fill='%23012169' d='M0 0v30h60V0z'/%3e%3cpath stroke='%23fff' stroke-width='6' d='m0 0 60 30m0-30L0 30'/%3e%3cpath stroke='%23C8102E' stroke-width='4' d='m0 0 60 30m0-30L0 30' clip-path='url(%23b)'/%3e%3cpath stroke='%23fff' stroke-width='10' d='M30 0v30M0 15h60'/%3e%3cpath stroke='%23C8102E' stroke-width='6' d='M30 0v30M0 15h60'/%3e%3c/g%3e%3c/svg%3e)
