Arnaud Bisson

Should Atrial Fibrillation Patients With Only 1 Nongender-Related CHA2DS2-VASc Risk Factor Be Anticoagulated?

Background and Purpose— There is some uncertainty about treating patients with atrial fibrillation (AF) with 1 nongender-related (NGR) stroke risk factor (CHA2DS2-VASc [ie, congestive heart failure, hypertension, age (≥75 years; 2 points), diabetes, stroke/transient ischemic attack (2 points), vascular disease, age (65–74 years), sex (female)] score of 1 in males and 2 in females) with oral anticoagulation (OAC). Methods— We investigated adverse outcomes and calculated the net clinical benefit of OAC use in a community-based cohort of unselected AF patients with 0 compared with 1 NGR stroke risk factor (CHA2DS2-VASc 0 versus 1 in males; and 1 versus 2 in females). Among 8962 patients with AF, 2208 (25%) had 0 or 1 NGR stroke risk factors, of which 45% were not prescribed OAC. Results— During a follow-up of 1028±1189 days (median, 495; interquartile range, 5–1882 days), the yearly rate of the combined end point of stroke/systemic embolism in nonanticoagulated AF patients with 1 NGR stroke risk factor was 2.09% (95% confidence interval, 1.37–3.18). This corresponded to an adjusted hazard ratio of 2.82 (95% confidence interval, 1.32–6.04) relative to the group with 0 NGR stroke risk factor. When the benefit of ischemic stroke reduction was balanced against the increased risk of intracranial hemorrhage among patients with 1 NGR stroke risk factor, the net clinical benefit was positive in favor of OAC use versus no antithrombotic therapy or antiplatelet therapy use. The net clinical benefit was negative for antiplatelet therapy use versus no antithrombotic therapy. Conclusions— Among AF patients with 1 NGR stroke risk factor (ie, CHA2DS2-VASc 1 in males or 2 in females), OAC use as indicated according to the guidelines was associated with a positive net clinical benefit for the prevention of stroke and thromboembolic events.

Galectin-3 in Atrial Fibrillation: Mechanisms and Therapeutic Implications

Maintenance of atrial fibrillation is a complex mechanism, including extensive electrical and structural remodeling of the atria which involves progressive fibrogenesis. Galectin-3 is a biomarker of fibrosis, and, thus, may be involved in atrial remodeling in atrial fibrillation patients. We review the role of galectin-3 in AF mechanisms and its potential therapeutic implications.

Prediction of Incident Atrial Fibrillation According to Gender in Patients with Ischemic Stroke From a Nationwide Cohort

The CHA2DS2-VASc score may identify patients at higher risk of atrial fibrillation (AF) following ischemic stroke (IS) in patients without known AF. We compared gender-related differences in items from CHA2DS2-VASc score and their relation with AF occurrence after IS. This French cohort study was based on the database covering hospital care from 2009 to 2012 for the entire population. Of 336,291 patients with IS, 240,459 (71.5%) had no AF at baseline. Women were older, more frequently had hypertension, heart failure, and had a higher CHA2DS2-VASc score than men (4.63 vs 4.39, p<2DS2-VASc score items were independent predictors of incident AF, except diabetes and vascular disease). Results were mostly similar in men and women when one analyzed separately these predictors. Predictive value of the CHA2DS2-VASc score for identifying patients at higher risk of incident AF was somewhat higher in men (C statistic 0.720, 95% confidence interval 0.717 to 0.722) than in women (0.702, 95% confidence interval 0.699 to 0.704). Coronary artery disease, valvular disease, and history of pacemaker or defibrillator implantation were also independent predictors of incident AF. In conclusion, there were significant differences in co-morbidities, possible mechanisms, incidence, and predictors of AF between men and women after IS. However, a strategy using CHA2DS2-VASc score for identifying a higher risk of incident AF following IS was useful in both genders.

Relationship of Preexisting Cardiovascular Comorbidities to Newly Diagnosed Atrial Fibrillation After Ischemic Stroke

Background and Purpose— There remains uncertainty as whether newly diagnosed atrial fibrillation (AF) after ischemic stroke reflects underlying heart disease and represents an increased risk of cardioembolic stroke, or whether it is triggered by neurogenic mechanisms. We aimed to determine whether cardiovascular comorbidities in patients with new AF after ischemic stroke differ from patients with previous known AF or without AF. Methods— This French longitudinal cohort study was based on the database covering hospital care from 2009 to 2012 for the entire population. Results— Of 336 291 patients with ischemic stroke, 240 459 (71.5%) had no AF and 95 832 (28.5%) had previously known AF at baseline. Patients without previous AF had a mean CHA2DS2-VASc score of 4.98±1.63 SD. During a mean follow-up of 7.9±11.5 months, 14 095 (5.9%) of these patients had incident AF, representing an annual incidence of AF after ischemic stroke of 8.9 per 100 person-years (95% confidence interval, 8.8–9.0). New AF patients had higher CHA2DS2-VASc score, more likely comorbidities, and more frequent history of previous transient ischemic attack than patients with previous known AF or without AF. Conclusions— Preexisting cardiovascular comorbidities underlie AF newly diagnosed after stroke. Consequently, these high-risk patients should be closely monitored for incident AF to facilitate an earlier diagnosis of AF and avoid stroke with appropriate thromboprophylaxis.

Non-Vitamin K Oral Anticoagulants for Stroke Prevention in Special Populations with Atrial Fibrillation

Atrial fibrillation (AF) is associated with an increased risk of ischemic stroke or systemic embolism compared with normal sinus rhythm. These strokes may efficiently be prevented in patients with risk factors using oral anticoagulant therapy, with either vitamin K antagonists (VKAs) or non-vitamin K antagonist oral anticoagulants (NOACs) (i.e., direct thrombin inhibitors or direct factor Xa inhibitors). Owing to their specific risk profiles, some AF populations may have increased risks of both thromboembolic and bleeding events. These AF patients may be denied oral anticoagulants, whilst evidence shows that the absolute benefits of oral anticoagulants are greatest in patients at highest risk. NOACs are an alternative to VKAs to prevent stroke in patients with “non-valvular AF”, and NOACs may offer a greater net clinical benefit compared with VKAs, particularly in these high-risk patients. Physicians have to learn how to use these drugs optimally in specific settings. We review concrete clinical scenarios for which practical answers are currently proposed for use of NOACs based on available evidence for patients with kidney disease, elderly patients, women, patients with diabetes, patients with low or high body weight, and those with valve disease.

Prognosis in Familial Atrial Fibrillation

Atrial fibrillation (AF) is a common arrhythmia associated with substantial morbidity and a markedly increased risk of ischemic stroke. It accounts for one third of all strokes in patients above the age of 65 and is also associated with an increased mortality.[1][1] In recent years, risk models for

Galectin-3 level predicts response to ablation and outcomes in patients with persistent atrial fibrillation and systolic heart failure

Introduction Mechanisms of maintenance of both atrial fibrillation and structural left ventricular disease are known to include fibrosis. Galectin-3, a biomarker of fibrosis, is elevated both in patients with heart failure and persistent atrial fibrillation. We sought to find whether galectin-3 has a prognostic value in patients with heart failure and a reduced left ventricular ejection fraction undergoing ablation of persistent atrial fibrillation. Methods Serum concentrations of galectin-3 were determined in a consecutive series of patients with an ejection fraction ≤40%, addressed for ablation of persistent atrial fibrillation. Responders to ablation were patients in sinus rhythm and with an ejection fraction ≥50% at 6 months. A combined endpoint of heart failure hospitalization, transplantation and/or death was used at 12 months. Results Seventy-five patients were included (81% male, age 63±10 years, ejection fraction 34±7%, galectin-3 21±12 ng/mL). During follow-up, eight patients were hospitalized for decompensated heart failure, 1 underwent heart transplantation, and 4 died; 50 patients were considered as responders to ablation. After adjustment, galectin-3 level independently predicted both 6-month absence of response to ablation (OR = 0.89 per unit increase, p = 0.002). Patients with galectin-3 levels <26 had a 95% 1-year event-free survival versus 46% in patients with galectin-3 ≥26 ng/mL (p<0.0001). Conclusions Galectin-3 levels independently predict outcomes in patients with reduced left ventricular systolic function addressed for ablation of persistent AF, and may be of interest in defining the therapeutic strategy in this population.

Alcohol and Cardiac Structure: Less Is Better

A lcohol consumption of any beverage type is a significant cause of nonischemic dilated cardiomyopathy (DCM), known as alcoholic cardiomyopathy (ACM). Alcohol drinking is linked to DCM because ethanol acts as a toxin that directly weakens the heart muscle (1,2). ACM may be caused by both ethanol (pure alcohol) and acetaldehyde, the first metabolite of ethanol, and it can be worsened by interaction with other toxins, such as heavy metals, or by lack of nutrients (3). In a worldwide analysis in 2015, it was estimated that 6.3% of all global deaths from cardiomyopathy were caused by alcohol (4). However, there were large regional variations with regard to ACM mortality burden, which seems heavily concentrated on a few countries from Eastern Europe and Central Asia. These variations may partly be the result of a lack of detection or underdeclaration of the condition. ACM incidence has been mainly linked to very heavy alcohol consumption over an extended period of time (5). However, the relationship between alcohol intake and cardiac function does not seem unequivocal.

PREDICTORS OF INCIDENT ATRIAL FIBRILLATION IN PATIENTS WITH ISCHEMIC STROKE: A NATIONWIDE COHORT STUDY

Background: Atrial Fibrillation (AF) is associated with of a substantial part of ischemic strokes (IS). CHA2DS2-VASc score is able to identify patients at higher risk of AF following IS among patients without known AF. We aimed to find other independent predictive factors related to AF occurrence

Nonsustained Ventricular Tachycardia at the Time of Implantation Predicts Appropriate Therapies on Rapid Ventricular Arrhythmia in Primary Prevention Patients With Nonischemic Cardiomyopathy: Results From the Very-High-Rate Registry

Recent results from the Danish trial call into question the benefits of implantable cardioverter-defibrillator (ICD) in primary prevention for patients with nonischemic cardiomyopathy (NICM) and a reduced left ventricular ejection fraction (LVEF), considering that a majority of these well-treated