Tsu-Juey Wu

The association between the use of non-steroidal anti-inflammatory drugs and atrial fibrillation: A nationwide case–control study

BACKGROUND Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia. The goal of the present study was to investigate whether exposure to non-steroidal anti-inflammatory drugs (NSAIDs) was a risk factor for AF, and to discern which patients were at the highest risk for AF due to NSAID use. METHODS A total of 7280 patients with newly diagnosed AF from 2000 to 2009 were identified from the National Health Insurance Research Database. On the same date of enrollment, 10 patients without AF, who were matched for age, sex, and underlying disease for each study patient, were selected to be the control group. The relationship between NSAID exposure before enrollment and AF risk was analyzed. RESULTS The NSAID use was associated with an increased AF risk, especially for new users (odds ratio [OR]=1.651). Among new users, subgroup analysis revealed that patients with heart failure were at the highest risk for AF (OR=1.920). For patients who were only exposed to selective cyclooxygenase 2 (COX2) inhibitors, no significant associations were found between AF and selective COX2 inhibitor use, except for patients with chronic kidney or pulmonary disease (OR=1.656 and 1.707, respectively). CONCLUSIONS New NSAID use may predispose patients to AF, and the risk is almost doubled in heart failure patients. Use of selective COX2 inhibitors was not significantly related to AF occurrence, except in patients with chronic kidney or pulmonary disease.

CHADS2 Score, Statin Therapy, and Risks of Atrial Fibrillation

OBJECTIVE Little is known about the effectiveness of statins on primary prevention of atrial fibrillation in elderly patients. This study aimed to evaluate the efficacy of statin treatment for atrial fibrillation prevention in elderly patients with hypertension, and to determine if comorbidity or CHADS(2) (Congestive heart failure, Hypertension, Age ≥75 years, Diabetes mellitus, prior Stroke or transient ischemic attack) score can predict the effectiveness of statin treatment. METHODS Patients aged ≥65 years with hypertension were identified from a National Health Insurance research database (a systemic sampling from 2000 to 2009 with a total of 1,000,000 subjects). Medical records of 27,002 patients were used in this study, in which 2400 (8.9%) were receiving statin therapy. Risk of new-onset atrial fibrillation in statin users and nonusers was analyzed. RESULTS During the 9-year follow-up period, 2241 patients experienced new-onset atrial fibrillation. Statin users were younger than nonusers (72.4 vs 73.4 years) but had a higher prevalence of ischemic heart disease, diabetes mellitus, stroke, and chronic renal disease. Overall, statin therapy reduced the risk of atrial fibrillation by 19% (adjusted hazard ratio 0.81; 95% confidence interval, 0.69-0.95; P=.009). Subgroup analysis showed that statin use was beneficial in patients with or without a particular comorbidity. The effectiveness of statins was significant in patients with CHADS(2) score ≥2 (adjusted hazard ratio 0.69; 95% confidence interval, 0.57-0.85; P <.001). However, statin therapy was not as beneficial in hypertensive patients without other cardiovascular comorbidities (CHADS(2) score =1). CONCLUSION Statin therapy in elderly patients with hypertension reduces the risk of new-onset atrial fibrillation. Statins are more beneficial in patients with CHADS(2) score ≥2 than in those with score of 1.

Dosage of statin, cardiovascular comorbidities, and risk of atrial fibrillation: A nationwide population-based cohort study

BACKGROUND Statin has potential protective effects against atrial fibrillation. Clinically, there is a need to predict the atrial fibrillation protective effects in statin-treated patients. The purpose of this study was to investigate if cardiovascular co-morbidities or cumulative defined daily doses (cDDDs) of statin use could predict statin efficacy in atrial fibrillation prevention. METHODS Patients aged ≥ 50 years were identified from the Taiwan National Health Insurance Research Database. Medical records of 171,885 patients were used in this study, and 40,001 (23.3%) of the patients received statin therapy (≥ 28 cDDDs). Risk of new-onset atrial fibrillation in statin users and non-users (<28 cDDDs) was estimated. RESULTS During the 9-year follow-up period, 6049 patients experienced new-onset atrial fibrillation. Overall, statin therapy reduced the risk of atrial fibrillation by 28% (adjusted hazard ratio [HR] 0.72; 95% CI 0.68 to 0.77). There was a dose-response relationship between statin use and the risk of atrial fibrillation. The adjusted HRs for atrial fibrillation were 1.04, 0.85, and 0.50 when cDDDs ranged from 28 to 90, 91 to 365, and more than 365, respectively. Subgroup analysis showed that statin use was more beneficial in patients with higher CHADS2 and CHA2DS2VASc scores than those with a score of 0 (P value for interaction<0.001). The therapy provided no obvious beneficial effect in those with a CHADS2 score of 0, a CHA2DS2VASc score of 0, or cDDDs less than 91. CONCLUSIONS Statin therapy reduces the risk of new-onset atrial fibrillation in a dose-dependent manner, and is beneficial in patients with cardiovascular co-morbidities.

Fulminant myocarditis in an adult with 2009 pandemic influenza A (H1N1 influenza) infection

The worldwide outbreak of pandemic influenza A (H1N1 influenza) infection in 2009 caused numerous hospitalizations and deaths resulting from severe complications such as pneumonia, sepsis, and acute respiratory distress syndrome. Fulminant myocarditis caused by H1N1 infection has been reported in children but rarely in adults. We present an adult who contracted H1N1 infection followed by fulminant myocarditis. Early implementation of extra-corporeal membrane oxygenation support in conjunction with a specific anti-influenza viral medication (Oseltamivir) led to the patients complete recovery from cardiogenic shock in 2 weeks.

Resistant Hypertension, Patient Characteristics, and Risk of Stroke

Background Little is known about the prognosis of resistant hypertension (RH) in Asian population. This study aimed to evaluate the impacts of RH in Taiwanese patients with hypertension, and to ascertain whether patient characteristics influence the association of RH with adverse outcomes. Methods and Results Patients aged ≥45 years with hypertension were identified from the National Health Insurance Research Database. Medical records of 111,986 patients were reviewed in this study, and 16,402 (14.6%) patients were recognized as having RH (continuously concomitant use of ≥3 anti-hypertensive medications, including a diuretic, for ≥2 years). Risk of major adverse cardiovascular events (MACE, a composite of all-cause mortality, acute coronary syndrome, and stroke [included both fatal and nonfatal events]) in patients with RH and non-RH was analyzed. A total of 11,856 patients experienced MACE in the follow-up period (average 7.1±3.0 years). There was a higher proportion of females in the RH group, they were older than the non-RH (63.1 vs. 60.5 years) patients, and had a higher prevalence of cardiovascular co-morbidities. Overall, patients with RH had higher risks of MACE (adjusted HR 1.17; 95%CI 1.09–1.26; p<0.001). Significantly elevated risks of stroke (10,211 events; adjusted HR 1.17; 95%CI 1.08–1.27; p<0.001), especially ischemic stroke (6,235 events; adjusted HR 1.34; 95%CI 1.20–1.48; p<0.001), but not all-cause mortality (4,594 events; adjusted HR 1.06; 95%CI 0.95–1.19; p = 0.312) or acute coronary syndrome (2,145 events; adjusted HR 1.17; 95%CI 0.99–1.39; p = 0.070) were noted in patients with RH compared to those with non-RH. Subgroup analysis showed that RH increased the risks of stroke in female and elderly patients. However, no significant influence was noted in young or male patients. Conclusions Patients with RH were associated with higher risks of MACE and stroke, especially ischemic stroke. The risks were greater in female and elderly patients than in male or young patients.

Statin Therapy for Primary Prevention of Atrial Fibrillation: Guided by CHADS2/CHA2DS2VASc Score.

Atrial fibrillation (AF) is the most common arrhythmia and is associated with increased cardiovascular morbidity and mortality. The anti-arrhythmic effect of statins on AF prevention appears to be highly significant in most clinical studies. However, some discrepancies do exist among different clinical studies. Different clinical settings and types of stains used may explain these differences between trials. The CHADS2 and CHA2DS2VASc scoring systems have been used for stroke risk stratification in AF patients. The recent study suggested that these scores can also be used to guide statin therapy for AF prevention. Patients with higher scores had a higher risk of developing AF and gained more benefits from statins therapy than those with lower scores. This review article focused on the ability of these scores to predict AF prevention by statins.

Acute massive pulmonary embolism after radiofrequency catheter ablation: A rare complication after a common procedure

A 41-year-old man received an electrophysiological study (EPS) and radiofrequency catheter ablation (RFCA) for atrioventricular reentrant tachycardia (AVRT) in our hospital. Massive pulmonary embolism (PE) with hypotension developed 9 hours after these procedures. After emergent pulmonary angiography and catheter-directed intrathrombus urokinase infusion and clot breaking, the patient recovered well. This case suggests that life-threatening PE may occur in patients who receive EPS, RFCA, or both. An adequate observation time after RFCA and clinical alertness are necessary for immediate diagnosis and treatment. Emergent catheter-directed therapy may be of benefit in some patients with acute massive PE.

A long slanted transseptal accessory pathway.

A 63-year-old male with Wolff-Parkinson-White syndrome was admitted for ablation of accessory pathway. Intracardiac electrogram revealed a left-side accessory pathway during tachycardia, which was successfully ablated from the right posterior tricuspid annulus because of a long slanted transseptal accessory pathway (2.2 cm).