Yuri Mariannini

Abnormal troponin level as short-term predictor of poor outcome in acute atrial fibrillation

BACKGROUND The link between minor troponin (cardiac troponin I [cTnI]) elevations and atrial fibrillation (AF) is still debated. METHODS A total of 948 patients with AF lasting less than 48 hours participated in the study and were required to undergo 1-month and 12-month follow-up. The exclusion criteria were represented by younger than 18 years, the presence of hemodynamic instability, or severe comorbidity. Primary end point was the composite of ischemic vascular events inclusive of stroke, acute coronary syndrome, revascularization, and death. RESULTS In the short term, 4 patients (5%) of 78 with abnormal cTnI reached the primary end point (P = .001 vs others). Conversely, in the long term, 13 patients (17%) with abnormal cTnI, 21 (10%) with known ischemic vascular disease, and 50 (5%) aged patients (75 ± 10 years) reached the primary end point (P < .001, P < .001, and P = .002, respectively). At multivariate analysis, abnormal cTnI (hazard ratio [HR], 2.84; 95% confidence interval, 1.38-5.84; P = .005), known ischemic vascular disease (HR, 2.03; 95% confidence interval, 1.11-3.70; P = .021), and age (HR, 1.05; 95 confidence interval, 1.02-1.08; P = .002) were predictors of the primary end point. Minimal or minor cTnI elevation (<0.45 or ≥ 0.45 ng/mL, respectively) showed no differences when associated with the primary end point. The C-statistic demonstrated the significant prognostic value of older age and known ischemic vascular disease, beyond troponin. Clinical parameters inclusive of heart rate, blood pressure, and risk factors for arteriosclerosis showed no relationship with adverse events. Readmission rate did not differ between groups. CONCLUSIONS In patients with acute AF, minor cTnI elevations link to short-term adverse events. Known ischemic vascular disease and older age showed prognostic value only in the long term.

Clinical management of atrial fibrillation: early interventions, observation, and structured follow-up reduce hospitalizations

BACKGROUND Novel facilities such as an intensive observation unit and an outpatient clinic could result in improving management of patients presenting with atrial fibrillation (AF). METHODS This observational study enrolled 3475 patients. Group 1 (1120 patients; years 2004-2005) was managed with standard approach; group 2 (992 patients; years 2006-2007) was managed with additional intensive observation; group 3 (1363 patients; years 2008-2009) was managed with additional intensive observation and outpatient clinic. Primary end point was admission to hospital. Secondary end points included modalities of rhythm conversion and administration of class IC vs class III antiarrhythmic drugs in patients with AF lasting less than 48 hours. RESULTS Lack of rhythm control, comorbidities, diabetes, and age were independent predictors of hospitalization. Admissions significantly decreased from group 1 (50%) to 2 (38%) and to 3 (24%) (P < .001). Interestingly, more than a quarter of patients in group 3 were referred to the outpatient clinic for short-term follow-up, eventually avoiding admission. Patients with AF lasting less than 48 hours (n = 2189) and without structural heart disease (n = 1685) achieved sinus rhythm in 89% of cases and were discharged. In these patients, early administration of antiarrhythmic drugs of class IC and III gained sinus rhythm in 80% and 20%, respectively (P < .001). Spontaneous conversion occurred in 26%; electrical, 17%; and pharmacological, 57%. CONCLUSIONS In patients with AF, beyond the standard approach, the novel organization with an additional intensive observation unit for early pharmacological interventions and an outpatient clinic for elective treatment and short-term follow-up significantly reduced admission irrespective of independent predictors of hospitalizations. Patients without structural heart disease treated with antiarrhythmic drugs achieved sinus rhythm in 89% of cases, mostly with class IC drugs.

Role of masked coronary heart disease in patients with recent-onset atrial fibrillation and troponin elevations

Background Patients with recent-onset atrial fibrillation (AF) and cardiac troponin I (cTnI) elevations show poor outcomes. Coronary heart disease might be a cause, consequence, or an innocent bystander. Objective The aim of this study was to recognize and treat coronary heart disease to avoid adverse events. Methods Patients with recent-onset AF participated in the study. The exclusion criteria were acute coronary syndrome and severe comorbidities. Patients managed with standard care (group 1, n=1086, years 2010–2011) were compared with patients managed with tailored care inclusive of echocardiography and stress testing when required (group 2, n=1055, years 2012–2013). Endpoint The endpoint was a composite of ischemic vascular events including stroke, acute coronary syndrome, revascularization and cardiovascular death at 6 months of follow-up. Results Of 4008 patients considered, 2141 were enrolled; 183 showed cTnI elevations, 92 in group 1 and 91 in group 2. cTnI elevations, known ischemic heart disease and age were predictors of the endpoint on multivariate analysis. Overall, two versus seven patients (P=0.033) in groups 1 and 2, respectively, underwent revascularization. Eventually, 16 patients in group 1 versus five patients in group 2 reached the endpoint (P=0.019). Patients of group 2 were managed as follow: 35 were admitted, 15 with positive stress testing and 20 with high cTnI values (mean values: 0.64±1.01 ng/ml). Fifty-six patients were discharged with negative stress testing results (n=13) or very low cTnI values (n=43, mean values 0.29±0.30 ng/ml). Conclusion In patients with AF and cTnI elevations, tailored care inclusive of echocardiography and stress testing succeeded in recognizing and treating masked ‘critical’ coronary heart disease, avoiding adverse events.

Nuclear Scan Strategy and Outcomes in Chest Pain Patients Value of Stress Testing with Dipyridamole or Adenosine

Objective: To update the prognostic value of scan strategy with pharmacological stress agent in chest pain (CP) patients presenting with normal electrocardiography (ECG) and troponin. Methods: Two consecutive nonrandomized series of patients with CP and negative first-line workup inclusive of serial ECG, serial troponin, and echocardiography underwent myocardial perfusion imaging single photon emission computed tomography (SPECT) in the emergency department. Of 170 patients enrolled, 52 patients underwent dipyridamole-SPECT and 118 adenosine-SPECT. Patients with perfusion defects underwent angiography, whereas the remaining patients were discharged and followed-up. Primary endpoint was the composite of nonfatal myocardial infarction, unstable angina, revascularization, and cardiovascular death at follow-up or the presence of coronary stenosis > 50% at angiography. Results: At multivariate analysis, the presence of perfusion defects or hypertension was independent predictor of the primary endpoint. Sensitivity and negative predictive value were higher in patients subjected to adenosine-SPECT (95% and 99%, respectively) versus dipyridamole-SPECT (56% and 89%; yield 70% and 11%, respectively; P < 0.03). Of note, sensitivity, negative, and positive predictive values were high in patients with hypertension (100%, 93%, and 60%, respectively) or nonischemic echocardiography alterations (100%, 100%, and 100%, respectively). Conclusions: In CP patients, presenting with normal ECG and troponin, adenosine-SPECT adds incremental prognostic values to dipyridamole-SPECT. Costly scan strategy is more appropriate and avoids unnecessary angiograms in patients with hypertension or nonischemic echocardiography alterations.

Aggressive approach and outcome in patients presenting atrial fibrillation and hypertension

AIM Aggressive approach in patients presenting atrial fibrillation (AF) and hypertension could result in improving rhythm control and reducing admission. METHODS Out of 3475 patients presenting AF, those with hypertension (n=1739, 52%) underwent standard (n=591, group 1, years 2004-2005) or aggressive pharmacological and electrical approach (n=1148, group 2, years 2006-2009). Overall, in 1071 patients AF duration was less than 48 h. Primary endpoint was rhythm conversion; secondary endpoints were modalities of rhythm conversion and reduction of admissions. RESULTS At univariate and multivariate analyses, AF lasting less than 48 h, absence of comorbidities and younger age were independent predictors of sinus rhythm; conversely, lack of sinus rhythm, older age, AF lasting more than 48 h and comorbidities were independent predictors of hospitalization. Overall, 55% of patients achieved sinus rhythm in group 1 versus 62% in group 2 (p=0.018). Interestingly, in patients with AF lasting less than 48 h, 89% achieved sinus rhythm, more likely by class 1C than by class III antiarrhythmic drugs (p<0.001). Overall reduction of admission accounts for 60%; 50% of patients need admission in group 1 versus 29% in group 2 (p<0.001). CONCLUSIONS Aggressive pharmacological and electrical approach in patients presenting AF and hypertension significantly improved rhythm conversion overall up to 62%. Patients with AF lasting less than 48 h eventually achieved sinus rhythm up to 89%, mostly by class IC antiarrhythmic drugs. Admissions eventually reduced up to 60%.

Long-term prognostic value of dysglycemia and ischemic vascular disease beyond abnormal troponin levels in patients presenting acute atrial fibrillation.

BACKGROUND Prognostication beyond troponin levels in patients with acute atrial fibrillation (AF) is still unclear. METHODS One-month and 1-year outcomes in 1091 patients with acute AF were analyzed. Primary endpoints were stroke or the composite of acute coronary syndrome, revascularization, and death. RESULTS In the short term, troponin (odds ratio (OR) 15, 95% confidence interval (CI), 3.4-67.9, P < 0.001) and known ischemic heart disease (OR 5.83, 95% CI, 1.3-26.2, P = 0.021) were predictors of the composite endpoint, with multivariate analysis. No variables linked with stroke. In the long term, metabolic syndrome (OR 4.7, 95% CI, 1.2-18.3, P = 0.024) and age (OR 1.1, 95% CI, 1.0-1.1, P = 0.009) were predictors of stroke; metabolic syndrome (OR 4.3, 95% CI, 1.6-11.0, P = 0.003), known ischemic heart disease (OR 3.3, 95% CI, 1.7-6.4, P = 0.001), persistence of AF after the first-line approach (OR 2.2, 95% CI, 1.2-4.3, P = 0.018), and age (OR 1.0, 95% CI, 1.0-1.1, P = 0.025), but not troponin so were of the composite endpoint. In the short term, increased discriminative values in prognostication of the composite endpoint were observed with C-statistic when troponin was compared with dysglycemia (P = 0.032). No variables did better than others in the prognostication of stroke. In the long term, increased discriminative values in the prognostication of stroke were observed with C-statistic when age was compared with troponin (P = 0.020), ischemic heart disease (P = 0.025), and persistence of AF after the first-line approach (P = 0.049); so was for CHADS2 score ≥1 versus vascular disease (P = 0.038). CONCLUSIONS In patients with acute AF, abnormal troponin levels add prognostic value to clinical parameters in the short term; dysglycemia and known vascular disease in the long term.

Troponin rise and poor outcome in patients with acute atrial fibrillation: rationale and criteria of selection of patients.

impact in stroke and mortality. It has been shown that, in patients with AF, a rising prevalence of transesophageal echocardiogram changes as left atrial appendage thrombus, dense spontaneous echocardiographic contrast, and low flow velocities alongside with the measured levels of cTnI may be found [9]. These changes have been associated with increased mortality and thromboembolic events [10] and may be coresponsible for the number of events observed in this population, with lower than expected anticoagulation levels. However, this is hypothetical because transesophageal echocardiogram was not performed in all these patients to confirm this possibility. The clarification of these points reinforces the importance of the study, and we think that the authors must be acknowledged because their manuscript succeeded in demonstrating the adverse impact of new onset AF in the patient presenting to the ED with detectable levels of troponin and the possible benefit of excluding the presence of underlying coronary artery disease and starting oral anticoagulation for the prevention of systemic thromboembolism.