Efficacy and Safety of the WATCHMAN Left Atrial Appendage System for Stroke Prevention in Chinese Patients with Nonvalvular Atrial Fibrillation： A Single-center, Prospective, Observational Study

Background： In patients with nonvalvular atrial fibrillation （NVAF）, embolic stroke is thought to be associated with left atrial appendage （LAA） thrombi. The WATCHMAN LAA Occlusion Device has been shown to be noninferior to conventional oral anticoagulation with warfarin for stroke prevention in patients with NVAF. This study aimed to evaluate the procedural feasibility, safety and 12-month outcomes of the WATCHMAN LAA Occlusion Device in NVAF patients with high risk for stroke in China. Methods： The clinical data of 106 NVAF patients, who were consecutively underwent LAA closure with the WATCHMAN Device between April 2014 and May 2015, were collected. Patients were followed up at 1,3, 6, and 12 months after discharge. A transesophageal echocardiograph was performed at 45 days after implantation and repeated in case of an unexpected event during the follow-up period. Results： This study included 106 NVAF patients with a mean age of 64.2 ± 8.6 years （ranging from 50 to 88 years）, and the mean CHA,DS,-VASc score of all patients was 3.6 ± 1.6 （ranging from 2 to 9）. Among those 106 NVAF patients, 100 （94.3%） patients were implanted with the device successfully. The procedural success rate was 94.3% （100/106）, and the occlusion rate was 100.0% （100/100）. There were one tamponade, one ischemic stroke, and eight minor pericardial effusions during hospitalization. During 12-month follow-up period, two patients developed a tbrombus layer on the device that resolved with additional anticoagulation： one with visible device-thrombus experienced transient ischemic stroke, and one had a hemorrhagic stroke. There were no deaths in this study. The overall survival rate was 100.0%, and nonmajor adverse event rate was 95.0% （95/100）. In this study, the expected annual rate ofischemic stroke risk in these patients according to the CHA2DS2-VASc score was 4.0%, while the observed ischemic stroke rate was 2.0% per year. Conclusions： LAA closure with the WATCHMAN Device was feasible, efficient, and safe for NVAF to prevent the accidence of stroke in Chinese patients. During the 12-month follow-up period, the observed ischemic stroke rate （2.0% per year） in our study was lower than the predicted annual stroke risk （4.0%） using the CHA2DS：-VASc score.

Assessing Cardiovascular Health Using Life＇s Simple 7 in a Chinese Population Undergoing Stroke Prevention

Background： The American Heart Association/American Stroke Association proposed a metric called Life＇s Simple 7 （LS7） to define cardiovascular health （CVH）. The presence of a large number of ideal components of CVH is associated with lower cardiovascular disease and all-cause mortality. We aimed to assess CVH using LS7 in a Chinese population undergoing primary and secondary stroke prevention. Methods： Patients with either ischemic stroke or cardiovascular risk factors were enrolled in the study from October 2010 to July 2013. LS7 components were scored as poor （0 points）, intermediate （1 point）, or ideal （2 points）. The overall LS7 score was categorized as inadequate （0-4）, average （5-9）, or optimal （10-14） CVH. The Chi-square test, Mann-Whitney U-test, and Kruskal-Wallis test were used. Results： In total, 706 patients were enrolled. （1） The distribution of the overall LS7 score （n = 255） indicated that 9.4%, 82.4%, and 8.2% of the patients had inadequate, average, and optimal CVH, respectively. The proportion of patients with optimal CVH undergoing secondary stroke prevention was lower than that for patients undergoing primary stroke prevention （3.8% vs. 12.8%, P = 0,005）. The vast laaajority of participants （76.1%） presented with 〈2 ideal health components. （2） The proportions of patients with poor, intermediate, and ideal status, respectively, lbr the following LS7 components were assessed： Total cholesterol （n = 275; 5.1%, 73.8%, and 21.1%）, blood pressure （11 = 351 ; 32.5%. 59.0%, and 8.5%）, blood glucose （n = 280; 9.3%, 39.6%, and 51.1%）, physical activity （n = 540; 90.7%, 8.7%, and 0.6%）, diet （n = 524; 0.2%. 92.4%, and 7.4%）, smoking （n = 619： 20.7%, 2.9%, and 76.4%）, and body mass index （n = 259; 6.6%, 35.5%, and 57.9%）. Conclusions： Few Chinese patients undergoing stroke prevention had optimal CVH （determined using LS7）. Additionally, fewer patients undergoing secondary prevention had optimal CVH than those undergoing primary prevention. In particular, physical activity and diet status in this population require improvement.

Percutaneous left atrial appendage closure:Technical aspects and prevention of periprocedural complications with the watchman device

Transcatheter closure of the left atrial appendage has been developed as an alternative to chronic oral anticoagulation for stroke prevention in patients with atrial fibrillation, and as a primary therapy for patients with contraindications to chronic oral anticoagulation. The promise of this new intervention compared with warfarin has been supported by several, small studies and two pivotal randomized trial with the Watchman Device. The results regarding risk reduction for stroke have been favourable although acute complications were not infrequent. Procedural complications, which are mainly related to transseptal puncture and device implantation, include air embolism, pericardial effusions/tamponade and device embolization. Knowledge of nature, management and prevention of complications should minimize the risk of complications and allow transcatheter left atrial appendage closure to emerge as a therapeutic option for patients with atrial fibrillation at risk for cardioembolic stroke.

Pre-ischemia electro-acupuncture potentiates the expression of Bcl-2 and transforming growth factor-beta 1 in rat brains

The expression of the anti-apoptotic molecules Bcl-2 and transforming growth factor-beta 1 is known to confer protective effects on the cerebral ischemia-reperfusion injury.The current study investigated the expression levels of Bcl-2 and transforming growth factor-beta 1 in response to multiple pre-ischemia electro-acupuncture at acupoints Zusanli（ST36）and Fengchi（GB20） stimulation.Rats were divided into five groups：uninjured,control,non-acupoint,GB20 and ST36. Rats in the non-acupoint,GB20 and ST36 groups received 30 minutes（3 times or 18 times）of electro-acupuncture stimulation before experimental cerebral ischemia was induced.Bcl-2 and transforming growth factor-beta 1 were found to be significantly increased in the ST36 groups with either 3 or 18 electro-acupuncture treatments（P〈0.05）.The production was higher with 18 electro-acupuncture treatments in the ST36 groups（P〈0.05）.In the GB20 groups,significant increase was only observed in transforming growth factor-beta 1 with 18 electro-acupuncture treatments（P〈0.05）.No significant elevation of the level of transforming growth factor-beta 1 was observed in the non-acupoint groups.However,the production of Bcl-2 increased with 18 treatments in the non-acupoint groups（P〈0.05）.The data suggest that multiple pre-ischemia electro-acupuncture at ST36 was effective in conferring neuroprotective effect on the brain by means of upregulation of Bcl-2 and transforming growth factor-beta 1 and the effect was increase with the number of treatment.

Screening of unknown atrial fibrillation through handheld device in the elderly

Objective To estimate the prevalence of unknown atrial fibrillation(AF)in the elderly population of the Veneto Region,Italy.Methods 1820 patients aged≥65 years with no history of AF and not anticoagulated were enrolled in primary-care settings.They underwent an opportunistic electrocardiogram screening with a handheld device(My Diagnostick)designed to specifically detect AF.The electrocardiogram recordings were reviewed by the researchers,who confirmed the presence of AF.Results The device detected an arrhythmia in 143 patients,which was confirmed as AF in 101/143(70.6%),with an overall prevalence of AF of 5.5%(101/1820).Prevalence of unknown AF resulted in 3.6%in patients aged 65–74 years,and 7.5%in patients age 75 or older,and increased according to CHA2 DS2-VASc score:3.5%in patients with a score of 1 or 2,5.6%in patients with a score of 3,7.0%in patients with a score of 4,and 7.2%in patients with a score≥5.The detection rate was significantly higher in patients with mild symptoms compared to asymptomatic counterparts(24.1%vs.4.0%,P<0.0001).At multivariate analysis,congestive heart failure and age≥75 years-old were independent predictors for screen-detected AF.Conclusions An opportunistic screening with handheld device revealed an unexpectedly high prevalence of unknown AF in elderly patients with mild symptoms.Prevalence increased with age and CHA2DS2-VASc score.

Oral anti-coagulants use in Chinese hospitalized patients with atrial fibrillation

Background:Oral anti-coagulants(OAC)are the intervention for the prevention of stroke,which consistently improve clinical outcomes and survival among patients with atrial fibrillation(AF).The main purpose of this study is to identify problems in OAC utilization among hospitalized patients with AF in China.Methods:Using data from the Improving Care for Cardiovascular Disease in China-Atrial Fibrillation(CCC-AF)registry,guideline-recommended OAC use in eligible patients was assessed.Results:A total of 52,530 patients with non-valvular AF were enrolled from February 2015 to December 2019,of whom 38,203 were at a high risk of stroke,9717 were at a moderate risk,and 4610 were at a low risk.On admission,only 20.0%(6075/30,420)of patients with a diagnosed AF and a high risk of stroke were taking OAC.The use of pre-hospital OAC on admission was associated with a lower risk of new-onset ischemic stroke/transient ischemic attack among the diagnosed AF population(adjusted odds ratio:0.54,95%confidence interval:0.43-0.68;P<0.001).At discharge,the prescription rate of OAC was 45.2%(16,757/37,087)in eligible patients with high stroke risk and 60.7%(2778/4578)in eligible patients with low stroke risk.OAC utilization in patients with high stroke risk on admission or at discharge both increased largely over time(all P<0.001).Multivariate analysis showed that OAC utilization at discharge was positively associated with in-hospital rhythm control strategies,including catheter ablation(adjusted odds ratio[OR]11.63,95%confidence interval[CI]10.04-13.47;P<0.001),electronic cardioversion(adjusted OR 2.41,95%CI 1.65-3.51;P<0.001),and anti-arrhythmic drug use(adjusted OR 1.45,95%CI 1.38-1.53;P<0.001).Conclusions:In hospitals participated in the CCC-AF project,>70%of AF patients were at a high risk of stroke.Although poor performance on guideline-recommended OAC use was found in this study,over time the CCC-AF project has made progress in stroke prevention in the Chinese AF population.Registration:ClinicalTrials.gov,NCT02309398.

Underuse of statins in patients with atherosclerotic ischemic stroke in China

Background Well designed randomized trials and meta-analyses have clearly shown that statins reduce the risk of major vascular events, including ischemic stroke, in a wide range of patients and their routine use is recommended for patients at an increased cardiovascular risk. Survivors of a first ischemic stroke are at a risk of recurrence and of other vascular events and statins are generally recommended to reduce this risk. This study investigated how widely statins were being used for such patients in China. Methods Totally 6422 patients with a history of ischemic stroke were identified by reviewing medical records at 51 highest-ranking hospitals in 14 cities in China, and invited to attend a screening clinic to assess eligibility for a randomized trial. Their current statin and other drug uses were recorded alongside clinical and demographic characteristics. Univariate chi-square test and multivariate Logistic regression were used to determine the factors associated with treatment. Results Only 24% of these patients reported currently taking a statin. The most important predictor of statin use among these patients was prior history of coronary heart disease. History of diabetes or hypertension, as well as treated in university affiliated hospitals is related to increased use. The status had improved significantly during a 2-year period. Atorvastatin （40%） and simvastatin （39%） were the most commonly used. Conclusions In China, statins are still underused for secondary prevention among survivors of ischemic stroke. Reasons for this Door use need to be understood in order to increase use of these evidence based therapies.

Statins in acute neurologic disease:which one,which dose,when to start,and when not to stop

Statins could have physiologic properties that may benefit patients that have been diagnosed with various acute neurological diseases.This review aims tosummarize the literature pertaining to stain use in acute neurological disease such as subarachnoid hemorrhage,intracerebral hemorrhage(ICH),cerebral ischemia(CI),traumatic brain injury,status epilepticus and meningitis.The authors reviewed published abstracts and manuscripts pertaining to experimental and clinical trials relevant to statins in acute neurological disease.Although acute statin therapy in the setting of subarachnoid hemorrhage might reduce delayed cerebral ischemia and mortality,it should not be considered standard care at this time.Acute statins therapy has not demonstrated anybenefit yet following an ICH or CI.Acute statin withdrawal may worsen outcome in acute CI.Observational and case-control studies suggest that pretreatment with statin at time of onset may be associated with better outcomes.Even though preclinical studies have shown statins to have beneficial effects,there has been no clinical evidence.In conclusion,current published studies have not shown that acute statin therapy has any benefical effects in acute neurologic diseases and therefore further large randomized clinical trials are needed.