Atrial fibrillation(AF) and heart failure(HF) are complex clinical entities that occur concomitantly in a significant population of patients, and their prevalence is rising in epidemic proportions. Traditionally, both...Atrial fibrillation(AF) and heart failure(HF) are complex clinical entities that occur concomitantly in a significant population of patients, and their prevalence is rising in epidemic proportions. Traditionally, both rate and rhythm control strategies have been regarded as equivalent in the management of dysrhythmia in this AF-HF cohort with escalation of treatment largely guided by symptoms. Both disorders are involved in an elaborate pathophysiological interplay with shared cardiovascular risk factors that contribute to the development and sustenance of both AF and HF. Recent studies and continued development of evidence to support catheter ablation for AF has brought into question the traditional belief in equivalence between rate and rhythm control. Indeed, recent trials, in particular the CASTLE-AF(Catheter Ablation versus Standard Conventional Therapy in Patients with Left Ventricular Dysfunction and Atrial Fibrillation) study, suggest that catheter ablation for AF improves survival and rates of hospitalisation in patients with concomitant HF and AF, threatening a paradigm shift in the management of this patient cohort. The evident mortality benefit from clinical trials suggests that catheter ablation for AF should be considered as a therapeutic intervention in all suitable patients with the AF-HF syndrome as these patients may derive the greatest benefit from restoration of sinus rhythm. Further research is needed to refine the evidence base, especially to determine which subgroup of HF patients benefit most from catheter ablation and what is the optimal timing.展开更多
Background:Elderly adults with atrial fi brillation(AF)are at increased risk of frailty and thromboembolic complications.However,studies on the prevalence of frailty in AF patients and data on the relationship between...Background:Elderly adults with atrial fi brillation(AF)are at increased risk of frailty and thromboembolic complications.However,studies on the prevalence of frailty in AF patients and data on the relationship between frailty and the use of anticoagulants are limited.Methods:We conducted a cross-sectional study involving 500 participants.Patients aged 65 years or older were consecutively selected from the Chinese Atrial Fibrillation Registry study.The patient’s frailty status was assessed with use of the Canadian Study of Health and Aging Clinical Frailty Scale.We assessed the prevalence of and factors associated with frailty,and how frailty affects anticoagulant therapy.Results:In 500 elderly adults with AF(age 75.2±6.7 years;51.6%female),201 patients(40.2%)were frail.The prevalence of frailty was higher in females(P=0.002)and increased with age and CHA 2 DS 2-VASc score(P for trend less than 0.001 for both).The factors associated with frailty were a history of heart failure(odds ratio[OR]2.40,95%confi dence interval[CI]1.39–4.14),female sex(OR 2.09,95%CI 1.27–3.43),and advanced age(OR 1.13,95%CI 1.09–1.17).Frail patients were signifi cantly less likely to have ever been prescribed anticoagulants compared with nonfrail patients(81.7 vs.54.9%,P<0.001).Conclusions:Frailty is prevalent in elderly adults with AF,especially in females,those of advanced age,and those with heart failure.Frailty status has a signifi cant impact on prescription of anticoagulants for high-risk AF patients.展开更多
Penetrating injuries to anterior chest may result in life-threatening complications such as massive haemothorax,?as a result of injury to the internal mammary artery.?Isolated internal mammary injury is a very rare ca...Penetrating injuries to anterior chest may result in life-threatening complications such as massive haemothorax,?as a result of injury to the internal mammary artery.?Isolated internal mammary injury is a very rare cause of massive haemothorax and associated with high mortality.?We are presenting this?32-year-old gentleman who sustained a thoracic stab wound and had an emergency right anterior mini-thoracotomy?by extending the stab wound rather than standard thoracotomy or sternotomy.?This case of isolated penetrating IMA injury managed with mini-thoracotomy is the only documented case so far. We are publishing this case report with patient’s both written and informed consent and institutional approval.?This potentially life-threating injury can be managed by mini-thoracotomy with enhanced recovery;however, it is case specific and needs proper judgement.展开更多
Cardiac involvement in Churg Strauss Syndrome is common and a poor prognostic indicator. Myocarditis in Churg Strauss Syndrome can present in different ways. It has been shown that basic cardiac investigations includi...Cardiac involvement in Churg Strauss Syndrome is common and a poor prognostic indicator. Myocarditis in Churg Strauss Syndrome can present in different ways. It has been shown that basic cardiac investigations including echocardiography can be normal even in symptomatic patients. More recently cardiac magnetic resonance imaging (MRI) has been shown to be more sensitive in its diagnosis. Our case report describes a 45 year old male who presented with palpitations and breathlessness. Echocardiography was normal but cardiac MRI demonstrated abnormalities consistent with Myocarditis. He was treated with Cyclophosphamide and follow up MRI imaging demonstrated complete resolution of these abnormalities which was accompanied by resolution of symptoms. This case therefore supports the use of cardiac MRI in Churg Strauss Syndrome as a sensitive diagnostic tool in and as a means of monitoring response to therapy. It also supports the therapeutic effectiveness of Cyclophosphamide therapy in Churg Strauss related Myocarditis, something that has yet to be assessed on a large scale.展开更多
A 78-year-old woman with a background of type 2 diabetes mellitus,hyperlipidaemia and hypertension experienced sudden onset severe chest pain while in the emergency department,after a stressful emotional event.The pai...A 78-year-old woman with a background of type 2 diabetes mellitus,hyperlipidaemia and hypertension experienced sudden onset severe chest pain while in the emergency department,after a stressful emotional event.The pain lasted for 20-30 min and the patient developed widespread T-wave inversion on 12-lead ECG.展开更多
Background： Accelerometers have been suggested to provide additional information during the 6-min walk test which may be useful in evaluating changes in functional exercise capacity. The aim of the study was to ident...Background： Accelerometers have been suggested to provide additional information during the 6-min walk test which may be useful in evaluating changes in functional exercise capacity. The aim of the study was to identify whether the additional information measured by the My Wellness Key^TM（MWK） accelerometer during a treadmill 6-min walk test（t-6MWT） was related to currently used outcome measures.Methods： Fifteen participants（9 males, 6 females） performed a self-paced t-6MWT. Respiratory gas analysis and walking distance were measured whilst wearing the MWK.Results： A significant correlation was established between activity counts and 6-min walk distance（6MWD）（r=-0.847, p 〈 0.001） yet not 6-min walk work（6MWW）（r=-0.337, p=0.220）. Energy expenditure estimated by the MWK was strongly correlated to 6MWW（r=0.938, p 〈 0.001）but not 6MWD（r=0.477, p=0.072）. The MWK significantly underestimated energy expenditure（36.73, CI=33.9-39.7 kcal） compared to gas analysis（54.35, CI=46.2-61.4 kcal） demonstrating poor agreement between the two analyses（Bias=-17.61 kcal, Limits of agreement=-37.4,t2.2 kcal）. Measurement of time spent undertaking light, moderate, and vigorous physical activity was not significantly different（ p 〉 0.05）between the MWK and gas analysis.Conclusion： Estimated energy expenditure provided by the MWK was strongly correlated to 6MWW; however, MWK underestimated energy expenditure as measured by gas analysis. The MWK may provide outcome data that supplement those currently provided by the 6MWD for functional capacity assessment during the t-6MWT.展开更多
New-onset postoperative atrial fibrillation (POAF) following Coronary artery bypass graft (CABG) surgery has been described in up to 15% to 40% of patients in the initial postoperative period. POAF is related with hig...New-onset postoperative atrial fibrillation (POAF) following Coronary artery bypass graft (CABG) surgery has been described in up to 15% to 40% of patients in the initial postoperative period. POAF is related with higher mortality, increased hospital resource utilization, postoperative extra ITU hours and hospital days, consequently increasing hospital-related budgets. Beta blocker administration decreases the rate of POAF from 30% - 40% to 12% - 16% after CABG. According to the EACTS (European Association of Cardiothoracic Surgery) guideline December 2006, β-Blockers should routinely be used as the first choice for the prophylaxis of atrial fibrillation (AF) in all patients undergoing cardiac surgery, if not contraindicated (IB). To compare the contemporary practice with the recommended standard retrospective data of consecutive 400 patients treated with isolated CABG between July 2015 and June 2017 were collected. Those patients who received β-blockers on the day of surgery or the following morning (Continued and Restarted on 1st POD) met the standard guidelines. Thus, according to the data (12% + 20%) 32% of the patients met the standard. To compare the rate of Postoperative Atrial fibrillation, we divided the patients into two groups. Group A, who followed the guideline (128 patients) and Group B, who resumed β-Blockers 48 hours onwards (272 Patients). In group A, only 8 patients developed postoperative AF whereas in group B 88 patients developed postoperative AF which is also statistically significant (P β-blockers use at perioperative period.展开更多
Coronary malperfusion is a complication of aortic dissection, and can lead to ventricular failure. We report 2 cases of right ventricular (RV) failure, following aortic dissection, successfully bridged to recovery usi...Coronary malperfusion is a complication of aortic dissection, and can lead to ventricular failure. We report 2 cases of right ventricular (RV) failure, following aortic dissection, successfully bridged to recovery using right ventricular assist devices (RVADs). The first was a 54 year-old man, who had difficulty weaning from bypass due to a stunned RV following aortic root replacement. The second was a 34 year-old woman, who after replacement of the ascending aorta, suffered episodes of ventricular fibrillation (VF), and RV failure. Both had an RVAD implanted, allowing eventual recovery. We recommend more widespread use of VADs in such cases.展开更多
Background:The age,biomarkers,and clinical history(ABC)-atrial fibrillation(AF)-Stroke score have been proposed to refine stroke risk stratification,beyond what clinical risk scores such as the CHA2DS2-VASc score can ...Background:The age,biomarkers,and clinical history(ABC)-atrial fibrillation(AF)-Stroke score have been proposed to refine stroke risk stratification,beyond what clinical risk scores such as the CHA2DS2-VASc score can offer.This study aimed to identify risk factors associated with thromboembolism and evaluate the performance of the ABC-AF-Stroke score in predicting thromboembolism in non-anticoagulated AF patients following successful ablations.Methods:A total of 2692 patients who underwent successful ablations with discontinued anticoagulation after a 3-month blanking period in the Chinese Atrial Fibrillation Registry(CAFR)between 2013 and 2019 were included.Cox regression analysis was conducted to present the association of risk factors with thromboembolism risk.The ABC-AF-Stroke score was evaluated in terms of discrimination,including concordance index(C-index),net reclassification improvement(NRI)and integrated discrimination improvement(IDI),clinical utilization by decision curve analysis(DCA),and calibration by comparing the predicted risk with the observed annualized event rate.Results:After a median follow-up of 3.5 years,64 patients experienced thromboembolism events.Age,prior history of stroke/transient ischemic attack(TIA),high-sensitivity cardiac troponin T(cTnT-hs),and N-terminal pro-B-type natriuretic peptide(NT-proBNP)were independently associated with thromboembolism risk.The ABC-AF-Stroke score performed statistically significantly better than the CHA2DS2-VASc score in terms of C-index(0.67,95%confidence interval[CI]:0.59-0.74 vs.0.60,95%CI:0.52-0.67,P=0.030)and reclassification capacity.The DCA implied that the ABC-AF-Stroke score could identify more thromboembolism events without increasing the false positive rate compared to the CHA2DS2-VASc score.The calibration curve showed that the ABC-AF-Stroke score was well calibrated in this population.Conclusions:In this real-world study enrolling non-anticoagulated AF patients following successful ablations,age,prior history of stroke/TIA,level of NT-proBNP,and cTnT-hs were independently associated with an increased risk of thromboembolism.The ABC-AF-Stroke score was well-calibrated and statistically significantly outperformed the CHA2DS2-VASc score in predicting thromboembolism risk.展开更多
文摘Atrial fibrillation(AF) and heart failure(HF) are complex clinical entities that occur concomitantly in a significant population of patients, and their prevalence is rising in epidemic proportions. Traditionally, both rate and rhythm control strategies have been regarded as equivalent in the management of dysrhythmia in this AF-HF cohort with escalation of treatment largely guided by symptoms. Both disorders are involved in an elaborate pathophysiological interplay with shared cardiovascular risk factors that contribute to the development and sustenance of both AF and HF. Recent studies and continued development of evidence to support catheter ablation for AF has brought into question the traditional belief in equivalence between rate and rhythm control. Indeed, recent trials, in particular the CASTLE-AF(Catheter Ablation versus Standard Conventional Therapy in Patients with Left Ventricular Dysfunction and Atrial Fibrillation) study, suggest that catheter ablation for AF improves survival and rates of hospitalisation in patients with concomitant HF and AF, threatening a paradigm shift in the management of this patient cohort. The evident mortality benefit from clinical trials suggests that catheter ablation for AF should be considered as a therapeutic intervention in all suitable patients with the AF-HF syndrome as these patients may derive the greatest benefit from restoration of sinus rhythm. Further research is needed to refine the evidence base, especially to determine which subgroup of HF patients benefit most from catheter ablation and what is the optimal timing.
基金This work was supported by the National Key Research and Development Program of China(2016YFC0900901,2016YFC1301002,2017YFC0908803,2018YFC1312501)a grant from the National Natural Science Foundation of China(81530016).
文摘Background:Elderly adults with atrial fi brillation(AF)are at increased risk of frailty and thromboembolic complications.However,studies on the prevalence of frailty in AF patients and data on the relationship between frailty and the use of anticoagulants are limited.Methods:We conducted a cross-sectional study involving 500 participants.Patients aged 65 years or older were consecutively selected from the Chinese Atrial Fibrillation Registry study.The patient’s frailty status was assessed with use of the Canadian Study of Health and Aging Clinical Frailty Scale.We assessed the prevalence of and factors associated with frailty,and how frailty affects anticoagulant therapy.Results:In 500 elderly adults with AF(age 75.2±6.7 years;51.6%female),201 patients(40.2%)were frail.The prevalence of frailty was higher in females(P=0.002)and increased with age and CHA 2 DS 2-VASc score(P for trend less than 0.001 for both).The factors associated with frailty were a history of heart failure(odds ratio[OR]2.40,95%confi dence interval[CI]1.39–4.14),female sex(OR 2.09,95%CI 1.27–3.43),and advanced age(OR 1.13,95%CI 1.09–1.17).Frail patients were signifi cantly less likely to have ever been prescribed anticoagulants compared with nonfrail patients(81.7 vs.54.9%,P<0.001).Conclusions:Frailty is prevalent in elderly adults with AF,especially in females,those of advanced age,and those with heart failure.Frailty status has a signifi cant impact on prescription of anticoagulants for high-risk AF patients.
文摘Penetrating injuries to anterior chest may result in life-threatening complications such as massive haemothorax,?as a result of injury to the internal mammary artery.?Isolated internal mammary injury is a very rare cause of massive haemothorax and associated with high mortality.?We are presenting this?32-year-old gentleman who sustained a thoracic stab wound and had an emergency right anterior mini-thoracotomy?by extending the stab wound rather than standard thoracotomy or sternotomy.?This case of isolated penetrating IMA injury managed with mini-thoracotomy is the only documented case so far. We are publishing this case report with patient’s both written and informed consent and institutional approval.?This potentially life-threating injury can be managed by mini-thoracotomy with enhanced recovery;however, it is case specific and needs proper judgement.
文摘Cardiac involvement in Churg Strauss Syndrome is common and a poor prognostic indicator. Myocarditis in Churg Strauss Syndrome can present in different ways. It has been shown that basic cardiac investigations including echocardiography can be normal even in symptomatic patients. More recently cardiac magnetic resonance imaging (MRI) has been shown to be more sensitive in its diagnosis. Our case report describes a 45 year old male who presented with palpitations and breathlessness. Echocardiography was normal but cardiac MRI demonstrated abnormalities consistent with Myocarditis. He was treated with Cyclophosphamide and follow up MRI imaging demonstrated complete resolution of these abnormalities which was accompanied by resolution of symptoms. This case therefore supports the use of cardiac MRI in Churg Strauss Syndrome as a sensitive diagnostic tool in and as a means of monitoring response to therapy. It also supports the therapeutic effectiveness of Cyclophosphamide therapy in Churg Strauss related Myocarditis, something that has yet to be assessed on a large scale.
文摘A 78-year-old woman with a background of type 2 diabetes mellitus,hyperlipidaemia and hypertension experienced sudden onset severe chest pain while in the emergency department,after a stressful emotional event.The pain lasted for 20-30 min and the patient developed widespread T-wave inversion on 12-lead ECG.
文摘Background： Accelerometers have been suggested to provide additional information during the 6-min walk test which may be useful in evaluating changes in functional exercise capacity. The aim of the study was to identify whether the additional information measured by the My Wellness Key^TM（MWK） accelerometer during a treadmill 6-min walk test（t-6MWT） was related to currently used outcome measures.Methods： Fifteen participants（9 males, 6 females） performed a self-paced t-6MWT. Respiratory gas analysis and walking distance were measured whilst wearing the MWK.Results： A significant correlation was established between activity counts and 6-min walk distance（6MWD）（r=-0.847, p 〈 0.001） yet not 6-min walk work（6MWW）（r=-0.337, p=0.220）. Energy expenditure estimated by the MWK was strongly correlated to 6MWW（r=0.938, p 〈 0.001）but not 6MWD（r=0.477, p=0.072）. The MWK significantly underestimated energy expenditure（36.73, CI=33.9-39.7 kcal） compared to gas analysis（54.35, CI=46.2-61.4 kcal） demonstrating poor agreement between the two analyses（Bias=-17.61 kcal, Limits of agreement=-37.4,t2.2 kcal）. Measurement of time spent undertaking light, moderate, and vigorous physical activity was not significantly different（ p 〉 0.05）between the MWK and gas analysis.Conclusion： Estimated energy expenditure provided by the MWK was strongly correlated to 6MWW; however, MWK underestimated energy expenditure as measured by gas analysis. The MWK may provide outcome data that supplement those currently provided by the 6MWD for functional capacity assessment during the t-6MWT.
文摘New-onset postoperative atrial fibrillation (POAF) following Coronary artery bypass graft (CABG) surgery has been described in up to 15% to 40% of patients in the initial postoperative period. POAF is related with higher mortality, increased hospital resource utilization, postoperative extra ITU hours and hospital days, consequently increasing hospital-related budgets. Beta blocker administration decreases the rate of POAF from 30% - 40% to 12% - 16% after CABG. According to the EACTS (European Association of Cardiothoracic Surgery) guideline December 2006, β-Blockers should routinely be used as the first choice for the prophylaxis of atrial fibrillation (AF) in all patients undergoing cardiac surgery, if not contraindicated (IB). To compare the contemporary practice with the recommended standard retrospective data of consecutive 400 patients treated with isolated CABG between July 2015 and June 2017 were collected. Those patients who received β-blockers on the day of surgery or the following morning (Continued and Restarted on 1st POD) met the standard guidelines. Thus, according to the data (12% + 20%) 32% of the patients met the standard. To compare the rate of Postoperative Atrial fibrillation, we divided the patients into two groups. Group A, who followed the guideline (128 patients) and Group B, who resumed β-Blockers 48 hours onwards (272 Patients). In group A, only 8 patients developed postoperative AF whereas in group B 88 patients developed postoperative AF which is also statistically significant (P β-blockers use at perioperative period.
文摘Coronary malperfusion is a complication of aortic dissection, and can lead to ventricular failure. We report 2 cases of right ventricular (RV) failure, following aortic dissection, successfully bridged to recovery using right ventricular assist devices (RVADs). The first was a 54 year-old man, who had difficulty weaning from bypass due to a stunned RV following aortic root replacement. The second was a 34 year-old woman, who after replacement of the ascending aorta, suffered episodes of ventricular fibrillation (VF), and RV failure. Both had an RVAD implanted, allowing eventual recovery. We recommend more widespread use of VADs in such cases.
基金funded by the National Key Research and Development Program of China(2020YFC2004803)the National Natural Science Foundation of China(82100326,82103904)+2 种基金the Beijing Municipal Science and Technology Commission(D171100006817001)the Beijing Municipal Education Commission(KM202210025012)The construction of CARF was supported by grants from Bristol-Myers Squibb,Pfizer,Johnson&Johnson,Boehringer Ingelheim,and Bayer.
文摘Background:The age,biomarkers,and clinical history(ABC)-atrial fibrillation(AF)-Stroke score have been proposed to refine stroke risk stratification,beyond what clinical risk scores such as the CHA2DS2-VASc score can offer.This study aimed to identify risk factors associated with thromboembolism and evaluate the performance of the ABC-AF-Stroke score in predicting thromboembolism in non-anticoagulated AF patients following successful ablations.Methods:A total of 2692 patients who underwent successful ablations with discontinued anticoagulation after a 3-month blanking period in the Chinese Atrial Fibrillation Registry(CAFR)between 2013 and 2019 were included.Cox regression analysis was conducted to present the association of risk factors with thromboembolism risk.The ABC-AF-Stroke score was evaluated in terms of discrimination,including concordance index(C-index),net reclassification improvement(NRI)and integrated discrimination improvement(IDI),clinical utilization by decision curve analysis(DCA),and calibration by comparing the predicted risk with the observed annualized event rate.Results:After a median follow-up of 3.5 years,64 patients experienced thromboembolism events.Age,prior history of stroke/transient ischemic attack(TIA),high-sensitivity cardiac troponin T(cTnT-hs),and N-terminal pro-B-type natriuretic peptide(NT-proBNP)were independently associated with thromboembolism risk.The ABC-AF-Stroke score performed statistically significantly better than the CHA2DS2-VASc score in terms of C-index(0.67,95%confidence interval[CI]:0.59-0.74 vs.0.60,95%CI:0.52-0.67,P=0.030)and reclassification capacity.The DCA implied that the ABC-AF-Stroke score could identify more thromboembolism events without increasing the false positive rate compared to the CHA2DS2-VASc score.The calibration curve showed that the ABC-AF-Stroke score was well calibrated in this population.Conclusions:In this real-world study enrolling non-anticoagulated AF patients following successful ablations,age,prior history of stroke/TIA,level of NT-proBNP,and cTnT-hs were independently associated with an increased risk of thromboembolism.The ABC-AF-Stroke score was well-calibrated and statistically significantly outperformed the CHA2DS2-VASc score in predicting thromboembolism risk.
基金The National Guideline Alliance was commissioned and funded by the National Institute for Health and C are Excellence to develop this guidelinewrite this BMJ summary.
