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We thank Dr Cheen for the insightful commentary on our article.[1] We agree that immortal time bias can be an important issue for observational analyses. Even if these 580 patients were to be included in the matching process with the warfarin group, their contribution to the follow-up of the warfarin group would be marginal, particularly considering that only 22% of the warfarin patients would be eventually matched to apixaban patients. [Extracted from the article]

Background: Patients with atrial fibrillation and severely decreased kidney function were excluded from the pivotal non-vitamin K antagonist oral anticoagulants (NOAC) trials, thereby raising questions about comparative safety and effectiveness in patients with reduced kidney function. The study aimed to compare oral anticoagulants across the range of kidney function in patients with atrial fibrillation.Methods and Results: Using a US administrative claims database with linked laboratory data, 34 569 new users of oral anticoagulants with atrial fibrillation and estimated glomerular filtration rate ≥15 mL/(min·1.73 m2) were identified between October 1, 2010 to November 29, 2017. The proportion of patients using NOACs declined with decreasing kidney function-73.5%, 69.6%, 65.4%, 59.5%, and 45.0% of the patients were prescribed a NOAC in estimated glomerular filtration rate ≥90, 60 to 90, 45 to 60, 30 to 45, 15 to 30 mL/min per 1.73 m2 groups, respectively. Stabilized inverse probability of treatment weighting was used to balance 4 treatment groups (apixaban, dabigatran, rivaroxaban, and warfarin) on 66 baseline characteristics. In comparison to warfarin, apixaban was associated with a lower risk of stroke (hazard ratio [HR], 0.57 [0.43-0.75]; P<0.001), major bleeding (HR, 0.51 [0.44-0.61]; P<0.001), and mortality (HR, 0.68 [0.56-0.83]; P<0.001); dabigatran was associated with a similar risk of stroke but a lower risk of major bleeding (HR, 0.57 [0.43-0.75]; P<0.001) and mortality (HR, 0.68 [0.48-0.98]; P=0.04); rivaroxaban was associated with a lower risk of stroke (HR, 0.69 [0.51-0.94]; P=0.02), major bleeding (HR, 0.84 [0.72-0.99]; P=0.04), and mortality (HR, 0.73 [0.58-0.91]; P=0.006). There was no significant interaction between treatment and estimated glomerular filtration rate categories for any outcome. When comparing one NOAC to another NOAC, there was no significant difference in mortality, but some differences existed for stroke or major bleeding. No relationship between treatments and falsification end points was found, suggesting no evidence for substantial residual confounding.Conclusions: Relative to warfarin, NOACs are used less frequently as kidney function declines. However, NOACs appears to have similar or better comparative effectiveness and safety across the range of kidney function. [ABSTRACT FROM AUTHOR]

Background: Artificial intelligence (AI) is increasingly utilized in interventional cardiology (IC) and holds the potential to revolutionize the field., Methods: We conducted a global, web-based, anonymous survey of IC fellows and attendings to assess the knowledge and perceptions of interventional cardiologists regarding AI use in IC., Results: A total of 521 interventional cardiologists participated in the survey. The median age range of participants was 36 to 45 years, most (51.5%) practice in the United States, and 7.5% were women. Most (84.7%) could explain well or somehow knew what AI is about, and 63.7% were optimistic/very optimistic about AI in IC. However, 73.5% believed that physicians know too little about AI to use it on patients and most (46.1%) agreed that training will be necessary. Only 22.1% were currently implementing AI in their personal clinical practice, while 60.6% estimated implementation of AI in their practice during the next 5 years. Most agreed that AI will increase diagnostic efficiency, diagnostic accuracy, treatment selection, and healthcare expenditure, and decrease medical errors. The most tried AI-powered tools were image analysis (57.3%), ECG analysis (61.7%), and AI-powered algorithms (45.9%). Interventional cardiologists practicing in academic hospitals were more likely to have AI tools currently implemented in their clinical practice and to use them, women had a higher likelihood of expressing concerns regarding AI, and younger interventional cardiologists were more optimistic about AI integration in IC., Conclusions: Our survey suggests a positive attitude of interventional cardiologists regarding AI implementation in the field of IC.

Background: Frequent premature ventricular complexes (PVCs) can be an indicator of structural heart disease., Objective: The purpose of this study was to determine the prevalence of scarring detected by delayed enhancement cardiac magnetic resonance (DE-CMR) imaging in patients with frequent PVCs without apparent structural heart disease and to determine the value of programmed ventricular stimulation (PVS) for risk stratification in patients with frequent PVCs and myocardial scarring., Methods: DE-CMR imaging was performed in patients without apparent heart disease who had frequent PVCs and were referred for ablation. In the presence of scarring, scar volume was measured and correlated with outcome variables. All patients underwent PVS and were monitored for the occurrence of ventricular arrhythmias. Logistic regression was used to compare imaging and procedural findings with long-term outcomes, with adjustment for postablation ejection fraction (EF)., Results: The study consisted of 272 patients (135 men; mean age 52 ± 15 years; EF 52% ± 12%). DE-CMR scar was found in 67 patients (25%), and 7 (3%) were found to have inducible ventricular tachycardia (VT). The presence and amount of DE-CMR were related to the risk of long-term VT independent of EF (hazard ratio 18.8 [95% confidence interval] [2.0-176.6], P = .01; and hazard ratio 1.4 [1.1-1.7] per cm 3 scar, P <.001, respectively). The positive predictive value and negative predictive value of PVS for VT during long-term follow-up were 71% and 100%, respectively., Conclusion: Preprocedural cardiac DE-CMR and PVS can be used to identify patients with frequent PVCs without apparent heart disease who are at risk for VT., (Copyright © 2019 Heart Rhythm Society. All rights reserved.)

Background Atrial fibrillation is the most common arrhythmia worldwide. Data regarding 30-day readmission rates after discharge for atrial fibrillation remain poorly reported. Methods and Results The Nationwide Readmission Database (2010-2014) was queried using the International Classification of Diseases, Ninth Revision ( ICD-9 ) codes to identify study population. Incidence, etiologies of 30-day readmission and predictors of 30-day readmissions, and cost of care were analyzed. Among 1 723 378 patients who survived to discharge, 249 343 (14.4%) patients were readmitted within 30 days. Compared with the readmitted group, the nonreadmitted group had higher utilization of electrical cardioversion and catheter ablation. Atrial fibrillation was the most common cause of readmission (24.1%). Median time to 30-day readmission was 13 days. Advancing age, female sex, and longer stay during index hospitalization predicted higher 30-day readmissions, whereas private insurance, electrical cardioversion, catheter ablation, higher income, and elective admissions correlated with lower 30-day readmission. Comorbidities such as heart failure, neurological disorder, chronic obstructive pulmonary disease, diabetes mellitus, chronic kidney disease, chronic liver failure, coagulopathy, anemia, peripheral vascular disease, and electrolyte disturbance, correlated with increased 30-day readmissions and cost burden. Trend analysis showed a progressive decline in 30-day readmission rates from 14.7% in 2010 to 14.3% in 2014 ( P trend, <0.001). Conclusions Approximately 1 in 7 patients were readmitted within 30 days of discharge, with symptomatic atrial fibrillation being the most common cause. We identified a predictive model for increased risk of readmissions and treatment expense. Electrical cardioversion during index admission was associated with a significant reduction in 30-day readmissions and service charges. The 30-day readmissions correlated with a substantial rise in the cost of care.

Background: Atrial fibrillation (AF) is associated with elevated risk for ischemic stroke and myocardial infarction (MI). The aim of the study is to assess the role of insulin use on the risk of stroke and MI in AF patients with diabetes., Methods: We identified Medicare beneficiaries with new AF in 2011 to 2013. Primary outcomes were ischemic stroke and MI. Multivariate Cox regression models were used to assess the association between AF and time to stroke and MI. We adjusted for anticoagulant as a time-dependent covariate., Results: Out of 798,592 AF patients, 53,212 (6.7%) were insulin-requiring diabetics (IRD), 250,214 (31.3%) were non-insulin requiring diabetics (NIRD) and 495,166 (62%) were non-diabetics (ND). IRD had a higher risk of stroke when compared to NIRD (adjusted HR: 1.15, 95% CI 1.10-1.21) and ND (aHR 1.24, 95% CI 1.18-1.31) (P < .01 for both). The risk of stroke was higher in NIRD compared to ND (aHR 1.08, 95% CI 1.05-1.12). For the outcome of MI, IRD had a higher risk compared to NIRD (aHR 1.24, 95% CI 1.18-1.31) and ND (aHR 1.46, 95% CI 1.38-1.54)]. NIRD had a higher risk compared to ND (aHR 1.17, 95% CI 1.13-1.22). Anticoagulation were most effective at preventing stroke in ND [0.72 (0.69-0.75)], and NIRD [0.88 (0.85-0.92)], but were not associated with significant reduction in stroke in IRD [0.96 (0.89-1.04)]., Conclusion: There is an incremental risk of ischemic stroke and MI from non-diabetics to non-insulin diabetics with the highest risk in insulin users. Protective effect of anticoagulation is attenuated with insulin use., (Published by Elsevier Inc.)

Background: Patients with end-stage kidney disease (ESKD) on dialysis were excluded from clinical trials of direct oral anticoagulants for atrial fibrillation (AF). Recent data have raised concerns regarding the safety of dabigatran and rivaroxaban, but apixaban has not been evaluated despite current labeling supporting its use in this population. The goal of this study was to determine patterns of apixaban use and its associated outcomes in dialysis-dependent patients with ESKD and AF., Methods: We performed a retrospective cohort study of Medicare beneficiaries included in the United States Renal Data System (October 2010 to December 2015). Eligible patients were those with ESKD and AF undergoing dialysis who initiated treatment with an oral anticoagulant. Because of the small number of dabigatran and rivaroxaban users, outcomes were only assessed in patients treated with apixaban or warfarin. Apixaban and warfarin patients were matched (1:3) based on prognostic score. Differences between groups in survival free of stroke or systemic embolism, major bleeding, gastrointestinal bleeding, intracranial bleeding, and death were assessed using Kaplan-Meier analyses. Hazard ratios (HRs) and 95% CIs were derived from Cox regression analyses., Results: The study population consisted of 25 523 patients (45.7% women; 68.2±11.9 years of age), including 2351 patients on apixaban and 23 172 patients on warfarin. An annual increase in apixaban prescriptions was observed after its marketing approval at the end of 2012, such that 26.6% of new anticoagulant prescriptions in 2015 were for apixaban. In matched cohorts, there was no difference in the risks of stroke/systemic embolism between apixaban and warfarin (HR, 0.88; 95% CI, 0.69-1.12; P=0.29), but apixaban was associated with a significantly lower risk of major bleeding (HR, 0.72; 95% CI, 0.59-0.87; P<0.001). In sensitivity analyses, standard-dose apixaban (5 mg twice a day; n=1034) was associated with significantly lower risks of stroke/systemic embolism and death as compared with either reduced-dose apixaban (2.5 mg twice a day; n=1317; HR, 0.61; 95% CI, 0.37-0.98; P=0.04 for stroke/systemic embolism; HR, 0.64; 95% CI, 0.45-0.92; P=0.01 for death) or warfarin (HR, 0.64; 95% CI, 0.42-0.97; P=0.04 for stroke/systemic embolism; HR, 0.63; 95% CI, 0.46-0.85; P=0.003 for death)., Conclusions: Among patients with ESKD and AF on dialysis, apixaban use may be associated with a lower risk of major bleeding compared with warfarin, with a standard 5 mg twice a day dose also associated with reductions in thromboembolic and mortality risk.

Background: There is significant practice variation in oral anticoagulation (OAC) use following catheter ablation for atrial fibrillation. It is not clear whether the risk of cardioembolism increases after discontinuation of OAC following catheter ablation., Methods and Results: We identified 6886 patients within a large national administrative claims database who underwent catheter ablation for atrial fibrillation between January 1, 2005, and September 30, 2014. We assessed the effect of time off of OAC by CHA2DS2-VASc score (after adjusting for other comorbidities) on risk of cardioembolism, using Cox proportional hazards models. There was an increase in the use of non-vitamin K OAC after ablation from 0% in 2005 to 69.8% in 2014. OAC discontinuation was high, with only 60.5% and 31.3% of patients remaining on OAC at 3 and 12 months, respectively. The rate of discontinuation was higher in low-risk patients (82% versus 62.5% at 12 months for CHA2DS2-VASc 0-1 versus ≥2, respectively; P<0.001). Stroke occurred in 1.4% of patients with CHA2DS2-VASc ≥2 and 0.3% of those with CHA2DS2-VASc 0 or 1 over the study follow-up. The risk of cardioembolism in the first 3 months after ablation was increased among those with any time off OAC (hazard ratio 8.06 [95% CI 1.53-42.3], P<0.05). The risk of cardioembolism beyond 3 months was increased with OAC discontinuation among high-risk patients (hazard ratio 2.48 [95% CI 1.11-5.52], P<0.05) but not low-risk patients., Conclusion: The overall risk of stroke in postablation patients is low; however, OAC discontinuation after ablation is common and is associated with increased risk of cardioembolism for all patients within the first 3 months and for high-risk patients in the long term. Continuing OAC for at least 3 months in all patients and indefinitely in high-risk patients appears to be the safest strategy., (© 2015 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.)