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Electrical isolation of the left atrial appendage (LAA) improves outcomes of patients with persistent atrial fibrillation (AF) but may increase the risk of thromboembolism.The purpose of this study was to describe a method to map and ablate appendage drivers without complete electrical isolation.One hundred thirteen patients underwent an ablation procedure for persistent AF. The procedure was performed during AF and consisted of pulmonary vein and posterior LA isolation as well as ablation of the LAA. The right atrium (RA) was targeted in patients with a right-to-left gradient in cycle length (CL). The end point of appendage ablation was CL slowing or AF termination but not complete isolation.Among the 113 patients (mean age 64.6 ± 8.6 years; ejection fraction 54% ± 13%; LA diameter 46 ± 6.5 mm), radiofrequency ablation terminated AF in 51 patients (45%). RA ablation was performed in 41 patients (36%) at the index or repeat procedure. The mean AF CL in the RA appendage (RAA) was shorter than that in the LAA (160 ± 32 ms vs 186 ± 29 ms; P.01) in these patients. The most frequent target in the RA was the RAA (CLs approaching 50-60 ms). Discontinuing radiofrequency ablation upon AF termination or conduction slowing prevented LAA isolation. After a mean follow-up of 24 ± 15 months, 89 patients (78%) remained arrhythmia-free without antiarrhythmic medications.An ablation strategy guided by the AF CL addresses LAA drivers without complete electrical isolation and also helps identify the RAA as a source of persistent AF.

Background: Atrial fibrillation (AF) is the most common cardiac arrhythmia associated with high morbidity and mortality. AF treatment is guided by a patient–provider risk–benefit discussion regarding drug versus ablation or combination. Thermal ablation has a high rate of adverse events compared to pulsed field ablation (PFA). In this systematic review, we aimed to determine the safety and efficacy of PFA. Methods: The electronic search for relevant articles in English was completed in PubMed, PubMed Central, Cochrane library, Scopus, and Embase databases till July 2022. The screening was completed via the use of Covidence software. The risk of bias assessment and data extraction from the included studies was performed, and the narrative synthesis was performed accordingly. Results: A total of six studies were selected for review and 1897 patients receiving PFA were involved in these studies. Our review was focused on pulmonary vein isolation success, major adverse events, and arrhythmia recurrence. Successful pulmonary vein isolation (PVI) was completed in 100% of cases except in two studies. In one of them, six out of seven patients (86%) in the epicardial cohort had successful PVI. In the MANIFEST-PF survey, the acute PVI success rate was 99.9%. The major complications were rare and included pericardial tamponade, vascular complications requiring surgery, and stroke. The atrial arrhythmia recurrence was higher in the thermal group than in the PFA group (39% vs. 11%). Conclusions: The success rate of PVI by PFA is high, and major adverse events are low. PFA is found to decrease the recurrence of atrial arrhythmia compared to thermal ablation. Substantial randomized controlled trials (RCTs) are needed to validate the efficacy and safety of PFA over conventional methods.

Although the absolute risk of sudden death in the athlete is low, pre-articipation evaluation is an important opportunity to assess risk as well as establish a working relationship with the patient. In this chapter, we review the basis for our approach to pre-participation evaluation of an athlete. To date, no randomized study has compared the additive benefit of the screening ECG; however, the false positive rate is now in an acceptably low range. Different imaging modalities and/or exercise stress testing may provide important adjunctive information. Thoughtful assessment of the athlete should account for exercise-induced adaptation and shared decision-making in challenging cases. Future research continues on distinguishing between the physiologic and pathologic changes in the athlete’s heart. No matter what screening program is in place, a well-thought-out and well-rehearsed emergency action plan is paramount.

Postcardiac surgery cardiogenic shock (PCCS) is seen in 2% to 6% of patients who undergo cardiac surgery. There are limited large-scale data on the use of mechanical circulatory support (MCS) in these patients. This study sought to evaluate the in-hospital mortality, trends, and resource utilization for PCCS admissions with and without MCS. A retrospective cohort of PCCS between 2005 and 2014 with and without the use of temporary MCS was identified from the National Inpatient Sample. Admissions for permanent MCS and heart transplant were excluded. Propensity-matching for baseline characteristics was performed. The primary outcome was in-hospital mortality and secondary outcomes included trends in use, hospital costs and lengths of stay. In the period between 2005 and 2014, there were 132,485 admissions with PCCS, with 51.3% requiring MCS. The intra-aortic balloon pump was the predominant device used with a steady increase in other devices. MCS use for more frequent in younger patients, males and those with higher co-morbidity. There was a decrease in MCS use across all demographic categories and hospital characteristics over time. Older age, female sex, previous cardiovascular morbidity and MCS use were independently predictive of higher in-hospital mortality. In 6,830 propensity-matched pairs, PCCS admissions that required MCS use, had higher in-hospital mortality (odds ratio 2.4; p

With the growing obesity epidemic, the global burden of AF and obstructive sleep apnoea (OSA) is increasing at an alarming rate. Obesity, age, male gender, alcohol consumption, smoking and heart failure are common risk factors for both AF and OSA and they are independently associated with adverse cardiovascular outcomes. Weak evidence from observational studies link OSA to the development of AF. Hypoxia/hypercapnia, systemic inflammation and autonomic nervous system modulation are biological mechanisms that link OSA to AF. Patients with OSA have a poor response to catheter ablation of AF and often suffer recurrences. Observational data shows that continuous positive airway pressure is associated with a reduction in AF burden and a better response to catheter ablation of AF. However, prospective randomised studies are needed to confirm the usefulness of continuous positive airway pressure in the treatment of AF in patients with OSA.

Objectives The study’s goal was to compare the efficacy and safety of dofetilide (DOF) versus amiodarone (AMIO) in patients with atrial fibrillation (AF). Background Comparative efficacy of DOF versus AMIO in patients with AF has not been well established. In addition, proarrhythmia has been a concern with DOF therapy. Methods Rhythm control was attempted by using DOF in 657 consecutive patients (mean age 72 ± 9 years; 35% women) with AF (n = 528) or atrial flutter and AF (n = 129) between January 2014 and December 2018. Results DOF was successfully initiated in 573 (87%) of 657 patients, including 510 (89%) with persistent AF and 63 (11%) with paroxysmal AF. During a mean follow-up of 19 ± 7 months, sinus rhythm was maintained in 361 (63%) of the 573 DOF-treated patients. At 12 months, patients on DOF had a similar likelihood of experiencing recurrent atrial arrhythmias compared with the 2,476 consecutive patients treated with AMIO for rhythm control during the study period (37% vs. 39%; p = 0.56). The efficacy of DOF and AMIO was also similar in specific subgroups of patients, including patients >75 years of age, with a low left ventricular ejection fraction, obesity, renal insufficiency, and prior catheter ablation for AF. Among patients with atypical atrial flutter, likelihood of recurrent atrial flutter was similar between the DOF (43 of 108 [40%]) and AMIO (211 of 555 [38%]; p = 0.69) groups. Conclusions When properly initiated and monitored, DOF has efficacy comparable to that of amiodarone for rhythm control in patients with AF.

BACKGROUND Implanted defibrillators are capable of recording activity data based on company-specific proprietary algorithms. This study aimed to determine the prognostic significance of baseline and decline in device-derived activity level across different device companies in the real world. METHODS We performed a retrospective cohort study of patients (n = 280) who underwent a defibrillator implantation (Boston, Medtronic, St. Jude, and Biotronik) for primary prevention at the University of Michigan from 2014 to 2016. Graphical data obtained from device interrogations were retrospectively converted to numerical data. The activity level averaged over a month from a week postimplantation was used as baseline. Subsequent weekly average activity levels (SALs) were standardized to this baseline. SAL below 59.4% was used as a threshold to group patients. All-cause mortality and death/heart failure were the primary end-points of this study. RESULTS Fifty-six patients died in this study. On average, they experienced a 50% decline in SAL prior to death. Patients (n = 129) who dropped their SAL below threshold were more likely to be older, male, diabetic, and have more symptomatic heart failure. They also had a significantly increased risk of heart failure/death (hazard ratio [HR] 3.6, 95% confidence interval [95% CI] 2.3-5.8, P

Left ventricular assist devices (LVADs) have emerged as an attractive option in patients with advance heart failure. Nationwide readmission database 2013 to 2014 was utilized to identify LVAD recipients using ICD-9 procedure code 37.66. The primary outcome was 90-day readmission. Readmission causes were identified using ICD-9 codes in primary diagnosis field. The secondary outcomes were LVAD associated with hospital complications. Hierarchic 2-level logistic models were used to evaluate study outcomes. We identified 4,693 LVAD recipients (mean age 57 years, 76.2% males). Of which 53.9% were readmitted in first 90 days of discharge. Cardiac causes (33.3%), bleeding (21.3%), and infections (12.4%) were leading etiologies of 90-day readmissions. Significant predictors (odds ratio, 95% confidence interval, p value) of readmission were disposition to nursing facilities (1.33, 1.09 to 1.63, p = 0.01) and longer length of stay (1.01, 1.00 to 1.01, p

We compared the risk of radial artery occlusion (RAO) in patients undergoing coronary intervention with introducer sheath (SG) or without introducer sheath (SLG). 1251 consecutive patients, from 2 tertiary care center in Pennsylvania, USA, undergoing percutaneous coronary interventions (PCI) between 2008–2013 formed the study cohort (SLG: 161 patients, SG: 1090 patients). Radial artery patency was assessed using plethysmography. The association between sheath use and RAO was assessed using unadjusted, adjusted and propensity macthed logistic regression analyses. Mean age: 65 years, men: 63%, diabetics: 37%. SG was associated with lower RAO at band removal [unadjusted (OR: 0.31, 95% CI: 0.21–0.46), adjusted (OR: 0.10, 95% CI: 0.05–0.20) and propensity matched (OR: 0.20, 95% CI: 0.13–0.32)], at 24 hours [unadjusted (OR: 0.20, 95% CI: 0.12–0.34), adjusted (OR: 0.12, 95% CI: 0.06–0.24) and propensity matched (OR: 0.13, 95% CI: 0.07–0.25)] and 30 days [unadjusted (OR: 0.28, 95% CI: 0.14–0.54), adjusted (OR: 0.22, 95% CI: 0.10–0.50) and propensity matched (OR: 0.18, 95% CI: 0.10–0.40)], compared to SLG. Sheath use during radial access for PCI is associated with less RAO. It is unclear if use of introducer sheath during radial access for PCI reduces incidence of RAO. In this prospective cohort study involving 1251 concecutive patients undergoing PCI via radial access between 2008–2013, we assessed the difference in incidence of RAO between the SG (n = 1090) and the SLG (n = 161 patients) groups. SG group experienced lower incidence of RAO at band removal, 24 hours and 30 days post PCI in the unadjusted, adjusted, and propensity matched analyses compared to the SLG group. In conclusion sheath use during radial access for PCI is associated with less RAO.

Electroanatomic mapping (EAM) has been utilized as a modality to improve the sensitivity of endomyocardial biopsy (EMB). We sought to systematically review published medical literature on the efficacy and safety of EAM-guided EMB. We searched Ovid MEDLINE, Ovid Embase, Ovid CDR, Cochrane Central, Scopus, and Web of Science for studies where EAM was used for EMB. Data abstracted included demographics, indications, final diagnoses, histology findings, and technical details of biopsy extraction. Test characteristics including sensitivity (Se), specificity (Sp), and area under curve (AUC) were calculated on a per-patient and per-biopsy level. Seventeen studies (9 case series, 8 case reports) were included in this systematic review. EAM-guided EMB was performed in 148 patients and results of 207 individual biopsies were available for analysis. The most common indications for EAM-guided EMB were suspected arrhythmogenic right ventricular cardiomyopathy (ARVC), myocarditis, and cardiac sarcoidosis (CS). The pooled sensitivity and specificity for EAM-guided EMB for the diagnosis of cardiomyopathies (ARVC, myocarditis, CS, and other specific diagnoses) were 92 and 58% on per-biopsy analysis and 100 and 39% on per-patient analysis. Among the individual components of abnormal EGMs, abnormal unipolar EGM had the best AUC on per-biopsy (0.81, 95% CI 0.68–0.90) and per-patient analysis (0.84, 95% CI 0.68–0.92). EAM-guided EMB appears safe. Adverse events included 1 hemopericardium, 2 minimal asymptomatic pericardial effusions, and 1 femoral hematoma. EAM-guided EMB is a safe and efficacious method and might improve test characteristics over conventional fluoroscopy-guided biopsy.

Purpose In aortic stenosis patients referred for surgical and transcatheter aortic valve replacement (AVR), the evidence of diagnostic accuracy of coronary computed tomography angiography (CCTA) has been limited. The objective of this study was to investigate the diagnostic accuracy of CCTA for significant coronary artery disease (CAD) in patients referred for AVR using invasive coronary angiography (ICA) as the gold standard. Materials and methods We searched databases for all diagnostic studies of CCTA in patients referred for AVR, which reported diagnostic testing characteristics on patient-based analysis required to pool summary sensitivity, specificity, positive-likelihood ratio, and negative-likelihood ratio. Significant CAD in both CCTA and ICA was defined by >50% stenosis in any coronary artery, coronary stent, or bypass graft. Results Thirteen studies evaluated 1498 patients (mean age, 74 y; 47% men; 76% transcatheter AVR). The pooled prevalence of significant stenosis determined by ICA was 43%. Hierarchical summary receiver-operating characteristic analysis demonstrated a summary area under curve of 0.96. The pooled sensitivity, specificity, and positive-likelihood and negative-likelihood ratios of CCTA in identifying significant stenosis determined by ICA were 95%, 79%, 4.48, and 0.06, respectively. In subgroup analysis, the diagnostic profiles of CCTA were comparable between surgical and transcatheter AVR. Conclusions Despite the higher prevalence of significant CAD in patients with aortic stenosis than with other valvular heart diseases, our meta-analysis has shown that CCTA has a suitable diagnostic accuracy profile as a gatekeeper test for ICA. Our study illustrates a need for further study of the potential role of CCTA in preoperative planning for AVR.

BACKGROUND Catheter ablation is widely accepted intervention for atrial fibrillation (AF) refractory to antiarrhythmic drugs, but limited data are available regarding contemporary trends in major complications and in-hospital mortality due to the procedure. This study was aimed at exploring the temporal trends of in-hospital mortality, major complications, and impact of hospital volume on frequency of AF ablation-related outcomes. METHODS The Nationwide Inpatient Sample database was utilized to identify the AF patients treated with catheter ablation. In-hospital death and common complications including vascular access complications, cardiac perforation and/or tamponade, pneumothorax, stroke, and transient ischemic attack, were identified using International Classification of Disease (ICD-9-CM) codes. RESULT In-hospital mortality rate of 0.15% and overall complication rate of 5.46% were noted among AF ablation recipients (n = 50,969). Significant increase in complications during study period (relative increase 56.37%, P-trend

Female gender was included in stroke prediction algorithms in an attempt to improve anticoagulation rates in women with atrial fibrillation (AF). It is unclear if these efforts reduced stroke burden in women with AF. To bridge this literature gap, using the Nationwide Inpatient Sample, we assessed gender differences in the trends of hospitalizations for stroke among patients with AF in the United States in 2005 to 2014. International classification of diseases, 9th revision, clinical modification codes were used to abstract AF and stroke diagnoses. From 2005 to 2014, 18,413,291 hospitalizations of women with AF and 18,035,866 hospitalizations of men with AF were reported. Of these, 740,635 hospitalizations in women and 595,730 hospitalizations in men had stroke as the primary diagnosis. Age-adjusted stroke hospitalizations increased in women (443 per million in 2005 to 495 per million in 2014) as well as in men (351 per million in 2005 to 453 per million in 2014) (p trend 0.001). Further, anticoagulation rates increased in women (11.5% in 2005 to 24.0% in 2014) as well as in men (11.7% in 2005 to 24.9% in 2014). Stroke hospitalizations involving anticoagulated patients with AF decreased in women (411 per million in 2005 to 347 per million in 2014) as well as in men (402 per million in 2005 to 311 per million in 2014) (p trend 0.001). In conclusion, although we noted an increasing trend of stroke hospitalizations in both genders, it is reassuring to note that stroke hospitalizations involving anticoagulated patients with AF is decreasing in both genders and in particular among women.

Background Coronary artery calcium score (CACS) is a well-established test for risk stratifying asymptomatic patients for overall cardiovascular or coronary events. However; the prognostic value for incident stroke remains controversial. The objective of this study was to investigate the predictive value of CACS obtained by non-contrast electrocardiogram-gated computed tomography for incident stroke. Methods We searched PubMed, EMBASE, Cochrane databases for prospective longitudinal studies of CACS which reported the incidence of stroke. Incidence of stroke was compared in patients with and without coronary calcification. Results Three studies evaluated 13,262 asymptomatic patients (mean age=60years, 50% men) without apparent cardiovascular diseases. During a follow-up of 7.2years (median 5years, range 4.4–9.5years, 95,434patient-years), the overall pooled incidence of stroke was 0.26%/year. The pooled risk ratio of CACS>0 for incident stroke was 2.95 (95% CI: 2.18–4.01, p 2 =0%). The pooled incidence rate of stroke categorized by CACS was 0.12%/year for CACS 0, 0.26%/year for CACS 1–99, 0.41%/year for CACS 100–399 and 0.70%/year for CACS ≥400. Conclusions In asymptomatic patients without apparent cardiovascular diseases, the incidence of stroke was overall low. The presence and severity of coronary artery calcification were associated with incident stroke over mid-long term follow-up.

Atrial fibrillation-flutter (AF) has been described in 10% to 24% of patients after heart transplant (HT). Data on AF hospitalizations after HT are limited to single-center experiences. To bridge this gap, we performed an analysis of admissions for AF in HT patients from the National Inpatient Sample (NIS) years 2000 to 2014. All hospitalizations with a primary diagnosis of 427.31 or 427.32 and V42.1 were used to identify hospitalizations with AF and previous HT respectively. Among a total of 211,961 HT related hospitalizations, 1,304 (0.62%) (955 males, 349 females, mean age 59 years, median CHA2DS2Vasc score 2 [Interquartile range 1 to 3]) were admitted with a primary diagnosis AF. Most hospitalizations were nonelective (80.17%). In-hospital mortality was 2.3% and the mean length of stay (LOS) was 3.7 days. Among those patients who were discharged from hospital, 85 % were discharged to home with self-care. Most commonly reported secondary diagnoses included hypertension (57.9%), diabetes (33%), renal failure (31.3%), and congestive heart failure (22%). The event rates for ischemic stroke and gastrointestinal bleeding in the same admission with the AF hospitalization were low (1.2% and 1.2% respectively). Cardioversion was performed in 37% and ablation in 11.2% of admissions. The adjusted median cost of hospitalization was $6478.7 (IQR $3561.8 to $12352.3) and did not change significantly during the study period. AF is a relatively infrequent cause of hospitalization among HT recipients. The number of hospitalizations, ablations, cardioversions, disposition, LOS, and cost of hospitalization for AF remained stable during the study period.

Objective Atrial fibrillation (AF) weekend hospitalizations were reported to have poor outcomes compared to weekday hospitalizations. The relatively poor outcomes on the weekends are usually referred to as ‘weekend effect’. We aim to understand trends and outcomes among weekend AF hospitalizations. The primary purpose of this study is to evaluate the trends for weekend AF hospitalizations using Nationwide Inpatient Sample 2005–2014. Hospitalizations with AF as the primary diagnosis, in-hospital mortality, length of stay, co-morbidities and cardioversion procedures have been identified using the international classification of diseases 9 codes. Results Since 2005, the weekend AF hospitalizations increased by 27% (72,216 in 2005 to 92,220 in 2014), mortality decreased by 29% (1.32% in 2005 to 0.94% in 2014), increase in urban teaching hospitalizations by 72% (33.32% in 2005 to 57.64% in 2014), twofold increase in depression and a threefold increase in the prevalence of renal failure were noted over the period of 10 years. After adjusting for significant covariates, weekend hospitalizations were observed to have higher odds of in-hospital mortality OR 1.17 (95% CI 1.108–1.235, P

Background It is not clear if antiarrhythmic drug therapy (AAD) after catheter ablation (CA) of atrial fibrillation (AF) increases mortality. Objective To determine whether there is an association between AAD therapy and mortality after CA of AF. Methods There were 3624 consecutive patients with AF (mean age: 59 ± 11 years, women: 27%, paroxysmal AF: 58%). An AAD was used in 2253 patients (62%, AAD group) for a mean duration of 1.3 ± 0.8 years, during a mean follow-up of 6.7 ± 2.2 years after CA of AF. Using propensity score matching, with every 2 patients using an AAD matched to 1 patient who did not use AAD (NO-AAD group), Cox regression models were utilized to assess the association between AAD use (as a time-variable covariate) and all-cause mortality. Results There were a total of 50 deaths (2.2%) in the AAD and 62 deaths (4.5%) in the NO-AAD groups, respectively (P = .02). At the time of death, 46 of 50 patients (92%) who died in the AAD cohort were still using an AAD (P = .21, compared to baseline use). On multivariate analysis, although the risk of death was not statistically significant between the AAD and NO-AAD cohorts, there was a trend towards mortality benefit with AAD therapy (hazard ratio [HR]: 0.66, 95% confidence interval [CI]: 0.43–1.00, P = .05), regardless of the rhythm or anticoagulation status. Conclusion AAD use after CA of AF is not associated with an increased risk of mortality, suggesting that when carefully chosen and monitored, AADs appear to be safe after CA of AF.

Background There are limited data on the role of temporary mechanical circulatory support ( MCS ) devices for cardiogenic shock before left ventricular assist device ( LVAD ) surgery. This study sought to evaluate the trends of use and outcomes of MCS in cardiogenic shock before LVAD surgery. Methods and Results This was a retrospective cohort study from 2005 to 2014 using the National Inpatient Sample (20% stratified sample of US hospitals). This study identified admissions undergoing LVAD surgery with preoperative cardiogenic shock. Admissions for other cardiac surgery and heart transplant were excluded. Temporary MCS was identified using administrative codes. The primary outcome was hospital mortality and secondary outcomes were hospital costs and lengths of stay in admissions with and without MCS use. In this 10‐year period, 9753 admissions were identified with 40.6% requiring pre‐ LVAD MCS . There was a temporal increase in the frequency of cardiogenic shock associated with an increase in non–intra‐aortic balloon pump MCS devices. The cohort receiving MCS had greater in‐hospital myocardial infarction, ventricular arrhythmias, and use of coronary angiography. On multivariable analysis, older age, myocardial infarction, and need for MCS devices were independently predictive of higher in‐hospital mortality. In 696 propensity‐matched pairs, use of MCS was predictive of higher in‐hospital mortality (odds ratio 1.4 [95% confidence interval 1.1–1.6]; P =0.02) and higher hospital costs, but similar lengths of stay. Conclusions In patients with cardiogenic shock bridged to LVAD therapy, there was a steady increase in preoperative MCS use. Use of MCS identified patients at higher risk for in‐hospital mortality and greater resource utilization.

Heart failure (HF) increases stroke risk in atrial fibrillation (AF) patients. Differential impact of HF category on thromboembolic and bleeding risk in AF patients on oral anticoagulation (OAC) is unknown. We used Medicare data for beneficiaries with new AF diagnosed between 2011 and 2013 to identify patients with HF with reduced ejection fraction (HFrEF), HF with preserved ejection fraction (HFpEF), and no HF. The primary endpoint of admission for ischemic stroke was evaluated using Cox proportional hazards regression models that controlled for patient demographics, comorbidities (including CHA(2)DS(2)-VASc and HASBLED scores), and OAC use as a time-dependent covariate. Secondary endpoints included all-cause mortality, admissions for gastrointestinal bleeding (GIB), intracranial hemorrhage (ICH), acute myocardial infarction (AMI), or HF. The 3 groups included 47840, 32360, and 718392 patients respectively. Patients with HFrEF and HFpEF had higher comorbidity burden, CHA(2)DS(2)-VASc and HASBLED scores compared with patients without HF. In multivariable analysis adjusting for patient comorbidities and OAC, HFrEF and HFpEF were associated with higher risk of ischemic stroke, HF and AMI compared with no HF. HFrEF was associated with higher all-cause mortality and HF-hospitalization risk compared with HFpEF. In conclusion, in AF patients, HFrEF and HFpEF are both associated with higher risk of ischemic stroke, HF and AMI admissions, even after adjusting for OAC use, compared with patients without HF. Published by Elsevier Inc.

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 2011-2013. 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, 53212 (6.7%) were insulin-requiring diabetics (IRD), 250214 (31.3%) were non-insulin requiring diabetics (NIRD) and 495166 (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

Background: We assessed the predictive accuracy of an empirically-derived score (weight loss, insulin resistance, and glycemic control: “WIG”) to predict patients who will be successful in reducing diabetes mellitus (DM) medication use with weight loss. Methods: Case records of 121 overweight and obese patients with DM at two outpatient weight management centers were analyzed. Results: Mean period of follow-up was 12.5 ± 3.5 months. To derive the “WIG” scoring algorithm, one point each was assigned to “W” (loss of 5% of initial body weight within the first 3 months of attempting weight loss), “I” (triglyceride [TGL]/highdensity lipoprotein ratio >3 [marker of insulin resistance] at baseline), and “G” (glycosylated hemoglobin [A1c%] >8.5 at baseline). WIG score showed moderate accuracy in discriminating anti-DM dose reductions at baseline, and after 3 months of weight loss efforts (likelihood ratios [LR] + >1, LR− 0.7), and demonstrated good reproducibility. Conclusions: WIG score shows promise as a tool to predict success with dose reductions of antidiabetes medications.

Background The Trial of Routine Aspiration Thrombectomy with PCI versus PCI alone in patients with STEMI (TOTAL trial) refuted the salutary effect of routine aspiration thrombectomy (AT) in PPCI for patients with ST-elevation myocardial infarction (STEMI). Objectives We performed an updated meta-analysis to assess clinical outcomes with AT prior to PPCI compared with conventional PPCI alone including the additional trial data. Methods and Results Clinical trials (n = 20) that randomized patients (n = 21,281) with STEMI between Routine AT (n = 10,619) and PPCI (n = 10,662) were pooled. There was no difference in all-cause mortality between the 2 groups (RR: 0.89, 95%CI: 0.78–1.01, P = 0.08). Stratifying by follow up at 1-month (RR: 0.87, 95%CI: 0.69–1.10, P = 0.25), up to 6 months (RR: 0.91, 95%CI: 0.74–1.13, P = 0.39 and beyond 6 months (RR: 0.88, 95%CI: 0.74–1.05, P = 0.16) yielded similar results. There was a statistically significant increase risk of stoke rate in the AT arm (RR: 1.51, 95%CI: 1.01–2.25, P = 0.04). The 2 groups were similar with regards to target vessel revascularization (0.94, 95%CI: 0.83–1.06, P = 0.28) recurrent MI (RR: 0.96, 95%CI: 0.80–1.16, P = 0.68, MACE events (RR: 0.91 95%CI: 0.81–1.02, P = 0.11), early (0.59, 95%CI: 0.23–1.50, P = 0.27) and late (RR: 0.91, 95%CI: 0.69–1.18, P = 0.47) stent thrombosis and net clinical benefit (RR 0.99, 95%CI: 0.91–1.07, P = 0.76). Conclusion Routine AT prior to PPCI in STEMI is associated with higher risk of stroke. There is no statistical difference in clinical outcome parameters of mortality, major adverse cardiac events, target vessel revascularization, stent thrombosis, and net clinical benefit between AT and PCI alone. (J Interven Cardiol 2015;28:503–513)

Background Reducing readmission after catheter ablation ( CA ) in atrial fibrillation (AF) is important. Methods and Results We utilized National Readmission Data ( NRD ) 2010–2014. AF was identified by International Classification of Diseases, Ninth Edition, Clinical Modification (ICD‐9‐CM) diagnostic code 427.31 in the primary field, while first CA of AF was identified via ICD‐9 ‐procedure code 37.34. Any admission within 30 or 90 days of index admission was considered a readmission. Cox proportional hazard regression was used to adjust for confounders. The primary outcomes were 30‐ and 90‐day readmissions and the secondary outcome was AF recurrence. In total, 1 128 372 patients with AF were identified from January 1, 2010 to September 30, 2014. Of which 37 360 (3.3%) underwent CA . Patients aged ≥65 years and female sex were less likely to receive CA for AF . Overall, 10.9% and 16.5% of CA patients were readmitted within 30 and 90 days post‐CA, respectively. Most common causes of readmissions were arrhythmia ( AF , atrial flutter), heart failure, pulmonary causes (pneumonia, chronic obstructive pulmonary disease) and bleeding complications (gastrointestinal bleed, intracranial hemorrhage). Patients with diabetes mellitus, heart failure, coronary artery disease ( CAD ), chronic pulmonary and kidney disease, prior stroke/transient ischemic attack (TIA), female sex, length of stay ≥2 and disposition to the facility were prone to higher 30‐ and 90‐day readmissions post ‐CA . Predictors of increase in AF recurrence post‐ CA were female sex, diabetes mellitus, chronic pulmonary disease, and length of stay ≥2. Trends of 90‐day readmission and AF recurrence were found to improve over the study period. Conclusions We identified several demographic and clinical factors associated with the use of CA in AF , and short‐term outcomes of the same, which could potentially help in the patient selection and improve outcomes.

Patent foramen ovale (PFO), an embryonic remnant of the fetal circulation, is present in 20-25% of adults. Although recent observational studies and clinical trials have established the link between PFO-mediated right-to-left shunting with cryptogenic stroke and migraine with aura, the role of a PFO in exacerbating hypoxemic medical conditions (ie, sleep apnea, chronic obstructive pulmonary disease, pulmonary hypertension, platypnea-orthodeoxia, pulmonary arteriovenous malformation, high-altitude pulmonary edema, and exercise desaturation) remains less understood. PFO-mediated hypoxemia occurs when deoxygenated venous blood from the right atrium enters and mixes with oxygenated arterial blood in the left atrium. Patients with an intracardiac right-to-left shunt may have profound hypoxemia out of proportion to underlying primary lung disease, even in the presence of normal right-sided pressures. The presence of right-to-left cardiac shunting can exacerbate the degree of hypoxemia in patients with underlying pulmonary disorders. In a subset of these patients, percutaneous PFO closure may result in marked improvement in dyspnea and hypoxemia. This review discusses the association between PFO-mediated right-to-left shunting with medical conditions associated with hypoxemia and explores the role of percutaneous PFO closure in alleviating the hypoxemia.

Background Sex‐specific effectiveness of rivaroxaban ( RIVA ), dabigatran ( DABI ), and warfarin in reducing myocardial infarction ( MI ), heart failure ( HF ), and all‐cause mortality among patients with atrial fibrillation are not known. We assessed sex‐specific associations of RIVA , DABI , or warfarin use with the risk of MI , HF , and all‐cause mortality among patients with atrial fibrillation. Methods and Results Medicare beneficiaries (men: 65 734 [44.8%], women: 81 135 [55.2%]) with atrial fibrillation who initiated oral anticoagulants formed the study cohort. Inpatient admissions for MI , HF , and all‐cause mortality were compared between the 3 drugs separately for men and women using 3‐way propensity‐matched samples. In men, RIVA use was associated with a reduced risk of MI admissions compared with warfarin use (hazard ratio [95% confidence interval ( CI ): 0.59 [0.38–0.91]), with a trend towards reduced risk compared with DABI use (0.67 [0.44–1.01]). In women, there were no significant differences in the risk of MI admissions across all 3 anticoagulants. In both sexes, RIVA use and DABI use were associated with reduced risk of HF admissions (men: RIVA ; 0.75 [0.63–0.89], DABI ; 0.81 [0.69–0.96]) (women: RIVA ; 0.64 [0.56–0.74], DABI ; 0.73 [0.63–0.83]) and all‐cause mortality (men: RIVA ; 0.66 [0.53–0.81], DABI ; 0.75 [0.61–0.93]) (women: RIVA ; 0.76 [0.63–0.91], DABI ; 0.77 [0.64–0.93]) compared with warfarin use. Conclusions RIVA use and DABI use when compared with warfarin use was associated with a reduced risk of HF admissions and all‐cause mortality in both sexes. However, reduced risk of MI admissions noted with RIVA use appears to be limited to men.

Background— Sex-specific comparative effectiveness of direct oral anticoagulants among patients with nonvalvular atrial fibrillation is not known. Via this retrospective cohort study, we assessed the sex-specific, comparative effectiveness of direct oral anticoagulants (rivaroxaban and dabigatran), compared to each other and to warfarin among patients with atrial fibrillation. Methods and Results— Elderly (aged ≥66 years) Medicare beneficiaries enrolled in Medicare Part D benefit plan from November 2011 to October 2013 with newly diagnosed atrial fibrillation formed the study cohort (65 734 [44.8%] men and 81 137 [55.2%] women). Primary outcomes of inpatient admissions for ischemic strokes and major bleeding were compared across the 3 drugs (rivaroxaban: 20 mg QD, dabigatran: 150 mg BID, or warfarin) using 3-way propensity-matched samples. In men, rivaroxaban use decreased stroke risk when compared with warfarin use (hazard ratio, 0.69; 95% confidence interval, 0.48–0.99; P =0.048) and dabigatran use (hazard ratio, 0.66; 95% confidence interval, 0.45–0.96; P =0.029) and was associated with a similar risk of any major bleeding when compared with warfarin and dabigatran. In women, although ischemic stroke risk was similar in the 3 anticoagulant groups, rivaroxaban use significantly increased the risk for any major bleeding when compared with warfarin (hazard ratio, 1.20; 95% confidence interval, 1.03–1.42; P =0.021) and dabigatran (hazard ratio, 1.27; 95% confidence interval, 1.09–1.48; P =0.011). Conclusions— The reduced risk of ischemic stroke in patients taking rivaroxaban, compared with dabigatran and warfarin, seems to be limited to men, whereas the higher risk of bleeding seems to be limited to women.

Data comparing the effect of renal denervation (RD) with those of maximal medical therapy (MMT) have shown conflicting results. Also, effect of RD on pulse pressure (PP) has not been evaluated. The aim of this meta-analysis was to compare the effect of RD with that of MMT on blood pressure (BP) and PP at 6-month follow-up in patients with resistant hypertension. Randomized controlled trials and nonrandomized controlled trials reporting systolic BP, diastolic BP, and PP results in RD and MMT groups at 6-month follow-up in patients with resistant hypertension were systematically reviewed, and eligible citations were pooled using a random-effects model. Five studies (3 randomized controlled trials, 2 nonrandomized controlled trials, n = 800) met the inclusion criteria. In the pooled analysis, RD was associated with a significant decrease in systolic BP (weighted mean difference -19.4 mm Hg, 95% confidence interval -32.8 to -5.9, p = 0.005), diastolic BP (weighted mean difference -6.4 mm Hg, 95% confidence interval -10.7 to -2.0 mm Hg, p = 0.004), and PP (weighted mean difference -12.7 mm Hg, 95% confidence interval -22.3 to -3.1 mm Hg, p = 0.009) compared with MMT at 6-month follow-up. Sensitivity analysis limited to randomized controlled trials showed a borderline significant difference in lowering systolic BP, a significant difference in lowering diastolic BP, and a nonsignificant difference in lowering PP when RD was compared with MMT. In conclusion, this meta-analysis shows that RD is superior to MMT in lowering BP, but heterogeneity among study populations in this pooled sample is high, and further data are needed to better compare these treatment strategies.

BACKGROUND Recent evidence suggests that insufficient oxidative capacity or mitochondrial dysfunction may play a causal role in the development of high blood pressure. However, this hypothesis has not been tested in the general population. We hypothesized that lactate, a measure of oxidative capacity, would be positively associated with incident hypertension even after accounting for traditional hypertension risk factors. METHODS Plasma lactate was measured in 5,554 participants from the Atherosclerosis Risk in Communities (ARIC) Study with no subclinical or diagnosed hypertension at baseline (1996-1998). Incident hypertension was defined by self-report or hypertension medication use. Analyses were performed with Cox proportional hazards models. RESULTS The mean age was 61.9 years, and the mean lactate was 0.8 mmol/L. During a median follow-up period of 11.9 years (range = 26.9 days to 13.4 years), there were 3,849 new cases of hypertension. The fourth quartile of lactate (compared with the first quartile) was associated with an elevated risk of hypertension (hazard ratio (HR) = 1.18; 95% confidence interval (CI) = 1.07-1.31) even after adjustment for traditional risk factors, including baseline systolic and diastolic blood pressure. This association was stronger when the population was restricted to participants with normal blood pressure (

Recent evidence associates sympathetic tone with severity of obstructive sleep apnea (OSA). Renal sympathetic denervation (RDN), by decreasing sympathetic tone, has the potential to decrease OSA severity. Small observational studies that assessed this hypothesis lacked precision. Hence, in this meta-analysis, we have attempted to pool available data from studies that have assessed the effect of RDN on OSA severity in patients with OSA.Medline, Embase, Cochrane central, Ovid, Cinahl, web of science, and conference abstracts were searched for eligible citations by two independent reviewers using key words "renal denervation," "hypertension," and "obstructive sleep apnea." From a total of 2,863 identified citations, using meta-analysis of observational studies in epidemiology method, five studies were assessed eligible and included in the meta-analysis.All five studies followed an observational study design, involved patients with OSA and HTN, and reported an apnea-hypopnea index (AHI) 6 months post-RDN. Four were "before and after" studies and one compared continuous positive airway pressure with RDN. In the pooled analysis, involving 49 patients, RDN was associated with a significant reduction in mean AHI [weighted mean difference -9.61 (95 % CI -15.43 to -3.79, P = 0.001)] 6 months post-RDN. One study also reported improvement in oxygen desaturation index and Epworth sleepiness scale score 6 months post-RDN.RDN is associated with significant improvement in OSA severity. However, our results need validation in RCTs that assess effect of RDN in patients with OSA, which can potentially broaden the clinical applicability of RDN.