Citation : Paraish Misra, MD, Eddy S. Lang, MD, Catherine M. Clement, RN, Robert J. Brison, MD, MPH, Brian H. Rowe, MD, MSc, Bjug Borgundvaag, MD, PhD, Trevor Langhan, MD, Kirk Magee, MD, MSc, Rob Stenstrom, MD, PhD, Jeffrey J. Perry, MD, MSc, David Birnie, MD, George A. Wells, PhD, X. Xue MSc, G. Innes, MD, Ian G. Stiell, MD, MSc.
Guidelines strongly recommend long-term anticoagulation with warfarin for patients with newly recognized AF who have high embolic risk by virtue of a CHADS2 (Congestive Heart Failure, Hypertension, Age >65, Diabetes, History of Stroke) score ≥ 2. The goal of this study was to determine patterns of emergency department-initiated anticoagulation among eligible patients discharged from Canadian centers with an episode of recent-onset atrial fibrillation and flutter (RAFF) and determine if decision-making is driven by the CHADS2 score or other factors. This was accomplished by examining health records using uniform case identification and data abstraction as well as centralized quality control; it was conducted in 8 Canadian university emergency departments over a 12-month period. Eligible patients for this analysis demonstrated RAFF requiring emergency management, were not already taking warfarin and were not admitted to hospital. Univariate analyses were conducted using T-test or Chi-square to select factors associated with anticoagulation initiation at a significance level of p < 0.15 and multiple logistic regression was employed to evaluate independent predictors after adjustment for confounders. Among 633 eligible patients, only 21 out of 120 patients (18%) with a CHADS2 score ≥ 2 received anticoagulation and among 70 patients who were given anticoagulation only 21 (30%) had a CHADS2 score ≥ 2. Independent predictors of anticoagulation included age by 10-year strata: (OR = 1.7; 95% CI 1.3 – 2.1), heparin use in the anticoagulation (OR = 9.6; 95% CI 4.9 – 18.9), a new prescription for metoprolol (OR = 9.6; 95% CI 4.9 – 18.9) and being referred to cardiology for follow-up (OR = 5.6; 95% CI 2.6 – 12.0). CHADS2 ≥ 2 doubled the likelihood of being prescribed anticoagulation (OR= 2.0; 95% CI 1.5 – 3.5) but was not an independent predictor. It was thus determined that patients discharged from the emergency department in this study were not prescribed anticoagulation in keeping with current recommendations. This practice gap merits further investigation and may benefit from educational efforts or enhanced support for anticoagulation use from the emergency department.
Wednesday, July 3, 2013
Prediction of Atrial Fibrillation by B-type Natriuretic Peptide
Citation : Hiroyuki Takase, MD, Yasuaki Dohi, MD, Hiroo Sonoda, MD, Genjiro Kimura, MD
Background: Although several conditions have been proposed as risk factors contributing to the incidence of atrial fibrillation, many individuals without such ‘risk factors’ also suffer from atrial fibrillation. The present study tested the hypothesis that the risk of new-onset atrial fibrillation increases with increasing circulating levels of B-type natriuretic peptide in the general population.
Methods: Participants in our health checkup program without atrial fibrillation or a history of atrial fibrillation were enrolled (n=10,058, 54.3±11.3 years old). After baseline evaluation, subjects were followed up for the median of 1,791 days with the endpoint being the new onset of atrial fibrillation.
Results: Atrial fibrillation occurred in 53 subjects during the follow-up period (1.16 per 1,000 person-year). The risk of new-onset atrial fibrillation increased across the gender-specific quartiles of B-type natriuretic peptide levels at baseline. In multivariate Cox proportional hazard regression analysis where B-type natriuretic peptide concentrations were taken as a continuous variable, B-type natriuretic peptide was a significant predictor of new onset of atrial fibrillation after adjustment for possible factors (hazard ratio 5.65 [95% CI 2.63–12.41]).
Conclusions: The risk of new onset of atrial fibrillation increases with increasing B-type natriuretic peptide levels in the general population. Measurement of B-type natriuretic peptide may improve the prediction of incident atrial fibrillation.
Background: Although several conditions have been proposed as risk factors contributing to the incidence of atrial fibrillation, many individuals without such ‘risk factors’ also suffer from atrial fibrillation. The present study tested the hypothesis that the risk of new-onset atrial fibrillation increases with increasing circulating levels of B-type natriuretic peptide in the general population.
Methods: Participants in our health checkup program without atrial fibrillation or a history of atrial fibrillation were enrolled (n=10,058, 54.3±11.3 years old). After baseline evaluation, subjects were followed up for the median of 1,791 days with the endpoint being the new onset of atrial fibrillation.
Results: Atrial fibrillation occurred in 53 subjects during the follow-up period (1.16 per 1,000 person-year). The risk of new-onset atrial fibrillation increased across the gender-specific quartiles of B-type natriuretic peptide levels at baseline. In multivariate Cox proportional hazard regression analysis where B-type natriuretic peptide concentrations were taken as a continuous variable, B-type natriuretic peptide was a significant predictor of new onset of atrial fibrillation after adjustment for possible factors (hazard ratio 5.65 [95% CI 2.63–12.41]).
Conclusions: The risk of new onset of atrial fibrillation increases with increasing B-type natriuretic peptide levels in the general population. Measurement of B-type natriuretic peptide may improve the prediction of incident atrial fibrillation.
Left Atrial Anatomy in Patients Undergoing Ablation for Atrial Fibrillation
Citation : David Krum, MS, John Hare, BS, Carol Gilbert, RN, Indrajit Choudhuri, MD, Naoyo Mori, PhD, Jasbir Sra, MD
Background: Left atrial anatomy is highly variable, asymmetric, irregular and three-dimensionally unique. This variability can affect the outcome of atrial ablation. A catalog of anatomic varieties may aid patient selection and ablation approach and provide better tools for left atrial ablation.
Methods: We analyzed computed tomography scans from 514 patients undergoing left atrial ablation. Images were processed on Advantage Windows with CardEP™ software (GE Healthcare, Waukesha, WI). Measurements of pulmonary vein (PV) ostial size along the long and short axes were made using double oblique cuts, and area of the ostia was calculated.
Results: Low peak LAA emptying velocities (<40cm/s) were identified in 111 (24.7%) patients and LAA thrombus was identified in 3 patients (0.5%) despite having therapeutic INRs. The 3 patients with thrombus had LAA emptying velocities of 23, 29 and 31 cm/s. None of the remaining patients had a peri-procedural stroke. Patients with peak LAA emptying velocities <40cm/s or thrombus on TEE had significantly (p<0.05) higher CHA2DS2-VASc scores (1.7± 0.1 v’s 1.4±0.1), and were more likely to have impaired LVSF (odds ratio [95% CI]: 2.66 [1.52-4.66]), a LA diameter >4.6cm on TTE (2.40 [2.13-5.41]), or persistent AF (2.60 [1.63-4.14]) compared to those with a higher LAA velocity without thrombus.
Conclusions: More than 37% of patients have a left atrial anatomy other than 2 left and 2 right PVs. This data may help in designing approaches for left atrial ablation, tailoring the procedure to individual patients and improving ablation tools.
Background: Left atrial anatomy is highly variable, asymmetric, irregular and three-dimensionally unique. This variability can affect the outcome of atrial ablation. A catalog of anatomic varieties may aid patient selection and ablation approach and provide better tools for left atrial ablation.
Methods: We analyzed computed tomography scans from 514 patients undergoing left atrial ablation. Images were processed on Advantage Windows with CardEP™ software (GE Healthcare, Waukesha, WI). Measurements of pulmonary vein (PV) ostial size along the long and short axes were made using double oblique cuts, and area of the ostia was calculated.
Results: Low peak LAA emptying velocities (<40cm/s) were identified in 111 (24.7%) patients and LAA thrombus was identified in 3 patients (0.5%) despite having therapeutic INRs. The 3 patients with thrombus had LAA emptying velocities of 23, 29 and 31 cm/s. None of the remaining patients had a peri-procedural stroke. Patients with peak LAA emptying velocities <40cm/s or thrombus on TEE had significantly (p<0.05) higher CHA2DS2-VASc scores (1.7± 0.1 v’s 1.4±0.1), and were more likely to have impaired LVSF (odds ratio [95% CI]: 2.66 [1.52-4.66]), a LA diameter >4.6cm on TTE (2.40 [2.13-5.41]), or persistent AF (2.60 [1.63-4.14]) compared to those with a higher LAA velocity without thrombus.
Conclusions: More than 37% of patients have a left atrial anatomy other than 2 left and 2 right PVs. This data may help in designing approaches for left atrial ablation, tailoring the procedure to individual patients and improving ablation tools.
The Prevalence of Low Left Atrial Appendage Emptying Velocity and Thrombus in Patients Undergoing Catheter Ablation for Atrial Fibrillation on Uninterrupted Peri-procedural Warfarin Therapy
Citation : Neil Herring, Stephen P. Page, Mohammed Ahmed, Melanie R. Burg, Ross J. Hunter, Mark J. Earley, Simon C. Sporton, James D. Newton, Nikant K. Sabharwal, Saul G. Myerson, Yaver Bashir, Tim R Betts, Richard J. Schilling, and Kim Rajappan
Introduction: The 2012 HRS/EHRA/ECAS guidelines encourage pre-procedural transesophageal echocardiography (TEE) prior to ablation for atrial fibrillation (AF), but acknowledge a lack of consensus in patients maintained on therapeutic warfarin before, during and after the procedure. This is partly because the incidence of left atrial appendage (LAA) thrombus is so low, that it is hard to draw clear conclusion regarding the characteristics of patients who develop thrombus. We hypothesize that the presence of low LAA emptying velocities, which predisposes to thrombus, and/or thrombus itself can be predicted in patients undergoing ablation, based upon clinical characteristics and transthoracic echocardiography (TTE).
Methods: In this multicentre study, we undertook TTE and transesophageal echocardiograms (TEE) in 586 patients (age 59.9±0.4 years old, 64.5% male) undergoing catheter ablation for AF who were anticoagulated on warfarin (target international normalized ratio 2–3.5) for ≥3 consecutive weeks prior to procedure and maintained on warfarin for the procedure.
Results: Low peak LAA emptying velocities (<40cm/s) were identified in 111 (24.7%) patients and LAA thrombus was identified in 3 patients (0.5%) despite having therapeutic INRs. The 3 patients with thrombus had LAA emptying velocities of 23, 29 and 31 cm/s. None of the remaining patients had a peri-procedural stroke. Patients with peak LAA emptying velocities <40cm/s or thrombus on TEE had significantly (p<0.05) higher CHA2DS2-VASc scores (1.7± 0.1 v’s 1.4±0.1), and were more likely to have impaired LVSF (odds ratio [95% CI]: 2.66 [1.52-4.66]), a LA diameter >4.6cm on TTE (2.40 [2.13-5.41]), or persistent AF (2.60 [1.63-4.14]) compared to those with a higher LAA velocity without thrombus.
Conclusion: In patients on uninterrupted warfarin therapy, a CHA2DS2-VASc score ≥1 or LA diameter >4.6cm on TTE identifies 91.5% of those at risk of developing thrombus with LAA emptying velocity of <40 100="" and="" br="" cm="" cohort.="" in="" of="" our="" s="" those="" thrombus="" with="">
Introduction: The 2012 HRS/EHRA/ECAS guidelines encourage pre-procedural transesophageal echocardiography (TEE) prior to ablation for atrial fibrillation (AF), but acknowledge a lack of consensus in patients maintained on therapeutic warfarin before, during and after the procedure. This is partly because the incidence of left atrial appendage (LAA) thrombus is so low, that it is hard to draw clear conclusion regarding the characteristics of patients who develop thrombus. We hypothesize that the presence of low LAA emptying velocities, which predisposes to thrombus, and/or thrombus itself can be predicted in patients undergoing ablation, based upon clinical characteristics and transthoracic echocardiography (TTE).
Methods: In this multicentre study, we undertook TTE and transesophageal echocardiograms (TEE) in 586 patients (age 59.9±0.4 years old, 64.5% male) undergoing catheter ablation for AF who were anticoagulated on warfarin (target international normalized ratio 2–3.5) for ≥3 consecutive weeks prior to procedure and maintained on warfarin for the procedure.
Results: Low peak LAA emptying velocities (<40cm/s) were identified in 111 (24.7%) patients and LAA thrombus was identified in 3 patients (0.5%) despite having therapeutic INRs. The 3 patients with thrombus had LAA emptying velocities of 23, 29 and 31 cm/s. None of the remaining patients had a peri-procedural stroke. Patients with peak LAA emptying velocities <40cm/s or thrombus on TEE had significantly (p<0.05) higher CHA2DS2-VASc scores (1.7± 0.1 v’s 1.4±0.1), and were more likely to have impaired LVSF (odds ratio [95% CI]: 2.66 [1.52-4.66]), a LA diameter >4.6cm on TTE (2.40 [2.13-5.41]), or persistent AF (2.60 [1.63-4.14]) compared to those with a higher LAA velocity without thrombus.
Conclusion: In patients on uninterrupted warfarin therapy, a CHA2DS2-VASc score ≥1 or LA diameter >4.6cm on TTE identifies 91.5% of those at risk of developing thrombus with LAA emptying velocity of <40 100="" and="" br="" cm="" cohort.="" in="" of="" our="" s="" those="" thrombus="" with="">
Relationship of Ostial Pulmonary Vein Scar with Reduction in Pulmonary Vein Size after Radiofrequency Ablation for the Treatment of Atrial Fibrillation: An Observational Cohort Study
Citation : Thomas H. Hauser, MD, MMSc, MPH, Dana C. Peters PhD, John V. Wylie, MD, Catherine Lau, MD, Mark E. Josephson MD, Warren J. Manning, MD
Background: Radiofrequency (RF) ablation procedures to electrically isolate the pulmonary veins (PV) from the left atrium are frequently used to treat atrial fibrillation. We hypothesized that changes in PV size after RF ablation would correlate with the volume of ostial PV scar as assessed by high resolution late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR).
Methods: The study cohort included 23 consecutive subjects. Contrast enhanced PV CMR angiography and LGE were obtained before and 42 ± 18 days after RF ablation.
Results: Patients with 2 left (LPV) and 2 right PVs (RPV) (62.6%), 2 LPVs and 3 RPVs (17.3%) and 1 LPV and 2 RPVs (14.2%) made up the three most common variants. In the 2-LPV/2-RPV anatomy, the ostial size and area of the RPVs were larger than their corresponding LPVs (p<0.001), and the ostial size and area of the superior PVs were larger than their corresponding inferior PVs (p<0.001). In the 2-LPV/3-RPV anatomy, the total area of the RPVs was larger than the total area of the LPVs (p<0.001). In the 1-LPV/2-RPV anatomy, the ostial size of the left common PV was larger than either right PV (p<0.007). However, the total area of the RPVs was larger than the area of the left common PV (p<0.002). The left common PV was also larger than any of the left veins in any of the other anatomies. The total PV area between the three most common anatomies was not significantly different.
Conclusion: PV size decreases significantly after RF ablation for the treatment of AF. The change in PV size is linearly related to the quantity of LGE scar at the PV ostium.
Background: Radiofrequency (RF) ablation procedures to electrically isolate the pulmonary veins (PV) from the left atrium are frequently used to treat atrial fibrillation. We hypothesized that changes in PV size after RF ablation would correlate with the volume of ostial PV scar as assessed by high resolution late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR).
Methods: The study cohort included 23 consecutive subjects. Contrast enhanced PV CMR angiography and LGE were obtained before and 42 ± 18 days after RF ablation.
Results: Patients with 2 left (LPV) and 2 right PVs (RPV) (62.6%), 2 LPVs and 3 RPVs (17.3%) and 1 LPV and 2 RPVs (14.2%) made up the three most common variants. In the 2-LPV/2-RPV anatomy, the ostial size and area of the RPVs were larger than their corresponding LPVs (p<0.001), and the ostial size and area of the superior PVs were larger than their corresponding inferior PVs (p<0.001). In the 2-LPV/3-RPV anatomy, the total area of the RPVs was larger than the total area of the LPVs (p<0.001). In the 1-LPV/2-RPV anatomy, the ostial size of the left common PV was larger than either right PV (p<0.007). However, the total area of the RPVs was larger than the area of the left common PV (p<0.002). The left common PV was also larger than any of the left veins in any of the other anatomies. The total PV area between the three most common anatomies was not significantly different.
Conclusion: PV size decreases significantly after RF ablation for the treatment of AF. The change in PV size is linearly related to the quantity of LGE scar at the PV ostium.
Age-Dependent Impact of Fluoroscopic Radiation on the Gender of Off-Spring: An International Survey of Cardiologists
Citation :Jayasree Pillarisetti MD, Sowjanya Duthuluru MD, Hari Sayana MD, Haley Goucher BA, Akshar Patel BA, Mazda Biria MD, James Vacek MD, Loren Berenbom MD, Sudharani Bommana M.Phil, Jayant Nath MD, Mark Wiley MD, Ajay Nangia MD, Luigi Di Biase MD, Andrea Natale MD, Madhuri Reddy MD, Buddhadeb Dawn, MD, Dhanunjaya Lakkireddy MD.
Background: Fluoroscopic radiation has been implicated in reducing the sex ratio (M:F) by potentially damaging the Y chromosome. We examined the effects of exposure to fluoroscopic radiation on gender of offspring of cardiologists across the world.
Methods: An internet based survey was e-mailed worldwide to 8000 physicians who practice invasive electrophysiology and/or interventional cardiology. Survey questions included age, race, sub-specialty, hours of exposure to radiation, number of children, gender of off-spring, miscarriages and mutations and exposure to radiation prior to conception of each child. Logistic regression analyses were performed on years of exposure and gender of offspring born post radiation exposure.
Results: Responses of 377 cardiologists (84% male and 16% female) were reviewed. With a total of 398 males and 402 females born to 377 cardiologists, although reduced, the overall sex ratio (0.99) was not significantly different from that observed in the general population (1.05). Univariate logistic regression analysis identified higher male births with increasing hours of radiation exposure (OR 1.034, CI 1.003-1.067 p=0.03) and increasing paternal age (OR 1.05, CI 1.01-1.08, p=0.002). Subgroup analysis of children of male cardiologists revealed higher incidence of male births with increasing age and radiation exposure and multivariate analysis only identified paternal age as predictor of higher incidence of male births (OR 1.05, CI 1.01-1.089, p=0.0027).
Conclusion: Exposure to ionizing radiation leads to a decrease in the sex ratio (M/F) in younger male cardiologists, while this effect is reversed with greater number of male births in older male cardiologists.
Background: Fluoroscopic radiation has been implicated in reducing the sex ratio (M:F) by potentially damaging the Y chromosome. We examined the effects of exposure to fluoroscopic radiation on gender of offspring of cardiologists across the world.
Methods: An internet based survey was e-mailed worldwide to 8000 physicians who practice invasive electrophysiology and/or interventional cardiology. Survey questions included age, race, sub-specialty, hours of exposure to radiation, number of children, gender of off-spring, miscarriages and mutations and exposure to radiation prior to conception of each child. Logistic regression analyses were performed on years of exposure and gender of offspring born post radiation exposure.
Results: Responses of 377 cardiologists (84% male and 16% female) were reviewed. With a total of 398 males and 402 females born to 377 cardiologists, although reduced, the overall sex ratio (0.99) was not significantly different from that observed in the general population (1.05). Univariate logistic regression analysis identified higher male births with increasing hours of radiation exposure (OR 1.034, CI 1.003-1.067 p=0.03) and increasing paternal age (OR 1.05, CI 1.01-1.08, p=0.002). Subgroup analysis of children of male cardiologists revealed higher incidence of male births with increasing age and radiation exposure and multivariate analysis only identified paternal age as predictor of higher incidence of male births (OR 1.05, CI 1.01-1.089, p=0.0027).
Conclusion: Exposure to ionizing radiation leads to a decrease in the sex ratio (M/F) in younger male cardiologists, while this effect is reversed with greater number of male births in older male cardiologists.
Atrial Fibrillation Associated Costs for Stroke Hospitalizations of Medicare Beneficiaries in the Stroke Belt of the United States
Citation :Guijing Wang, PhD, Xin Tong, MS, Mary G George, MD.
Purpose: To estimate atrial fibrillation (AF)−associated costs for stroke hospitalizations among Medicare beneficiaries aged ≥65 years in a 11-state region called stroke belt in the United States.
Methods: Using the 2010 Medicare Provider Analysis and Review File database, we analyzed costs of stroke hospitalizations conditional on presence of AF (n=226 289) after excluding those with subarachnoid hemorrhage, no information on race, or a length of stay [LOS] of 30 or more days. We employed regression analysis to estimate for defined subgroups the impact of AF on costs while controlling for major potential confounders.
Results: The average cost of all stroke hospitalizations was $27 915. The presence of AF increased this cost by $2711 (9.4%; P<0.001). AF-associated costs were $3159, $2610, and $2197 for patients aged 65-74, 75-84, and ≥85 years, respectively (all P<0.001). Among hospitalization with a length of stay (LOS) of 14-29 days, AF increased the costs by $5888 (P<0.001). AF was not associated with higher costs for hospitalizations involving intracerebral hemorrhage.
Conclusions: The costs of stroke hospitalizations are high, and they are even higher if the patient has AF. Further information is needed on the costs in patients with AF who are taking anticoagulants.
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