CHA2DS2-VASc score predicts atrial fibrillation recurrence after cardioversion: systematic review and individual patient pooled meta-analysis

BackgroundDespite progresses in the treatment of the thromboembolic risk related to atrial fibrillation (AF), the management of recurrences remains a challenge.HypothesisTo assess if congestive heart failure or left ventricular systolic dysfunction (CHA2DS2‐VASc) score is predictive of early arrhythmia recurrence after AF cardioversion.MethodsSystematic review and individual patient pooled meta‐analysis following Preferred Reporting Items for Systematic reviews and Meta‐Analyses guidelines. Inclusion criteria: observational trials in patients with AF undergoing cardioversion, available data on recurrence of AF and available data on CHA2DS2‐VASc score. Clinical studies of interest were retrieved by PubMed, Cochrane Library, and Biomed Central. Seven authors were contacted for joining the patient level meta‐analysis, and three shared data regarding anthropometric measurements, risk factors, major comorbidities, and CHA2DS2‐VASc score. The primary outcome was the recurrence of AF after cardioversion in patients free from antiarrhythmic prophylaxis. Univariate and multivariate logistic regression was performed.ResultsOverall, we collect data of 2889 patients: 61% were male, 50% with hypertension, 12% with diabetes, and 23% with history of ischemic heart disease. The median CHA2DS2‐VASc score was 2.. At the multivariate analysis, chronic kidney disease (odds ratio [OR] 1.94; 95% confidence interval [CI] 1.12‐3.27; P = 0.01), peripheral artery disease (OR 1.65; 95% CI 1.23‐2.19; P P  2 (OR 1.37; 95% CI 1.1‐1.68; P = 0.002) were independent predictors of early recurrence of AF.ConclusionsCHA2DS2‐VASc score predicts early recurrence of AF in the first 30 days after electrical or pharmacological cardioversion.N

Influence of socioeconomic factors on pregnancy outcome in women with structural heart disease

OBJECTIVE: Cardiac disease is the leading cause of indirect maternal mortality. The aim of this study was to analyse to what extent socioeconomic factors influence the outcome of pregnancy in women with heart disease.  METHODS: The Registry of Pregnancy and Cardiac disease is a global prospective registry. For this analysis, countries that enrolled ≥10 patients were included. A combined cardiac endpoint included maternal cardiac death, arrhythmia requiring treatment, heart failure, thromboembolic event, aortic dissection, endocarditis, acute coronary syndrome, hospitalisation for cardiac reason or intervention. Associations between patient characteristics, country characteristics (income inequality expressed as Gini coefficient, health expenditure, schooling, gross domestic product, birth rate and hospital beds) and cardiac endpoints were checked in a three-level model (patient-centre-country).  RESULTS: A total of 30 countries enrolled 2924 patients from 89 centres. At least one endpoint occurred in 645 women (22.1%). Maternal age, New York Heart Association classification and modified WHO risk classification were associated with the combined endpoint and explained 37% of variance in outcome. Gini coefficient and country-specific birth rate explained an additional 4%. There were large differences between the individual countries, but the need for multilevel modelling to account for these differences disappeared after adjustment for patient characteristics, Gini and country-specific birth rate.  CONCLUSION: While there are definite interregional differences in pregnancy outcome in women with cardiac disease, these differences seem to be mainly driven by individual patient characteristics. Adjustment for country characteristics refined the results to a limited extent, but maternal condition seems to be the main determinant of outcome

Assessment of acute myocardial infarction: current status and recommendations from the North American society for cardiovascular imaging and the European society of cardiac radiology

There are a number of imaging tests that are used in the setting of acute myocardial infarction and acute coronary syndrome. Each has their strengths and limitations. Experts from the European Society of Cardiac Radiology and the North American Society for Cardiovascular Imaging together with other prominent imagers reviewed the literature. It is clear that there is a definite role for imaging in these patients. While comparative accuracy, convenience and cost have largely guided test decisions in the past, the introduction of newer tests is being held to a higher standard which compares patient outcomes. Multicenter randomized comparative effectiveness trials with outcome measures are required

Comparative effectiveness and safety of non-vitamin K antagonists for atrial fibrillation in clinical practice: GLORIA-AF Registry

Background and purpose: Prospectively collected data comparing the safety and effectiveness of individual non-vitamin K antagonists (NOACs) are lacking. Our objective was to directly compare the effectiveness and safety of NOACs in patients with newly diagnosed atrial fibrillation (AF). Methods: In GLORIA-AF, a large, prospective, global registry program, consecutive patients with newly diagnosed AF were followed for 3 years. The comparative analyses for (1) dabigatran vs rivaroxaban or apixaban and (2) rivaroxaban vs apixaban were performed on propensity score (PS)-matched patient sets. Proportional hazards regression was used to estimate hazard ratios (HRs) for outcomes of interest. Results: The GLORIA-AF Phase III registry enrolled 21,300 patients between January 2014 and December 2016. Of these, 3839 were prescribed dabigatran, 4015 rivaroxaban and 4505 apixaban, with median ages of 71.0, 71.0, and 73.0 years, respectively. In the PS-matched set, the adjusted HRs and 95% confidence intervals (CIs) for dabigatran vs rivaroxaban were, for stroke: 1.27 (0.79–2.03), major bleeding 0.59 (0.40–0.88), myocardial infarction 0.68 (0.40–1.16), and all-cause death 0.86 (0.67–1.10). For the comparison of dabigatran vs apixaban, in the PS-matched set, the adjusted HRs were, for stroke 1.16 (0.76–1.78), myocardial infarction 0.84 (0.48–1.46), major bleeding 0.98 (0.63–1.52) and all-cause death 1.01 (0.79–1.29). For the comparison of rivaroxaban vs apixaban, in the PS-matched set, the adjusted HRs were, for stroke 0.78 (0.52–1.19), myocardial infarction 0.96 (0.63–1.45), major bleeding 1.54 (1.14–2.08), and all-cause death 0.97 (0.80–1.19). Conclusions: Patients treated with dabigatran had a 41% lower risk of major bleeding compared with rivaroxaban, but similar risks of stroke, MI, and death. Relative to apixaban, patients treated with dabigatran had similar risks of stroke, major bleeding, MI, and death. Rivaroxaban relative to apixaban had increased risk for major bleeding, but similar risks for stroke, MI, and death. Registration: URL: https://www.clinicaltrials.gov. Unique identifiers: NCT01468701, NCT01671007. Date of registration: September 2013

Anticoagulant selection in relation to the SAMe-TT2R2 score in patients with atrial fibrillation. the GLORIA-AF registry

Aim: The SAMe-TT2R2 score helps identify patients with atrial fibrillation (AF) likely to have poor anticoagulation control during anticoagulation with vitamin K antagonists (VKA) and those with scores >2 might be better managed with a target-specific oral anticoagulant (NOAC). We hypothesized that in clinical practice, VKAs may be prescribed less frequently to patients with AF and SAMe-TT2R2 scores >2 than to patients with lower scores. Methods and results: We analyzed the Phase III dataset of the Global Registry on Long-Term Oral Antithrombotic Treatment in Patients with Atrial Fibrillation (GLORIA-AF), a large, global, prospective global registry of patients with newly diagnosed AF and ≥1 stroke risk factor. We compared baseline clinical characteristics and antithrombotic prescriptions to determine the probability of the VKA prescription among anticoagulated patients with the baseline SAMe-TT2R2 score >2 and ≤ 2. Among 17,465 anticoagulated patients with AF, 4,828 (27.6%) patients were prescribed VKA and 12,637 (72.4%) patients an NOAC: 11,884 (68.0%) patients had SAMe-TT2R2 scores 0-2 and 5,581 (32.0%) patients had scores >2. The proportion of patients prescribed VKA was 28.0% among patients with SAMe-TT2R2 scores >2 and 27.5% in those with scores ≤2. Conclusions: The lack of a clear association between the SAMe-TT2R2 score and anticoagulant selection may be attributed to the relative efficacy and safety profiles between NOACs and VKAs as well as to the absence of trial evidence that an SAMe-TT2R2-guided strategy for the selection of the type of anticoagulation in NVAF patients has an impact on clinical outcomes of efficacy and safety. The latter hypothesis is currently being tested in a randomized controlled trial. Clinical trial registration: URL: https://www.clinicaltrials.gov//Unique identifier: NCT01937377, NCT01468701, and NCT01671007

Stress concentration around oval hole

W pracy przedstawiono rozwiązanie zagadnienia rozciąganej płaszczyzny osłabionej otworem o ksztacie owalnym z wierzchołkami o dowolnej krzywiźnie. Wykorzystano metodę jednolitego podejścia do rozwiązywania zagadnień koncentracji naprężeń wokół karbów ostrych i zaokrąglonych. Dla parametrów, charakteryzujących geometrię otworu, zmieniających się w bardzo szerokim zakresie obliczono współczynniki koncentracji naprężeń w wierzchołku owalu. Wykorzystując zależność wiążące współczynniki koncentracji naprężeń ze współczynnikami intensywności naprężeń, wyznaczono wartości współczynnikow intensywności dla odpowiedniego otworu o wierzchołkach ostrych. Przeprowadzając porównanie wyników obliczeń ze znanym rozwiązaniem analitycznym dla otworu soczewkowego, wykazano nie tylko dużą precyzję zastosowanej metody lecz również jej uniwersalność i efektywność. Otrzymane rezultaty posłużyły do skonstruowania przydatnych w praktyce inżynierskiej wzorów aproksymacyjnych służących do oszacowania wartości współczynnikow intensywności naprężeń w wierzchołku soczewki oraz koncentracji naprężeń w wierzchołku otworu owalnego.In the paper the application of the unified approach method to solve problems of stress concentration around sharp and rounded oval hole in elastic plane was presented. The stress field distribution was obtained for various vertex angles and curvature radii using singular integral equation method. The method based on passage to the limit (when curvature radius tends to zero), was used to obtain stress intensity factor at the vertex of sharp lens hole in a plane under tension. Accuracy of the new method was analyzed by comparing numerical results of stress intensity factors to well known analytical solution. The approximation formulas for estimation of stress intensity and concentration factors were presented

Stress intensity factors at crack tips located at rounded v-notch vertex

Przedstawiono metodę obliczania współczynników intensywności naprężeń w szczelinach wychodzących z wierzchołka zaokrąglonego karbu V w nieskończonej, izotropowej, rozciąganej płaszczyźnie sprężystej. Wartości numeryczne współczynników intensywności naprężeń otrzymano dla dwóch podstawowych symetrycznych przypadków – pojedynczej szczeliny i układu dwóch równych szczelin. Przeprowadzono analizę wpływu wielkości promienia zaokrąglenia wierzchołka karbu V na obliczane współczynniki intensywności naprężeń szczelin. Uzyskane rozwiązanie asymptotyczne ma charakter ogólny – współczynniki intensywności naprężeń w szczelinach są wyrażone poprzez współczynnik intensywności naprężeń w wierzchołku karbu V – umożliwiając oszacowanie parametrów mechaniki pękania w symetrycznych ciałach skończonych osłabionych rozrywanymi karbami.The problem of the stress intensity factors for system of cracks emanating from infinite rounded V-notch apex subjected to tearing load was solved. Numerical values was obtained for two most important symmetrical cases – the single crack and the sys- tem of two cracks of equal length. The influence of the notch apex rounding radius on the stress intensity factors at crack tips was analyzed. The asymptotic solution which was obtained has general nature – stress concentration factors at the crack tip are expressed as a function of V-notch stress intensity factor, so this relationship could be applied to estimate essential fracture mechanics parame- ters in the wide range of particular symmetrical problems of fracture of V-notched structural elements subjected to tearing loads