CHA2DS2-VASc in the prediction of early atrial fibrillation relapses after electrical or pharmacological cardioversion

Background In hemodynamically stable patients, mortality and morbidity related to atrial fibrillation are mainly due to cardioembolic disorder. No difference in the survival rate and incidence of embolic events has been described in patients undergoing rhythm or rate control if the latter is combined with an appropriate anticoagulant therapy. CHA2DS 2-VASc is a score that allows clinicians to stratify embolic risk in patients affected by nonvalvular atrial fibrillation. Each item can be involved in triggering and maintaining atrial fibrillation. Thus, we hypothesized that CHA2DS2-VASc may help to predict early recurrences after cardioversion. Methods A total of 319 consecutive patients, admitted to our emergency department or hemodynamically stable persistent atrial fibrillation, were enrolled and treated with electrical or pharmacological sinus rhythm restoration. Outcome was defined as recurrence of atrial fibrillation 5 days after cardioversion. Predicted probability of sinus rhythm stability was assessed with an ordinal regression model using CHA2DS 2-VASc as an independent variable. Results The model showed a progressive decrease in the predicted probability of sinus rhythm stability after electrical or pharmacological cardioversion along with an increase in the CHA2DS2-VASc score. A logarithmic relationship was the best-fit trend among CHA2DS2-VASc ranks and the predicted probability of sinus rhythm stability in patients undergoing both electrical and pharmacological cardioversion (r2=0.98, P<0.05 for electrical cardioversion; r2=0.91, P<0.05 for pharmacological cardioversion). Conclusion Our preliminary results suggest that CHA2DS2- VASc score could be useful in evaluating the risk of early recurrence of atrial fibrillation after cardioversion. This information may have implications for disease monitoring and treatment strategies in clinical practice. \uc2\ua9 2014 Italian Federation of Cardiology

Charlson comorbidity index as a predictor of in-hospital death in acute ischemic stroke among very old patients: a single-cohort perspective study

Chronic diseases are increasing worldwide. Association of two or more chronic conditions is related with poor health status and reduced life expectancy, particularly among elderly patients. Comorbidities represent a risk factor for adverse events in several critical illnesses. We aimed to evaluate if elderly patients are affected by multiple chronic pathologies, assessed by Charlson comorbidity index (CCI), showed a reduced in-hospital survival after ischemic stroke. In a 3-year period, we evaluated all the subjects admitted to our internal medicine department for ischemic stroke. Age, sex, NIHSS score and all the comorbidities were recorded. Days of hospitalization, hospital-related infections and in-hospital mortality were also assessed. For each patient, we evaluated CCI, obtaining four classes: group 1 (CCI: 2\ue2\u80\u933), group 2 (CCI: 4\ue2\u80\u935), group 3 (CCI: 6\ue2\u80\u937) and group 4 (CCI: \ue2\u89\ua58). Survival was evaluated with Kaplan\ue2\u80\u93Meier and Cox regression analyses. The complete model considered in-hospital death as the main outcome, days of hospitalization as the time variable and CCI as the main predictor, adjusting for NIHSS, sex and nosocomial infections. Patients in CCI group 3 and 4 had an increased risk of in-hospital mortality, independently of NIHSS, sex and nosocomial infections. Elderly patients with multiple comorbidities have higher risk of in-hospital death when affected by ischemic stroke

Impact of the comorbidities in the outcomes of a cohort of elderly patients affected by acute ischemic stroke

Background: Acute ischemic stroke (AIS) is common among elderly patients, affecting 6,5% of the population aged 64-85 years and representing the third cause of death among old subjects. Prevalence of chronic diseases is increasing worldwide: the association of two or more chronic conditions, called multimorbidity, is associated to a poor health status and reduced life expectancy, in particular among elderly patients. Moreover, multimorbidity has been associated to an increased rate of adverse events in several critical illnesses. We aimed to evaluate the number and the type of chronic pathologies in a cohort of elderly patients admitted in an Internal Medicine department for AIS. We also evaluated if the number of comorbidities reduced in-hospital survival in this specific population of patients. Methods: 294 consecutive patients admitted to our Internal Medicine Unit (IM) for AIS were enrolled. Age, sex, lenght of admission, in-hospital mortality and comorbidities (hypertension,diabetes, chronic cardiopathy, atrial fibrillation(AF), dyslipidemia, active cancer, COPD, chronic kidney disease (CKD) and dementia) were collected. The trend of days of hospitalization in relation with the number of comorbidities was evaluated with analysis of variance (ANOVA). Statistical analysis was performed with SPSS 13.0. Results: Mean age was 82,37 (\ub19,19) years. Mean length of stay in our department was 9,87 (\ub17,14) days. In-hospital mortality was 10,9%. Hypertension was present in 54%, diabetes in 18%, dyslipidemia in 11,9%, chronic cardiopathy in 36,4%, AF in 18,4%, cancer in 4,1%, COPD in 10,5%, CKD in 21,7% and cognitive deterioration in 13,3% of the sample. 93,4% of the subjects had at least one comorbidity, with a median of two concomitant pathologies at the admission in IM. We observed a linear trend in the days of admission proportional to the increasing number of comorbidities (from 7,35\ub13,97 days, no comorbidities to 16,00\ub112,52 days, >=4 comorbidities; p<0.05). Patients with 0 or 1 concomitant pathologies had a prevalence of in-hospital death rate of 2,3%, while subjects affected by 2 or more comorbid diseases ad a prevalence of 8,2%. Discussion: Proportion of world population people over 60 years will double by 2050. The proinflammatory status associated to degenerative aging processes represents the major underlying cause for chronic diseases. Aging itself is deemed to be the strongest risk factor for several chronic conditions, such as CVD, CKD, systemic atherosclerosis, dementia, diabetes, COPD and cancer. Thus, elderly patients are often affected by multimorbidity, which implies the coexistence of multiple chronic pathologies and increases the risk of multiple drug therapies, drug-drug and drug-pathology interactions. Aging increases the risk of AIS, with about one third of the events occurring in elderly patients. An increased stroke prevalence and a higher stroke-related mortality is observed among old or very old subjects.In this study we underline how most of the elderly subjects admitted by AIS is affected by one or more complicating pathologies and how the number of comorbidities is associated to and increased in-hospital length of stay and in-hospital death. Conclusions: Comorbidities are common in elderly patients admitted for AIS. An increased number of comorbidities is associated to longer in-hospital stay and a higher risk of in-hospital death. However, larger studies are required to validate these observations

A study on the relationship between serum uric acid and acute ischemic stroke: the role of chronic kidney disease

Background: Both chronic kidney disease (CKD) and serum uric acid levels (SUA) are associated to an increased risk of acute ischemic stroke (AIS). This is mediated by several mechanisms including platelet dysfunction, coagulation disorders, endothelial dysfunction, inflammation, and increased risk of atrial fibrillation (AF). Methods: We enrolled 294 consecutive patients admitted for AIS and collected age, sex, lenght of admission, in-hospital mortality and comorbidities (hypertension, diabetes, chronic cardiopathy, AF, dyslipidemia, active cancer, COPD, CKD and dementia). Survival was performed with Kaplan-Meier and Cox regression (forward stepwise method) analysis with SPSS 13.0. Results: Mean age was 82,37 (±9,19) years. Mean length of stay in our internal medicine department was 9,87 (±7,14) days. In-hospital mortality was 10,9%. Patients with SUA >7,0 mg/dl had an increased risk of in-hospital mortality at Kaplan-Meiers regression (p<0,05, at log-rank test). Cox regression model, including all the collected comorbidities, age and sex showed that, in the overall sample, high serum uric acid was independently associated to an increased risk of in-hospital mortality (HR:3,873; 95%CI:1,567-9,573; p<0,05). This effect was even more evident among patients with moderate-to-severe CKD, defined as eVFG<60 ml/min (HR:5,863; 95%CI:1,403-20,501; p<0,05). In the population with normal renal function, we observed that SUA was not associated to a worse outcome (HR: 0,775; 95%CI:0,101-5,980; p=n.s.). Discussion: Increased serum uric acid levels have been associated to increased incidence of cerebrovascular and cardiovascular events in several studies. However, it is not well estabilished whether SUA has a direct effect on the pathogenesis of cardiovascular and cerebrovascular diseases or, merely, a waste product of purine turnover in patients with different alterations of metabolism. Our results suggest that the effects of SUA in the prediction of in-hospital mortality are evident only in patients with CKD which is a well-recongized risk factor for cardiovascular or cerebrovascular diseases. A similar effect can be observed in other high-risk conditions in this population: increased SUA levels do not predict in-hospital death in patients who are not affected by hypertension and diabetes, while in patients with one of these two conditions SUA reaches a statistical significance in predicting the outcome (data not shown). Conclusion: In this population of elderly patients affected by acute ischemic stroke, serum uric acid seem to predict an increased in-hospital mortality only in the subpopulation affected by CKD, while in patients with normal renal function this effect is not significant. A similar effect can be observed in other high-risk conditions, such as hypertension and diabetes. However, larger studies are required to validate these observations

Relationship between low Ankle-Brachial Index and rapid renal function decline in patients with atrial fibrillation: a prospective multicentre cohort study

OBJECTIVE: To investigate the relationship between Ankle-Brachial Index (ABI) and renal function progression in patients with atrial fibrillation (AF). DESIGN: Observational prospective multicentre cohort study. SETTING: Atherothrombosis Center of I Clinica Medica of 'Sapienza' University of Rome; Department of Medical and Surgical Sciences of University Magna Græcia of Catanzaro; Atrial Fibrillation Registry for Ankle-Brachial Index Prevalence Assessment-Collaborative Italian Study. PARTICIPANTS: 897 AF patients on treatment with vitamin K antagonists. MAIN OUTCOME MEASURES: The relationship between basal ABI and renal function progression, assessed by the estimated Glomerular Filtration Rate (eGFR) calculated with the CKD-EPI formula at baseline and after 2 years of follow-up. The rapid decline in eGFR, defined as a decline in eGFR &gt;5 mL/min/1.73 m(2)/year, and incident eGFR&lt;60 mL/min/1.73 m(2) were primary and secondary end points, respectively. RESULTS: Mean age was 71.8±9.0 years and 41.8% were women. Low ABI (ie, ≤0.90) was present in 194 (21.6%) patients. Baseline median eGFR was 72.7 mL/min/1.73 m(2), and 28.7% patients had an eGFR&lt;60 mL/min/1.73 m(2). Annual decline of eGFR was -2.0 (IQR -7.4/-0.4) mL/min/1.73 m(2)/year, and 32.4% patients had a rapid decline in eGFR. Multivariable logistic regression analysis showed that ABI ≤0.90 (OR 1.516 (95% CI 1.075 to 2.139), p=0.018) and arterial hypertension (OR 1.830 95% CI 1.113 to 3.009, p=0.017) predicted a rapid eGFR decline, with an inverse association for angiotensin converting enzyme (ACE) inhibitors/angiotensin receptor blockers (OR 0.662 95% CI 0.464 to 0.944, p=0.023). Among the 639 patients with AF with eGFR &gt;60 mL/min/1.73 m(2), 153 (23.9%) had a reduction of the eGFR &lt;60 mL/min/1.73 m(2). ABI ≤0.90 was also an independent predictor for incident eGFR&lt;60 mL/min/1.73 m(2) (HR 1.851, 95% CI 1.205 to 2.845, p=0.005). CONCLUSIONS: In patients with AF, an ABI ≤0.90 is independently associated with a rapid decline in renal function and incident eGFR&lt;60 mL/min/1.73 m(2). ABI measurement may help identify patients with AF at risk of renal function deterioration

Frequency of Left Ventricular Hypertrophy in Non-Valvular Atrial Fibrillation

Left ventricular hypertrophy (LVH) is significantly related to adverse clinical outcomes in patients at high risk of cardiovascular events. In patients with atrial fibrillation (AF), data on LVH, that is, prevalence and determinants, are inconsistent mainly because of different definitions and heterogeneity of study populations. We determined echocardiographic-based LVH prevalence and clinical factors independently associated with its development in a prospective cohort of patients with non-valvular (NV) AF. From the "Atrial Fibrillation Registry for Ankle-brachial Index Prevalence Assessment: Collaborative Italian Study" (ARAPACIS) population, 1,184 patients with NVAF (mean age 72 \ub1 11 years; 56% men) with complete data to define LVH were selected. ARAPACIS is a multicenter, observational, prospective, longitudinal on-going study designed to estimate prevalence of peripheral artery disease in patients with NVAF. We found a high prevalence of LVH (52%) in patients with NVAF. Compared to those without LVH, patients with AF with LVH were older and had a higher prevalence of hypertension, diabetes, and previous myocardial infarction (MI). A higher prevalence of ankle-brachial index 640.90 was seen in patients with LVH (22 vs 17%, p = 0.0392). Patients with LVH were at significantly higher thromboembolic risk, with CHA2DS2-VASc 652 seen in 93% of LVH and in 73% of patients without LVH (p <0.05). Women with LVH had a higher prevalence of concentric hypertrophy than men (46% vs 29%, p = 0.0003). Logistic regression analysis demonstrated that female gender (odds ratio [OR] 2.80, p <0.0001), age (OR 1.03 per year, p <0.001), hypertension (OR 2.30, p <0.001), diabetes (OR 1.62, p = 0.004), and previous MI (OR 1.96, p = 0.001) were independently associated with LVH. In conclusion, patients with NVAF have a high prevalence of LVH, which is related to female gender, older age, hypertension, and previous MI. These patients are at high thromboembolic risk and deserve a holistic approach to cardiovascular prevention