Effectiveness of only aspirin or clopidogrel following percutaneous left atrial appendage closure

Abstract Percutaneous left atrial appendage closure (LAAC) offers a feasible option for stroke prevention in patients with atrial fibrillation (AF), but the optimal antithrombotic treatment strategy for patients with strict contraindications to oral anticoagulation (OAC) remains uncertain. We sought to evaluate short- and long-term outcome after percutaneous LAAC in these very patients discharged on single antiplatelet therapy (SAPT) alone. All consenting AF patients who underwent LAAC from February 2009 to August 2018 in Turku University Hospital, Finland, were enrolled into a prospectively maintained registry. Only patients discharged on SAPT alone were considered for the present analysis. Patients were prospectively followed up to 5 years. The primary end points were thromboembolic event (stroke, transient ischemic attack, or systemic embolism) and intracranial bleeding. Of the 165 LAAC patients, 81 patients (mean age 75 ± 7 years; 44% women; CHA₂DS₂-VASc 4.8 ± 1.4; HAS-BLED 3.2 ± 0.8) were discharged on SAPT only (77 with aspirin 100 mg) after successful LAAC using Amplatzer devices. The duration of SAPT was ≤6 months in 61 (75%) patients. The most common contraindication to OAC was previous intracranial bleeding in 48 (59%) patients. During a mean follow-up of 2.9 years, there were 6 thromboembolic events (2.7 of 100 patient-years; 73% lower-than-predicted rate of thromboembolism). Eight patients (3.6 of 100 patient-years) had a major bleeding event after discharge, and 4 patients had intracerebral bleeding (1.7 of 100 patient-years). At 6-month landmark analysis, freedom from thromboembolism and intracranial bleeding at 3-year follow-up was similar in those with discontinued and life-long SAPT (95.1% vs 88.9% and 97.6% vs 91.7%, respectively). In conclusion, long-term outcome is satisfactory after LAAC in selected AF patients with strict contraindications to OAC receiving short-term SAPT. However, adverse events are not infrequent during early postoperative months

Predicting unsuccessful electrical cardioversion for acute atrial fibrillation (from the AF-CVS score)

Abstract Electrical cardioversion (ECV) is the standard treatment for acute atrial fibrillation (AF), but identification of patients with increased risk of ECV failure or early AF recurrence is of importance for rational clinical decision-making. The objective of this study was to derive and validate a clinical risk stratification tool for identifying patients at high risk for unsuccessful outcome after ECV for acute AF. Data on 2,868 patients undergoing 5,713 ECVs of acute AF in 3 Finnish hospitals from 2003 through 2010 (the FinCV study data) were included in the analysis. Patients from western (n = 3,716 cardioversions) and eastern (n = 1,997 cardioversions) hospital regions were used as derivation and validation datasets. The composite of cardioversion failure and recurrence of AF within 30 days after ECV was recorded. A clinical scoring system was created using logistic regression analyses with a repeated-measures model in the derivation data set. A multivariate analysis for prediction of the composite end point resulted in identification of 5 clinical variables for increased risk: Age (odds ratio [OR] 1.31, confidence interval [CI] 1.13 to 1.52), not the First AF (OR 1.55, CI 1.19 to 2.02), Cardiac failure (OR 1.52, CI 1.08 to 2.13), Vascular disease (OR 1.38, CI 1.11 to 1.71), and Short interval from previous AF episode (within 1 month before ECV, OR 2.31, CI 1.83 to 2.91) [hence, the acronym, AF-CVS]. The c-index for the AF-CVS score was 0.67 (95% CI 0.65 to 0.69) with Hosmer–Lemeshow p value 0.84. With high (>5) scores (i.e., 12% to 16% of the patients), the rate of composite end point was ∼40% in both cohorts, and among low-risk patients (score <3), the composite end point rate was ∼10%. In conclusion, the risk of ECV failure and early recurrence of AF can be predicted with simple patient and disease characteristics

Etiology of minor troponin elevations in patients with atrial fibrillation at emergency department-tropo-AF study

Abstract Patients with atrial fibrillation (AF) presenting to the emergency department (ED) often have elevated cardiac troponin T (TnT) levels without evidence of type 1 myocardial infarction. We sought to explore the causes and significance of minor TnT elevations in patients with AF at the ED. All patients with AF admitted to the ED of Turku University Hospital between 1 March, 2013 and 11 April, 2016, and at least two TnT measurements, were screened. Overall, 2911 patients with a maximum TnT of 100 ng/L during hospitalization were analyzed. TnT was between 15 and 100 ng/L in 2116 patients. The most common primary discharge diagnoses in this group were AF (18.1%), infection (18.3%), ischemic stroke/transient ischemic attack (10.7%), and heart failure (5.0%). Acute coronary syndrome (ACS) was equally uncommon both in patients with normal TnT and elevated TnT (4.4% vs. 4.5%). Age ≥75 years, low estimated glomerular filtration rate (eGFR), high C-reactive protein (CRP), and hemoglobin &lt;10.0 g/dL, were the most important predictors of elevated TnT. Importantly, TnT elevation was a very frequent (&gt;93%) finding in elderly (≥75 years) AF patients with either low eGFR or high CRP. In conclusion, minor TnT elevations carry limited diagnostic value in elderly AF patients with comorbidities