The role of glucose lowering agents on restenosis after percutaneous coronary intervention in patients with diabetes mellitus

Introduction: The prevalence of diabetes is increasing rapidly, and individuals with diabetes are at high risk for cardiovascular disorders. Subsequently the percentage of patients with diabetes subjected to revascularisation, i.e. either percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) also rises rapidly. The outcome of patients with diabetes after PCI is worse than for patients without diabetes. Restenosis is the main limiting factor of the long-term success of PCI. Although stents and antithrombotics improved outcome after PCI in both diabetics and non-diabetics, diabetics still have a worse prognosis. This leads to the suggestion that the restenosis mechanism in diabetics might be different from that in non-diabetics. Conclusion: Several glucose lowering agents have been shown to influence the restenosis process and thus the outcome after PCI. Current data of especially metformin and thiazolidinediones indicate beneficial results as compared to insulin and sulfonylurea on restenosis. However, no large trials have been undertaken in which the effect of glucose lowering agents on restenosis is associated with improved outcome. The purpose of this review is to summarize the effect of diabetes and glucose lowering agents on restenosis

Health economic evaluation of nation-wide screening programmes for atrial fibrillation in the Netherlands

AIMS: Screening for atrial fibrillation (AF) is recommended by the European Society of Cardiology guideline to prevent strokes. Cost-effectiveness analyses of different screening programs for AF are difficult to compare, because of varying settings and models used. We compared the impact and cost-effectiveness of various AF screening programs in the Netherlands.METHODS AND RESULTS: The base case economic analysis was conducted from the societal perspective. Health effects and costs were analysed using a Markov model. The main model inputs were derived from the ARISTOTLE, RE-LY and ROCKET AF trial combined with Dutch observational data. Univariate, probabilistic sensitivity and various scenario analyses were performed. The maximum number of newly detected AF patients in The Netherlands ranged from 4554 to 39 270, depending on the screening strategy used. Adequate treatment with anticoagulation would result in a maximum of more than 3000 strokes prevented using single time point AF screening. Compared with no screening, screening 100 000 persons provided a gain in QALYs ranging from 984 to 8727, and a mean cost difference ranging from -6650 000€ to 898 000€, depending on the screening strategy used. Probabilistic sensitivity analysis (PSA) demonstrated a 100% likelihood that screening all patients ≥ 75 years visiting the Geriatric outpatient clinic was cost-saving. Four out of six strategies were cost-saving in ≥ 74% of the PSA simulations. Out of these, opportunistic screening of all patients ≥ 65 years visiting the GPs office had the highest impact on strokes prevented.CONCLUSION: Most single-time point AF screening strategies are cost-saving and have an important impact on stroke prevention.</p

Health economic evaluation of nation-wide screening programmes for atrial fibrillation in the Netherlands

AIMS: Screening for atrial fibrillation (AF) is recommended by the European Society of Cardiology guideline to prevent strokes. Cost-effectiveness analyses of different screening programs for AF are difficult to compare, because of varying settings and models used. We compared the impact and cost-effectiveness of various AF screening programs in the Netherlands.METHODS AND RESULTS: The base case economic analysis was conducted from the societal perspective. Health effects and costs were analysed using a Markov model. The main model inputs were derived from the ARISTOTLE, RE-LY and ROCKET AF trial combined with Dutch observational data. Univariate, probabilistic sensitivity and various scenario analyses were performed. The maximum number of newly detected AF patients in The Netherlands ranged from 4554 to 39 270, depending on the screening strategy used. Adequate treatment with anticoagulation would result in a maximum of more than 3000 strokes prevented using single time point AF screening. Compared with no screening, screening 100 000 persons provided a gain in QALYs ranging from 984 to 8727, and a mean cost difference ranging from -6650 000€ to 898 000€, depending on the screening strategy used. Probabilistic sensitivity analysis (PSA) demonstrated a 100% likelihood that screening all patients ≥ 75 years visiting the Geriatric outpatient clinic was cost-saving. Four out of six strategies were cost-saving in ≥ 74% of the PSA simulations. Out of these, opportunistic screening of all patients ≥ 65 years visiting the GPs office had the highest impact on strokes prevented.CONCLUSION: Most single-time point AF screening strategies are cost-saving and have an important impact on stroke prevention.</p

Health economic evaluation of nation-wide screening programmes for atrial fibrillation in the Netherlands

AIMS: Screening for atrial fibrillation (AF) is recommended by the European Society of Cardiology guideline to prevent strokes. Cost-effectiveness analyses of different screening programs for AF are difficult to compare, because of varying settings and models used. We compared the impact and cost-effectiveness of various AF screening programs in the Netherlands.METHODS AND RESULTS: The base case economic analysis was conducted from the societal perspective. Health effects and costs were analysed using a Markov model. The main model inputs were derived from the ARISTOTLE, RE-LY and ROCKET AF trial combined with Dutch observational data. Univariate, probabilistic sensitivity and various scenario analyses were performed. The maximum number of newly detected AF patients in The Netherlands ranged from 4554 to 39 270, depending on the screening strategy used. Adequate treatment with anticoagulation would result in a maximum of more than 3000 strokes prevented using single time point AF screening. Compared with no screening, screening 100 000 persons provided a gain in QALYs ranging from 984 to 8727, and a mean cost difference ranging from -6650 000€ to 898 000€, depending on the screening strategy used. Probabilistic sensitivity analysis (PSA) demonstrated a 100% likelihood that screening all patients ≥ 75 years visiting the Geriatric outpatient clinic was cost-saving. Four out of six strategies were cost-saving in ≥ 74% of the PSA simulations. Out of these, opportunistic screening of all patients ≥ 65 years visiting the GPs office had the highest impact on strokes prevented.CONCLUSION: Most single-time point AF screening strategies are cost-saving and have an important impact on stroke prevention.</p

Health economic evaluation of nation-wide screening programmes for atrial fibrillation in the Netherlands

AIMS: Screening for atrial fibrillation (AF) is recommended by the European Society of Cardiology guideline to prevent strokes. Cost-effectiveness analyses of different screening programs for AF are difficult to compare, because of varying settings and models used. We compared the impact and cost-effectiveness of various AF screening programs in the Netherlands.METHODS AND RESULTS: The base case economic analysis was conducted from the societal perspective. Health effects and costs were analysed using a Markov model. The main model inputs were derived from the ARISTOTLE, RE-LY and ROCKET AF trial combined with Dutch observational data. Univariate, probabilistic sensitivity and various scenario analyses were performed. The maximum number of newly detected AF patients in The Netherlands ranged from 4554 to 39 270, depending on the screening strategy used. Adequate treatment with anticoagulation would result in a maximum of more than 3000 strokes prevented using single time point AF screening. Compared with no screening, screening 100 000 persons provided a gain in QALYs ranging from 984 to 8727, and a mean cost difference ranging from -6650 000€ to 898 000€, depending on the screening strategy used. Probabilistic sensitivity analysis (PSA) demonstrated a 100% likelihood that screening all patients ≥ 75 years visiting the Geriatric outpatient clinic was cost-saving. Four out of six strategies were cost-saving in ≥ 74% of the PSA simulations. Out of these, opportunistic screening of all patients ≥ 65 years visiting the GPs office had the highest impact on strokes prevented.CONCLUSION: Most single-time point AF screening strategies are cost-saving and have an important impact on stroke prevention.</p

Acute cardioversion vs a wait-and-see approach for recent-onset symptomatic atrial fibrillation in the emergency department:Rationale and design of the randomized ACWAS trial

Background Current standard of care for patients with recent-onset atrial fibrillation (AF) in the emergency department aims at urgent restoration of sinus rhythm, although paroxysmal AF is a condition that resolves spontaneously within 24 hours in more than 70% of the cases. A wait-and-see approach with rate-control medication only and when needed cardioversion within 48 hours of onset of symptoms is hypothesized to be noninferior, safe, and cost-effective as compared with current standard of care and to lead to a higher quality of life. Design The ACWAS trial (NCT02248753) is an investigator-initiated, randomized, controlled, 2-arm noninferiority trial that compares a wait-and-see approach to the standard of care. Consenting adults with recent-onset symptomatic AF in the emergency department without urgent need for cardioversion are eligible for participation. A total of 437 patients will be randomized to either standard care (pharmacologic or electrical cardioversion) or the wait-and-see approach, consisting of symptom reduction through rate control medication until spontaneous conversion is achieved, with the possibility of cardioversion within 48 hours after onset of symptoms. Primary end point is the presence of sinus rhythm on 12-lead electrocardiogram at 4 weeks; main secondary outcomes are adverse events, total medical and societal costs, quality of life, and cost-effectiveness for 1 year. Conclusions The ACWAS trial aims at providing evidence for the use of a wait-and-see approach for patients with recent-onset symptomatic AF in the emergency department

Design and rationale of DUTCH-AF:a prospective nationwide registry programme and observational study on long-term oral antithrombotic treatment in patients with atrial fibrillation

Introduction Anticoagulation therapy is pivotal in the management of stroke prevention in atrial fibrillation (AF). Prospective registries, containing longitudinal data are lacking with detailed information on anticoagulant therapy, treatment adherence and AF-related adverse events in practice-based patient cohorts, in particular for non-vitamin K oral anticoagulants (NOAC). With the creation of DUTCH-AF, a nationwide longitudinal AF registry, we aim to provide clinical data and answer questions on the (anticoagulant) management over time and of the clinical course of patients with newly diagnosed AF in routine clinical care. Within DUTCH-AF, our current aim is to assess the effect of non-adherence and non-persistence of anticoagulation therapy on clinical adverse events (eg, bleeding and stroke), to determine predictors for such inadequate anticoagulant treatment, and to validate and refine bleeding prediction models. With DUTCH-AF, we provide the basis for a continuing nationwide AF registry, which will facilitate subsequent research, including future registry-based clinical trials. Methods and analysis The DUTCH-AF registry is a nationwide, prospective registry of patients with newly diagnosed 'non-valvular' AF. Patients will be enrolled from primary, secondary and tertiary care practices across the Netherlands. A target of 6000 patients for this initial cohort will be followed for at least 2 years. Data on thromboembolic and bleeding events, changes in antithrombotic therapy and hospital admissions will be registered. Pharmacy-dispensing data will be obtained to calculate parameters of adherence and persistence to anticoagulant treatment, which will be linked to AF-related outcomes such as ischaemic stroke and major bleeding. In a subset of patients, anticoagulation adherence and beliefs about drugs will be assessed by questionnaire. Ethics and dissemination This study protocol was approved as exempt for formal review according to Dutch law by the Medical Ethics Committee of the Leiden University Medical Centre, Leiden, the Netherlands. Results will be disseminated by publications in peer-reviewed journals and presentations at scientific congresses

Campylobacter jejuni: Enterocolitis and myopericarditis

Campylobacter jejuni enteritis is the commonest enteric infection in the developed world. There are only few reported cases in the medical literature of cardiac complications associated with C. jejuni enterocolitis, most of the patients in the reported literature were males and most of the cases followed a benign course. Severe left ventricular dysfunction complicated only two cases of C. jejuni myocarditis. We report here a young male with Campylobacter myopericarditis. We believe that this is the first reported case of Campylobacter associated myopericarditis in The Netherlands. The mechanism by which Campylobacter causes myo(peri) carditis remains uncertain, it may be caused by direct bacterial invasion of cardiac tissue, bacterial toxins, circulating immune complexes, or cytotoxic T-cells. Since the number of C. jejuni infection is increasing worldwide, cardiac complications, although rare, are a remarkable manifestation of this pathogen and should be always kept in mind