Aktualne wskazania do przezskórnej ablacji migotania przedsionków

  Atrial fibrillation (AF) is the most common cardiac arrhythmia. Despite progress in the management of patients with AF, the number of new cases of AF is rising steeply. According to the European Society of Cardiology guidelines AF ablation is recommended in patients with symptomatic paroxysmal AF to reduce AF symptoms in patients who have symptomatic recurrences of AF on antiarrhythmic drug therapy and who prefer further rhythm control therapy. Catheter ablation should be considered in symptomatic patients with AF and heart failure with impaired systolic function to improve symptoms and cardiac function when tachycardiomyopathy is suspected. Patients who have AF-related symptoms should be treated with rate control therapy and antiarrhythmic drugs, cardioversion, or catheter or surgical ablation.  Migotanie przedsionków (AF) jest najczęściej występującym zaburzeniem rytmu serca w populacji dorosłych osób. Szacuje się, że w najbliższej przyszłości liczba chorych z AF znacznie wzrośnie. W związku z tym chorobę tę można uznać za „epidemię XXI wieku”. Według wytycznych European Society of Cardiology, dotyczących AF, przezskórna ablacja AF jest wskazana w przypadku nieskuteczności lub nietolerancji farmakoterapii antyarytmicznej u chorych z objawowym, napadowym oraz przetrwałym AF w celu zmniejszenia objawów arytmii. Również w grupie pacjentów z przewlekłą niewydolnością serca jest ona obiecującą metodą kontrolującą jego rytm. Należy rozważyć ablację u objawowych pacjentów z AF i niewydolnością serca z obniżoną frakcją wyrzutową lewej komory, aby zmniejszyć nasilenie objawów i poprawić funkcję skurczową lewej komory w przy­padku podejrzenia kardiomiopatii tachyarytmicznej. Przezskórna ablacja odgrywa coraz większą rolę w leczeniu AF. W przypadku występowania objawów związanych z AF, należy zawsze dążyć do ich redukcji poprzez leczenie kontrolujące częstość rytmu komór oraz stosowanie leków antyarytmicznych, kardiowersji, ablacji przezcewnikowej lub chirurgicznej

Predictors of Adherence to Stroke Prevention in the BALKAN-AF Study:A Machine-Learning Approach

Background  Compared with usual care, guideline-adherent stroke prevention strategy, based on the ABC (Atrial fibrillation Better Care) pathway, is associated with better outcomes. Given that stroke prevention is central to atrial fibrillation (AF) management, improved efforts to determining predictors of adherence with ‘A’ (avoid stroke) component of the ABC pathway are needed. Purpose  We tested the hypothesis that more sophisticated methodology using machine learning (ML) algorithms could do this. Methods  In this post-hoc analysis of the BALKAN-AF dataset, ML algorithms and logistic regression were tested. The feature selection process identified a subset of variables that were most relevant for creating the model. Adherence with the ‘A’ criterion of the ABC pathway was defined as the use of oral anticoagulants (OAC) in patients with AF with a CHA (2) DS (2) -VASc score of 0 (male) or 1 (female). Results  Among 2,712 enrolled patients, complete data on ‘A’-adherent management were available in 2,671 individuals (mean age 66.0 ± 12.8; 44.5% female). Based on ML algorithms, independent predictors of ‘A-criterion adherent management’ were paroxysmal AF, center in capital city, and first-diagnosed AF. Hypertrophic cardiomyopathy, chronic kidney disease with chronic dialysis, and sleep apnea were independently associated with a lower likelihood of ‘A’-criterion adherent management. ML evaluated predictors of adherence with the ‘A’ criterion of the ABC pathway derived an area under the receiver-operator curve of 0.710 (95%CI 0.67–0.75) for random forest with fine tuning. Conclusions  Machine learning identified paroxysmal AF, treatment center in the capital city, and first-diagnosed AF as predictors of adherence to the A pathway; and hypertrophic cardiomyopathy, chronic kidney disease with chronic dialysis, and sleep apnea as predictors of non adherence

Acute tricuspid valve regurgitation in a motorcycle accident

Tricuspid regurgitation is secondary in 90% of cases. We would like to present two case reports of primary tricuspid regurgitation caused by rupture of the papillary muscle as a result of traffic accidents. This series of cases presents a very rare heart injury caused by blunt chest trauma. Regular monitoring of echocardiographic parameters in the period between the stabilization of patients' condition after the accident and surgical correction of the tricuspid valve defect is an important point of patient care with severe tricuspid regurgitation.Tricuspid regurgitation is secondary in 90% of cases. We would like to present two case reports of primary tricuspid regurgitation caused by rupture of the papillary muscle as a result of traffic accidents. This series of cases presents a very rare heart injury caused by blunt chest trauma. Regular monitoring of echocardiographic parameters in the period between the stabilization of patients' condition after the accident and surgical correction of the tricuspid valve defect is an important point of patient care with severe tricuspid regurgitation

Adherence to the 4S-AF Scheme in the Balkan region:insights from the BALKAN-AF survey

BackgroundThe 4S-AF scheme includes stroke risk, symptoms, severity of burden, and substrate severity domain.AimWe aimed to assess the adherence to the 4S-AF scheme in patients classified according to stroke risk in post hoc analysis of the BALKAN-AF dataset.MethodsA 14-week prospective enrolment of consecutive patients with electrocardiographically documented atrial fibrillation (AF) was performed in seven Balkan countries from 2014 to 2015.ResultsLow stroke risk (CHA2DS2-VASc score, 0 in males or 1 in females) was present in 162 (6.0%) patients. 2 099 (77.4%) patients had CHA2DS2-VASc score ≥3 in females or ≥2 in males (high stroke risk), and 613 (22.6%) had CHA2DS2-VASc score ConclusionsOAC overuse was observed in patients with low stroke risk, whilst OAC underuse was evident in those with high risk of stroke. The percentage of highly symptomatic patients with high risk of stroke who were offered a rhythm control strategy was low

Atrial fibrillation and comorbidities:Clinical characteristics and antithrombotic treatment in GLORIA-AF

BackgroundPatients with AF often have multimorbidity (the presence of ≥2 concomitant chronic conditions).ObjectiveTo describe baseline characteristics, patterns of antithrombotic therapy, and factors associated with oral anticoagulant (OAC) prescription in patients with AF and ≥2 concomitant, chronic, comorbid conditions.MethodsPhase III of the GLORIA-AF Registry enrolled consecutive patients from January 2014 through December 2016 with recently diagnosed AF and CHA2DS2-VASc score ≥1 to assess the safety and effectiveness of antithrombotic treatment.ResultsOf 21,241 eligible patients, 15,119 (71.2%) had ≥2 concomitant, chronic, comorbid conditions. The proportions of patients with multimorbidity receiving non-vitamin K antagonist oral anticoagulants (NOACs) and vitamin K antagonists (VKA) were 60.2% and 23.6%, respectively. The proportion with paroxysmal AF was 57.0% in the NOAC group and 45.4% in the VKA group. Multivariable log-binomial regression analysis found the following factors were associated with no OAC prescription: pattern of AF (paroxysmal, persistent, or permanent), coronary artery disease, myocardial infarction, prior bleeding, smoking status, and region (Asia, North America, or Europe). Factors associated with OAC prescriptions were age, body mass index, renal function, hypertension, history of cerebral ischemic symptoms, and AF ablation.ConclusionMultimorbid AF patients prescribed NOACs have fewer comorbidities than those prescribed VKAs. Age, AF pattern, comorbidities, and renal function are associated with OAC prescription

Changes in anticoagulant prescription patterns over time for patients with atrial fibrillation around the world.

BackgroundPrescribing patterns for stroke prevention in atrial fibrillation (AF) patients evolved with approval of non-Vitamin K antagonist oral anticoagulants (NOACs) over time.ObjectivesTo assess changes in anticoagulant prescription patterns in various geographical regions upon first approval of a NOAC and to analyze the evolution of oral anticoagulants (OACs) use over time in relation to CHA2DS2-VASc and HAS-BLED risk profiles.MethodsGlobal Registry on Long-Term Oral Antithrombotic Treatment in Patients with Atrial Fibrillation (GLORIA-AF) Phases II and III reported data on antithrombotic therapy for patients with newly diagnosed AF and ≥1 stroke risk factor. We focused on sites enrolling patients in both phases and reported treatment patterns for the first 4 years after initial NOAC approval.ResultsFrom GLORIA-AF Phases II and III, 27 432 patients were eligible for this analysis. When contrasting the first year with the fourth year of enrolment, the proportion of NOAC prescriptions increased in Asia from 29.2% to 60.8%, in Europe from 53.4% to 75.8%, in North America from 49.0% to 73.9% and in Latin America from 55.7% to 71.1%. The proportion of Vitamin K antagonists (VKAs) use decreased across all regions over time, in Asia from 26.0% to 9.8%, in Europe from 35.5% to 16.8%, in North America from 28.9% to 12.1%, and in Latin America from 32.4% to 17.8%. In the multivariable analysis, factors associated with NOAC prescription were as follows: enrolment year, type of site, region, stroke and bleeding risk scores, and type and categorization of AF.ConclusionsDuring 4 years after the approval of the first NOAC, NOAC use increased, while VKA use decreased, across all regions

Meeting the WHO 90% target : antiretroviral treatment efficacy in Poland is associated with baseline clinical patient characteristics

Introduction: Modern combined antiretroviral therapies (cART) allow to effectively suppress HIV-1 viral load, with the 90% virologic success rate, meeting the WHO target in most clinical settings. The aim of this study was to analyse antiretroviral treatment efficacy in Poland and to identify variables associated with virologic suppression. Methods: Cross-sectional data on 5152 (56.92% of the countrywide treated at the time-point of analysis) patients on cART for more than six months with at least one HIV-RNA measurement in 2016 were collected from 14 Polish centres. Patients’ characteristics and treatment type-based outcomes were analysed for the virologic suppression thresholds of <50 and <200 HIV-RNA copies/ml. CART was categorized into two nucleos(t)ide (2NRTI) plus non-nucleoside reverse transcriptase (NNRTI) inhibitors, 2NRTI plus protease (PI) inhibitor, 2NRTI plus integrase (InI) inhibitor, nucleos(t)ide sparing PI/r+InI and three drug class regimens. For statistics Chi-square and U-Mann Whitney tests and adjusted multivariate logistic regression models were used. Results: Virologic suppression rates of <50 copies/mL were observed in 4672 (90.68%) and <200 copies/mL in 4934 (95.77%) individuals. In univariate analyses, for the suppression threshold <50 copies/mL higher efficacy was noted for 2NRTI+NNRTI-based combinations (94.73%) compared to 2NRTI+PI (89.93%), 2NRTI+InI (90.61%), nucleos(t)ide sparing PI/r+InI (82.02%) and three drug class regimens (74.49%) (p < 0.0001), with less pronounced but significant differences for the threshold of 200 copies/mL [2NRTI+NNRTI-97.61%, 2NRTI+PI-95.27%, 2NRTI+InI-96.61%, PI/r+InI- 95.51% and 86.22% for three drug class cART) (p < 0.0001). However, in multivariate model, virologic efficacy for viral load <50 copies/mL was similar across treatment groups with significant influence by history of AIDS [OR:1.48 (95%CI:1.01–2.17) if AIDS diagnosed, p = 0.046], viral load < 5 log copies/mL at care entry [OR:1.47 (95%CI:1.08–2.01), p = 0.016], baseline lymphocyte CD4 count ≥200 cells/µL [OR:1.72 (95%CI:1.04–2.78), p = 0.034] and negative HCV serology [OR:1.97 (95%CI:1.29–2.94), p = 0.002]. For viral load threshold <200 copies/mL higher likelihood of virologic success was only associated with baseline lymphocyte CD4 count ≥200 cells/µL [OR:2.08 (95%CI:1.01–4.35), p = 0.049] and negative HCV status [OR:2.84 (95%CI:1.52–5.26), p = 0.001]. Conclusions: Proportion of virologically suppressed patients is in line with WHO treatment target confirming successful application of antiretroviral treatment strategy in Poland. Virological suppression rates depend on baseline patient characteristics, which should guide individualized antiretroviral tre0atment decisions

Persistence with Anticoagulation for Atrial Fibrillation: Report from the GLORIA-AF Phase III 1-Year Follow-up

Background: We aimed to assess the extent to which drug persistence is better with non-vitamin K antagonist oral anticoagulants (NOACs) than vitamin K antagonists (VKAs) in atrial fibrillation (AF) patients and to estimate the difference in therapy persistence depending on NOAC dosing regimen (once daily (QD) vs. twice daily (BID)). Methods: Consecutive patients were followed for 1 year in phase III of the GLORIA-AF registry. Drug persistence was defined as the use of OAC without any discontinuation in &gt;30 days or switching to alternative therapy. Results: Among 21,109 eligible patients in phase III, 17,266 patients who were prescribed OAC at baseline and those who took &ge;1 OAC dose were included. The 1-year proportion of patients receiving NOAC and VKA who persisted on treatment was 80% and 75%, respectively. The 1-year persistence with NOACs BID and NOACs QD was 81% and 80%, respectively. Female gender, hypertension, older age, alcohol use, permanent, asymptomatic, and minimally symptomatic AF were associated with better OAC persistence. Region, medication usage predisposing to bleeding, being a current smoker, treatment reimbursement, and proton pump inhibitors were associated with lower OAC persistence. Conclusions: Drug persistence was higher with NOACs (1-year persistence was 80%) than with VKAs (75%). There was little difference in 1-year persistence between NOAC dosing regimens