Opportunities and challenges in atrial fibrillation management – Focus on left atrial appendage closure and cardiac troponin release in clinical practice

Oral anticoagulation (OAC) is to date the most effective treatment for ischaemic stroke prevention in atrial fibrillation (AF). However, percutaneous left atrial appendage closure (LAAC) is an emerging alternative for patients with contraindications to OAC, yet the optimal postprocedural antithrombotic treatment and patient selection criteria for LAAC are uncertain. Furthermore, the diagnostic utility of cardiac troponins (cTn) for myocardial infarction is often limited by mildly elevated cTns in AF, but the determinants of cTn release in AF remain incompletely understood. The aim of this thesis was to investigate single antiplatelet therapy after LAAC in patients at high bleeding risk (I), the feasibility of LAAC in AF patients with prior intracranial bleeding and thromboembolism (II), and the impact of heart rate on cTn levels in patients presenting to the emergency department primarily with AF (III). Percutaneous LAAC followed by single APT was associated with a 73% lowerthan predicted rate of thromboembolism (2.7 per 100 patient-years) than in historical controls. Individually tailored short-term (< 6 months) and long-term single antiplatelet therapy – based on cardiovascular risks – provided similar outcomes in terms of thromboembolism and intracranial bleeding (I). The results also suggest that similar conservative approach was safe in patients with prior intracranial bleeding and thromboembolism (II). Furthermore, high ventricular rate on admission was associated with mildly elevated peak cTn T levels in symptomatic AF patients (III). The association between heart rate and cTn T level was nonlinear and became prominent after exceeding an admission heart rate of 125 beats per minute. Additionally, new-onset AF, the absence of palpitations, old age, low haemoglobin level, decreased kidney function, diabetes, and heart failure were independently associated with cTn T level. In conclusion, LAAC followed by individually tailored and minimized single APT seems a reasonable strategy for AF patients who have contraindications to OAC, and also for high-risk AF patients with both prior intracranial bleeding and thromboembolism. High ventricular rate in AF should be taken into account when evaluating the diagnostic value of cTn elevation in the emergency department.Eteisvärinäpotilaan hoidon mahdollisuuksia ja haasteita. Eteiskorvakkeen katetrisulku ja troponiinipäästöt. Antikoagulaatiohoito on tehokkain tapa vähentää eteisvärinäpotilaiden aivoinfarktiriskiä. Vasemman eteiskorvakkeen katetrisulku on lupaava hoitovaihtoehto potilaille, joilla antikoagulaatiohoitoa ei voida käyttää. Toistaiseksi on vähän tietoa, miten antitromboottinen hoito optimoidaan eteiskorvakkeen sulun jälkeen ja millaiset eteisvärinäpotilaat hyötyvät eniten toimenpiteestä. Eteisvärinäpotilailla usein havaitut lievästi kohonnet troponiinipitoisuudet sydänlihasvaurion merkkiaineina häiritsevät sydäninfarktidiagnostiikkaa, mutta troponiiniarvoja nostavat tekijät ovat huonosti tunnettuja. Tämän väitöskirjan tavoitteina oli arvioida yhdellä verihiutaleestäjällä toteutetun hoidon turvallisuutta eteiskorvakkeen katetrisulun jälkeen suuren verenvuotoriskin eteisvärinäpotilailla (I) sekä katetrisulkua potilailla, jotka olivat sairastaneet sekä kallonsisäisen verenvuodon että tromboembolisen komplikaation ennen toimenpidettä (II), ja tarkastella syketaajuuden vaikutusta troponiinitasoon eteisvärinän vuoksi päivystykseen hakeutuneilla oireisilla potilailla (III). Eteiskorvakkeen katetrisulkuun ja yhden verihiutale-estäjän jatkohoitoon liittyi 73 % ennustettua alhaisempi tromboembolisten tapahtumien ilmaantuvuus (2.7/100 potilasvuotta) verrattuna historiallisiin verrokkeihin. Yksilöllisesti sydän- ja verisuonitautiriskien perusteella suunniteltu lyhytaikainen (alle 6 kuukauden) ja pitkäaikainen verihiutale-estohoito tuottivat samanlaiset seurantatulokset tromboembolisten komplikaatioiden ja kallonsisäisten verenvuotojen osalta (I). Tämäntyyppinen yksilöllisesti kevennetty hoitotapa osoittautui myös turvalliseksi eteisvärinäpotilailla, jotka olivat toipuneet aiemmasta kallonsisäisestä verenvuodosta ja tromboembolisesta komplikaatiosta (II). Päivystykseen hakeutuneilla potilailla nopea eteisvärinän kammiovaste oli yhteydessä lievästi kohonneisiin troponiini T:n pitoisuuksiin (III). Sykkeen ja troponiini T:n välinen yhteys oli epälineaarinen ja sykkeen troponiinitasoa nostava vaikutus tuli selkeimmin esiin vasta kammiovasteen ylittäessä 125/min. Eteiskorvakkeen katetrisulku yhdessä yksilöllisesti suunnitellun verihiutaleestohoidon kanssa vaikuttaa järkevältä hoitovaihtoehdolta potilaille, joilla on vasta-aiheita antikoagulaatiohoidolle ja ovat erityisen korkeassa tromboembolisten komplikaatioiden riskissä. Eteisvärinän nopea kammiovaste tulisi ottaa huomioon arvioitaessa troponiinipäästön diagnostista merkitystä päivystyksessä

Association of Heart Rate With Troponin Levels Among Patients With Symptomatic Atrial Fibrillation

This cohort study investigates heart rate and cardiac troponin levels in patients admitted to the emergency department with symptomatic atrial fibrillation.Non peer reviewe

Frequency of cardioversions as an additional risk factor for stroke in atrial fibrillation - the FinCV-4 study

BackgroundPatients with atrial fibrillation (AF) are selected for oral anticoagulation based on individual patient characteristics. There is little information on how clinical AF burden associates with the risk of ischaemic stroke or systemic embolism (SSE). The aim of this study was to explore the association of the frequency of cardioversions (CV) as a measure of clinical AF burden on the long-term SSE risk, with a focus on patients at intermediate stroke risk based on CHA(2)DS(2)-VASc score. For these patients, additional SSE risk stratification by assessing CV frequency may aid in the decision on whether to initiate oral anticoagulation.MethodsThis retrospective analysis of FinCV Study from years 2003-2010 included 2074 patients who were not using any oral anticoagulation (long term or temporary) after CVs and undergoing a total of 6534 CVs for AF from emergency departments of three hospitals. Two study groups were formed: high CV frequency (mean interval between CVs 12 months).ResultsA total of 107 SSEs occurred during a mean follow-up of 5.4 years. The event rates per 100 patient-years were 1.82 and 0.67 in high versus low CV frequency groups, respectively. After adjustment for CHA(2)DS(2)-VASc score, CV frequency independently predicted SSE (HR, 2.87 [95% CI, 1.47 to 5.64]; p = .002) at 3 years. Competing risk analysis also identified CV frequency (sHR, 2.70 [95% CI, 1.38-5.31]; p = .004) as an independent predictor for SSE. In patients with CHA(2)DS(2)-VASc score 1 and low CV frequency, the SSE risk was only 0.08 per 100 patient-years.ConclusionsFrequency of CVs for symptomatic AF episodes provides additional information on stroke risk in AF patients with CHA(2)DS(2)-VASc score 1. Key messages This retrospective study offers a unique opportunity to observe the natural course of AF patients with infrequent episodes of clinical arrhythmia when they were not using OAC (before introduction of CHA(2)DS(2)-VASc score). Stroke or systemic embolism rate was very low (0.08 per 100 patient-years) in patients with one CHA(2)DS(2)-VASc point who visited the emergency room for cardioversion less than once a year. Frequency of cardioversions can be used for additional risk stratification in patients at intermediate risk of stroke based on CHA(2)DS(2)-VASc score.</p

Association of Heart Rate With Troponin Levels Among Patients With Symptomatic Atrial Fibrillation

This cohort study investigates heart rate and cardiac troponin levels in patients admitted to the emergency department with symptomatic atrial fibrillation

Etiology of Minor Troponin Elevations in Patients with Atrial Fibrillation at Emergency Department-Tropo-AF Study

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 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

Adherence to risk-assessment protocols to guide computed tomography pulmonary angiography in patients with suspected pulmonary embolism

AimsThe use of computed tomography pulmonary angiography (CTPA) in the detection of pulmonary embolism (PE) has considerably increased due developing technology and better availability of imaging. The underuse of pre-test probability scores and overuse of CTPA has been previously reported. We sought to investigate the indications for CTPA at a University Hospital emergency clinic and seek for factors eliciting the potential overuse of CTPA.Methods and resultsAltogether 1001 patients were retrospectively collected and analysed from the medical records using a structured case report form. PE was diagnosed in 222/1001 (22.2%) of patients. Patients with PE had more often prior PE/deep vein thrombosis, bleeding/thrombotic diathesis and less often asthma, chronic obstructive pulmonary disease, coronary artery disease, or decompensated heart failure. Patients were divided into three groups based on Wells PE risk-stratification score and two groups based on the revised Geneva score. A total of 9/382 (2.4%), 166/527 (31.5%), and 47/92 (52.2%) patients had PE in the CTPA in the low, intermediate, and high pre-test likelihood groups according to Wells score, and 200/955 (20.9%) and 22/46 (47.8%) patients had PE in the CTPA in the low-intermediate and the high pre-test likelihood groups according to the revised Geneva score, respectively. D-dimer was only measured from 568/909 (62.5%) and 597/955 (62.5%) patients who were either in the low or the intermediate-risk group according to Wells score and the revised Geneva score. Noteworthy, 105/1001 (10.5%) and 107/1001 (10.7%) of the CTPAs were inappropriately ordered according to the Wells score and the revised Geneva score. Altogether 168/1001 (16.8%) could theoretically be avoided.ConclusionsThis study highlights scant utilization of guideline-recommended risk-stratification tools in CTPA use at the emergency department.</p

Percutaneous left atrial appendage closure in patients with prior intracranial bleeding and thromboembolism

Background: Percutaneous left atrial appendage closure (LAAC) is an alternative treatment in atrial fibrillation patients with contraindication to oral anticoagulation. Still, patient selection criteria for LAAC are debated. Objective: The aim of this study was to evaluate the outcome after LAAC in patients with prior intracranial bleeding and thromboembolism. Methods: Consecutive patients with atrial fibrillation and prior intracranial bleeding who underwent LAAC from February 2009 to August 2018 at the Turku University Hospital, Finland, were included in a prospective registry. Patients were followed through clinical visits and annual phone calls up to 5 years. Results: Overall 104 patients (mean age 73±7 years; women 30%; CHA₂DS₂-VASc 4.7±1.4; HAS-BLED 3.3±0.9) with atrial fibrillation and prior intracranial bleeding underwent successful LAAC using mainly (n=102) Amplatzer devices. Median time from intracranial bleeding to LAAC was 7 months and median follow-up 3.6 years. Antithrombotic treatment was ≤ 6 months in 71 (68%) patients, and 48 (46%) patients received aspirin or clopidogrel alone. The rates of thromboembolism and intracranial bleeding (per 100 patient-years) were 3.4 and 1.9, respectively. In 39 patients with previous thromboembolism, the rate of thromboembolism was 3.6 per 100 patient-years (95% confidence interval, 1.5–7.0) yielding a 69% relative risk reduction with respect to predicted risk based on median CHA2DS2-VASc score. Overall, rates of thromboembolism and intracranial bleeding were broadly similar in patients with and without prior thromboembolism. Conclusion: Percutaneous LAAC with minimized antithrombotic treatment demonstrated to be a valid treatment option in high-risk patients with prior intracranial bleeding and thromboembolism.Eteisvärinään liittyy kohonnut aivohalvausriski vasempaan eteiskorvakkeeseen muodostuvien hyytymien eli trombien vuoksi. Trombin embolisoituessa eli kulkeutuessa systeemiseen verenkiertoon voi seurauksena olla iskeeminen aivohalvaus, ohimenevä aivoverenkierron häiriö tai muu valtimotukkeuman aiheuttama iskeeminen tapahtuma. Oikein toteutettu antikoagulaatio- eli verenohennushoito pienentää aivohalvausriskin kolmasosaan. Eteiskorvakkeen mekaanista sulkua on esitetty iskeemisten aivohalvausten ehkäisyyn eteisvärinäpotilaille, joiden tromboembolisten tapahtumien riski on merkittävä, mutta verenvuotoriski antikoagulaatiohoidon aikana olisi liian suuri. Toistaiseksi on epäselvää, millainen potilasryhmä hyötyy eniten sulkutoimenpiteestä. Tutkimuksen tarkoituksena oli selvittää eteiskorvakkeen sulun seurantatuloksia potilailla, jotka olivat sairastaneet sekä aikaisemman kallonsisäisen verenvuodon että tromboembolisen tapahtuman. Ensisijaisia seurannan päätetapahtumia olivat tromboemboliset tapahtumat ja kallonsisäiset verenvuodot. Turun yliopistollisessa keskussairaalassa vuosina 2009–2018 sulkutoimenpiteeseen osallistuneista, kirjallisen suostumuksen antaneilta potilaista, kerättiin tiedot prospektiiviseen rekisteriin. Seuranta toteutettiin prospektiivisesti puhelinkontrolleilla tai kliinisillä kontrolleilla enintään 5 vuoden ajan sekä retrospektiivisesti sähköisistä potilasasiakirjoista huhtikuuhun 2019 asti. Tutkimuksen tulokset osoittavat, että kallonsisäisen vuodon sairastaneilla eteisvärinäpotilailla eteiskorvakkeen sulku on kohtuullinen vaihtoehto iskeemisten aivohalvausten ehkäisyssä. Suurimmalla osalla potilaista antitromboottista hoitoa jatkettiin enintään puoli vuotta sulkutoimenpiteestä. Huolimatta antitromboottisen hoidon minimoimisesta iskeemisiä aivotapahtumia ja kallonsisäisiä verenvuotoja ilmaantui seurannassa lähes yhtä paljon. Tromboemboliset tapahtumat vähenivät kolmasosaan verrattuna epidemiologiseen aineistoon. Tulokset olivat samansuuntaisia sekä potilailla, joilla oli aiempi tromboembolinen tapahtuma, että potilailla, joilla oli ainoastaan edeltänyt kallonsisäisen verenvuototapahtuma. Löydökset korostavat sitä, että kallonsisäisen verenvuodon sairastaneet eteisvärinäpotilaat tarvitsevat yksilöllisesti toteutetun hoitolinjan, joka ottaa huomioon iskeemisten ja verenvuototapahtumien riskit

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

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