Utilization and Predictors of Electrical Cardioversion in Patients Hospitalized for Atrial Fibrillation

Atrial fibrillation (AF) is a common arrhythmia in adults associated with thromboembolic complications. External electrical cardioversion (DCCV) is a safe procedure used to convert AF to normal sinus rhythm. We sought to study factors that affect utilization of DCCV in hospitalized patients with AF. The study sample was drawn from the Nationwide Inpatient Sample (NIS) of the Healthcare Cost and Utilization Project in the United States. Patients with a primary discharge diagnosis of AF that received DCCV during hospitalization in the years 2000–2010 were included. An estimated 2,810,530 patients with a primary diagnosis of AF were hospitalized between 2001 and 2010, of which 1,19,840 (4.26%) received DCCV. The likelihood of receiving DCCV was higher in patients who were males, whites, privately insured, and aged < 40 years and those with fewer comorbid conditions. Higher CHADS2 score was found to have an inverse association with DCCV use. In-hospital stroke, in-hospital mortality, length of stay, and cost for hospitalization were significantly lower for patients undergoing DCCV during AF related hospitalization. Further research is required to study the contribution of other disease and patient related factors affecting the use of this procedure as well as postprocedure outcomes

Temporal Trends and Outcomes of Acute Myocardial Infarction in Patients With Cancer

Background: Data on outcomes of ST-elevation myocardial infarction (STEMI) in patients with cancer are scarce. We investigated the nationwide trends in admissions for STEMI, utilization of percutaneous coronary intervention (PCI), and in-hospital outcomes in patients with the three most common cancer diagnoses (lung, breast, and colon) compared to patients without cancer. Methods: We conducted an administrative database study using the Nationwide Inpatient Sample (NIS). All in-patient hospitalizations for STEMI from 2001 to 2011 were identified. Patients with concomitant diagnosis of lung, breast or colon cancer were identified using appropriate International classification of diagnosis (ICD 9-CM) codes. Primary outcome was utilization of PCI and in-hospital mortality in patients with cancer compared to those without cancer. Results: Utilization of PCI was 30.8% (1,191/3,871), 20.2% (4,541/22,480) and 17.3% (1,716/9,944) in patients with breast, lung and colon cancer, respectively. Among patients without any of these cancers, use of PCI was 49.6%. In-hospital mortality was highest in patients with lung cancer (57.1%) and lowest in patients without cancer (25.7%). Conclusions: Patients with cancer have significantly worse in-hospital mortality compared to those without cancer, partly due to a relatively lower rate of PCI utilization in cancer patients with STEMI

Association between siesta (daytime sleep), dietary patterns and the presence of metabolic syndrome in elderly living in Mediterranean area (MEDIS study):The moderating effect of gender

Objectives: Several lifestyle parameters including diet, physical activity and sleep were associated in isolation with the presence of Metabolic Syndrome (MetS) in adults, to date there is a paucity of studies which evaluated their combined role aging populations and especially with respect to gender. Therefore, the aim of the present study was to provide a global consideration of the lifestyle factors associated with MetS among elderly individuals. Design: Cross-sectional observational study. Setting: 21 Mediterranean islands and the rural Mani region (Peloponnesus) of Greece. Participants: during 2005-2015, 2749 older (aged 65-100 years) from were voluntarily enrolled in the study. Measurements: Dietary habits, energy intake, physical activity status, sociodemographic characteristics, lifestyle parameters (sleeping and smoking habits) and clinical profile aspects were derived through standard procedures. The presence of MetS was defined using the definition provided by NCEP ATP III (revised) and cluster analysis was used to identify overall dietary habit patterns. Results: The overall prevalence of MetS in the study sample was 36.2%, but occurred more frequently in females (40.0% vs. 31.8%, respectively, p=0.03). Individuals with MetS were more likely to sleep during the day (89.4% vs. 76.8% respectively, p=0.039) and frequent ‘siesta’ was positively linked to the odds of MetS presence in females (Odds Ratio (OR) =3.43, 95% Confidence Intervals (CI): 1.08-10.9), but not for men (p=0.999). The lower carbohydrate (i.e., 45.2% of total daily energy, 120±16gr/day) dietary cluster was inversely associated with the odds for MetS presence, but only for men (OR=0.094, 95%CI: 0.010-0.883). Conclusions: Lifestyle parameters including sleep and diet quality are strongly associated with the presence of MetS in elderly cohort, but different their level of influence appears to be different, depending on gender. Further research is needed to better consider the role of lifestyle characteristics in the management of MetS in clinical practice

Efficacy and Safety of Dronedarone in the Treatment of Patients With Atrial Fibrillation

INTRODUCTION: Dronedarone, a derivative of amiodarone with structural modifications, was designed to have similar electrophysiological properties with a less toxic profile. Areas covered: Brief overview of the pharmacology of dronedarone followed by a summary of randomized clinical trials testing the efficacy of dronedarone in maintaining normal sinus rhythm and clinical outcomes associated with these trials. In depth discussion and commentary on trial findings which may seem contradictory at first approach and brief discussion of post-marketing surveillance studies. Expert opinion: Dronedarone is a moderately efficacious anti-arrhythmic agent which is safe for use in a carefully selected patient population, maintained in normal sinus rhythm, without advanced congestive heart failure, structural heart disease, permanent atrial fibrillation, digoxin use. It is especially useful in younger patients who lack other risk factors for cardiovascular events and, who stand to gain the most by avoiding long-term pulmonary and thyroid toxicities associated with more effective, but also significantly more toxic agents such as amiodarone

Managing Hypertension in Patients Aged 75 Years and Older

On the basis of the available data, we would diagnose a normal blood pressure in elderly persons including those 75 years of age and older if the blood pressure was below 120/80 mmHg. We would diagnose hypertension in elderly persons including those aged 75 years and older if the systolic blood pressure was 130 mmHg and higher or if the diastolic blood pressure was 80 mmHg and higher. We would treat these elderly patients with hypertension to a blood pressure goal of less than 130/80 mmHg if the blood pressure was obtained by automated blood pressure monitoring in a quiet room. We would consider treating high-risk persons aged 75 years and older to a blood pressure goal of less than 120/80 mmHg if they were carefully monitored for serious adverse events. If the blood pressure is more than 20/10 mmHg above the goal blood pressure, we would initiate antihypertensive drug therapy with two antihypertensive drugs. The initial drug of choice for the treatment of hypertension in adults aged 75 years and older should be based on co-morbidities, co-incidental indications, tolerability, and cost

Are Two Drugs Better Than One? A Review of Combination Therapies for Hypertension

INTRODUCTION: Current guidelines for pharmacotherapy briefly describe a role for combination antihypertensive therapy. However, guidance on whether combination therapy should be used at the time of initiating therapy or as add on, and the choice of combination therapy is scarce. Areas covered: Current literature suggests that intensive blood pressure control is the key to managing cardiovascular risk. Along with lifestyle management, pharmacotherapy is an central component in the treatment of hypertension. Here, we aim to review the pathophysiology of hypertension, rationale for using combination therapy, and the different combinations of antihypertensive drug classes that are available in the market. Papers from 1967 through 2016 listed on PubMed on this topic were reviewed. Expert opinion: Based on the review of the literature, combination antihypertensive therapies are more effective than monotherapy and are also well tolerated, safe and cost effective for treatment of hypertension. Further research is needed to help guide the choice of combination antihypertensive therapy in different patient populations based on age, gender, race and comorbidities

Newer Hormonal Pharmacotherapies for Heart Failure

INTRODUCTION: Heart failure (HF) is characterized by maladaptive neurohormonal activation of the cardiovascular and renal systems resulting in circulatory inadequacy and frequent acute exacerbations. The increasing burden of HF prompted investigation of underlying pathophysiological mechanisms and the design of pharmacotherapeutics that would target these pathways. Areas covered: A MEDLINE search for relevant original investigations and review articles of newer hormonal drugs for HF since the year 2005 till October 2017 provided us with necessary literature. Major trials and relevant clinical investigations were discussed. Expert commentary: A multitude of hormonal pathways central to HF were identified, including the natriuretic peptide system and neurohormones such as relaxin, arginine vasopressin, and endothelin. However, drugs targeting these novel pathways (aliskiren, tolvaptan, ularitide, serelaxin, bosentan, macitentan) failed to show mortality benefit. This emphasizes a tremendous unmet need in the pharmacotherapy for HF, especially for the subtypes of acute HF and HF with preserved ejection fraction. Sacubitril/valsartan demonstrated substantial mortality benefit in chronic systolic HF population and is endorsed by international HF guidelines. If proven to be efficacious in larger outcome trials, finerenone can be a valuable addition baseline HF therapy. More basic, translational, and phenotype specific clinical research is warranted to improve HF pharmacotherapy