Role of TSH and excess Heart Age in Predicting Atrial Fibrillation Recurrence Post-Ablation

Background: The association between atrial fibrillation (AF) and thyroid disease as defined by thyroid stimulating hormone (TSH) is established in literature. However, the relationship between TSH and recurrence of AF post ablation has not been established. Methods: We studied 207 patients (60.54±9.39yrs, 35.7% female) with persistent or paroxysmal AF who underwent either Cryo or RFA ablation between April 2011 and Jan 2015 at our center. Patients were stratified into hypothyroid (TSH \u3e \u3e4.5 U/mL), euthyroid (TSH 0.5-4.5 U/mL) and hyperthyroid (TSH \u3c 0.5 U/mL) based on pre procedure testing. Heart age was computed based on Framingham risk factors. Excess heart age was defined as the difference between actual age and heart age. Logistic regression and cox-proportional hazards model were implemented using R statistical software (v3.2.0). Results: There was a statistically significant lower rate of AF recurrence among male patients (OR 2.92, p=0.003). In univariate analysis, there was no statistically significant relationship between TSH and incidence of AF recurrence (OR 1.05, p=0.74). Cox proportional hazards models did not show an association between recurrence and TSH states (HR 0.85, p=0.74 for hypothyroid and HR 0.75, p=0.56 for hyperthyroid). Conclusions: This exploratory showed that TSH may not play a role in AF recurrence. While there is a tendency towards an association between TSH and AF recurrence, this was not statistically significant. We hypothesize that overt hyperthyroidism prior to ablation will not increase chance of recurrence. This was true after adjustment for Framingham risk factors. The limitation of this study was the small sample size of the patients with TSH in the hyperthyroid range. Further analysis using larger dataset is indicated

Predictors of Cardiac Mortality in the CCU: A Retrospective Study in a Tertiary Center

Background: Although prior studies have linked troponin I (TnI) elevation, serum sodium (Na) fluctuation, and reduced ejection fraction (EF) with an increased mortality in the medical/surgical critical care units, this has not been validated in the CCU. We aim to identify clinical and laboratory factors to predict cardiac related length of survival (LOS) in the CCU. Methods: We retrospectively analyzed 134 consecutive patients who were admitted to the CCU from December 2012 to March 2015, and who died during that admission. We used student T-test, correlation matrices, and Framingham risk factors adjusted multivariable logistic regression models to examine the role of TnI, serum Na, EF and other clinical covariates on LOS in cardiac death (CD) and non- cardiac death (NCD) group. Results: The average age of the study population was 70.0 ±14.3 (39.0% women). The prevalence of CD and NCD were 63% and 59%. LOS was statistically shorter in the CD vs. NCD group (5.3 days vs. 8.2 days, p=0.012). LOS negatively correlated with initial TnI (p= 0.05). LOS was not statistically affected by EF or Na level. Our regression models identified BMI and diabetes mellitus (DM) as strong predictors of CD (p= 0.04 and p=0.01). Conclusion: Our results validate prior studies showing that TnI, BMI, and DM are predictors of cardiac related mortality in the CCU. Patients with a cardiac etiology had a higher mortality rate and a shorter LOS. Future studies are needed to develop a scoring system specific for predicting mortality in the CCU

Effect of Left Atrial Function Index on Late Atrial Fibrillation Recurrence after Pulmonary Vein Isolation

Background: Although the rates of catheter ablation (CA) for atrial fibrillation (AF) are rapidly increasing, there are few predictors of outcome to help inform appropriate patient selection for this procedure. Traditional echocardiographic measures of atrial structure do not significantly reclassify risk of AF recurrence over and above the clinical risk factors. Left Atrial Function Index (LAFI) is a rhythm-independent measure of atrial function. We hypothesized that baseline LAFI would relate to AF recurrence after CA. Methods: Pre-procedural echocardiograms from 170 participants, who underwent CA for AF and were enrolled in the UMMC AF Treatment Registry, were analyzed. LAFI was calculated by a previously validated formula. Primary outcome was late or clinically significant AF recurrence 3-12 months after CA. Baseline clinical, laboratory and echocardiographic variables were compared between the recurrence and non-recurrence groups. Results: Study participants were middle aged (60+/10 years) and had a moderate-to-severe burden of cardiovascular comorbidities. 78 participants (46%) experienced late AF recurrence. Mean LAFI was 0.26+/-0.18. In multivariate analysis, lower LAFI was independently associated with the risk of recurrence (0.23 in recurrence group vs 0.29 in non-recurrence group, p \u3c 0.01). Predictive value of LAFI for AF recurrence was similar to CHADS2 score (c-statistic 0.60 vs 0.58, p 0.76). In subgroup of patients with persistent AF, LAFI predicted AF recurrence more strongly than CHADS2 score (c-statistic: 0.79 vs 0.58, p 0.02). Conclusions: In our cohort of 170 participants with AF undergoing index CA ablation, we observed that LAFI related to late AF recurrence after CA, independent of the traditional risk factors. Since LAFI can be calculated from almost any traditional echocardiographic recording, our findings suggest that LAFI may help guide therapeutic decision-making regarding application of CA, particularly among challenging patients with symptomatic persistent AF

Bilateral vas deferens calcification in a patient with multi-vessel coronary artery disease and severe aortic stenosis: linking infertility with cardiovascular disease

Vas deferens calcification is a chronic arterio-sclerotic process that develops over many years and is strongly associated with infertility. Incidental findings on imaging are the most common means of diagnosing this condition. We report a case of a 56-year man who likely has male factor infertility and was found to have bilateral vas deferens calcification on CT imaging. This was performed during pre-procedural workup for transcatheter aortic valve replacement (TAVR) for management of severe aortic stenosis (AS). The patient was also had severe calcific multi-vessel coronary artery disease requiring percutaneous coronary intervention with atherectomy. This case highlights a novel clinical association linking infertility with coronary and valvular heart disease. It is possible that this association exists in larger numbers than previously recognized. Closer monitoring of pelvic imaging for TAVR access planning in patients with severe AS may bring more cases to light

Atrial Fibrillation and Hypertension: Mechanistic, Epidemiologic, and Treatment Parallels

Atrial fibrillation (AF) is an increasingly prevalent condition and the most common sustained arrhythmia encountered in ambulatory and hospital practice. Several clinical risk factors for AF include age, sex, valvular heart disease, obesity, sleep apnea, heart failure, and hypertension (HTN). Of all the risk factors, HTN is the most commonly encountered condition in patients with incident AF. Hypertension is associated with a 1.8-fold increase in the risk of developing new-onset AF and a 1.5-fold increase in the risk of progression to permanent AF. Hypertension predisposes to cardiac structural changes that influence the development of AF such as atrial remodeling. The renin angiotensin aldosterone system has been demonstrated to be a common mechanistic link in the pathogenesis of HTN and AF. Importantly, HTN is one of the few modifiable AF risk factors, and guideline-directed management of HTN may reduce the incidence of AF

Clinical and Echocardiographic Correlates of Left Atrial Function Index: The Framingham Offspring Study

BACKGROUND: Left atrial (LA) remodeling is a predictor of cardiovascular disease (CVD). We performed measurement of the LA function index (LAFI), a composite measure of LA structure and function, in a community-based cohort and here report the distribution and cross-sectional correlates of LAFI. METHODS: In 1,719 Framingham Offspring Study participants (54% women, mean age 66 +/- 9 years), we derived LAFI from the LA emptying fraction, left ventricular (LV) outflow tract velocity time integral, and indexed maximal LA volume. We used multivariable linear regression to assess the clinical and echocardiographic correlates of LAFI adjusting for age, sex, anthropometric measurements, and CVD risk factors. RESULTS: The average LAFI was 35.2 +/- 12.1. Overall, LAFI declined with advancing age (beta = -0.27, P \u3c .001). LAFI was significantly higher (37.5 +/- 11.6) in a subgroup of participants free of CVD and CVD risk factors compared with those with either of these conditions (34.5 +/- 12.2). In multivariable models, LAFI was inversely related to antihypertensive use (beta = -1.26, P = .038), prevalent atrial fibrillation (beta = -4.46, P = .001), heart failure (beta = -5.86, P = .008), and coronary artery disease (beta = -2.01, P = .046). In models adjusting for echocardiographic variables, LAFI was directly related to LV ejection fraction (beta = 14.84, P \u3c .001) and inversely related to LV volume (beta = -7.03, P \u3c .001). CONCLUSIONS: LAFI was inversely associated with antihypertensive use and prevalent CVD and was related to established echocardiographic traits of LV remodeling. Our results offer normative ranges for LAFI in a white community-based sample and suggest that LAFI represents a marker of pathological atrial remodeling

Post myocardial infarction complications during the COVID-19 pandemic - A case series

We report 4 cases of post myocardial infarction complications due to the delay in presentation during COVID-19 era. We highlighted the need for auscultating the chest for early diagnosis. Through this case series, we urge to raise awareness among cardiac patients to access healthcare despite the fear of COVID-19