San luca milano cardiologia concord
Abate1, D. Fabbrini1, P. Nardi2, M. Todini1, P. Corsi1, S.
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Try out PMC Labs and tell us what you think. Learn More. Author Contributions: Dr Pieper had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Dr Kayani has received grants from Bayer. Dr Mantovani has received grants and personal fees from Bayer and Boehringer Ingelheim, grants from Daiichi Sankyo, and personal fees from Pfizer. Dr Misselwitz is employed by and owns stock in Bayer. No other disclosures were reported. San Martin S. Unidad de Investigacion Clinica en Medicina S. Gliem und FA S. Anna e S. Groenemeijer and E. Instytut Kardiologii im. Georgievskiy", Simferopol, Russia: Alexey Ushakov. Platt, M. She was not compensated for her contribution.
Rates of prescription of anticoagulants and antiplatelet and their combination in ischemic and nonischemic cardiomyopathy according to specialty. Rates of prescription of anticoagulants and antiplatelet and their combination in ischemic and nonischemic cardiomyopathy according to care setting. What are the management strategies and outcomes of patients with nonvalvular atrial fibrillation and concomitant congestive heart failure ischemic or nonischemic cardiomyopathy? There is a need for physicians to opt for improved adherence to guidelines-directed treatment of both atrial fibrillation and concomitant congestive heart failure, particularly in patients with ischemic cardiomyopathy.
Congestive heart failure CHF is commonly associated with nonvalvular atrial fibrillation AF , and their combination may affect treatment strategies and outcomes. Data were analyzed from December to September The median age of the population was Prescription of oral anticoagulant and antiplatelet drugs was not balanced between groups.
Oral anticoagulants with or without antiplatelet drugs were used in patients with ICM Antiplatelets were prescribed alone in patients with ICM Rates of all-cause and cardiovascular death per patient-years were significantly higher in the ICM group all-cause death: ICM, Major bleeding rates were significantly higher in the ICM group 1. Congestive heart failure CHF is commonly associated with atrial fibrillation AF , and their combined presentation confers a worse prognosis than either condition alone.
When random site selection did not generate the required number of sites in a given country, the national lead investigator was asked to recommend sites to make up the numbers 18 of sites. The sites represent the different care settings in each participating country office-based practice; hospital departments, including neurology, cardiology, geriatrics, internal medicine, and emergency; anticoagulation clinics; and general or family practice.
Independent ethics committee and hospital-based institutional review board approvals were obtained. The registry is being conducted in accordance with the principles of the Declaration of Helsinki, local regulatory requirements, and the International Conference on Harmonization—Good Pharmacoepidemiological and Clinical Practice guidelines. Written informed consent was obtained from all study participants.
Confidentiality and anonymity of all patients recruited into this registry are maintained. Baseline characteristics collected at inclusion in the registry included medical history, care setting, type of AF, date and method of diagnosis, symptoms, antithrombotic treatment ie, vitamin K antagonists, nonvitamin K antagonist oral anticoagulants, and antiplatelets [AP] , and all cardiovascular drugs. Collection of follow-up data was performed every 4 months up to 12 months.
Submitted data were examined for completeness and accuracy by the coordinating center Thrombosis Research Institute, London, England , and data queries were sent to study sites. Congestive heart failure was diagnosed according to clinical criteria at entry and classified according to the New York Heart Association NYHA functional class. Ischemic cardiomyopathy was defined as patients with a history of coronary artery disease, including known chronic angina pectoris, previous myocardial infarction or unstable angina, coronary artery bypass grafting, or previous percutaneous coronary intervention with or without stenting.
Nonischemic cardiomyopathy was the default diagnosis. Chronic kidney disease CKD was classified according to National Kidney Foundation guidelines into moderate-to-severe stages , mild stages 1 and 2 , or none. Continuous variables were expressed as medians and interquartile ranges IQR and categorical variables as frequencies and percentages.
Because studies with large sample sizes are prone to producing statistically significant findings in the presence of clinically irrelevant differences, no formal statistical tests are performed for the baseline tables. Instead, clinical interpretations are applied, and statistical tests are reserved for hypotheses of differences in outcomes. All cohorts of patients had been followed up for a minimum of 1 year.
Thus, events and time to events are censored at days. Person-year rates for the first occurrence of the event of interest were estimated using a Poisson model, with the number of events as the dependent variable and the log of time as an offset, ie, a covariate with a known coefficient of 1. Evaluation of 1-year outcomes by patients with ischemic vs nonischemic HF were performed both as unadjusted and adjusted analyses using Cox proportional hazards models. The association of type of HF with outcomes in patients who used AP therapy was also of interest.
The adjustment factors included those listed previously, except OAC use, which appears in the treatment of interest. All statistical analyses were performed using SAS, version 9.
A P value of less than. Detailed baseline characteristics of the population are reported in eTable 1 in the Supplement. At enrollment, patients 9. No antithrombotic drugs were prescribed in of patients with ICM 5. There were too few patients in neurology and geriatrics settings to have a reliable picture of the prescription patterns eFigure 2 in the Supplement. In anticoagulation clinics, most patients received AC with or without AP, primarily in the form of vitamin K antagonists eFigure 3 in the Supplement.
Rate control was attempted more frequently than rhythm control in both groups. The uptake of antiarrhythmic drugs was mostly similar in both groups, except that class 3 drugs were more frequently used in patients with ICM. Cardioversion was attempted in a minority of patients, at a similar rate in both groups. The use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers was higher in patients with ICM vs patients with NICM The use of mineralocorticoid receptor antagonists, loop diuretics, and digoxin and other digitalis was similar between the 2 groups Table 2.
Rates of noncardiovascular death were similar in both cardiomyopathy groups. A, Unadjusted and adjusted HRs for clinical outcomes at 1 year. New acute coronary syndromes occurred at a significantly higher rate in the ICM group 1. Nevertheless, there was some imbalance in the rates of other and undetermined causes of death between the 2 groups; in particular, the rate of undetermined cause of death was substantially higher in ICM group eTable 2 in the Supplement.
Ischemic cardiomyopathy was significantly associated with higher rates of all-cause death, cardiovascular death, and major bleeding in patients who did not receive AP therapy at enrollment. The main findings of this study are that patients with ICM and patients with NICM and concomitant AF substantially differ in terms of baseline characteristics, functional impairment, LV function impairment, and treatments that may be significantly associated with outcomes. They also significantly differ in terms of outcome, with higher rates of death, major bleeding, and new acute coronary syndromes.
The known causes of cardiovascular death were proportionally mostly similar in both groups, including death from ischemic stroke eTable 2 in the Supplement. In patients without AF, a higher risk of death in patients with ICM compared with patients with NICM was inconsistently reported in observational studies, in retrospective analyses of hospital records, and in reviews of randomized clinical trials. In addition, impaired myocardial perfusion is associated with electrical instability and a higher risk of sudden death.
Treatment strategy of AF and use of antiarrhythmic drugs were mostly similar in both groups, but there was some imbalance between the 2 groups regarding rate or rhythm control and use of class 3 antiarrhythmic drugs.
Antithrombotic therapy was suboptimal in the ICM group compared with the NICM group, as shown by a much lower rate of anticoagulation with or without AP therapy and, consequently, a high rate of AP alone prescription even in patients without indication for AP therapy, as already reported 17 Table 2. This may have had a detrimental effect on the risk of death because anticoagulation was shown to be associated with a substantial reduction of the risk of death in previous reports.
Additionally, there were higher rates of heart failure and cardiovascular death in the AF population than in the non-AF population. The reasons for inadequate antithrombotic treatment in the ICM group remain to be determined. These patients, often elderly, need treatments for stroke prevention, heart failure, and coronary disease, resulting in an extensive list of drugs, which may deter the physician from prescribing them all and deter the patient from complying with the prescription.
Lack of adherence may have played a role because the implementation of guidelines was shown to have a favorable association with outcomes in other settings. In patients who did not receive AP therapy, the risks of all-cause and cardiovascular death as well as the risk of major bleeding were significantly higher in those with ICM than in those with NICM; in contrast, in patients who did receive AP therapy, there was no excess of events in those with ICM Figure 2 B. This tends to confirm that AP therapy is associated with a more positive outcome in patients with ischemic heart disease.
However, these data were generated from a nonprespecified subgroup analysis. As such, no firm conclusions can be derived, and these data are only hypothesis generating. Congestive heart failure without AF is associated with a higher risk of stroke, and the combination of CHF and AF further increases this risk irrespective of LV function preserved or depressed or of etiology ischemic or nonischemic. Furthermore, as already mentioned, stroke prophylaxis was suboptimal in the ICM group, where twice as many patients received AP therapy alone compared with the NICM group.
Finally, to our knowledge, this study is the first to assess the outcomes of ICM and NICM in patients with AF from an unselected prospective registry population representative of real life. Ischemic cardiomyopathy carried a poorer prognosis than NICM in terms of all-cause and cardiovascular death. In addition, patients with ICM were suboptimally treated with regards to stroke prophylaxis, which may have affected outcomes.
Our study had limitations. Nevertheless, we cannot rule out that some patients in the NICM group had ischemic heart disease. They were suboptimally given anticoagulation therapy and more often received AP therapy alone or in combination with anticoagulants. National Center for Biotechnology Information , U.
JAMA Cardiology. JAMA Cardiol. Published online May 8. Fitzmaurice , MD, 6 Keith A. Pieper , MS, 3, 13 Alexander G. Turpie , MD, 14 Freek W.
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