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Mortality after acute stroke worsened by accompanying acute AFib
The study covered in this summary was published on ResearchSquare.com as a preprint and has not yet been peer-reviewed.
Key takeaway
Why this matters
- A comprehensive understanding of the relationship between acute AF and risk for acute ischemic stroke and prognosis will help improve management and treatment of patients with acute ischemic stroke.
Study design
- The retrospective study included patients with acute ischemic stroke within the prior 24 hours; 12-lead electrocardiogram in the emergency department; and hospitalization and treatment at the hospital stroke center.
- The cohort of 706 patients admitted to a single center in Shanghai, China, from December 2019 to December 2021, included 142 with episodes of acute AF and 564 without such episodes.
- Patients with acute ischemic stroke and acute AF – including AF of new onset, paroxysmal, persistent, or permanent with symptoms such as palpitations or dizziness attributed to rapid ventricular rates – were identified.
- Neurological deficits were assessed using the 7-day National Institutes of Health Stroke Scale/Score (NIHSS). Patients with a 7-day NIHSS score of at least 16 were considered to have moderate to severe stroke.
- Associations between acute AF onset and the severity of early neurological deficits were assessed and related to all-cause mortality within 30 days of the stroke.
Key results
- Patients with acute AF were older than those without acute AF (80.3 years vs. 71.0 years; P < .001).
- Baseline NIHSS scores averaged 16.09 for the stroke patients with acute AF and 8.65 for those without acute AF (P < .001).
- Significantly more patients with acute AF than without acute AF had a 7-day NIHSS score of at least 16 (45.1% vs. 14.4%; P < .001).
- More patients with than without acute AF underwent transcatheter thrombectomy (44.4% vs. 24.5%; P < .001) or received thrombolytic therapy (31.6% vs. 19.7%; P = .005).
- Patients aged 73 years or older showed baseline NIHSS score and acute AF as independent risk factors for early neurological deficits in stroke patients admitted to the emergency department.
- Mortality at 30 days was significantly higher in patients with acute AF than in those without acute AF (30.3% vs. 10.1%; P < .001).
- Baseline NIHSS had an adjusted odds ratio for 30-day mortality of 1.18 (95% confidence interval, 1.15-1.22; P < .001).
- Other independent predictors included acute AF (1.87 [95% CI, 1.09-3.19; P = .022]) and age 73 or older (2.00 [95% CI, 1.18-3.37; P = .01]).
Limitations
- The study was retrospective and didn’t have access to some potentially relevant data, such as duration of AF.
- The single-center study with limited generalizability does not necessarily represent the broad population of stroke patients in China or elsewhere.
Disclosures
- This study was supported by the Cardiovascular Multidisciplinary Integrated Research Fund and Construction of Shanghai Municipal Health Commission.
- The authors report no relevant financial relationships.
This is a summary of a preprint research study, “Acute Atrial Fibrillation During Onset of Stroke Indicates Higher Probability of Post-Stroke Death Outcomes,” written by Yongxia Li, from the Shanghai Sixth People’s Hospital, and colleagues, on ResearchSquare.com. This study has not yet been peer reviewed. The full text of the study can be found on ResearchSquare.com.A version of this article first appeared on Medscape.com.
The study covered in this summary was published on ResearchSquare.com as a preprint and has not yet been peer-reviewed.
Key takeaway
Why this matters
- A comprehensive understanding of the relationship between acute AF and risk for acute ischemic stroke and prognosis will help improve management and treatment of patients with acute ischemic stroke.
Study design
- The retrospective study included patients with acute ischemic stroke within the prior 24 hours; 12-lead electrocardiogram in the emergency department; and hospitalization and treatment at the hospital stroke center.
- The cohort of 706 patients admitted to a single center in Shanghai, China, from December 2019 to December 2021, included 142 with episodes of acute AF and 564 without such episodes.
- Patients with acute ischemic stroke and acute AF – including AF of new onset, paroxysmal, persistent, or permanent with symptoms such as palpitations or dizziness attributed to rapid ventricular rates – were identified.
- Neurological deficits were assessed using the 7-day National Institutes of Health Stroke Scale/Score (NIHSS). Patients with a 7-day NIHSS score of at least 16 were considered to have moderate to severe stroke.
- Associations between acute AF onset and the severity of early neurological deficits were assessed and related to all-cause mortality within 30 days of the stroke.
Key results
- Patients with acute AF were older than those without acute AF (80.3 years vs. 71.0 years; P < .001).
- Baseline NIHSS scores averaged 16.09 for the stroke patients with acute AF and 8.65 for those without acute AF (P < .001).
- Significantly more patients with acute AF than without acute AF had a 7-day NIHSS score of at least 16 (45.1% vs. 14.4%; P < .001).
- More patients with than without acute AF underwent transcatheter thrombectomy (44.4% vs. 24.5%; P < .001) or received thrombolytic therapy (31.6% vs. 19.7%; P = .005).
- Patients aged 73 years or older showed baseline NIHSS score and acute AF as independent risk factors for early neurological deficits in stroke patients admitted to the emergency department.
- Mortality at 30 days was significantly higher in patients with acute AF than in those without acute AF (30.3% vs. 10.1%; P < .001).
- Baseline NIHSS had an adjusted odds ratio for 30-day mortality of 1.18 (95% confidence interval, 1.15-1.22; P < .001).
- Other independent predictors included acute AF (1.87 [95% CI, 1.09-3.19; P = .022]) and age 73 or older (2.00 [95% CI, 1.18-3.37; P = .01]).
Limitations
- The study was retrospective and didn’t have access to some potentially relevant data, such as duration of AF.
- The single-center study with limited generalizability does not necessarily represent the broad population of stroke patients in China or elsewhere.
Disclosures
- This study was supported by the Cardiovascular Multidisciplinary Integrated Research Fund and Construction of Shanghai Municipal Health Commission.
- The authors report no relevant financial relationships.
This is a summary of a preprint research study, “Acute Atrial Fibrillation During Onset of Stroke Indicates Higher Probability of Post-Stroke Death Outcomes,” written by Yongxia Li, from the Shanghai Sixth People’s Hospital, and colleagues, on ResearchSquare.com. This study has not yet been peer reviewed. The full text of the study can be found on ResearchSquare.com.A version of this article first appeared on Medscape.com.
The study covered in this summary was published on ResearchSquare.com as a preprint and has not yet been peer-reviewed.
Key takeaway
Why this matters
- A comprehensive understanding of the relationship between acute AF and risk for acute ischemic stroke and prognosis will help improve management and treatment of patients with acute ischemic stroke.
Study design
- The retrospective study included patients with acute ischemic stroke within the prior 24 hours; 12-lead electrocardiogram in the emergency department; and hospitalization and treatment at the hospital stroke center.
- The cohort of 706 patients admitted to a single center in Shanghai, China, from December 2019 to December 2021, included 142 with episodes of acute AF and 564 without such episodes.
- Patients with acute ischemic stroke and acute AF – including AF of new onset, paroxysmal, persistent, or permanent with symptoms such as palpitations or dizziness attributed to rapid ventricular rates – were identified.
- Neurological deficits were assessed using the 7-day National Institutes of Health Stroke Scale/Score (NIHSS). Patients with a 7-day NIHSS score of at least 16 were considered to have moderate to severe stroke.
- Associations between acute AF onset and the severity of early neurological deficits were assessed and related to all-cause mortality within 30 days of the stroke.
Key results
- Patients with acute AF were older than those without acute AF (80.3 years vs. 71.0 years; P < .001).
- Baseline NIHSS scores averaged 16.09 for the stroke patients with acute AF and 8.65 for those without acute AF (P < .001).
- Significantly more patients with acute AF than without acute AF had a 7-day NIHSS score of at least 16 (45.1% vs. 14.4%; P < .001).
- More patients with than without acute AF underwent transcatheter thrombectomy (44.4% vs. 24.5%; P < .001) or received thrombolytic therapy (31.6% vs. 19.7%; P = .005).
- Patients aged 73 years or older showed baseline NIHSS score and acute AF as independent risk factors for early neurological deficits in stroke patients admitted to the emergency department.
- Mortality at 30 days was significantly higher in patients with acute AF than in those without acute AF (30.3% vs. 10.1%; P < .001).
- Baseline NIHSS had an adjusted odds ratio for 30-day mortality of 1.18 (95% confidence interval, 1.15-1.22; P < .001).
- Other independent predictors included acute AF (1.87 [95% CI, 1.09-3.19; P = .022]) and age 73 or older (2.00 [95% CI, 1.18-3.37; P = .01]).
Limitations
- The study was retrospective and didn’t have access to some potentially relevant data, such as duration of AF.
- The single-center study with limited generalizability does not necessarily represent the broad population of stroke patients in China or elsewhere.
Disclosures
- This study was supported by the Cardiovascular Multidisciplinary Integrated Research Fund and Construction of Shanghai Municipal Health Commission.
- The authors report no relevant financial relationships.
This is a summary of a preprint research study, “Acute Atrial Fibrillation During Onset of Stroke Indicates Higher Probability of Post-Stroke Death Outcomes,” written by Yongxia Li, from the Shanghai Sixth People’s Hospital, and colleagues, on ResearchSquare.com. This study has not yet been peer reviewed. The full text of the study can be found on ResearchSquare.com.A version of this article first appeared on Medscape.com.
Electrolyte disturbances a harbinger of eating disorders?
Electrolyte abnormalities may serve as a precursor to a future eating disorder diagnosis, a finding that may help pinpoint candidates for screening.
Researchers found that adolescents and adults with electrolyte abnormalities on routine outpatient lab work were twice as likely as those without these disturbances to be subsequently diagnosed with an eating disorder.
“These electrolyte abnormalities were in fact seen well ahead (> 1 year on average) of the time when patients were diagnosed with eating disorders,” study investigator Gregory Hundemer, MD, department of nephrology, University of Ottawa, told this news organization.
“Incidentally discovered outpatient electrolyte abnormalities may help to identify individuals who may benefit from more targeted screening into an underlying eating disorder. This, in turn, may allow for earlier diagnosis and therapeutic intervention,” Dr. Hundemer said.
The study was published online in JAMA Network Open.
Tailored screening?
Electrolyte abnormalities are often found when an individual is diagnosed with an eating disorder, but it’s largely unknown whether electrolyte abnormalities prior to the acute presentation of an eating disorder are associated with the future diagnosis of an eating disorder.
To investigate, the researchers used administrative health data to match 6,970 individuals (mean age, 28 years; 13% male) with an eating disorder diagnosis to 27,878 controls without an eating disorder diagnosis.
They found that individuals with an eating disorder were more likely to have a preceding electrolyte abnormality, compared with peers without an eating disorder (18.4% vs. 7.5%).
An outpatient electrolyte abnormality present 3 years to 30 days prior to diagnosis was associated with about a twofold higher odds for subsequent eating disorder diagnosis (adjusted odds ratio, 2.12; 95% confidence interval, 1.86-2.41).
The median time from the earliest electrolyte abnormality to eating disorder diagnosis was 386 days (range, 157-716 days).
Hypokalemia was the most common electrolyte abnormality (present in 12% of cases vs. 5% of controls), while hyponatremia, hypernatremia, hypophosphatemia, and metabolic alkalosis were the most specific for a subsequent eating disorder diagnosis.
Severe hypokalemia (serum potassium levels of 3.0 mmol/L or lower) and severe hyponatremia (serum sodium, 128 mmol/L or lower) were associated with over sevenfold and fivefold higher odds for the diagnosis of an eating disorder, respectively.
The U.S. Preventive Services Task Force issued its first-ever statement on screening for eating disorders earlier this year.
The task force concluded that there is insufficient evidence to weigh the balance of benefits and harms of screening for eating disorders in adolescents and adults with no signs or symptoms of an eating disorder or concerns about their eating and who have not previously been diagnosed with an eating disorder.
Dr. Hundemer and colleagues believe an incidental electrolyte abnormality may identify candidates at high risk for an underlying eating disorder who many benefit from screening.
Several screening tools of varying complexity have been developed that are validated and accurate in identifying individuals with a potential eating disorder.
They include the SCOFF questionnaire, the Eating Disorder Screen for Primary Care, the Eating Attitudes Test, and the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire.
Underdiagnosed, undertreated
Offering perspective on the findings, Kamryn T. Eddy, PhD, codirector, Eating Disorders Clinical and Research Program, Massachusetts General Hospital, Boston, said the notion “that a physical sign may help to promote eating disorder assessment is important particularly given that early detection can improve outcomes.”
“But this finding appears in the current context of eating disorders going largely underdetected, underdiagnosed, and undertreated across medical and psychiatric settings,” said Dr. Eddy, associate professor, department of psychiatry, Harvard Medical School, Boston.
“Indeed, eating disorders are prevalent and cut across age, sex, gender, weight, race, ethnicity, and socioeconomic strata, and still, many providers do not routinely assess for eating disorders,” Dr. Eddy said.
“I might suggest that perhaps in addition to letting electrolyte abnormalities be a cue to screen for eating disorders, an even more powerful shift toward routine screening and assessment of eating disorders by medical providers be made,” Dr. Eddy said in an interview.
This study was supported by ICES, which is funded by an annual grant from the Ontario Ministry of Health and the Ministry of Health and Long-Term Care. Dr. Hundemer and Dr. Eddy have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Electrolyte abnormalities may serve as a precursor to a future eating disorder diagnosis, a finding that may help pinpoint candidates for screening.
Researchers found that adolescents and adults with electrolyte abnormalities on routine outpatient lab work were twice as likely as those without these disturbances to be subsequently diagnosed with an eating disorder.
“These electrolyte abnormalities were in fact seen well ahead (> 1 year on average) of the time when patients were diagnosed with eating disorders,” study investigator Gregory Hundemer, MD, department of nephrology, University of Ottawa, told this news organization.
“Incidentally discovered outpatient electrolyte abnormalities may help to identify individuals who may benefit from more targeted screening into an underlying eating disorder. This, in turn, may allow for earlier diagnosis and therapeutic intervention,” Dr. Hundemer said.
The study was published online in JAMA Network Open.
Tailored screening?
Electrolyte abnormalities are often found when an individual is diagnosed with an eating disorder, but it’s largely unknown whether electrolyte abnormalities prior to the acute presentation of an eating disorder are associated with the future diagnosis of an eating disorder.
To investigate, the researchers used administrative health data to match 6,970 individuals (mean age, 28 years; 13% male) with an eating disorder diagnosis to 27,878 controls without an eating disorder diagnosis.
They found that individuals with an eating disorder were more likely to have a preceding electrolyte abnormality, compared with peers without an eating disorder (18.4% vs. 7.5%).
An outpatient electrolyte abnormality present 3 years to 30 days prior to diagnosis was associated with about a twofold higher odds for subsequent eating disorder diagnosis (adjusted odds ratio, 2.12; 95% confidence interval, 1.86-2.41).
The median time from the earliest electrolyte abnormality to eating disorder diagnosis was 386 days (range, 157-716 days).
Hypokalemia was the most common electrolyte abnormality (present in 12% of cases vs. 5% of controls), while hyponatremia, hypernatremia, hypophosphatemia, and metabolic alkalosis were the most specific for a subsequent eating disorder diagnosis.
Severe hypokalemia (serum potassium levels of 3.0 mmol/L or lower) and severe hyponatremia (serum sodium, 128 mmol/L or lower) were associated with over sevenfold and fivefold higher odds for the diagnosis of an eating disorder, respectively.
The U.S. Preventive Services Task Force issued its first-ever statement on screening for eating disorders earlier this year.
The task force concluded that there is insufficient evidence to weigh the balance of benefits and harms of screening for eating disorders in adolescents and adults with no signs or symptoms of an eating disorder or concerns about their eating and who have not previously been diagnosed with an eating disorder.
Dr. Hundemer and colleagues believe an incidental electrolyte abnormality may identify candidates at high risk for an underlying eating disorder who many benefit from screening.
Several screening tools of varying complexity have been developed that are validated and accurate in identifying individuals with a potential eating disorder.
They include the SCOFF questionnaire, the Eating Disorder Screen for Primary Care, the Eating Attitudes Test, and the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire.
Underdiagnosed, undertreated
Offering perspective on the findings, Kamryn T. Eddy, PhD, codirector, Eating Disorders Clinical and Research Program, Massachusetts General Hospital, Boston, said the notion “that a physical sign may help to promote eating disorder assessment is important particularly given that early detection can improve outcomes.”
“But this finding appears in the current context of eating disorders going largely underdetected, underdiagnosed, and undertreated across medical and psychiatric settings,” said Dr. Eddy, associate professor, department of psychiatry, Harvard Medical School, Boston.
“Indeed, eating disorders are prevalent and cut across age, sex, gender, weight, race, ethnicity, and socioeconomic strata, and still, many providers do not routinely assess for eating disorders,” Dr. Eddy said.
“I might suggest that perhaps in addition to letting electrolyte abnormalities be a cue to screen for eating disorders, an even more powerful shift toward routine screening and assessment of eating disorders by medical providers be made,” Dr. Eddy said in an interview.
This study was supported by ICES, which is funded by an annual grant from the Ontario Ministry of Health and the Ministry of Health and Long-Term Care. Dr. Hundemer and Dr. Eddy have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Electrolyte abnormalities may serve as a precursor to a future eating disorder diagnosis, a finding that may help pinpoint candidates for screening.
Researchers found that adolescents and adults with electrolyte abnormalities on routine outpatient lab work were twice as likely as those without these disturbances to be subsequently diagnosed with an eating disorder.
“These electrolyte abnormalities were in fact seen well ahead (> 1 year on average) of the time when patients were diagnosed with eating disorders,” study investigator Gregory Hundemer, MD, department of nephrology, University of Ottawa, told this news organization.
“Incidentally discovered outpatient electrolyte abnormalities may help to identify individuals who may benefit from more targeted screening into an underlying eating disorder. This, in turn, may allow for earlier diagnosis and therapeutic intervention,” Dr. Hundemer said.
The study was published online in JAMA Network Open.
Tailored screening?
Electrolyte abnormalities are often found when an individual is diagnosed with an eating disorder, but it’s largely unknown whether electrolyte abnormalities prior to the acute presentation of an eating disorder are associated with the future diagnosis of an eating disorder.
To investigate, the researchers used administrative health data to match 6,970 individuals (mean age, 28 years; 13% male) with an eating disorder diagnosis to 27,878 controls without an eating disorder diagnosis.
They found that individuals with an eating disorder were more likely to have a preceding electrolyte abnormality, compared with peers without an eating disorder (18.4% vs. 7.5%).
An outpatient electrolyte abnormality present 3 years to 30 days prior to diagnosis was associated with about a twofold higher odds for subsequent eating disorder diagnosis (adjusted odds ratio, 2.12; 95% confidence interval, 1.86-2.41).
The median time from the earliest electrolyte abnormality to eating disorder diagnosis was 386 days (range, 157-716 days).
Hypokalemia was the most common electrolyte abnormality (present in 12% of cases vs. 5% of controls), while hyponatremia, hypernatremia, hypophosphatemia, and metabolic alkalosis were the most specific for a subsequent eating disorder diagnosis.
Severe hypokalemia (serum potassium levels of 3.0 mmol/L or lower) and severe hyponatremia (serum sodium, 128 mmol/L or lower) were associated with over sevenfold and fivefold higher odds for the diagnosis of an eating disorder, respectively.
The U.S. Preventive Services Task Force issued its first-ever statement on screening for eating disorders earlier this year.
The task force concluded that there is insufficient evidence to weigh the balance of benefits and harms of screening for eating disorders in adolescents and adults with no signs or symptoms of an eating disorder or concerns about their eating and who have not previously been diagnosed with an eating disorder.
Dr. Hundemer and colleagues believe an incidental electrolyte abnormality may identify candidates at high risk for an underlying eating disorder who many benefit from screening.
Several screening tools of varying complexity have been developed that are validated and accurate in identifying individuals with a potential eating disorder.
They include the SCOFF questionnaire, the Eating Disorder Screen for Primary Care, the Eating Attitudes Test, and the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire.
Underdiagnosed, undertreated
Offering perspective on the findings, Kamryn T. Eddy, PhD, codirector, Eating Disorders Clinical and Research Program, Massachusetts General Hospital, Boston, said the notion “that a physical sign may help to promote eating disorder assessment is important particularly given that early detection can improve outcomes.”
“But this finding appears in the current context of eating disorders going largely underdetected, underdiagnosed, and undertreated across medical and psychiatric settings,” said Dr. Eddy, associate professor, department of psychiatry, Harvard Medical School, Boston.
“Indeed, eating disorders are prevalent and cut across age, sex, gender, weight, race, ethnicity, and socioeconomic strata, and still, many providers do not routinely assess for eating disorders,” Dr. Eddy said.
“I might suggest that perhaps in addition to letting electrolyte abnormalities be a cue to screen for eating disorders, an even more powerful shift toward routine screening and assessment of eating disorders by medical providers be made,” Dr. Eddy said in an interview.
This study was supported by ICES, which is funded by an annual grant from the Ontario Ministry of Health and the Ministry of Health and Long-Term Care. Dr. Hundemer and Dr. Eddy have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM JAMA NETWORK OPEN
OSA raises risk of atrial fibrillation and stroke
compared with controls, based on data from 303 individuals.
OSA has become a common chronic disease, and cardiovascular diseases including AFib also are known independent risk factors associated with OSA, Anna Hojager, MD, of Zealand University Hospital, Roskilde, Denmark, and colleagues wrote. Previous studies have shown a significant increase in AFib risk in OSA patients with severe disease, but the prevalence of undiagnosed AFib in OSA patients has not been explored.
In a study published in Sleep Medicine, the researchers enrolled 238 adults with severe OSA (based on apnea-hypopnea index of 15 or higher) and 65 with mild or no OSA (based on an AHI of less than 15). The mean AHI across all participants was 34.2, and ranged from 0.2 to 115.8.
Participants underwent heart rhythm monitoring using a home system or standard ECG for 7 days; they were instructed to carry the device at all times except when showering or sweating heavily. The primary outcome was the detection of AFib, defined as at least one period of 30 seconds or longer with an irregular heart rhythm but without detectable evidence of another diagnosis. Sleep was assessed for one night using a portable sleep monitoring device. All participants were examined at baseline and measured for blood pressure, body mass index, waist-to-hip ratio, and ECG.
Overall, AFib occurred in 21 patients with moderate to severe OSA and 1 patient with mild/no OSA (8.8% vs. 1.5%, P = .045). The majority of patients across both groups had hypertension (66%) and dyslipidemia (77.6%), but the severe OSA group was more likely to be dysregulated and to have unknown prediabetes. Participants who were deemed candidates for anticoagulation therapy were referred for additional treatment. None of the 22 total patients with AFib had heart failure with reduced ejection fraction, and 68.2% had normal ejection fraction and ventricle function.
The researchers noted that no guidelines currently exist for systematic opportunistic screening for comorbidities in OSA patients, although the American Academy of Sleep Medicine recommends patient education as part of a multidisciplinary chronic disease management strategy. The high prevalence of AFib in OSA patients, as seen in the current study, “might warrant a recommendation of screening for paroxysmal [AFib] and could be valuable in the management of modifiable cardiovascular risk factors in patients with OSA,” they wrote.
The study findings were limited by several factors including the observational design and absence of polysomnography to assess OSA, the researchers noted. However, the study has the highest known prevalence of silent AFib in patients with moderate to severe OSA, and supports the value of screening and management for known comorbidities of OSA.
The study received no outside funding. The researchers had no financial conflicts to disclose.
compared with controls, based on data from 303 individuals.
OSA has become a common chronic disease, and cardiovascular diseases including AFib also are known independent risk factors associated with OSA, Anna Hojager, MD, of Zealand University Hospital, Roskilde, Denmark, and colleagues wrote. Previous studies have shown a significant increase in AFib risk in OSA patients with severe disease, but the prevalence of undiagnosed AFib in OSA patients has not been explored.
In a study published in Sleep Medicine, the researchers enrolled 238 adults with severe OSA (based on apnea-hypopnea index of 15 or higher) and 65 with mild or no OSA (based on an AHI of less than 15). The mean AHI across all participants was 34.2, and ranged from 0.2 to 115.8.
Participants underwent heart rhythm monitoring using a home system or standard ECG for 7 days; they were instructed to carry the device at all times except when showering or sweating heavily. The primary outcome was the detection of AFib, defined as at least one period of 30 seconds or longer with an irregular heart rhythm but without detectable evidence of another diagnosis. Sleep was assessed for one night using a portable sleep monitoring device. All participants were examined at baseline and measured for blood pressure, body mass index, waist-to-hip ratio, and ECG.
Overall, AFib occurred in 21 patients with moderate to severe OSA and 1 patient with mild/no OSA (8.8% vs. 1.5%, P = .045). The majority of patients across both groups had hypertension (66%) and dyslipidemia (77.6%), but the severe OSA group was more likely to be dysregulated and to have unknown prediabetes. Participants who were deemed candidates for anticoagulation therapy were referred for additional treatment. None of the 22 total patients with AFib had heart failure with reduced ejection fraction, and 68.2% had normal ejection fraction and ventricle function.
The researchers noted that no guidelines currently exist for systematic opportunistic screening for comorbidities in OSA patients, although the American Academy of Sleep Medicine recommends patient education as part of a multidisciplinary chronic disease management strategy. The high prevalence of AFib in OSA patients, as seen in the current study, “might warrant a recommendation of screening for paroxysmal [AFib] and could be valuable in the management of modifiable cardiovascular risk factors in patients with OSA,” they wrote.
The study findings were limited by several factors including the observational design and absence of polysomnography to assess OSA, the researchers noted. However, the study has the highest known prevalence of silent AFib in patients with moderate to severe OSA, and supports the value of screening and management for known comorbidities of OSA.
The study received no outside funding. The researchers had no financial conflicts to disclose.
compared with controls, based on data from 303 individuals.
OSA has become a common chronic disease, and cardiovascular diseases including AFib also are known independent risk factors associated with OSA, Anna Hojager, MD, of Zealand University Hospital, Roskilde, Denmark, and colleagues wrote. Previous studies have shown a significant increase in AFib risk in OSA patients with severe disease, but the prevalence of undiagnosed AFib in OSA patients has not been explored.
In a study published in Sleep Medicine, the researchers enrolled 238 adults with severe OSA (based on apnea-hypopnea index of 15 or higher) and 65 with mild or no OSA (based on an AHI of less than 15). The mean AHI across all participants was 34.2, and ranged from 0.2 to 115.8.
Participants underwent heart rhythm monitoring using a home system or standard ECG for 7 days; they were instructed to carry the device at all times except when showering or sweating heavily. The primary outcome was the detection of AFib, defined as at least one period of 30 seconds or longer with an irregular heart rhythm but without detectable evidence of another diagnosis. Sleep was assessed for one night using a portable sleep monitoring device. All participants were examined at baseline and measured for blood pressure, body mass index, waist-to-hip ratio, and ECG.
Overall, AFib occurred in 21 patients with moderate to severe OSA and 1 patient with mild/no OSA (8.8% vs. 1.5%, P = .045). The majority of patients across both groups had hypertension (66%) and dyslipidemia (77.6%), but the severe OSA group was more likely to be dysregulated and to have unknown prediabetes. Participants who were deemed candidates for anticoagulation therapy were referred for additional treatment. None of the 22 total patients with AFib had heart failure with reduced ejection fraction, and 68.2% had normal ejection fraction and ventricle function.
The researchers noted that no guidelines currently exist for systematic opportunistic screening for comorbidities in OSA patients, although the American Academy of Sleep Medicine recommends patient education as part of a multidisciplinary chronic disease management strategy. The high prevalence of AFib in OSA patients, as seen in the current study, “might warrant a recommendation of screening for paroxysmal [AFib] and could be valuable in the management of modifiable cardiovascular risk factors in patients with OSA,” they wrote.
The study findings were limited by several factors including the observational design and absence of polysomnography to assess OSA, the researchers noted. However, the study has the highest known prevalence of silent AFib in patients with moderate to severe OSA, and supports the value of screening and management for known comorbidities of OSA.
The study received no outside funding. The researchers had no financial conflicts to disclose.
FROM SLEEP MEDICINE
First-line AFib ablation cuts risk of progression vs. drug therapy
CHICAGO – Early ablation of atrial fibrillation (AFib) reduces the risk of progression, compared with antiarrhythmic therapies, according to results of a multicenter, randomized trial called PROGRESSIVE-AF.
Over 36 months of follow-up, the trial linked early ablation with a reduced risk of persistent AFib (1.9% vs. 7.4%), and in addition, those in the ablation group were less likely to have recurrent atrial tachyarrhythmias of any kind (56.5% vs. 77.2%), reported Jason G. Andrade, MD, at the American Heart Association scientific sessions.
Serving as a long-term extension of the EARLY-AF trial published almost 2 years ago, this trial expands evidence that progressive AFib can be attenuated, a concept that has been debated.
“Can early AFib ablation stop progression?” asked Carina Blomström-Lindqvist, MD, PhD. The invited discussant for the PROGRESSION-AF trial, Dr. Blomström-Lundqvist concluded, “here is another set of data that suggests it can.”
By another set of data, Dr. Blomström-Lindqvist was referring to a previously published multinational study called ATTEST In this study, which involved 29 sites worldwide and compared radiofrequency ablation to antiarrhythmic drug therapy, early ablation also produced a lower risk of persistent AFib at the end of 3 years (2.4% vs. 17.5%; P = .0009).
In the previously published open-label EARLY-AF trial, 303 patients with paroxysmal, untreated AFib were randomized to cryoballoon ablation or antiarrhythmic drugs. The primary endpoint was the first documented recurrence of an atrial tachyarrhythmia between 91 and 365 days. The lower rate following ablation (42.9% vs. 67.8%) represented a more than 50% reduction in risk (hazard ratio, 0.48; P < .001) relative to antiarrhythmic therapy.
In PROGRESSIVE-AF, the same 303 patients were monitored continuously for an additional 24 months with an implanted cardiac monitor programmed with an AFib-detection algorithm. The data from the monitor were obtained daily. Over the final 2 years of the study, office visits were conducted every 6 months.
Tachyarrhythmias represent primary endpoint
In addition to persistent AFib, defined as lasting ≥ 7 days or lasting 48 hours to 7 days but requiring cardioversion for termination, patients in PROGRESSIVE-AF were also monitored for recurrent atrial tachyarrhythmias, AFib burden, quality of life (QOL), and health care utilization, and safety.
The average age was roughly 58 years. Although more than one-third had hypertension, most had no other comorbidities. The authors emphasized that the study population overall was relatively young and healthy.
Those randomized to antiarrhythmic therapy in EARLY-AF/PROGRESSIVE-AF received commonly prescribed therapies titrated to maximally tolerated doses using standardized protocols. At the start of EARLY-AF, flecainide, taken by 65% of patients, was the most commonly used agent, followed by sotalol, propafenone, dronedarone, and amiodarone.
At the end of PROGRESSIVE-AF, the order of the most common therapies did not change relative to EARLY-AF, but only 49% of patients were taking flecainide and 31% were no longer taking any antiarrhythmic therapy.
At the end of 3 years of follow-up in EARLY-AF/PROGRESSIVE-AF, the difference in persistent AFib represented a 75% reduction in favor of early ablation (HR, 0.25; 95% confidence interval, 0.09-0.70).
In those treated with ablation relative to those treated with antiarrhythmic therapy, the lower rate of atrial tachyarrhythmia lasting more than 7 days (1.9% vs. 6.0%) represented a 70% risk reduction (HR, 0.30; 95% CI 0.10-0.93). The protection from cardioversion for atrial tachyarrhythmia lasting between 2 and 7 days in duration (0.6% vs. 4.7%) translated into an 86% relative reduction (HR, 0.14; 95% CI, 0.02-0.85).
The impact on QOL for those randomized to ablation, which was measured with both AFib-specific and generic measures, was meaningful to patients, according to Dr. Andrade, director of the Cardiac Electrophysiology Laboratory, Vancouver General Hospital.
For example, the mean difference in the AF Quality of Life Survey (AFEQT), was 8.0 at 1 year and 7.4 at 3 years in favor of ablation. A change of 5 points in this score is considered to be a clinically meaningful difference, according to Dr. Andrade.
Numerically, the relative risk of emergency room visits and cardioversion were lower in the ablation group, but the differences did not reach statistical significance. However, the lower hazard ratio for hospitalization was significant (HR, 0.31; 95% CI, 0.15-0.66), supporting a reduction in consumption of health care resources.
Ablation found safer than drugs
The rate of adverse events of any kind (11.0% vs. 23.5%) and serious adverse events (4.5% vs. 10.1%) were lower in the ablation group.
There were no differences in major adverse cardiovascular events observed in this period of follow-up, but Dr. Andrade pointed out that follow-up was not long enough to expect differences in these events.
Impressed by the magnitude of the reduction in persistent AFib in a population of relatively young and healthy patients considered to be at a low risk of AFib progression, Dr. Blomström-Lindqvist, a professor of cardiology at the Institution of Medical Science, Uppsala, Sweden, indicated that the data support early ablation as a means to reduce risk of this outcome.
However, she did caution that progressive AFib was observed in a relatively small proportion of patients managed with antiarrhythmic therapy at 3 years, an outcome relevant when discussing treatment options with patients.
The results were published in New England Journal of Medicine simultaneously with Dr. Andrade’s presentation.
Dr. Andrade reports financial relationships with Bayer, Bayliss, Biosense, Bristol-Myers Squibb, Medtronic and Servier. The trial, funded largely by the Canadian government and Canadian professional societies, received additional funding from Bayliss and Medtronic. Dr. Blomström-Lundqvist reports financial relationships with Bayer, Boston Scientific, Cathprint, Medtronic, and Sanofi.
CHICAGO – Early ablation of atrial fibrillation (AFib) reduces the risk of progression, compared with antiarrhythmic therapies, according to results of a multicenter, randomized trial called PROGRESSIVE-AF.
Over 36 months of follow-up, the trial linked early ablation with a reduced risk of persistent AFib (1.9% vs. 7.4%), and in addition, those in the ablation group were less likely to have recurrent atrial tachyarrhythmias of any kind (56.5% vs. 77.2%), reported Jason G. Andrade, MD, at the American Heart Association scientific sessions.
Serving as a long-term extension of the EARLY-AF trial published almost 2 years ago, this trial expands evidence that progressive AFib can be attenuated, a concept that has been debated.
“Can early AFib ablation stop progression?” asked Carina Blomström-Lindqvist, MD, PhD. The invited discussant for the PROGRESSION-AF trial, Dr. Blomström-Lundqvist concluded, “here is another set of data that suggests it can.”
By another set of data, Dr. Blomström-Lindqvist was referring to a previously published multinational study called ATTEST In this study, which involved 29 sites worldwide and compared radiofrequency ablation to antiarrhythmic drug therapy, early ablation also produced a lower risk of persistent AFib at the end of 3 years (2.4% vs. 17.5%; P = .0009).
In the previously published open-label EARLY-AF trial, 303 patients with paroxysmal, untreated AFib were randomized to cryoballoon ablation or antiarrhythmic drugs. The primary endpoint was the first documented recurrence of an atrial tachyarrhythmia between 91 and 365 days. The lower rate following ablation (42.9% vs. 67.8%) represented a more than 50% reduction in risk (hazard ratio, 0.48; P < .001) relative to antiarrhythmic therapy.
In PROGRESSIVE-AF, the same 303 patients were monitored continuously for an additional 24 months with an implanted cardiac monitor programmed with an AFib-detection algorithm. The data from the monitor were obtained daily. Over the final 2 years of the study, office visits were conducted every 6 months.
Tachyarrhythmias represent primary endpoint
In addition to persistent AFib, defined as lasting ≥ 7 days or lasting 48 hours to 7 days but requiring cardioversion for termination, patients in PROGRESSIVE-AF were also monitored for recurrent atrial tachyarrhythmias, AFib burden, quality of life (QOL), and health care utilization, and safety.
The average age was roughly 58 years. Although more than one-third had hypertension, most had no other comorbidities. The authors emphasized that the study population overall was relatively young and healthy.
Those randomized to antiarrhythmic therapy in EARLY-AF/PROGRESSIVE-AF received commonly prescribed therapies titrated to maximally tolerated doses using standardized protocols. At the start of EARLY-AF, flecainide, taken by 65% of patients, was the most commonly used agent, followed by sotalol, propafenone, dronedarone, and amiodarone.
At the end of PROGRESSIVE-AF, the order of the most common therapies did not change relative to EARLY-AF, but only 49% of patients were taking flecainide and 31% were no longer taking any antiarrhythmic therapy.
At the end of 3 years of follow-up in EARLY-AF/PROGRESSIVE-AF, the difference in persistent AFib represented a 75% reduction in favor of early ablation (HR, 0.25; 95% confidence interval, 0.09-0.70).
In those treated with ablation relative to those treated with antiarrhythmic therapy, the lower rate of atrial tachyarrhythmia lasting more than 7 days (1.9% vs. 6.0%) represented a 70% risk reduction (HR, 0.30; 95% CI 0.10-0.93). The protection from cardioversion for atrial tachyarrhythmia lasting between 2 and 7 days in duration (0.6% vs. 4.7%) translated into an 86% relative reduction (HR, 0.14; 95% CI, 0.02-0.85).
The impact on QOL for those randomized to ablation, which was measured with both AFib-specific and generic measures, was meaningful to patients, according to Dr. Andrade, director of the Cardiac Electrophysiology Laboratory, Vancouver General Hospital.
For example, the mean difference in the AF Quality of Life Survey (AFEQT), was 8.0 at 1 year and 7.4 at 3 years in favor of ablation. A change of 5 points in this score is considered to be a clinically meaningful difference, according to Dr. Andrade.
Numerically, the relative risk of emergency room visits and cardioversion were lower in the ablation group, but the differences did not reach statistical significance. However, the lower hazard ratio for hospitalization was significant (HR, 0.31; 95% CI, 0.15-0.66), supporting a reduction in consumption of health care resources.
Ablation found safer than drugs
The rate of adverse events of any kind (11.0% vs. 23.5%) and serious adverse events (4.5% vs. 10.1%) were lower in the ablation group.
There were no differences in major adverse cardiovascular events observed in this period of follow-up, but Dr. Andrade pointed out that follow-up was not long enough to expect differences in these events.
Impressed by the magnitude of the reduction in persistent AFib in a population of relatively young and healthy patients considered to be at a low risk of AFib progression, Dr. Blomström-Lindqvist, a professor of cardiology at the Institution of Medical Science, Uppsala, Sweden, indicated that the data support early ablation as a means to reduce risk of this outcome.
However, she did caution that progressive AFib was observed in a relatively small proportion of patients managed with antiarrhythmic therapy at 3 years, an outcome relevant when discussing treatment options with patients.
The results were published in New England Journal of Medicine simultaneously with Dr. Andrade’s presentation.
Dr. Andrade reports financial relationships with Bayer, Bayliss, Biosense, Bristol-Myers Squibb, Medtronic and Servier. The trial, funded largely by the Canadian government and Canadian professional societies, received additional funding from Bayliss and Medtronic. Dr. Blomström-Lundqvist reports financial relationships with Bayer, Boston Scientific, Cathprint, Medtronic, and Sanofi.
CHICAGO – Early ablation of atrial fibrillation (AFib) reduces the risk of progression, compared with antiarrhythmic therapies, according to results of a multicenter, randomized trial called PROGRESSIVE-AF.
Over 36 months of follow-up, the trial linked early ablation with a reduced risk of persistent AFib (1.9% vs. 7.4%), and in addition, those in the ablation group were less likely to have recurrent atrial tachyarrhythmias of any kind (56.5% vs. 77.2%), reported Jason G. Andrade, MD, at the American Heart Association scientific sessions.
Serving as a long-term extension of the EARLY-AF trial published almost 2 years ago, this trial expands evidence that progressive AFib can be attenuated, a concept that has been debated.
“Can early AFib ablation stop progression?” asked Carina Blomström-Lindqvist, MD, PhD. The invited discussant for the PROGRESSION-AF trial, Dr. Blomström-Lundqvist concluded, “here is another set of data that suggests it can.”
By another set of data, Dr. Blomström-Lindqvist was referring to a previously published multinational study called ATTEST In this study, which involved 29 sites worldwide and compared radiofrequency ablation to antiarrhythmic drug therapy, early ablation also produced a lower risk of persistent AFib at the end of 3 years (2.4% vs. 17.5%; P = .0009).
In the previously published open-label EARLY-AF trial, 303 patients with paroxysmal, untreated AFib were randomized to cryoballoon ablation or antiarrhythmic drugs. The primary endpoint was the first documented recurrence of an atrial tachyarrhythmia between 91 and 365 days. The lower rate following ablation (42.9% vs. 67.8%) represented a more than 50% reduction in risk (hazard ratio, 0.48; P < .001) relative to antiarrhythmic therapy.
In PROGRESSIVE-AF, the same 303 patients were monitored continuously for an additional 24 months with an implanted cardiac monitor programmed with an AFib-detection algorithm. The data from the monitor were obtained daily. Over the final 2 years of the study, office visits were conducted every 6 months.
Tachyarrhythmias represent primary endpoint
In addition to persistent AFib, defined as lasting ≥ 7 days or lasting 48 hours to 7 days but requiring cardioversion for termination, patients in PROGRESSIVE-AF were also monitored for recurrent atrial tachyarrhythmias, AFib burden, quality of life (QOL), and health care utilization, and safety.
The average age was roughly 58 years. Although more than one-third had hypertension, most had no other comorbidities. The authors emphasized that the study population overall was relatively young and healthy.
Those randomized to antiarrhythmic therapy in EARLY-AF/PROGRESSIVE-AF received commonly prescribed therapies titrated to maximally tolerated doses using standardized protocols. At the start of EARLY-AF, flecainide, taken by 65% of patients, was the most commonly used agent, followed by sotalol, propafenone, dronedarone, and amiodarone.
At the end of PROGRESSIVE-AF, the order of the most common therapies did not change relative to EARLY-AF, but only 49% of patients were taking flecainide and 31% were no longer taking any antiarrhythmic therapy.
At the end of 3 years of follow-up in EARLY-AF/PROGRESSIVE-AF, the difference in persistent AFib represented a 75% reduction in favor of early ablation (HR, 0.25; 95% confidence interval, 0.09-0.70).
In those treated with ablation relative to those treated with antiarrhythmic therapy, the lower rate of atrial tachyarrhythmia lasting more than 7 days (1.9% vs. 6.0%) represented a 70% risk reduction (HR, 0.30; 95% CI 0.10-0.93). The protection from cardioversion for atrial tachyarrhythmia lasting between 2 and 7 days in duration (0.6% vs. 4.7%) translated into an 86% relative reduction (HR, 0.14; 95% CI, 0.02-0.85).
The impact on QOL for those randomized to ablation, which was measured with both AFib-specific and generic measures, was meaningful to patients, according to Dr. Andrade, director of the Cardiac Electrophysiology Laboratory, Vancouver General Hospital.
For example, the mean difference in the AF Quality of Life Survey (AFEQT), was 8.0 at 1 year and 7.4 at 3 years in favor of ablation. A change of 5 points in this score is considered to be a clinically meaningful difference, according to Dr. Andrade.
Numerically, the relative risk of emergency room visits and cardioversion were lower in the ablation group, but the differences did not reach statistical significance. However, the lower hazard ratio for hospitalization was significant (HR, 0.31; 95% CI, 0.15-0.66), supporting a reduction in consumption of health care resources.
Ablation found safer than drugs
The rate of adverse events of any kind (11.0% vs. 23.5%) and serious adverse events (4.5% vs. 10.1%) were lower in the ablation group.
There were no differences in major adverse cardiovascular events observed in this period of follow-up, but Dr. Andrade pointed out that follow-up was not long enough to expect differences in these events.
Impressed by the magnitude of the reduction in persistent AFib in a population of relatively young and healthy patients considered to be at a low risk of AFib progression, Dr. Blomström-Lindqvist, a professor of cardiology at the Institution of Medical Science, Uppsala, Sweden, indicated that the data support early ablation as a means to reduce risk of this outcome.
However, she did caution that progressive AFib was observed in a relatively small proportion of patients managed with antiarrhythmic therapy at 3 years, an outcome relevant when discussing treatment options with patients.
The results were published in New England Journal of Medicine simultaneously with Dr. Andrade’s presentation.
Dr. Andrade reports financial relationships with Bayer, Bayliss, Biosense, Bristol-Myers Squibb, Medtronic and Servier. The trial, funded largely by the Canadian government and Canadian professional societies, received additional funding from Bayliss and Medtronic. Dr. Blomström-Lundqvist reports financial relationships with Bayer, Boston Scientific, Cathprint, Medtronic, and Sanofi.
AT AHA 2022
AHA 2022 to recapture in-person vibe but preserve global reach
That a bustling medical conference can have global reach as it unfolds is one of the COVID pandemic’s many lessons for science. Hybrid meetings such as the American Heart Association scientific sessions, getting underway Nov. 5 in Chicago and cyberspace, are one of its legacies.
The conference is set to recapture the magic of the in-person Scientific Sessions last experienced in Philadelphia in 2019. But planners are mindful of a special responsibility to younger clinicians and scientists who entered the field knowing only the virtual format and who may not know “what it’s like in a room when major science is presented or to present posters and have people come by for conversations,” Manesh R. Patel, MD, chair of the AHA 2022 Scientific Sessions program committee, told this news organization.
Still, the pandemic has underlined the value of live streaming for the great many who can’t attend in person, Dr. Patel said. At AHA 2022, virtual access doesn’t mean only late breaking and featured presentations; more than 70 full sessions will be streamed from Friday through Monday.
Overall, the conference has more than 800 sessions on the schedule, about a third are panels or invited lectures and two-thirds are original reports on the latest research. At the core of the research offerings, 78 studies and analyses are slated across 18 Late-Breaking Science (LBS) and Featured Science (FS) sessions from Saturday through Monday. At least 30 presentations and abstracts will enter the peer-reviewed literature right away with their simultaneous online publication, Dr. Patel said.
More a meet-and-greet than a presentation, the Puppy Snuggles Booth will make a return appearance in Chicago after earning rave reviews at the 2019 Sessions in Philadelphia. All are invited to take a breather from their schedules to pet, cuddle, and play with a passel of pups, all in need of homes and available for adoption. The experience’s favorable effect on blood pressure is almost guaranteed.
LBS and FS highlights
“It’s an amazing year for Late Breaking Science and Featured Science at the Scientific Sessions,” Dr. Patel said of the presentations selected for special attention after a rigorous review process. “We have science that is as broad and as deep as we’ve seen in years.”
Saturday’s two LBS sessions kick off the series with studies looking at agents long available in heart failure and hypertension but lacking solid supporting evidence, “pretty large randomized trials that are, we think, going to affect clinical practice as soon as they are presented,” Dr. Patel said.
They include TRANSFORM-HF, a comparison of the loop diuretics furosemide and torsemide in patients hospitalized with heart failure. And the Diuretic Comparison Project (DCP), with more than 13,000 patients with hypertension assigned to the diuretics chlorthalidone or hydrochlorothiazide, “is going to immediately impact how people think about blood pressure management,” Dr. Patel said.
Other highlights in the hypertension arena include the CRHCP trial, the MB-BP study, the Rich Life Project, and the polypill efficacy and safety trial QUARTET-USA, all in Sunday’s LBS-4; and the FRESH, PRECISION, and BrigHTN trials, all in LBS-9 on Monday.
Other heart failure trials joining TRANSFORM-HF in the line-up include IRONMAN, which revisited IV iron therapy in iron-deficient patients, in LBS-2 on Saturday and, in FS-4 on Monday, BETA3LVH and STRONG-HF, the latter a timely randomized test of pre- and post-discharge biomarker-driven uptitration of guideline-directed heart failure meds.
STRONG-HF was halted early, the trial’s nonprofit sponsor announced only weeks ago, after patients following the intensive uptitration strategy versus usual care showed a reduced risk of death or heart failure readmission; few other details were given.
Several sessions will be devoted to a rare breed of randomized trial, one that tests the efficacy of traditional herbal meds or nonprescription supplements against proven medications. “These are going to get a lot of people’s interest, one can imagine, because they are on common questions that patients bring to the clinic every day,” Dr. Patel said.
Such studies include CTS-AMI, which explored the traditional Chinese herbal medicine tongxinluo in ST-segment elevation myocardial infarction, in LBS-3 on Sunday, and SPORT in Sunday’s LBS-5, a small randomized comparison of low-dose rosuvastatin, cinnamon, garlic, turmeric, an omega-3 fish-oil supplement, a plant sterol, red yeast rice, and placebo for any effects on LDL-C levels.
Other novel approaches to dyslipidemia management are to be covered in RESPECT-EPA and OCEAN(a)-DOSE, both in LBS-5 on Sunday, and all five presentations in Monday’s FS-9, including ARCHES-2, SHASTA-2, FOURIER-OLE, and ORION-3.
The interplay of antiplatelets and coronary interventions will be explored in presentations called OPTION, in LBS-6 on Sunday, and HOST-EXAM and TWILIGHT, in FS-6 on Monday.
Coronary and peripheral-vascular interventions are center stage in reports on RAPCO in LBS-3 and BRIGHT-4 in LBS-6, both on Sunday, and BEST-CLI in LBS-7 and the After-80 Study in FS-6, both on Monday.
Several Monday reports will cover comorbidities and complications associated with COVID-19, including PREVENT-HD in LBS-7, and PANAMO, FERMIN, COVID-NET, and a secondary analysis of the DELIVER trial in FS-5.
Rebroadcasts for the Pacific Rim
The sessions will also feature several evening rebroadcasts of earlier LBS sessions that meeting planners scored highly for scientific merit and potential clinical impact but also for their “regional pull,” primarily for our colleagues in Asia, Dr. Patel said.
The first two LBS sessions presented live during the day in Chicago will be rebroadcast that evening as, for example, Sunday morning and afternoon fare in Tokyo and Singapore. And LBS-5 live Sunday afternoon will rebroadcast that night as a Monday mid-morning session in, say, Hong Kong or Seoul.
This year’s AHA meeting spans the range of cardiovascular care, from precision therapies, such as gene editing or specific drugs, to broad strategies that consider, for example, social determinants of health, Dr. Patel said. “I think people, when they leave the Scientific Sessions, will feel very engaged in the larger conversation about how you impact very common conditions globally.”
A version of this article first appeared on Medscape.com.
That a bustling medical conference can have global reach as it unfolds is one of the COVID pandemic’s many lessons for science. Hybrid meetings such as the American Heart Association scientific sessions, getting underway Nov. 5 in Chicago and cyberspace, are one of its legacies.
The conference is set to recapture the magic of the in-person Scientific Sessions last experienced in Philadelphia in 2019. But planners are mindful of a special responsibility to younger clinicians and scientists who entered the field knowing only the virtual format and who may not know “what it’s like in a room when major science is presented or to present posters and have people come by for conversations,” Manesh R. Patel, MD, chair of the AHA 2022 Scientific Sessions program committee, told this news organization.
Still, the pandemic has underlined the value of live streaming for the great many who can’t attend in person, Dr. Patel said. At AHA 2022, virtual access doesn’t mean only late breaking and featured presentations; more than 70 full sessions will be streamed from Friday through Monday.
Overall, the conference has more than 800 sessions on the schedule, about a third are panels or invited lectures and two-thirds are original reports on the latest research. At the core of the research offerings, 78 studies and analyses are slated across 18 Late-Breaking Science (LBS) and Featured Science (FS) sessions from Saturday through Monday. At least 30 presentations and abstracts will enter the peer-reviewed literature right away with their simultaneous online publication, Dr. Patel said.
More a meet-and-greet than a presentation, the Puppy Snuggles Booth will make a return appearance in Chicago after earning rave reviews at the 2019 Sessions in Philadelphia. All are invited to take a breather from their schedules to pet, cuddle, and play with a passel of pups, all in need of homes and available for adoption. The experience’s favorable effect on blood pressure is almost guaranteed.
LBS and FS highlights
“It’s an amazing year for Late Breaking Science and Featured Science at the Scientific Sessions,” Dr. Patel said of the presentations selected for special attention after a rigorous review process. “We have science that is as broad and as deep as we’ve seen in years.”
Saturday’s two LBS sessions kick off the series with studies looking at agents long available in heart failure and hypertension but lacking solid supporting evidence, “pretty large randomized trials that are, we think, going to affect clinical practice as soon as they are presented,” Dr. Patel said.
They include TRANSFORM-HF, a comparison of the loop diuretics furosemide and torsemide in patients hospitalized with heart failure. And the Diuretic Comparison Project (DCP), with more than 13,000 patients with hypertension assigned to the diuretics chlorthalidone or hydrochlorothiazide, “is going to immediately impact how people think about blood pressure management,” Dr. Patel said.
Other highlights in the hypertension arena include the CRHCP trial, the MB-BP study, the Rich Life Project, and the polypill efficacy and safety trial QUARTET-USA, all in Sunday’s LBS-4; and the FRESH, PRECISION, and BrigHTN trials, all in LBS-9 on Monday.
Other heart failure trials joining TRANSFORM-HF in the line-up include IRONMAN, which revisited IV iron therapy in iron-deficient patients, in LBS-2 on Saturday and, in FS-4 on Monday, BETA3LVH and STRONG-HF, the latter a timely randomized test of pre- and post-discharge biomarker-driven uptitration of guideline-directed heart failure meds.
STRONG-HF was halted early, the trial’s nonprofit sponsor announced only weeks ago, after patients following the intensive uptitration strategy versus usual care showed a reduced risk of death or heart failure readmission; few other details were given.
Several sessions will be devoted to a rare breed of randomized trial, one that tests the efficacy of traditional herbal meds or nonprescription supplements against proven medications. “These are going to get a lot of people’s interest, one can imagine, because they are on common questions that patients bring to the clinic every day,” Dr. Patel said.
Such studies include CTS-AMI, which explored the traditional Chinese herbal medicine tongxinluo in ST-segment elevation myocardial infarction, in LBS-3 on Sunday, and SPORT in Sunday’s LBS-5, a small randomized comparison of low-dose rosuvastatin, cinnamon, garlic, turmeric, an omega-3 fish-oil supplement, a plant sterol, red yeast rice, and placebo for any effects on LDL-C levels.
Other novel approaches to dyslipidemia management are to be covered in RESPECT-EPA and OCEAN(a)-DOSE, both in LBS-5 on Sunday, and all five presentations in Monday’s FS-9, including ARCHES-2, SHASTA-2, FOURIER-OLE, and ORION-3.
The interplay of antiplatelets and coronary interventions will be explored in presentations called OPTION, in LBS-6 on Sunday, and HOST-EXAM and TWILIGHT, in FS-6 on Monday.
Coronary and peripheral-vascular interventions are center stage in reports on RAPCO in LBS-3 and BRIGHT-4 in LBS-6, both on Sunday, and BEST-CLI in LBS-7 and the After-80 Study in FS-6, both on Monday.
Several Monday reports will cover comorbidities and complications associated with COVID-19, including PREVENT-HD in LBS-7, and PANAMO, FERMIN, COVID-NET, and a secondary analysis of the DELIVER trial in FS-5.
Rebroadcasts for the Pacific Rim
The sessions will also feature several evening rebroadcasts of earlier LBS sessions that meeting planners scored highly for scientific merit and potential clinical impact but also for their “regional pull,” primarily for our colleagues in Asia, Dr. Patel said.
The first two LBS sessions presented live during the day in Chicago will be rebroadcast that evening as, for example, Sunday morning and afternoon fare in Tokyo and Singapore. And LBS-5 live Sunday afternoon will rebroadcast that night as a Monday mid-morning session in, say, Hong Kong or Seoul.
This year’s AHA meeting spans the range of cardiovascular care, from precision therapies, such as gene editing or specific drugs, to broad strategies that consider, for example, social determinants of health, Dr. Patel said. “I think people, when they leave the Scientific Sessions, will feel very engaged in the larger conversation about how you impact very common conditions globally.”
A version of this article first appeared on Medscape.com.
That a bustling medical conference can have global reach as it unfolds is one of the COVID pandemic’s many lessons for science. Hybrid meetings such as the American Heart Association scientific sessions, getting underway Nov. 5 in Chicago and cyberspace, are one of its legacies.
The conference is set to recapture the magic of the in-person Scientific Sessions last experienced in Philadelphia in 2019. But planners are mindful of a special responsibility to younger clinicians and scientists who entered the field knowing only the virtual format and who may not know “what it’s like in a room when major science is presented or to present posters and have people come by for conversations,” Manesh R. Patel, MD, chair of the AHA 2022 Scientific Sessions program committee, told this news organization.
Still, the pandemic has underlined the value of live streaming for the great many who can’t attend in person, Dr. Patel said. At AHA 2022, virtual access doesn’t mean only late breaking and featured presentations; more than 70 full sessions will be streamed from Friday through Monday.
Overall, the conference has more than 800 sessions on the schedule, about a third are panels or invited lectures and two-thirds are original reports on the latest research. At the core of the research offerings, 78 studies and analyses are slated across 18 Late-Breaking Science (LBS) and Featured Science (FS) sessions from Saturday through Monday. At least 30 presentations and abstracts will enter the peer-reviewed literature right away with their simultaneous online publication, Dr. Patel said.
More a meet-and-greet than a presentation, the Puppy Snuggles Booth will make a return appearance in Chicago after earning rave reviews at the 2019 Sessions in Philadelphia. All are invited to take a breather from their schedules to pet, cuddle, and play with a passel of pups, all in need of homes and available for adoption. The experience’s favorable effect on blood pressure is almost guaranteed.
LBS and FS highlights
“It’s an amazing year for Late Breaking Science and Featured Science at the Scientific Sessions,” Dr. Patel said of the presentations selected for special attention after a rigorous review process. “We have science that is as broad and as deep as we’ve seen in years.”
Saturday’s two LBS sessions kick off the series with studies looking at agents long available in heart failure and hypertension but lacking solid supporting evidence, “pretty large randomized trials that are, we think, going to affect clinical practice as soon as they are presented,” Dr. Patel said.
They include TRANSFORM-HF, a comparison of the loop diuretics furosemide and torsemide in patients hospitalized with heart failure. And the Diuretic Comparison Project (DCP), with more than 13,000 patients with hypertension assigned to the diuretics chlorthalidone or hydrochlorothiazide, “is going to immediately impact how people think about blood pressure management,” Dr. Patel said.
Other highlights in the hypertension arena include the CRHCP trial, the MB-BP study, the Rich Life Project, and the polypill efficacy and safety trial QUARTET-USA, all in Sunday’s LBS-4; and the FRESH, PRECISION, and BrigHTN trials, all in LBS-9 on Monday.
Other heart failure trials joining TRANSFORM-HF in the line-up include IRONMAN, which revisited IV iron therapy in iron-deficient patients, in LBS-2 on Saturday and, in FS-4 on Monday, BETA3LVH and STRONG-HF, the latter a timely randomized test of pre- and post-discharge biomarker-driven uptitration of guideline-directed heart failure meds.
STRONG-HF was halted early, the trial’s nonprofit sponsor announced only weeks ago, after patients following the intensive uptitration strategy versus usual care showed a reduced risk of death or heart failure readmission; few other details were given.
Several sessions will be devoted to a rare breed of randomized trial, one that tests the efficacy of traditional herbal meds or nonprescription supplements against proven medications. “These are going to get a lot of people’s interest, one can imagine, because they are on common questions that patients bring to the clinic every day,” Dr. Patel said.
Such studies include CTS-AMI, which explored the traditional Chinese herbal medicine tongxinluo in ST-segment elevation myocardial infarction, in LBS-3 on Sunday, and SPORT in Sunday’s LBS-5, a small randomized comparison of low-dose rosuvastatin, cinnamon, garlic, turmeric, an omega-3 fish-oil supplement, a plant sterol, red yeast rice, and placebo for any effects on LDL-C levels.
Other novel approaches to dyslipidemia management are to be covered in RESPECT-EPA and OCEAN(a)-DOSE, both in LBS-5 on Sunday, and all five presentations in Monday’s FS-9, including ARCHES-2, SHASTA-2, FOURIER-OLE, and ORION-3.
The interplay of antiplatelets and coronary interventions will be explored in presentations called OPTION, in LBS-6 on Sunday, and HOST-EXAM and TWILIGHT, in FS-6 on Monday.
Coronary and peripheral-vascular interventions are center stage in reports on RAPCO in LBS-3 and BRIGHT-4 in LBS-6, both on Sunday, and BEST-CLI in LBS-7 and the After-80 Study in FS-6, both on Monday.
Several Monday reports will cover comorbidities and complications associated with COVID-19, including PREVENT-HD in LBS-7, and PANAMO, FERMIN, COVID-NET, and a secondary analysis of the DELIVER trial in FS-5.
Rebroadcasts for the Pacific Rim
The sessions will also feature several evening rebroadcasts of earlier LBS sessions that meeting planners scored highly for scientific merit and potential clinical impact but also for their “regional pull,” primarily for our colleagues in Asia, Dr. Patel said.
The first two LBS sessions presented live during the day in Chicago will be rebroadcast that evening as, for example, Sunday morning and afternoon fare in Tokyo and Singapore. And LBS-5 live Sunday afternoon will rebroadcast that night as a Monday mid-morning session in, say, Hong Kong or Seoul.
This year’s AHA meeting spans the range of cardiovascular care, from precision therapies, such as gene editing or specific drugs, to broad strategies that consider, for example, social determinants of health, Dr. Patel said. “I think people, when they leave the Scientific Sessions, will feel very engaged in the larger conversation about how you impact very common conditions globally.”
A version of this article first appeared on Medscape.com.
Best anticoagulant for minimizing bleeding risk identified
A commonly prescribed direct oral anticoagulant (DOAC) has the lowest risk of bleeding, say researchers. Used to prevent strokes in those with atrial fibrillation (AFib), DOACs have recently become more common than warfarin, the previous standard treatment, as they do not require as much follow-up monitoring – which was “particularly valuable” during the COVID-19 pandemic – and have “less risk” of side effects, highlighted the authors of a new study, published in Annals of Internal Medicine.
However, the authors explained that, although current guidelines recommend using DOACs over warfarin in patients with AFib, “head-to-head trial data do not exist to guide the choice of DOAC.” So, they set out to try and fill this evidence gap by doing a large-scale comparison between all DOACs – apixaban, dabigatran, edoxaban, and rivaroxaban – in routine clinical practice.
Wallis Lau, PhD, University College London, and co–lead author, said: “Direct oral anticoagulants have been prescribed with increasing frequency worldwide in recent years, but evidence comparing them directly has been limited.”
One drug stood out
For the multinational population-based cohort study the researchers compared the efficacy and risk of side effects for the four most common DOACs. They reviewed data – from five standardized electronic health care databases that covered 221 million people in the United Kingdom, France, Germany, and the United States – of 527,226 patients who had been newly diagnosed with AFib between 2010 and 2019, and who had received a new DOAC prescription. The study included 281,320 apixaban users, 61,008 dabigatran users, 12,722 edoxaban users, and 172,176 rivaroxaban users.
Database-specific hazard ratios of ischemic stroke or systemic embolism, intracranial hemorrhage, gastrointestinal bleeding, and all-cause mortality between DOACs were estimated using a Cox regression model stratified by propensity score and pooled using a random-effects model.
In total, 9,530 ischemic stroke or systemic embolism events, 841 intercranial hemorrhage events, 8,319 gastrointestinal bleeding events, and 1,476 deaths were identified over the study follow-up. The researchers found that all four drugs were comparable on outcomes for ischemic stroke, intercranial hemorrhage, and all-cause mortality.
However, they identified a difference in the risk of gastrointestinal bleeding, which they highlighted “is one of the most common and concerning side effects of DOACs.”
“Apixaban stood out as having lower risk of gastrointestinal bleeding,” said the authors, with a 19%-28% lower risk when compared directly with each of the other three DOACs. Specifically, apixaban use was associated with lower risk for gastrointestinal bleeding than use of dabigatran (HR, 0.81; 95% confidence interval, 0.70-0.94), edoxaban (HR, 0.77; 95% CI, 0.66-0.91), or rivaroxaban (HR, 0.72; 95% CI, 0.66-0.79).
The researchers also highlighted that their findings held true when looking at data only from those aged over 80, and those with chronic kidney disease, two groups that are “often underrepresented” in clinical trials.
Apixaban may be preferable
The researchers concluded that, compared with dabigatran, edoxaban, and rivaroxaban.
“Our results indicate that apixaban may be preferable to other blood thinners because of the lower rate of gastrointestinal bleeding and similar rates of stroke, a finding that we hope will be supported by randomized controlled trials,” said Dr. Lau.
However, he emphasized that, “as with all medications, potential risks and benefits can differ between people, so considering the full spectrum of outcomes and side effects will still be necessary for each individual patient.”
The authors all declared no conflicting interests.
A version of this article first appeared on Medscape UK.
A commonly prescribed direct oral anticoagulant (DOAC) has the lowest risk of bleeding, say researchers. Used to prevent strokes in those with atrial fibrillation (AFib), DOACs have recently become more common than warfarin, the previous standard treatment, as they do not require as much follow-up monitoring – which was “particularly valuable” during the COVID-19 pandemic – and have “less risk” of side effects, highlighted the authors of a new study, published in Annals of Internal Medicine.
However, the authors explained that, although current guidelines recommend using DOACs over warfarin in patients with AFib, “head-to-head trial data do not exist to guide the choice of DOAC.” So, they set out to try and fill this evidence gap by doing a large-scale comparison between all DOACs – apixaban, dabigatran, edoxaban, and rivaroxaban – in routine clinical practice.
Wallis Lau, PhD, University College London, and co–lead author, said: “Direct oral anticoagulants have been prescribed with increasing frequency worldwide in recent years, but evidence comparing them directly has been limited.”
One drug stood out
For the multinational population-based cohort study the researchers compared the efficacy and risk of side effects for the four most common DOACs. They reviewed data – from five standardized electronic health care databases that covered 221 million people in the United Kingdom, France, Germany, and the United States – of 527,226 patients who had been newly diagnosed with AFib between 2010 and 2019, and who had received a new DOAC prescription. The study included 281,320 apixaban users, 61,008 dabigatran users, 12,722 edoxaban users, and 172,176 rivaroxaban users.
Database-specific hazard ratios of ischemic stroke or systemic embolism, intracranial hemorrhage, gastrointestinal bleeding, and all-cause mortality between DOACs were estimated using a Cox regression model stratified by propensity score and pooled using a random-effects model.
In total, 9,530 ischemic stroke or systemic embolism events, 841 intercranial hemorrhage events, 8,319 gastrointestinal bleeding events, and 1,476 deaths were identified over the study follow-up. The researchers found that all four drugs were comparable on outcomes for ischemic stroke, intercranial hemorrhage, and all-cause mortality.
However, they identified a difference in the risk of gastrointestinal bleeding, which they highlighted “is one of the most common and concerning side effects of DOACs.”
“Apixaban stood out as having lower risk of gastrointestinal bleeding,” said the authors, with a 19%-28% lower risk when compared directly with each of the other three DOACs. Specifically, apixaban use was associated with lower risk for gastrointestinal bleeding than use of dabigatran (HR, 0.81; 95% confidence interval, 0.70-0.94), edoxaban (HR, 0.77; 95% CI, 0.66-0.91), or rivaroxaban (HR, 0.72; 95% CI, 0.66-0.79).
The researchers also highlighted that their findings held true when looking at data only from those aged over 80, and those with chronic kidney disease, two groups that are “often underrepresented” in clinical trials.
Apixaban may be preferable
The researchers concluded that, compared with dabigatran, edoxaban, and rivaroxaban.
“Our results indicate that apixaban may be preferable to other blood thinners because of the lower rate of gastrointestinal bleeding and similar rates of stroke, a finding that we hope will be supported by randomized controlled trials,” said Dr. Lau.
However, he emphasized that, “as with all medications, potential risks and benefits can differ between people, so considering the full spectrum of outcomes and side effects will still be necessary for each individual patient.”
The authors all declared no conflicting interests.
A version of this article first appeared on Medscape UK.
A commonly prescribed direct oral anticoagulant (DOAC) has the lowest risk of bleeding, say researchers. Used to prevent strokes in those with atrial fibrillation (AFib), DOACs have recently become more common than warfarin, the previous standard treatment, as they do not require as much follow-up monitoring – which was “particularly valuable” during the COVID-19 pandemic – and have “less risk” of side effects, highlighted the authors of a new study, published in Annals of Internal Medicine.
However, the authors explained that, although current guidelines recommend using DOACs over warfarin in patients with AFib, “head-to-head trial data do not exist to guide the choice of DOAC.” So, they set out to try and fill this evidence gap by doing a large-scale comparison between all DOACs – apixaban, dabigatran, edoxaban, and rivaroxaban – in routine clinical practice.
Wallis Lau, PhD, University College London, and co–lead author, said: “Direct oral anticoagulants have been prescribed with increasing frequency worldwide in recent years, but evidence comparing them directly has been limited.”
One drug stood out
For the multinational population-based cohort study the researchers compared the efficacy and risk of side effects for the four most common DOACs. They reviewed data – from five standardized electronic health care databases that covered 221 million people in the United Kingdom, France, Germany, and the United States – of 527,226 patients who had been newly diagnosed with AFib between 2010 and 2019, and who had received a new DOAC prescription. The study included 281,320 apixaban users, 61,008 dabigatran users, 12,722 edoxaban users, and 172,176 rivaroxaban users.
Database-specific hazard ratios of ischemic stroke or systemic embolism, intracranial hemorrhage, gastrointestinal bleeding, and all-cause mortality between DOACs were estimated using a Cox regression model stratified by propensity score and pooled using a random-effects model.
In total, 9,530 ischemic stroke or systemic embolism events, 841 intercranial hemorrhage events, 8,319 gastrointestinal bleeding events, and 1,476 deaths were identified over the study follow-up. The researchers found that all four drugs were comparable on outcomes for ischemic stroke, intercranial hemorrhage, and all-cause mortality.
However, they identified a difference in the risk of gastrointestinal bleeding, which they highlighted “is one of the most common and concerning side effects of DOACs.”
“Apixaban stood out as having lower risk of gastrointestinal bleeding,” said the authors, with a 19%-28% lower risk when compared directly with each of the other three DOACs. Specifically, apixaban use was associated with lower risk for gastrointestinal bleeding than use of dabigatran (HR, 0.81; 95% confidence interval, 0.70-0.94), edoxaban (HR, 0.77; 95% CI, 0.66-0.91), or rivaroxaban (HR, 0.72; 95% CI, 0.66-0.79).
The researchers also highlighted that their findings held true when looking at data only from those aged over 80, and those with chronic kidney disease, two groups that are “often underrepresented” in clinical trials.
Apixaban may be preferable
The researchers concluded that, compared with dabigatran, edoxaban, and rivaroxaban.
“Our results indicate that apixaban may be preferable to other blood thinners because of the lower rate of gastrointestinal bleeding and similar rates of stroke, a finding that we hope will be supported by randomized controlled trials,” said Dr. Lau.
However, he emphasized that, “as with all medications, potential risks and benefits can differ between people, so considering the full spectrum of outcomes and side effects will still be necessary for each individual patient.”
The authors all declared no conflicting interests.
A version of this article first appeared on Medscape UK.
FROM ANNALS OF INTERNAL MEDICINE
IV potassium and magnesium an acute treatment for AFib?
Compared with no treatment, potassium and magnesium administration was associated with a 10% higher rate of SVC.
The finding suggests that giving intravenous potassium and magnesium might lessen the need for antiarrhythmic therapy and the associated potential adverse effects in patients with nonpermanent atrial fibrillation (AFib), the study authors say.
Still, they add, “The results of our study have no direct implications for clinical practice in the management of care for patients with AF [atrial fibrillation] or AFL [atrial flutter] in the ED. The findings are purely exploratory and hypothesis-generating but could potentially provide a rationale for an appropriate prospective trial.”
The study was published online in JAMA Network Open.
“Atrial fibrillation is becoming an increasing burden for health care systems worldwide owing to population aging,” write Filippo Cacioppo, MD, and colleagues from Medical University of Vienna (Austria).
“Pharmacologic and electrical conversion are common therapies in emergency departments, especially for highly symptomatic patients. Each intervention has specific risks, and neither is considered cost-effective owing to frequent recurrence of AF. In addition, AF often terminates spontaneously,” Dr. Cacioppo and colleagues write.
They add that evidence suggests hypokalemia and hypomagnesemia contribute to AFib development, and so the administration of potassium and magnesium could be a reasonable strategy to improve SCV rates.
To test their hypothesis, Dr. Cacioppo and associates conducted a registry-based cohort study in all patients with AFib or AFL presenting to their center’s ED between Feb. 6, 2009, and Feb. 16, 2020.
During this time, they observed a total of 2,546 episodes of nonpermanent AFib. The median patient age was 68 years (interquartile range, 58-75 years). Most were men (n = 1,411 patients, 55.4%).
In addition, there were 573 episodes of nonpermanent AFL. The median patient age was 68 years (IQR, 58-75 years), and 332 patients (57.9%) were men.
Intravenous potassium and magnesium were administered in just over half (n = 1,763; 56.5%) of the episodes.
The median amount of potassium and magnesium was delivered via one 250-mL infusion bag, which consisted of 24 mEq potassium and 145.8 mg magnesium combined with 500 mL of balanced crystalloid fluid containing 2.5 mEq potassium and 18.2 mg magnesium, administered for 90 minutes, the authors write.
If patients experienced pain at the injection site, the infusion rate was reduced until the pain subsided.
Conversion to sinus rhythm was considered spontaneous if no attempt at pharmacologic rhythm control was made until conversion occurred; if SCV occurred after an unsuccessful attempt at electrical cardioversion; or following rate control with beta-blockers, nondihydropyridine calcium channel blockers, or digitalis glycosides, the authors state.
IV treatment increased odds of SCV
The median duration of stay in the ED was 6.4 hours (IQR, 3.9-11.6 hours) for patients with AFib and 6.1 hours (IQR, 3.9-11.8 hours) for patients with AFL.
During the stay in the ED, SCV occurred in 15.4% (n = 393) of AFib episodes and 12.7% (n = 73) of AFL episodes.
Intravenous potassium and magnesium increased the possibility of SCV compared with no IV potassium and magnesium in AFib, but not in AFL.
In episodes of AFib, administration of intravenous potassium and magnesium was associated with 19.2% increased odds of SCV, compared with 10.4% with no administration (odds ratio, 1.98; 95% CI, 1.53-2.57).
In contrast, for AFL, no association was observed for the probability of SCV with potassium and magnesium administration when compared with no administration (13.0% vs. 12.5%; OR, 1.05; 95% CI, 0.65-1.69).
Not in the guidelines
“To date, it is unclear whether potassium and magnesium administration might be reasonable in the acute treatment of AF and AFL, and although this intervention may be common practice in some EDs, it is not part of the treatment recommendations in current guidelines,” Dr. Cacioppo and colleagues write.
“Our findings suggest that intravenous potassium and magnesium administration may increase the chance of SCV in patients with AF with either hypokalemia or with plasma potassium levels in the range of 3.50 to 3.99 mEq/L. In patients with AFL, however, potassium and magnesium administration may not be associated with SCV probability,” they write.
Dr. Cacioppo and associates add that in their study IV administration of potassium and magnesium was associated with SCV only in patients with symptom onset of less than 48 hours, suggesting a time-dependent outcome. However, they caution, “because only a limited number of patients with SCV had symptom onset greater than or equal to 48 hours, this finding warrants further investigation.”
A Band-Aid approach
“I’m a little skeptical about this study,” Georgios Syros, MD, director of arrhythmia services at Mount Sinai Queens and Mount Sinai Brooklyn, New York, said in an interview.
“Atrial fibrillation is a chronic disease. The natural history of this disease is that it is paroxysmal in the beginning, and at some point the episodes become more frequent and longer in duration. For some people, at some point, it becomes permanent,” Dr. Syros said.
“Suppose I cut my finger while slicing bread. I put a Band-Aid on the cut. That doesn’t mean I have fixed it, it means I’ve helped it temporarily. Atrial fibrillation in this paper is very analogous,” he said. “The patient may have episodes, goes to the emergency room, you give them medication, and temporarily alleviate the situation so that the patient does not have to be admitted. It’s simple, inexpensive, you make the heart rate go back to normal, not permanently, with few side effects, except perhaps for some pain at the injection site, but that doesn’t mean you have fixed the AFib permanently. But for someone who has had a first incidence, or doesn’t want to stay in the hospital because it’s the weekend, yes, you can use this as a Band-Aid,” he said.
Intravenous potassium and magnesium, as proposed in the current study, is similar to a medication currently in use in Europe, called vernakalant, Dr. Syros said.
“Vernakalant is not FDA approved in the U.S. It is not meant to treat atrial fibrillation permanently, so we have to inform the public about the limitations of what we are doing,” he said. “Vernakalant is similar to IV potassium and magnesium, as given in this study, but it is more expensive. It temporarily allows people to go back to sinus rhythm, but it’s not going to be there forever and you may go back to permanent AFib, so this is not magic, unfortunately.”
Dr. Syros emphasized that the current study results apply only to cases of paroxysmal atrial fibrillation of less than 48 hours duration. “This is a very important distinction,” he said.
“For example, a patient who drank a lot and the day after is in AFib, with what we call holiday heart, would be a good candidate for the treatment in this study. He’s young, without any heart damage, no diabetes, no hypertension, no prior stroke, so sure, help him out with potassium and magnesium, provided that he can prove to us that this started within 48 hours,” Dr. Syros said.
Dr. Cacioppo and colleagues and Dr. Syros report no relevant financial relationships. Study corresponding author Jan Niederdoeckl, MD, PhD, obtained funding for the study.
A version of this article first appeared on Medscape.com.
Compared with no treatment, potassium and magnesium administration was associated with a 10% higher rate of SVC.
The finding suggests that giving intravenous potassium and magnesium might lessen the need for antiarrhythmic therapy and the associated potential adverse effects in patients with nonpermanent atrial fibrillation (AFib), the study authors say.
Still, they add, “The results of our study have no direct implications for clinical practice in the management of care for patients with AF [atrial fibrillation] or AFL [atrial flutter] in the ED. The findings are purely exploratory and hypothesis-generating but could potentially provide a rationale for an appropriate prospective trial.”
The study was published online in JAMA Network Open.
“Atrial fibrillation is becoming an increasing burden for health care systems worldwide owing to population aging,” write Filippo Cacioppo, MD, and colleagues from Medical University of Vienna (Austria).
“Pharmacologic and electrical conversion are common therapies in emergency departments, especially for highly symptomatic patients. Each intervention has specific risks, and neither is considered cost-effective owing to frequent recurrence of AF. In addition, AF often terminates spontaneously,” Dr. Cacioppo and colleagues write.
They add that evidence suggests hypokalemia and hypomagnesemia contribute to AFib development, and so the administration of potassium and magnesium could be a reasonable strategy to improve SCV rates.
To test their hypothesis, Dr. Cacioppo and associates conducted a registry-based cohort study in all patients with AFib or AFL presenting to their center’s ED between Feb. 6, 2009, and Feb. 16, 2020.
During this time, they observed a total of 2,546 episodes of nonpermanent AFib. The median patient age was 68 years (interquartile range, 58-75 years). Most were men (n = 1,411 patients, 55.4%).
In addition, there were 573 episodes of nonpermanent AFL. The median patient age was 68 years (IQR, 58-75 years), and 332 patients (57.9%) were men.
Intravenous potassium and magnesium were administered in just over half (n = 1,763; 56.5%) of the episodes.
The median amount of potassium and magnesium was delivered via one 250-mL infusion bag, which consisted of 24 mEq potassium and 145.8 mg magnesium combined with 500 mL of balanced crystalloid fluid containing 2.5 mEq potassium and 18.2 mg magnesium, administered for 90 minutes, the authors write.
If patients experienced pain at the injection site, the infusion rate was reduced until the pain subsided.
Conversion to sinus rhythm was considered spontaneous if no attempt at pharmacologic rhythm control was made until conversion occurred; if SCV occurred after an unsuccessful attempt at electrical cardioversion; or following rate control with beta-blockers, nondihydropyridine calcium channel blockers, or digitalis glycosides, the authors state.
IV treatment increased odds of SCV
The median duration of stay in the ED was 6.4 hours (IQR, 3.9-11.6 hours) for patients with AFib and 6.1 hours (IQR, 3.9-11.8 hours) for patients with AFL.
During the stay in the ED, SCV occurred in 15.4% (n = 393) of AFib episodes and 12.7% (n = 73) of AFL episodes.
Intravenous potassium and magnesium increased the possibility of SCV compared with no IV potassium and magnesium in AFib, but not in AFL.
In episodes of AFib, administration of intravenous potassium and magnesium was associated with 19.2% increased odds of SCV, compared with 10.4% with no administration (odds ratio, 1.98; 95% CI, 1.53-2.57).
In contrast, for AFL, no association was observed for the probability of SCV with potassium and magnesium administration when compared with no administration (13.0% vs. 12.5%; OR, 1.05; 95% CI, 0.65-1.69).
Not in the guidelines
“To date, it is unclear whether potassium and magnesium administration might be reasonable in the acute treatment of AF and AFL, and although this intervention may be common practice in some EDs, it is not part of the treatment recommendations in current guidelines,” Dr. Cacioppo and colleagues write.
“Our findings suggest that intravenous potassium and magnesium administration may increase the chance of SCV in patients with AF with either hypokalemia or with plasma potassium levels in the range of 3.50 to 3.99 mEq/L. In patients with AFL, however, potassium and magnesium administration may not be associated with SCV probability,” they write.
Dr. Cacioppo and associates add that in their study IV administration of potassium and magnesium was associated with SCV only in patients with symptom onset of less than 48 hours, suggesting a time-dependent outcome. However, they caution, “because only a limited number of patients with SCV had symptom onset greater than or equal to 48 hours, this finding warrants further investigation.”
A Band-Aid approach
“I’m a little skeptical about this study,” Georgios Syros, MD, director of arrhythmia services at Mount Sinai Queens and Mount Sinai Brooklyn, New York, said in an interview.
“Atrial fibrillation is a chronic disease. The natural history of this disease is that it is paroxysmal in the beginning, and at some point the episodes become more frequent and longer in duration. For some people, at some point, it becomes permanent,” Dr. Syros said.
“Suppose I cut my finger while slicing bread. I put a Band-Aid on the cut. That doesn’t mean I have fixed it, it means I’ve helped it temporarily. Atrial fibrillation in this paper is very analogous,” he said. “The patient may have episodes, goes to the emergency room, you give them medication, and temporarily alleviate the situation so that the patient does not have to be admitted. It’s simple, inexpensive, you make the heart rate go back to normal, not permanently, with few side effects, except perhaps for some pain at the injection site, but that doesn’t mean you have fixed the AFib permanently. But for someone who has had a first incidence, or doesn’t want to stay in the hospital because it’s the weekend, yes, you can use this as a Band-Aid,” he said.
Intravenous potassium and magnesium, as proposed in the current study, is similar to a medication currently in use in Europe, called vernakalant, Dr. Syros said.
“Vernakalant is not FDA approved in the U.S. It is not meant to treat atrial fibrillation permanently, so we have to inform the public about the limitations of what we are doing,” he said. “Vernakalant is similar to IV potassium and magnesium, as given in this study, but it is more expensive. It temporarily allows people to go back to sinus rhythm, but it’s not going to be there forever and you may go back to permanent AFib, so this is not magic, unfortunately.”
Dr. Syros emphasized that the current study results apply only to cases of paroxysmal atrial fibrillation of less than 48 hours duration. “This is a very important distinction,” he said.
“For example, a patient who drank a lot and the day after is in AFib, with what we call holiday heart, would be a good candidate for the treatment in this study. He’s young, without any heart damage, no diabetes, no hypertension, no prior stroke, so sure, help him out with potassium and magnesium, provided that he can prove to us that this started within 48 hours,” Dr. Syros said.
Dr. Cacioppo and colleagues and Dr. Syros report no relevant financial relationships. Study corresponding author Jan Niederdoeckl, MD, PhD, obtained funding for the study.
A version of this article first appeared on Medscape.com.
Compared with no treatment, potassium and magnesium administration was associated with a 10% higher rate of SVC.
The finding suggests that giving intravenous potassium and magnesium might lessen the need for antiarrhythmic therapy and the associated potential adverse effects in patients with nonpermanent atrial fibrillation (AFib), the study authors say.
Still, they add, “The results of our study have no direct implications for clinical practice in the management of care for patients with AF [atrial fibrillation] or AFL [atrial flutter] in the ED. The findings are purely exploratory and hypothesis-generating but could potentially provide a rationale for an appropriate prospective trial.”
The study was published online in JAMA Network Open.
“Atrial fibrillation is becoming an increasing burden for health care systems worldwide owing to population aging,” write Filippo Cacioppo, MD, and colleagues from Medical University of Vienna (Austria).
“Pharmacologic and electrical conversion are common therapies in emergency departments, especially for highly symptomatic patients. Each intervention has specific risks, and neither is considered cost-effective owing to frequent recurrence of AF. In addition, AF often terminates spontaneously,” Dr. Cacioppo and colleagues write.
They add that evidence suggests hypokalemia and hypomagnesemia contribute to AFib development, and so the administration of potassium and magnesium could be a reasonable strategy to improve SCV rates.
To test their hypothesis, Dr. Cacioppo and associates conducted a registry-based cohort study in all patients with AFib or AFL presenting to their center’s ED between Feb. 6, 2009, and Feb. 16, 2020.
During this time, they observed a total of 2,546 episodes of nonpermanent AFib. The median patient age was 68 years (interquartile range, 58-75 years). Most were men (n = 1,411 patients, 55.4%).
In addition, there were 573 episodes of nonpermanent AFL. The median patient age was 68 years (IQR, 58-75 years), and 332 patients (57.9%) were men.
Intravenous potassium and magnesium were administered in just over half (n = 1,763; 56.5%) of the episodes.
The median amount of potassium and magnesium was delivered via one 250-mL infusion bag, which consisted of 24 mEq potassium and 145.8 mg magnesium combined with 500 mL of balanced crystalloid fluid containing 2.5 mEq potassium and 18.2 mg magnesium, administered for 90 minutes, the authors write.
If patients experienced pain at the injection site, the infusion rate was reduced until the pain subsided.
Conversion to sinus rhythm was considered spontaneous if no attempt at pharmacologic rhythm control was made until conversion occurred; if SCV occurred after an unsuccessful attempt at electrical cardioversion; or following rate control with beta-blockers, nondihydropyridine calcium channel blockers, or digitalis glycosides, the authors state.
IV treatment increased odds of SCV
The median duration of stay in the ED was 6.4 hours (IQR, 3.9-11.6 hours) for patients with AFib and 6.1 hours (IQR, 3.9-11.8 hours) for patients with AFL.
During the stay in the ED, SCV occurred in 15.4% (n = 393) of AFib episodes and 12.7% (n = 73) of AFL episodes.
Intravenous potassium and magnesium increased the possibility of SCV compared with no IV potassium and magnesium in AFib, but not in AFL.
In episodes of AFib, administration of intravenous potassium and magnesium was associated with 19.2% increased odds of SCV, compared with 10.4% with no administration (odds ratio, 1.98; 95% CI, 1.53-2.57).
In contrast, for AFL, no association was observed for the probability of SCV with potassium and magnesium administration when compared with no administration (13.0% vs. 12.5%; OR, 1.05; 95% CI, 0.65-1.69).
Not in the guidelines
“To date, it is unclear whether potassium and magnesium administration might be reasonable in the acute treatment of AF and AFL, and although this intervention may be common practice in some EDs, it is not part of the treatment recommendations in current guidelines,” Dr. Cacioppo and colleagues write.
“Our findings suggest that intravenous potassium and magnesium administration may increase the chance of SCV in patients with AF with either hypokalemia or with plasma potassium levels in the range of 3.50 to 3.99 mEq/L. In patients with AFL, however, potassium and magnesium administration may not be associated with SCV probability,” they write.
Dr. Cacioppo and associates add that in their study IV administration of potassium and magnesium was associated with SCV only in patients with symptom onset of less than 48 hours, suggesting a time-dependent outcome. However, they caution, “because only a limited number of patients with SCV had symptom onset greater than or equal to 48 hours, this finding warrants further investigation.”
A Band-Aid approach
“I’m a little skeptical about this study,” Georgios Syros, MD, director of arrhythmia services at Mount Sinai Queens and Mount Sinai Brooklyn, New York, said in an interview.
“Atrial fibrillation is a chronic disease. The natural history of this disease is that it is paroxysmal in the beginning, and at some point the episodes become more frequent and longer in duration. For some people, at some point, it becomes permanent,” Dr. Syros said.
“Suppose I cut my finger while slicing bread. I put a Band-Aid on the cut. That doesn’t mean I have fixed it, it means I’ve helped it temporarily. Atrial fibrillation in this paper is very analogous,” he said. “The patient may have episodes, goes to the emergency room, you give them medication, and temporarily alleviate the situation so that the patient does not have to be admitted. It’s simple, inexpensive, you make the heart rate go back to normal, not permanently, with few side effects, except perhaps for some pain at the injection site, but that doesn’t mean you have fixed the AFib permanently. But for someone who has had a first incidence, or doesn’t want to stay in the hospital because it’s the weekend, yes, you can use this as a Band-Aid,” he said.
Intravenous potassium and magnesium, as proposed in the current study, is similar to a medication currently in use in Europe, called vernakalant, Dr. Syros said.
“Vernakalant is not FDA approved in the U.S. It is not meant to treat atrial fibrillation permanently, so we have to inform the public about the limitations of what we are doing,” he said. “Vernakalant is similar to IV potassium and magnesium, as given in this study, but it is more expensive. It temporarily allows people to go back to sinus rhythm, but it’s not going to be there forever and you may go back to permanent AFib, so this is not magic, unfortunately.”
Dr. Syros emphasized that the current study results apply only to cases of paroxysmal atrial fibrillation of less than 48 hours duration. “This is a very important distinction,” he said.
“For example, a patient who drank a lot and the day after is in AFib, with what we call holiday heart, would be a good candidate for the treatment in this study. He’s young, without any heart damage, no diabetes, no hypertension, no prior stroke, so sure, help him out with potassium and magnesium, provided that he can prove to us that this started within 48 hours,” Dr. Syros said.
Dr. Cacioppo and colleagues and Dr. Syros report no relevant financial relationships. Study corresponding author Jan Niederdoeckl, MD, PhD, obtained funding for the study.
A version of this article first appeared on Medscape.com.
FROM JAMA NETWORK OPEN
Four commonly abused drugs linked with atrial fibrillation
Cocaine, methamphetamine, opioids, and cannabis may independently increase risk of atrial fibrillation (AFib), based on data from almost 24 million people.
While more work is needed to uncover causal links, physicians should be aware that these commonly abused substances could be driving new cases of AFib, reported investigators from the University of California, San Francisco.
“Though alcohol and tobacco smoking have each been associated with a heightened risk of [AFib], relationships between other drug use and [AFib] are poorly understood,” they wrote in European Heart Journal.
Some previous studies have ventured into this terrain, but most focused on fatal arrhythmias, or offered anecdotal evidence. This knowledge gap is particularly concerning for cannabis, the researchers noted, as medical and recreational use are on the rise.
The present analysis included data from 23.5 million adults in California who received care through a hospital, emergency department, or outpatient surgery center during 2005-2015. Based on ICD-9 diagnostic codes, 132,834 of these patients used cannabis, 98,271 used methamphetamines, 48,701 used cocaine, and 10,032 used opiates. Inclusion required lack of AFib at baseline.
Reliance on ICD-9 codes makes the data “quite specific,” but lacking sensitivity, according to principal author Gregory M. Marcus, MD, cardiologist and professor of medicine at UCSF.
“If they were designated as using these drugs, that is very likely true,” Dr. Marcus said in an interview. “But certainly, the absence of any mention of use of these drugs does not exclude the possibility that some people were still using them. That would not create spurious false-positive relationships; if anything, it attenuates existing relationships.”
In other words, using ICD-9 codes reduced the power to detect an association between each drug and AFib, meaning any relationship needed to be sufficiently strong enough to generate a significant result.
At the end of the decade-long study period, 998,747 patients (4.2%) had developed incident AFib. After adjusting for potential confounders and mediators, all four drugs showed significant, independent associations with AFib. Methamphetamines presented the greatest risk (hazard ratio, 1.86%), followed by opiates (HR, 1.74), cocaine (HR, 1.61), and cannabis (HR, 1.35).
“Our findings provide the first evidence utilizing a longitudinal cohort to demonstrate that cannabis use predicts the future onset of AFib,” Dr. Marcus and colleagues wrote.
Dose-response relationships were not detected for any of the substances; however, usage levels were also derived from ICD-9 codes, which may have been insufficient for this purpose, according to the investigators.
Causal mechanisms deserve a closer look
Causal links between AFib and each of the drugs remain unclear. Citing prior research, Dr. Marcus and colleagues explained how methamphetamines are capable of “significant cardiac electrical remodeling,” while cocaine may cause sodium channel dysregulation, and opioids can render atrial myocytes more susceptible to oxidative damage. Although cannabis has previously been linked with hospitalization for arrhythmia, a pharmacologic driver of this phenomenon remains largely unexamined.
“We don’t know for sure precisely what the constituents are that are responsible for our findings,” Dr. Marcus said. “It’s possible that there are some effects that are much more generic, such as inhaling a burned substance. There is good evidence that if you inhale pretty much any sort of particulate matter, that increases inflammation in the body. Inflammation is known to be a trigger for atrial fibrillation.”
Alternatively, all four drugs – whether stimulants or depressants – cause “quite dramatic and often rapid effects on the autonomic nervous system,” Dr. Marcus said, noting that these rapid swings are a known trigger for AFib.
Brian Olshansky, MD, emeritus professor of internal medicine-cardiovascular medicine at the University of Iowa, Iowa City, suggested that nonpharmacologic factors are likely also playing a role.
“All these drugs have slightly different mechanisms of action, so there’s not one mechanism that would explain why all of them would cause atrial fibrillation,” Dr. Olshansky said in an interview. “That does suggest that there’s something else going on, besides just the drug itself. It would be potentially concerning if we were to lay the blame totally on these drugs.”
Dr. Olshansky, who recently coauthored a review of stimulant drugs and arrhythmias, suggested that lifestyle, comorbidities, and drug impurities may have added to the risk of AF.
“[The investigators] did try to correct for that kind of stuff, but it’s very hard to correct for a lot of the issues that may be ongoing with individuals who partake in these drugs,” Dr. Olshansky said in an interview. “They may not be a healthy lot, in general.”
Still, considering previous data linking drugs of abuse with arrhythmias, he said the detected risks were “intriguing,” and deserved a closer look.
“It’s a nice groundbreaking study, with regard to the fact that they showed unique relationships that we don’t completely understand,” Dr. Olshansky said. “It opens up a new opportunity for further investigation.”
The investigators disclosed relationships with InCarda, Baylis Medical, Johnson & Johnson, and others. Dr. Olshansky disclosed no relevant competing interests.
Cocaine, methamphetamine, opioids, and cannabis may independently increase risk of atrial fibrillation (AFib), based on data from almost 24 million people.
While more work is needed to uncover causal links, physicians should be aware that these commonly abused substances could be driving new cases of AFib, reported investigators from the University of California, San Francisco.
“Though alcohol and tobacco smoking have each been associated with a heightened risk of [AFib], relationships between other drug use and [AFib] are poorly understood,” they wrote in European Heart Journal.
Some previous studies have ventured into this terrain, but most focused on fatal arrhythmias, or offered anecdotal evidence. This knowledge gap is particularly concerning for cannabis, the researchers noted, as medical and recreational use are on the rise.
The present analysis included data from 23.5 million adults in California who received care through a hospital, emergency department, or outpatient surgery center during 2005-2015. Based on ICD-9 diagnostic codes, 132,834 of these patients used cannabis, 98,271 used methamphetamines, 48,701 used cocaine, and 10,032 used opiates. Inclusion required lack of AFib at baseline.
Reliance on ICD-9 codes makes the data “quite specific,” but lacking sensitivity, according to principal author Gregory M. Marcus, MD, cardiologist and professor of medicine at UCSF.
“If they were designated as using these drugs, that is very likely true,” Dr. Marcus said in an interview. “But certainly, the absence of any mention of use of these drugs does not exclude the possibility that some people were still using them. That would not create spurious false-positive relationships; if anything, it attenuates existing relationships.”
In other words, using ICD-9 codes reduced the power to detect an association between each drug and AFib, meaning any relationship needed to be sufficiently strong enough to generate a significant result.
At the end of the decade-long study period, 998,747 patients (4.2%) had developed incident AFib. After adjusting for potential confounders and mediators, all four drugs showed significant, independent associations with AFib. Methamphetamines presented the greatest risk (hazard ratio, 1.86%), followed by opiates (HR, 1.74), cocaine (HR, 1.61), and cannabis (HR, 1.35).
“Our findings provide the first evidence utilizing a longitudinal cohort to demonstrate that cannabis use predicts the future onset of AFib,” Dr. Marcus and colleagues wrote.
Dose-response relationships were not detected for any of the substances; however, usage levels were also derived from ICD-9 codes, which may have been insufficient for this purpose, according to the investigators.
Causal mechanisms deserve a closer look
Causal links between AFib and each of the drugs remain unclear. Citing prior research, Dr. Marcus and colleagues explained how methamphetamines are capable of “significant cardiac electrical remodeling,” while cocaine may cause sodium channel dysregulation, and opioids can render atrial myocytes more susceptible to oxidative damage. Although cannabis has previously been linked with hospitalization for arrhythmia, a pharmacologic driver of this phenomenon remains largely unexamined.
“We don’t know for sure precisely what the constituents are that are responsible for our findings,” Dr. Marcus said. “It’s possible that there are some effects that are much more generic, such as inhaling a burned substance. There is good evidence that if you inhale pretty much any sort of particulate matter, that increases inflammation in the body. Inflammation is known to be a trigger for atrial fibrillation.”
Alternatively, all four drugs – whether stimulants or depressants – cause “quite dramatic and often rapid effects on the autonomic nervous system,” Dr. Marcus said, noting that these rapid swings are a known trigger for AFib.
Brian Olshansky, MD, emeritus professor of internal medicine-cardiovascular medicine at the University of Iowa, Iowa City, suggested that nonpharmacologic factors are likely also playing a role.
“All these drugs have slightly different mechanisms of action, so there’s not one mechanism that would explain why all of them would cause atrial fibrillation,” Dr. Olshansky said in an interview. “That does suggest that there’s something else going on, besides just the drug itself. It would be potentially concerning if we were to lay the blame totally on these drugs.”
Dr. Olshansky, who recently coauthored a review of stimulant drugs and arrhythmias, suggested that lifestyle, comorbidities, and drug impurities may have added to the risk of AF.
“[The investigators] did try to correct for that kind of stuff, but it’s very hard to correct for a lot of the issues that may be ongoing with individuals who partake in these drugs,” Dr. Olshansky said in an interview. “They may not be a healthy lot, in general.”
Still, considering previous data linking drugs of abuse with arrhythmias, he said the detected risks were “intriguing,” and deserved a closer look.
“It’s a nice groundbreaking study, with regard to the fact that they showed unique relationships that we don’t completely understand,” Dr. Olshansky said. “It opens up a new opportunity for further investigation.”
The investigators disclosed relationships with InCarda, Baylis Medical, Johnson & Johnson, and others. Dr. Olshansky disclosed no relevant competing interests.
Cocaine, methamphetamine, opioids, and cannabis may independently increase risk of atrial fibrillation (AFib), based on data from almost 24 million people.
While more work is needed to uncover causal links, physicians should be aware that these commonly abused substances could be driving new cases of AFib, reported investigators from the University of California, San Francisco.
“Though alcohol and tobacco smoking have each been associated with a heightened risk of [AFib], relationships between other drug use and [AFib] are poorly understood,” they wrote in European Heart Journal.
Some previous studies have ventured into this terrain, but most focused on fatal arrhythmias, or offered anecdotal evidence. This knowledge gap is particularly concerning for cannabis, the researchers noted, as medical and recreational use are on the rise.
The present analysis included data from 23.5 million adults in California who received care through a hospital, emergency department, or outpatient surgery center during 2005-2015. Based on ICD-9 diagnostic codes, 132,834 of these patients used cannabis, 98,271 used methamphetamines, 48,701 used cocaine, and 10,032 used opiates. Inclusion required lack of AFib at baseline.
Reliance on ICD-9 codes makes the data “quite specific,” but lacking sensitivity, according to principal author Gregory M. Marcus, MD, cardiologist and professor of medicine at UCSF.
“If they were designated as using these drugs, that is very likely true,” Dr. Marcus said in an interview. “But certainly, the absence of any mention of use of these drugs does not exclude the possibility that some people were still using them. That would not create spurious false-positive relationships; if anything, it attenuates existing relationships.”
In other words, using ICD-9 codes reduced the power to detect an association between each drug and AFib, meaning any relationship needed to be sufficiently strong enough to generate a significant result.
At the end of the decade-long study period, 998,747 patients (4.2%) had developed incident AFib. After adjusting for potential confounders and mediators, all four drugs showed significant, independent associations with AFib. Methamphetamines presented the greatest risk (hazard ratio, 1.86%), followed by opiates (HR, 1.74), cocaine (HR, 1.61), and cannabis (HR, 1.35).
“Our findings provide the first evidence utilizing a longitudinal cohort to demonstrate that cannabis use predicts the future onset of AFib,” Dr. Marcus and colleagues wrote.
Dose-response relationships were not detected for any of the substances; however, usage levels were also derived from ICD-9 codes, which may have been insufficient for this purpose, according to the investigators.
Causal mechanisms deserve a closer look
Causal links between AFib and each of the drugs remain unclear. Citing prior research, Dr. Marcus and colleagues explained how methamphetamines are capable of “significant cardiac electrical remodeling,” while cocaine may cause sodium channel dysregulation, and opioids can render atrial myocytes more susceptible to oxidative damage. Although cannabis has previously been linked with hospitalization for arrhythmia, a pharmacologic driver of this phenomenon remains largely unexamined.
“We don’t know for sure precisely what the constituents are that are responsible for our findings,” Dr. Marcus said. “It’s possible that there are some effects that are much more generic, such as inhaling a burned substance. There is good evidence that if you inhale pretty much any sort of particulate matter, that increases inflammation in the body. Inflammation is known to be a trigger for atrial fibrillation.”
Alternatively, all four drugs – whether stimulants or depressants – cause “quite dramatic and often rapid effects on the autonomic nervous system,” Dr. Marcus said, noting that these rapid swings are a known trigger for AFib.
Brian Olshansky, MD, emeritus professor of internal medicine-cardiovascular medicine at the University of Iowa, Iowa City, suggested that nonpharmacologic factors are likely also playing a role.
“All these drugs have slightly different mechanisms of action, so there’s not one mechanism that would explain why all of them would cause atrial fibrillation,” Dr. Olshansky said in an interview. “That does suggest that there’s something else going on, besides just the drug itself. It would be potentially concerning if we were to lay the blame totally on these drugs.”
Dr. Olshansky, who recently coauthored a review of stimulant drugs and arrhythmias, suggested that lifestyle, comorbidities, and drug impurities may have added to the risk of AF.
“[The investigators] did try to correct for that kind of stuff, but it’s very hard to correct for a lot of the issues that may be ongoing with individuals who partake in these drugs,” Dr. Olshansky said in an interview. “They may not be a healthy lot, in general.”
Still, considering previous data linking drugs of abuse with arrhythmias, he said the detected risks were “intriguing,” and deserved a closer look.
“It’s a nice groundbreaking study, with regard to the fact that they showed unique relationships that we don’t completely understand,” Dr. Olshansky said. “It opens up a new opportunity for further investigation.”
The investigators disclosed relationships with InCarda, Baylis Medical, Johnson & Johnson, and others. Dr. Olshansky disclosed no relevant competing interests.
FROM EUROPEAN HEART JOURNAL
FDA OKs Medtronic lead for left bundle branch pacing
Labeling for a Medtronic pacing lead, already indicated for stimulation of the His bundle, has been expanded to include the left bundle branch (LBB), the company announced on Oct. 17.
The U.S. Food and Drug Administration previously expanded the Medtronic SelectSecure MRI SureScan Model 3830 lead’s approval in 2018 to include His-bundle pacing. “Now this cardiac lead is approved for pacing and sensing at the bundle of His or in the left bundle branch area as an alternative to apical pacing in the right ventricle in a single- or dual-chamber pacing system,” Medtronic states in a press release.
The Model 3830 lead was initially approved for atrial or right ventricular pacing and sensing, the announcement says, and now “has more than 20 years of proven performance and reliability.”
The newly expanded conduction system pacing indication is “based on evidence from multiple sources spanning more than 20,000 treated patients,” for which the company cited “Medtronic data on file.”
A version of this article first appeared on Medscape.com.
Labeling for a Medtronic pacing lead, already indicated for stimulation of the His bundle, has been expanded to include the left bundle branch (LBB), the company announced on Oct. 17.
The U.S. Food and Drug Administration previously expanded the Medtronic SelectSecure MRI SureScan Model 3830 lead’s approval in 2018 to include His-bundle pacing. “Now this cardiac lead is approved for pacing and sensing at the bundle of His or in the left bundle branch area as an alternative to apical pacing in the right ventricle in a single- or dual-chamber pacing system,” Medtronic states in a press release.
The Model 3830 lead was initially approved for atrial or right ventricular pacing and sensing, the announcement says, and now “has more than 20 years of proven performance and reliability.”
The newly expanded conduction system pacing indication is “based on evidence from multiple sources spanning more than 20,000 treated patients,” for which the company cited “Medtronic data on file.”
A version of this article first appeared on Medscape.com.
Labeling for a Medtronic pacing lead, already indicated for stimulation of the His bundle, has been expanded to include the left bundle branch (LBB), the company announced on Oct. 17.
The U.S. Food and Drug Administration previously expanded the Medtronic SelectSecure MRI SureScan Model 3830 lead’s approval in 2018 to include His-bundle pacing. “Now this cardiac lead is approved for pacing and sensing at the bundle of His or in the left bundle branch area as an alternative to apical pacing in the right ventricle in a single- or dual-chamber pacing system,” Medtronic states in a press release.
The Model 3830 lead was initially approved for atrial or right ventricular pacing and sensing, the announcement says, and now “has more than 20 years of proven performance and reliability.”
The newly expanded conduction system pacing indication is “based on evidence from multiple sources spanning more than 20,000 treated patients,” for which the company cited “Medtronic data on file.”
A version of this article first appeared on Medscape.com.
Diabetes becoming less potent risk factor for CVD events
Diabetes persists as a risk factor for cardiovascular events, but where it once meant the same risk of heart attack or stroke as cardiovascular disease itself, a large Canadian population study reports that’s no longer the case. Thanks to advances in diabetes management over the past quarter century, diabetes is no longer considered equivalent to CVD as a risk factor for cardiovascular events, researchers from the University of Toronto reported.
The retrospective, population-based study used administrative data from Ontario’s provincial universal health care system. The researchers created five population-based cohorts of adults at 5-year intervals from 1994 to 2014, consisting of 1.87 million adults in the first cohort and 1.5 million in the last. In that 20-year span, the prevalence of diabetes in this population tripled, from 3.1% to 9%.
“In the last 25 years we’ve seen wholesale changes in the way people approach diabetes,” lead study author Calvin Ke, MD, PhD, an endocrinologist and assistant professor at the University of Toronto, said in an interview. “Part of the findings show that diabetes and cardiovascular disease were equivalent for risk of cardiovascular events in 1994, but by 2014 that was not the case.”
However, Dr. Ke added, “Diabetes is still a very strong cardiovascular risk factor.”
The investigators for the study, reported as a research letter in JAMA, analyzed the risk of cardiovascular events in four subgroups: those who had both diabetes and CVD, CVD only, diabetes only, and no CVD or diabetes.
Between 1994 and 2014, the cardiovascular event rates declined significantly among people with diabetes alone, compared with people with no disease: from 28.4 to 12.7 per 1,000 person-years, or an absolute risk increase (ARI) of 4.4% and a relative risk (RR) more than double (2.06), in 1994 to 14 vs. 8 per 1,000 person-years, and an ARI of 2% and RR less than double (1.58) 20 years later.
Among people with CVD only, those values shifted from 36.1 per 1,000 person-years, ARI of 5.1% and RR of 2.16 in 1994 to 23.9, ARI of 3.7% and RR still more than double (2.06) in 2014.
People with both CVD and diabetes had the highest CVD event rates across all 5-year cohorts: 74 per 1,000 person-years, ARI of 12% and RR almost four times greater (3.81) in 1994 than people with no disease. By 2014, the ARI in this group was 7.6% and the RR 3.10.
The investigators calculated that event rates from 1994 to 2014 declined across all four subgroups, with rate ratios of 0.49 for diabetes only, 0.66 for CVD only, 0.60 for both diabetes and CVD, and 0.63 for neither disease.
Shift in practice
The study noted that the shift in diabetes as a risk factor for heart attack and stroke is “a change that likely reflects the use of modern, multifactorial approaches to diabetes.”
“A number of changes have occurred in practice that really focus on this idea of a multifactorial approach to diabetes: more aggressive management of blood sugar, blood pressure, and lipids,” Dr. Ke said. “We know from the statin trials that statins can reduce the risk of heart disease significantly, and the use of statins increased from 28.4% in 1999 to 56.3% in 2018 in the United States,” Dr. Ke said. He added that statin use in Canada in adults ages 40 and older went from 1.2% in 1994 to 58.4% in 2010-2015. Use of ACE inhibitors and angiotensin receptor blockers for hypertension followed similar trends, contributing further to reducing risks for heart attack and stroke, Dr. Ke said.
Dr. Ke also noted that the evolution of guidelines and advances in treatments for both CVD and diabetes since 1994 have contributed to improving risks for people with diabetes. SGLT2 inhibitors have been linked to a 2%-6% reduction in hemoglobin A1c, he said. “All of these factors combined have had a major effect on the reduced risk of cardiovascular events.”
Prakash Deedwania, MD, professor at the University of California, San Francisco, Fresno, said that this study confirms a trend that others have reported regarding the risk of CVD in diabetes. The large database covering millions of adults is a study strength, he said.
And the findings, Dr. Deedwania added, underscore what’s been published in clinical guidelines, notably the American Heart Association scientific statement for managing CVD risk in patients with diabetes. “This means that, from observations made 20-plus years ago, when most people were not being treated for diabetes or heart disease, the pendulum has swung,” he said.
However, he added, “The authors state clearly that it does not mean that diabetes is not associated with a higher risk of cardiovascular events; it just means it is no longer equivalent to CVD.”
Managing diabetes continues to be “particularly important,” Dr. Deedwania said, because the prevalence of diabetes continues to rise. “This is a phenomenal risk, and it emphasizes that, to really conquer or control diabetes, we should make every effort to prevent diabetes,” he said.
Dr. Ke and Dr. Deedwania have no relevant financial relationships to disclose.
Diabetes persists as a risk factor for cardiovascular events, but where it once meant the same risk of heart attack or stroke as cardiovascular disease itself, a large Canadian population study reports that’s no longer the case. Thanks to advances in diabetes management over the past quarter century, diabetes is no longer considered equivalent to CVD as a risk factor for cardiovascular events, researchers from the University of Toronto reported.
The retrospective, population-based study used administrative data from Ontario’s provincial universal health care system. The researchers created five population-based cohorts of adults at 5-year intervals from 1994 to 2014, consisting of 1.87 million adults in the first cohort and 1.5 million in the last. In that 20-year span, the prevalence of diabetes in this population tripled, from 3.1% to 9%.
“In the last 25 years we’ve seen wholesale changes in the way people approach diabetes,” lead study author Calvin Ke, MD, PhD, an endocrinologist and assistant professor at the University of Toronto, said in an interview. “Part of the findings show that diabetes and cardiovascular disease were equivalent for risk of cardiovascular events in 1994, but by 2014 that was not the case.”
However, Dr. Ke added, “Diabetes is still a very strong cardiovascular risk factor.”
The investigators for the study, reported as a research letter in JAMA, analyzed the risk of cardiovascular events in four subgroups: those who had both diabetes and CVD, CVD only, diabetes only, and no CVD or diabetes.
Between 1994 and 2014, the cardiovascular event rates declined significantly among people with diabetes alone, compared with people with no disease: from 28.4 to 12.7 per 1,000 person-years, or an absolute risk increase (ARI) of 4.4% and a relative risk (RR) more than double (2.06), in 1994 to 14 vs. 8 per 1,000 person-years, and an ARI of 2% and RR less than double (1.58) 20 years later.
Among people with CVD only, those values shifted from 36.1 per 1,000 person-years, ARI of 5.1% and RR of 2.16 in 1994 to 23.9, ARI of 3.7% and RR still more than double (2.06) in 2014.
People with both CVD and diabetes had the highest CVD event rates across all 5-year cohorts: 74 per 1,000 person-years, ARI of 12% and RR almost four times greater (3.81) in 1994 than people with no disease. By 2014, the ARI in this group was 7.6% and the RR 3.10.
The investigators calculated that event rates from 1994 to 2014 declined across all four subgroups, with rate ratios of 0.49 for diabetes only, 0.66 for CVD only, 0.60 for both diabetes and CVD, and 0.63 for neither disease.
Shift in practice
The study noted that the shift in diabetes as a risk factor for heart attack and stroke is “a change that likely reflects the use of modern, multifactorial approaches to diabetes.”
“A number of changes have occurred in practice that really focus on this idea of a multifactorial approach to diabetes: more aggressive management of blood sugar, blood pressure, and lipids,” Dr. Ke said. “We know from the statin trials that statins can reduce the risk of heart disease significantly, and the use of statins increased from 28.4% in 1999 to 56.3% in 2018 in the United States,” Dr. Ke said. He added that statin use in Canada in adults ages 40 and older went from 1.2% in 1994 to 58.4% in 2010-2015. Use of ACE inhibitors and angiotensin receptor blockers for hypertension followed similar trends, contributing further to reducing risks for heart attack and stroke, Dr. Ke said.
Dr. Ke also noted that the evolution of guidelines and advances in treatments for both CVD and diabetes since 1994 have contributed to improving risks for people with diabetes. SGLT2 inhibitors have been linked to a 2%-6% reduction in hemoglobin A1c, he said. “All of these factors combined have had a major effect on the reduced risk of cardiovascular events.”
Prakash Deedwania, MD, professor at the University of California, San Francisco, Fresno, said that this study confirms a trend that others have reported regarding the risk of CVD in diabetes. The large database covering millions of adults is a study strength, he said.
And the findings, Dr. Deedwania added, underscore what’s been published in clinical guidelines, notably the American Heart Association scientific statement for managing CVD risk in patients with diabetes. “This means that, from observations made 20-plus years ago, when most people were not being treated for diabetes or heart disease, the pendulum has swung,” he said.
However, he added, “The authors state clearly that it does not mean that diabetes is not associated with a higher risk of cardiovascular events; it just means it is no longer equivalent to CVD.”
Managing diabetes continues to be “particularly important,” Dr. Deedwania said, because the prevalence of diabetes continues to rise. “This is a phenomenal risk, and it emphasizes that, to really conquer or control diabetes, we should make every effort to prevent diabetes,” he said.
Dr. Ke and Dr. Deedwania have no relevant financial relationships to disclose.
Diabetes persists as a risk factor for cardiovascular events, but where it once meant the same risk of heart attack or stroke as cardiovascular disease itself, a large Canadian population study reports that’s no longer the case. Thanks to advances in diabetes management over the past quarter century, diabetes is no longer considered equivalent to CVD as a risk factor for cardiovascular events, researchers from the University of Toronto reported.
The retrospective, population-based study used administrative data from Ontario’s provincial universal health care system. The researchers created five population-based cohorts of adults at 5-year intervals from 1994 to 2014, consisting of 1.87 million adults in the first cohort and 1.5 million in the last. In that 20-year span, the prevalence of diabetes in this population tripled, from 3.1% to 9%.
“In the last 25 years we’ve seen wholesale changes in the way people approach diabetes,” lead study author Calvin Ke, MD, PhD, an endocrinologist and assistant professor at the University of Toronto, said in an interview. “Part of the findings show that diabetes and cardiovascular disease were equivalent for risk of cardiovascular events in 1994, but by 2014 that was not the case.”
However, Dr. Ke added, “Diabetes is still a very strong cardiovascular risk factor.”
The investigators for the study, reported as a research letter in JAMA, analyzed the risk of cardiovascular events in four subgroups: those who had both diabetes and CVD, CVD only, diabetes only, and no CVD or diabetes.
Between 1994 and 2014, the cardiovascular event rates declined significantly among people with diabetes alone, compared with people with no disease: from 28.4 to 12.7 per 1,000 person-years, or an absolute risk increase (ARI) of 4.4% and a relative risk (RR) more than double (2.06), in 1994 to 14 vs. 8 per 1,000 person-years, and an ARI of 2% and RR less than double (1.58) 20 years later.
Among people with CVD only, those values shifted from 36.1 per 1,000 person-years, ARI of 5.1% and RR of 2.16 in 1994 to 23.9, ARI of 3.7% and RR still more than double (2.06) in 2014.
People with both CVD and diabetes had the highest CVD event rates across all 5-year cohorts: 74 per 1,000 person-years, ARI of 12% and RR almost four times greater (3.81) in 1994 than people with no disease. By 2014, the ARI in this group was 7.6% and the RR 3.10.
The investigators calculated that event rates from 1994 to 2014 declined across all four subgroups, with rate ratios of 0.49 for diabetes only, 0.66 for CVD only, 0.60 for both diabetes and CVD, and 0.63 for neither disease.
Shift in practice
The study noted that the shift in diabetes as a risk factor for heart attack and stroke is “a change that likely reflects the use of modern, multifactorial approaches to diabetes.”
“A number of changes have occurred in practice that really focus on this idea of a multifactorial approach to diabetes: more aggressive management of blood sugar, blood pressure, and lipids,” Dr. Ke said. “We know from the statin trials that statins can reduce the risk of heart disease significantly, and the use of statins increased from 28.4% in 1999 to 56.3% in 2018 in the United States,” Dr. Ke said. He added that statin use in Canada in adults ages 40 and older went from 1.2% in 1994 to 58.4% in 2010-2015. Use of ACE inhibitors and angiotensin receptor blockers for hypertension followed similar trends, contributing further to reducing risks for heart attack and stroke, Dr. Ke said.
Dr. Ke also noted that the evolution of guidelines and advances in treatments for both CVD and diabetes since 1994 have contributed to improving risks for people with diabetes. SGLT2 inhibitors have been linked to a 2%-6% reduction in hemoglobin A1c, he said. “All of these factors combined have had a major effect on the reduced risk of cardiovascular events.”
Prakash Deedwania, MD, professor at the University of California, San Francisco, Fresno, said that this study confirms a trend that others have reported regarding the risk of CVD in diabetes. The large database covering millions of adults is a study strength, he said.
And the findings, Dr. Deedwania added, underscore what’s been published in clinical guidelines, notably the American Heart Association scientific statement for managing CVD risk in patients with diabetes. “This means that, from observations made 20-plus years ago, when most people were not being treated for diabetes or heart disease, the pendulum has swung,” he said.
However, he added, “The authors state clearly that it does not mean that diabetes is not associated with a higher risk of cardiovascular events; it just means it is no longer equivalent to CVD.”
Managing diabetes continues to be “particularly important,” Dr. Deedwania said, because the prevalence of diabetes continues to rise. “This is a phenomenal risk, and it emphasizes that, to really conquer or control diabetes, we should make every effort to prevent diabetes,” he said.
Dr. Ke and Dr. Deedwania have no relevant financial relationships to disclose.
FROM JAMA