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Anticoagulation Treatment for Stroke Prevention in Atrial Fibrillation Is Increasing, But Further Improvements Needed
A recent paper by Hsu et  al.(1) assessed antithrombotic treatment among atrial fibrillation (AF) patients. The data, from the American College of Cardiology PINNACLE (Practice Innovation and Clinical Excellence) registry between 2008 and 2012, showed that 61.8% of patients with moderate-to-high stroke risk received anticoagulant therapy with either warfarin or newer direct oral anticoagulants (DOACs). The investigators and an editorial commentary noted the alarming prevalence of aspirin-only treatment despite clear evidence that anticoagulants are superior for prevention of thromboembolism in AF (1,2).
Source: Journal of the American College of Cardiology - November 29, 2016 Category: Cardiology Source Type: research

Reply Anticoagulation Treatment for Stroke Prevention in Atrial Fibrillation Is Increasing, But Further Improvements Needed
We are appreciative of Dr. Brown and colleagues and their interest in our recent paper in theJournal(1) regarding prescription of aspirin instead of oral anticoagulation (OAC) in patients with atrial fibrillation (AF) who are at intermediate-to-high thromboembolic risk in the American College of Cardiology National Cardiovascular Data Registry ’s PINNACLE (Practice Innovation and Clinical Excellence) Registry. They appropriately highlight some of our main findings, including that OAC prescription was selected in 61.8% of patients with a CHADS2 score  ≥2 (meaning 38.2% of patients were treated with aspirin alone) and 5...
Source: Journal of the American College of Cardiology - November 29, 2016 Category: Cardiology Source Type: research

Thrombotic and Embolic Complications Associated With Atrial Arrhythmia After  Fontan Operation Role of Prophylactic Therapy
This study sought to determine the risk of TEC in this population and the role of anticoagulation therapy in TEC prevention.MethodsThis was a retrospective review of adults with atrial arrhythmia after Fontan operation who were evaluated at the Mayo Clinic between 1994 to 2014. TEC was classified into 2 groups: systemic TEC, defined as intracardiac thrombus, ischemic stroke, or systemic arterial embolus; and nonsystemic TEC, defined as Fontan conduit/right atrial thrombus or pulmonary embolus. Patients were divided into 3 groups: anticoagulation, antiplatelet, and no therapy cohorts.ResultsWe followed 278 patients, mean ag...
Source: Journal of the American College of Cardiology - September 13, 2016 Category: Cardiology Source Type: research

Fontan Anticoagulation A Never-Ending Debate? ∗
Thrombus formation is a significant cause of morbidity and mortality after Fontan operations. Intracardiac thrombus formation can lead to chronic pulmonary embolism (e.g., from system veins or subpulmonary ventricle) or stroke (e.g., from pulmonary veins or the systemic ventricle). Those “right-sided” embolisms may result in a ventilation/perfusion mismatch or an elevation of pulmonary vascular resistance, both of which may seriously hamper the cavopulmonary circulation. Preventing thromboembolism after the Fontan procedure and the role of a proper prophylaxis remains an ongoing discussion. The published reports are fr...
Source: Journal of the American College of Cardiology - September 13, 2016 Category: Cardiology Source Type: research

Hybrid Coronary Revascularization The Best of 2 Worlds? ∗
As early as 1997, Michael Mack’s essay discussed the outlook for the possibility of hybrid revascularization with the emergence of minimally invasive coronary surgery combining the off-pump and minimally invasive direct coronary artery bypass (MIDCAB) techniques with percutaneous coronary intervention (PCI) to a non-left anterior descending (LAD) artery target (1). Since that time, coronary surgery and PCI technology have evolved even more. Off-pump coronary artery bypass surgery and MIDCAB surgery have been established in clinical practice and, with the development of drug-eluting stents, a new era of PCI was born. Desp...
Source: Journal of the American College of Cardiology - July 18, 2016 Category: Cardiology Source Type: research

3-Year Outcomes in High-Risk Patients Who Underwent Surgical or Transcatheter Aortic Valve Replacement
This study sought to determine whether this clinical benefit was sustained over time.MethodsPatients with severe aortic stenosis deemed at increased risk for surgery by a multidisciplinary heart team were randomized 1:1 to TAVR or open surgical valve replacement (SAVR). Three-year clinical and echocardiographic outcomes were obtained in those patients with an attempted procedure.ResultsA total of 797 patients underwent randomization at 45 U.S. centers; 750 patients underwent an attempted procedure. Three-year all-cause mortality or stroke was significantly lower in TAVR patients (37.3% vs. 46.7% in SAVR; p = 0.006). Adver...
Source: Journal of the American College of Cardiology - May 30, 2016 Category: Cardiology Source Type: research

Left Atrial Appendage Closure in Patients With Contraindications to Oral Anticoagulation
The PROTECT AF (Watchman Left Atrial Appendage Closure Technology for Embolic Protection in Patients With Atrial Fibrillation) and PREVAIL (Prospective Randomized Evaluation of the Watchman LAA Closure Device In Patients With Atrial Fibrillation Versus Long-Term Warfarin Therapy) trials revealed that in atrial fibrillation (AF) patients suitable for oral anticoagulation (OAC), mechanical left atrial appendage closure (LAAC) with a catheter-delivered heart implant device (Watchman; Boston Scientific, Marlborough, Massachusetts) is effective for stroke prevention (1,2). Importantly, these patients received at least 6 weeks ...
Source: Journal of the American College of Cardiology - May 3, 2016 Category: Cardiology Source Type: research

Predicting Stroke in Patients With Atrial Fibrillation An Incomplete Picture Without Considering Quality of Anticoagulation
Van den Ham et al. (1) nicely compare the new stroke risk stratification tool anticoagulation and risk factors in atrial fibrillation (ATRIA) with CHADS2 (Congestive heart failure, Hypertension, Age ≥75 years, Diabetes mellitus, Prior stroke, TIA, or thromboembolism) and CHA2DS2-VASc (Congestive heart failure, Hypertension, Age ≥75 years, Diabetes mellitus, Prior stroke, TIA, or thromboembolism, Vascular disease, Age 65–74 years, Sex category [female]) in patients with atrial fibrillation.
Source: Journal of the American College of Cardiology - May 3, 2016 Category: Cardiology Source Type: research

A Diabetes-Atrial Fibrillation Conundrum Does Duration Trump Glycemia? ∗
The disease and cost burden of atrial fibrillation (AF) is expected to double over the next 25 years (1). With availability of newer therapies, efforts to refine the triage of who receives therapies, when, and for how long have assumed center stage. Over the last few years, a host of new scores such as CHADS-VASc (congestive heart failure [or Left ventricular systolic dysfunction], hypertension, age≥75 years, diabetes, prior Stroke, TIA, or thromboembolism, vascular disease [e.g. peripheral artery disease, myocardial infarction, aortic plaque], age 65–74 years, sex category) and ATRIA (Anticoagulation and Risk Factors...
Source: Journal of the American College of Cardiology - January 19, 2016 Category: Cardiology Source Type: research

CHA 2 DS 2 -VASc Score for Predicting Stroke and Thromboembolism in Patients With AF and Biological Valve Prosthesis
Patients with valvular atrial fibrillation (AF), as defined in the 2012 European Society of Cardiology guidelines (those with a valvular prosthesis or rheumatic mitral disease) should receive anticoagulation regardless of the CHA2DS2-VASc score, with vitamin K antagonist being recommended (1–3). Whether thromboembolic risk related to bioprosthetic valve implantation differs from other forms of AF is not established with certainty. We evaluated the prognostic value of the CHA2DS2-VASc score for thromboembolic in AF patients with aortic or mitral bioprosthesis.
Source: Journal of the American College of Cardiology - January 19, 2016 Category: Cardiology Source Type: research

Left Atrial Appendage Closure for Stroke Prevention in AF The Quest for the Holy Grail ∗
Strokes resulting from embolization of left atrial appendage (LAA) thrombi in patients with atrial fibrillation (AF) account for up to 25% of the 700,000 cerebrovascular accidents occurring annually in the United States. LAA, a complex structure with considerable anatomic variability, has been appropriately described as the “most lethal human attachment” (1). Stasis, hypercoagulability, and endothelial dysfunction (Virchow triad) contribute to LAA thrombus formation in AF patients. This pathophysiological process results in a 5-fold increased risk for cerebral embolization (2). Stroke is currently the major cause of di...
Source: Journal of the American College of Cardiology - December 14, 2015 Category: Cardiology Source Type: research

Fully Magnetically Levitated Left Ventricular Assist System for Treating Advanced HF A Multicenter Study
ConclusionsThe results show that the fully magnetically levitated centrifugal-flow chronic LVAS is safe, with high 30-day and 6-month survival rates, a favorable adverse event profile, and improved quality of life and functional status. (HeartMate 3™ CE Mark Clinical Investigation Plan [HM3 CE Mark]; NCT02170363)
Source: Journal of the American College of Cardiology - December 7, 2015 Category: Cardiology Source Type: research

Standards and Barriers in Acute Stroke Therapy A Leap Forward in the Evolution of Endovascular Interventions for Stroke ∗
Whether interventional approaches to stroke neurology have lagged behind those aimed at heart attack—for reasons biological or practical—are topics for another day. However, the balance has changed. Tissue plasminogen activator (tPA) was first approved in the United States for intravenous administration to patients with acute stroke in 1996 (1), and a study for catheter-directed intra-arterial infusion of a thrombolytic agent for this indication was first published in 1998 (2). The first positive randomized controlled study using mechanical thrombectomy devices for stroke came from the Netherlands just last year (3), ...
Source: Journal of the American College of Cardiology - November 30, 2015 Category: Cardiology Source Type: research

Stroke Risk Stratification in Patients With Atrial Fibrillation Comme Ci, Comme Ça, Plus Ça Change… ∗
There has been a huge increase in academic interest in atrial fibrillation (AF) and particularly its major complication: thromboembolism. This sustained flurry of activity is fueled by the development of better thromboprophylaxis with well-controlled vitamin K antagonist (VKA) anticoagulation rather than antiplatelet therapy or poorly controlled management with VKAs. The emergence of new therapies, such as non-VKA oral anticoagulant agents and left atrial appendage occlusion devices with better net clinical benefit (less strokes, fewer intracranial or life-threatening bleeds, and reduced mortality) than with warfarin or as...
Source: Journal of the American College of Cardiology - October 19, 2015 Category: Cardiology Source Type: research

Age, Ethnicity, and Stroke Risk in Patients With Atrial Fibrillation Another Stitch in the Patchwork ∗
The frequency with which clinicians encounter patients with nonvalvular atrial fibrillation (AF) and its association with ischemic stroke make estimation of the risk borne by individuals a daily issue in contemporary cardiology practice across the globe. In the balance lies the decision to employ long-term anticoagulation therapy with its attendant risk of severe bleeding. A variety of clinical risk scores are available to guide this decision, most prominently the CHA2DS2-VASc score, which cumulates the widely accepted, if unequally validated, clinical risk factors: heart failure (or impaired left ventricular function), hy...
Source: Journal of the American College of Cardiology - September 14, 2015 Category: Cardiology Source Type: research

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