Publications by authors named "Giuseppe Boriani"

643 Publications

Feasible approaches and implementation challenges to atrial fibrillation screening: a qualitative study of stakeholder views in 11 European countries.

BMJ Open 2022 Jun 21;12(6):e059156. Epub 2022 Jun 21.

Department of Cardiology, University Medical Center Hamburg-Eppendorf, University Heart & Vascular Center Hamburg, Hamburg, Germany.

Objectives: Atrial fibrillation (AF) screening may increase early detection and reduce complications of AF. European, Australian and World Heart Federation guidelines recommend opportunistic screening, despite a current lack of clear evidence supporting a net benefit for systematic screening. Where screening is implemented, the most appropriate approaches are unknown. We explored the views of European stakeholders about opportunities and challenges of implementing four AF screening scenarios.

Design: Telephone-based semi-structured interviews with results reported using Consolidated criteria for Reporting Qualitative research guidelines. Data were thematically analysed using the framework approach.

Setting: AF screening stakeholders in 11 European countries.

Participants: Healthcare professionals and regulators (n=24) potentially involved in AF screening implementation.

Intervention: Four AF screening scenarios: single time point opportunistic, opportunistic prolonged, systematic single time point/prolonged and patient-led screening.

Primary Outcome Measures: Stakeholder views about the challenges and feasibility of implementing the screening scenarios in the respective national/regional healthcare system.

Results: Three themes developed. (1) Current screening approaches: there are no national AF screening programmes, with most AF detected in symptomatic patients. Patient-led screening exists via personal devices, creating screening inequity. (2) Feasibility of screening: single time point opportunistic screening in primary care using single-lead ECG devices was considered the most feasible. Software algorithms may aid identification of suitable patients and telehealth services have potential to support diagnosis. (3) Implementation requirements: sufficient evidence of benefit is required. National screening processes are required due to different payment mechanisms and health service regulations. Concerns about data security, and inclusivity for those without primary care access or personal devices must be addressed.

Conclusions: There is an overall awareness of AF screening. Opportunistic screening appears the most feasible across Europe. Challenges are health inequalities, identification of best target groups for screening, streamlined processes, the need for evidence of benefit and a tailored approach adapted to national realities.
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http://dx.doi.org/10.1136/bmjopen-2021-059156DOI Listing
June 2022

Implantable cardioverter defibrillators for primary prevention of sudden cardiac death: what are the barriers to implementation in the "real world"?

Eur J Heart Fail 2022 Jun 19. Epub 2022 Jun 19.

Aston Medical School, Aston University, Birmingham, United Kingdom.

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http://dx.doi.org/10.1002/ejhf.2581DOI Listing
June 2022

Impact of anthropometric factors on outcomes in atrial fibrillation patients: analysis on 10 220 patients from the ESC-EHRA EORP AF general long-term registry.

Eur J Prev Cardiol 2022 Jun 7. Epub 2022 Jun 7.

Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom.

Aim: To investigate the association of anthropometric parameters [height, weight, body mass index (BMI), body surface area (BSA) and lean body mass (LBM)] with outcomes in atrial fibrillation (AF).

Methods And Results: 10220 patients were enrolled [40.3% females, median age 70 (62-77) years, followed for 728 (IQR 653-745) days]. Sex-specific tertiles were considered for the 5 anthropometric variables. At the end of follow-up survival free from all-cause death was worse in the lowest tertiles for all the anthropometric variables analyzed. On multivariable Cox regression analysis, an independent association with all-cause death was found for the lowest vs. middle tertile when body weight (hazard ratio [HR] 1.66, 95%CI 1.23-2.23), BMI (HR 1.65, 95%CI 1.23-2.21), BSA (HR 1.49, 95%CI 1.11-2.01) were analysed in female sex, as well as for body weight in male patients (HR 1.61, 95%CI 1.25-2 .07). Conversely, the risk of MACE was lower for the highest tertile (vs. middle tertile) of BSA and LBM in males and for the highest tertile of weight and BSA in female patients. A higher occurrence of hemorrhagic events was found for female patients in the lowest tertile of height [odds ratio (OR) 1.90, 95%CI 1.23-2.94] and LBM (OR 2.13, 95%CI 1.40-3.26).  .

Conclusions: In AF patients height, weight, BMI, BSA and LBM were associated with clinical outcomes, with all-cause death being higher for patients presenting lower values of these variables, i.e in the lowest tertiles of distribution. The anthropometric variables independently associated with other outcomes were also different between male and female subjects.
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http://dx.doi.org/10.1093/eurjpc/zwac115DOI Listing
June 2022

Frailty prevalence and impact on outcomes in patients with atrial fibrillation: A systematic review and meta-analysis of 1,187,000 patients.

Ageing Res Rev 2022 May 31;79:101652. Epub 2022 May 31.

Geriatric Unit, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy; Department of Clinical Sciences and Community Health, University of Milan, Italy.

Frailty is a clinical syndrome characterized by a reduced physiologic reserve, increased vulnerability to stressors and an increased risk of adverse outcomes. People with atrial fibrillation (AF) are often burdened by frailty due to biological, clinical, and social factors. The prevalence of frailty, its management and association with major outcomes in AF patients are still not well quantified. We systematically searched PubMed and EMBASE, from inception to September 13th, 2021, for studies reporting the prevalence of frailty in AF patients. The study was registered in PROSPERO (CRD42021235854). 33 studies were included in the systematic review (n = 1,187,651 patients). The frailty pooled prevalence was 39.7 % (95 %CI=29.9 %-50.5 %, I =100 %), while meta-regression analyses showed it is influenced by age, history of stroke, and geographical location. Meta-regression analyses showed that OAC prescription was influenced by study-level mean age, baseline thromboembolic risk, and study setting. Frail AF patients were associated with a higher risk of all-cause death (OR=5.56, 95 %CI=3.46-8.94), ischemic stroke (OR=1.59, 95 %CI=1.00-2.52), and bleeding (OR=1.64, 95 %CI=1.11-2.41), when compared to robust individuals. In this systematic review and meta-analysis, the prevalence of frailty was high in patients with AF. Frailty may influence the prognosis and management of AF patients, thus requiring person-tailored interventions in a holistic or integrated approach to AF care.
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http://dx.doi.org/10.1016/j.arr.2022.101652DOI Listing
May 2022

Atrial cardiomyopathy: a derangement in atrial volumes, geometry, function, and pathology with important clinical implications.

J Cardiovasc Med (Hagerstown) 2022 Jun;23(6):359-362

Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena.

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http://dx.doi.org/10.2459/JCM.0000000000001316DOI Listing
June 2022

Chronic Kidney Disease with Mild and Mild to Moderate Reduction in Renal Function and Long-Term Recurrences of Atrial Fibrillation after Pulmonary Vein Cryoballoon Ablation.

J Cardiovasc Dev Dis 2022 Apr 21;9(5). Epub 2022 Apr 21.

Department of Clinical Electrophysiology & Cardiac Pacing, Heart Rhythm Center, Monzino Cardiac Center IRCCS, 20122 Milan, Italy.

The aim of this research was to evaluate if patients with chronic kidney disease (CKD) and mild or mild to moderate depression of renal function have an increased risk of atrial fibrillation (AF) recurrences after cryoballoon (CB) ablation. We performed a retrospective analysis of AF patients undergoing pulmonary vein isolation (PVI) by CB. The cohort was divided according to the KDIGO CKD-EPI classification into a (1) normal, (2) mildly decreased, or (3) mild to moderate reduction in estimated glomerular filtration rate (eGFR). Freedom from AF recurrences was the primary endpoint. A total of 1971 patients were included (60 ± 10 years, 29.0% females, 73.6% paroxysmal AF) in the study. Acute success and complication rates were 99.2% and 3.7%, respectively, with no significant differences among the three groups. After a follow-up of 24 months, AF recurrences were higher in the mildly and mild to moderate CKD groups compared to the normal kidney function group (23.4% vs. 28.3% vs. 33.5%, < 0.05). Mild to moderate CKD was an independent predictor of AF recurrences after the blanking period (hazard ratio:1.38, 95% CI 1.02-1.86, = 0.037). In conclusion, a multicenter analysis of AF patients treated with cryoablation revealed mild to moderate reductions in renal functions were associated with a higher risk of AF recurrences. Conversely, the procedural success and complication rates were similar in patients with normal, mildly reduced, or mild to moderate reduction in eGFR.
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http://dx.doi.org/10.3390/jcdd9050126DOI Listing
April 2022

The search for a gold standard to clinically diagnose and monitor atrial cardiomyopathy.

Eur J Intern Med 2022 Jul 21;101:34-36. Epub 2022 May 21.

Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy; Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy; Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.

Invited Editorial Commenting On: Tufano A, Lancellotti P. "Atrial cardiomyopathy: Pathophysiology and clinical implications". Eur J Intern Med. 2022 Mar 11:S0953-6205(22)00097-8. doi: 10.1016/j.ejim.2022.03.007. Epub ahead of print. PMID: 35288030.
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http://dx.doi.org/10.1016/j.ejim.2022.05.019DOI Listing
July 2022

The effect of cardiac resynchronization without a defibrillator on morbidity and mortality: insights from an individual patient data meta-analysis of COMPANION and CARE-HF.

Eur J Heart Fail 2022 May 16. Epub 2022 May 16.

Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy.

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http://dx.doi.org/10.1002/ejhf.2536DOI Listing
May 2022

Integrated care for optimizing the management of stroke and associated heart disease: a position paper of the European Society of Cardiology Council on Stroke.

Eur Heart J 2022 May 13. Epub 2022 May 13.

School of Medicine, Belgrade University, Belgrade, Serbia.

The management of patients with stroke is often multidisciplinary, involving various specialties and healthcare professionals. Given the common shared risk factors for stroke and cardiovascular disease, input may also be required from the cardiovascular teams, as well as patient caregivers and next-of-kin. Ultimately, the patient is central to all this, requiring a coordinated and uniform approach to the priorities of post-stroke management, which can be consistently implemented by different multidisciplinary healthcare professionals, as part of the patient 'journey' or 'patient pathway,' supported by appropriate education and tele-medicine approaches. All these aspects would ultimately aid delivery of care and improve patient (and caregiver) engagement and empowerment. Given the need to address the multidisciplinary approach to holistic or integrated care of patients with heart disease and stroke, the European Society of Cardiology Council on Stroke convened a Task Force, with the remit to propose a consensus on Integrated care management for optimizing the management of stroke and associated heart disease. The present position paper summarizes the available evidence and proposes consensus statements that may help to define evidence gaps and simple practical approaches to assist in everyday clinical practice. A post-stroke ABC pathway is proposed, as a more holistic approach to integrated stroke care, would include three pillars of management: • A: Appropriate Antithrombotic therapy. • B: Better functional and psychological status. • C: Cardiovascular risk factors and Comorbidity optimization (including lifestyle changes).
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http://dx.doi.org/10.1093/eurheartj/ehac245DOI Listing
May 2022

Performance-based risk-sharing arrangements for devices and procedures in cardiac electrophysiology: an innovative perspective.

Europace 2022 Mar 24. Epub 2022 Mar 24.

Department of Cardiology, University Hospital of Rennes, Rennes, France.

There is an increasing pressure on demonstrating the value of medical interventions and medical technologies resulting in the proposal of new approaches for implementation in the daily practice of innovative treatments that might carry a substantial cost. While originally mainly adopted by pharmaceutical companies, in recent years medical technology companies have initiated novel value-based arrangements for using medical devices, in the form of 'outcomes-based contracts', 'performance-based contracts', or 'risk-sharing agreements'. These are all characterized by linking coverage, reimbursement, or payment for the innovative treatment to the attainment of pre-specified clinical outcomes. Risk-sharing agreements have been promoted also in the field of electrophysiology and offer the possibility to demonstrate the value of specific innovative technologies proposed in this rapidly advancing field, while relieving hospitals from taking on the whole financial risk themselves. Physicians deeply involved in the field of devices and technologies for arrhythmia management and invasive electrophysiology need to be prepared for involvement as stakeholders. This may imply engagement in the evaluation of risk-sharing agreements and specifically, in the process of assessment of technology performances or patient outcomes. Scientific Associations may have an important role in promoting the basis for value-based assessments, in promoting educational initiatives to help assess the determinants of the learning curve for innovative treatments, and in promoting large-scale registries for a precise assessment of patient outcomes and of specific technologies' performance.
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http://dx.doi.org/10.1093/europace/euac045DOI Listing
March 2022

Impact of diabetes on the management and outcomes in atrial fibrillation: an analysis from the ESC-EHRA EORP-AF Long-Term General Registry.

Eur J Intern Med 2022 May 5. Epub 2022 May 5.

Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark. Electronic address:

Background: The prevalence of atrial fibrillation(AF) and diabetes mellitus is rising to epidemic proportions. We aimed to assess the impact of diabetes on the management and outcomes of patients with AF.

Methods: The EORP-AF General Long-Term Registry is a prospective, observational registry from 250 centres across 27 European countries. Outcomes of interest were as follows: i)rhythm control interventions; ii)quality of life; iii)healthcare resource utilisation; and iv)major adverse events.

Results: Of 11,028 patients with AF, the median age was 71 (63-77) years and 2537 (23.0%) had diabetes. Median follow-up was 24 months. Diabetes was related to increased use of anticoagulation but less rhythm control interventions. Using multivariable analysis, at 2-year follow-up, patients with diabetes were associated with greater levels of anxiety (p = 0.038) compared to those without diabetes. Overall, diabetes was associated with worse health during follow-up, as indicated by Health Utility Score and Visual Analogue Scale. Healthcare resource utilisation was greater with diabetes in terms of length of hospital stay (8.1 (±8.2) vs. 6.1 (±6.7) days); cardiology and internal medicine/general practitioner visits; and emergency room admissions. Diabetes was an independent risk factor of major adverse cardiovascular event (MACE; HR 1.26 [95% CI, 1.04-1.52]), all-cause mortality (HR 1.28 [95% CI, 1.08-1.52]), and cardiovascular mortality (HR 1.41 [95% CI, 1.09-1.83]).

Conclusion: In this contemporary AF cohort, diabetes was present in 1 in 4 patients and it served as an independent risk factor for reduced quality of life, greater healthcare resource utilisation and excess MACE, all-cause mortality and cardiovascular mortality. There was increased use of anticoagulation therapy in diabetes but with less rhythm control interventions.
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http://dx.doi.org/10.1016/j.ejim.2022.04.026DOI Listing
May 2022

Comparing atrial fibrillation guidelines: Focus on stroke prevention, bleeding risk assessment and oral anticoagulant recommendations.

Eur J Intern Med 2022 Jul 5;101:1-7. Epub 2022 May 5.

Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, Policlinico di Modena, University of Modena and Reggio Emilia, Via del Pozzo, 71, Modena 41124, Italy. Electronic address:

Clinical practice in atrial fibrillation (AF) patient management is constantly evolving. In the past 3 years, various new AF guidelines or focused updates have been published, given this rapidly evolving field. In 2019, the American College of Cardiology/American Heart Association published a focused update of the 2014 guidelines. In 2020, both the European Society of Cardiology and the Canadian Cardiovascular Society released their new guidelines. Finally, the most recent guidelines were those published in 2021 by the Asian Pacific Heart Rhythm Society, which updates their 2017 version and the 2021 National Institute for Health and Care Excellence (NICE) guidelines. In the present narrative review, we compare these guidelines, emphasizing similarities and differences in the following mainstay elements of patient care: thromboembolic risk assessment, oral anticoagulants (OACs) prescription, bleeding risk evaluation, and integrated patient management. A formal evaluation of baseline thromboembolic and bleeding risks and their reassessment during follow-up is evenly recommended, although some differences in using risk stratification scores. OACs prescription is highly encouraged where appropriate, and prescription algorithms are broadly similar. The importance of an integrated and multidisciplinary approach to patient care is emerging, aiming to address several different aspects of a multifaceted disease.
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http://dx.doi.org/10.1016/j.ejim.2022.04.023DOI Listing
July 2022

Association between implantable defibrillator-detected sleep apnea and atrial fibrillation: The DASAP-HF study.

J Cardiovasc Electrophysiol 2022 May 2. Epub 2022 May 2.

Unità Operativa di Elettrofisiologia, Studio e Terapia delle Aritmie, Ospedale Monaldi, Naples, Italy.

Introduction: The Respiratory Disturbance Index (RDI) computed by an implantable cardioverter defibrillator (ICD) algorithm accurately identifies severe sleep apnea (SA). In the present analysis, we tested the hypothesis that RDI could also predict atrial fibrillation (AF) burden.

Methods: Patients with ejection fraction ≤35% implanted with an ICD were enrolled and followed up for 24 months. One month after implantation, patients underwent a polysomnographic study. The weekly mean RDI value was considered, as calculated during the entire follow-up period and over a 1-week period preceding the sleep study. The endpoints were as follows: daily AF burden of ≥5 min, ≥6 h, ≥23 h.

Results: Here, 164 patients had usable RDI values during the entire follow-up period. Severe SA (RDI ≥ 30 episodes/h) was diagnosed in 92 (56%) patients at the time of the sleep study. During follow-up, AF burden ≥ 5 min/day was documented in 70 (43%), ≥6 h/day in 48 (29%), and ≥23 h/day in 33 (20%) patients. Device-detected RDI ≥ 30 episodes/h at the time of the polygraphy, as well as the polygraphy-measured apnea hypopnea index ≥ 30 episodes/h, were not associated with the occurrence of the endpoints, using a Cox regression model. However, using a time-dependent model, continuously measured weekly mean RDI ≥ 30 episodes/h was independently associated with AF burden ≥ 5 min/day (hazard ratio [HR]: 2.13, 95% confidence interval [CI]: 1.24-3.65, p = .006), ≥6 h/day (HR: 2.75, 95% CI: 1.37-5.49, p = .004), and ≥23 h/day (HR: 2.26, 95% CI: 1.05-4.86, p = .037).

Conclusions: In heart failure patients, ICD-diagnosed severe SA on follow-up data review identifies patients who are from two- to three-fold more likely to experience an AF episode, according to various thresholds of daily AF burden.
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http://dx.doi.org/10.1111/jce.15506DOI Listing
May 2022

Dronedarone for the treatment of atrial fibrillation with concomitant heart failure and preserved or mildly reduced ejection fraction: closer to Ithaca after a long odyssey?

Eur J Heart Fail 2022 Apr 28. Epub 2022 Apr 28.

Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy.

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http://dx.doi.org/10.1002/ejhf.2519DOI Listing
April 2022

Clinical Profile, Arrhythmias, and Adverse Cardiac Outcomes in Emery-Dreifuss Muscular Dystrophies: A Systematic Review of the Literature.

Biology (Basel) 2022 Mar 30;11(4). Epub 2022 Mar 30.

Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, 41124 Modena, Italy.

Cardiolaminopathies are a heterogeneous group of disorders which are due to mutations in the genes encoding for nuclear lamins or their binding proteins. The whole spectrum of cardiac manifestations encompasses atrial arrhythmias, conduction disturbances, progressive systolic dysfunction, and malignant ventricular arrhythmias. Despite the prognostic significance of cardiac involvement in this setting, the current recommendations lack strong evidence. The aim of our work was to systematically review the current data on the main cardiovascular outcomes in cardiolaminopathies. We searched PubMed/Embase for studies focusing on cardiovascular outcomes in mutation carriers (atrial arrhythmias, ventricular arrhythmias, sudden cardiac death, conduction disturbances, thromboembolic events, systolic dysfunction, heart transplantation, and all-cause and cardiovascular mortality). In total, 11 studies were included (1070 patients, mean age between 26-45 years, with follow-up periods ranging from 2.5 years up to 45 ± 12). When available, data on the -mutated population were separately reported (40 patients). The incidence rates (IR) were individually assessed for the outcomes of interest. The IR for atrial fibrillation/atrial flutter/atrial tachycardia ranged between 6.1 and 13.9 events/100 pts-year. The IR of atrial standstill ranged between 0 and 2 events/100 pts-year. The IR for malignant ventricular arrhythmias reached 10.2 events/100 pts-year and 15.6 events/100 pts-year for appropriate implantable cardioverter-defibrillator (ICD) interventions. The IR for advanced conduction disturbances ranged between 3.2 and 7.7 events/100 pts-year. The IR of thromboembolic events reached up to 8.9 events/100 pts-year. Our results strengthen the need for periodic cardiological evaluation focusing on the early recognition of atrial arrhythmias, and possibly for the choice of preventive strategies for thromboembolic events. The frequent need for cardiac pacing due to advanced conduction disturbances should be counterbalanced with the high risk of malignant ventricular arrhythmias that would justify ICD over pacemaker implantation.
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http://dx.doi.org/10.3390/biology11040530DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9031530PMC
March 2022

Mobile health technology in atrial fibrillation.

Expert Rev Med Devices 2022 Apr 25;19(4):327-340. Epub 2022 Apr 25.

Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.

Introduction: Mobile health (mHealth) solutions in atrial fibrillation (AF) are becoming widespread, thanks to everyday life devices, such as smartphones. Their use is validated both in monitoring and in screening scenarios. In the published literature, the diagnostic accuracy of mHealth solutions wide differs, and their current clinical use is not well established in principal guidelines.

Areas Covered: mHealth solutions have progressively built an AF-detection chain to guide patients from the device's alert signal to the health-care practitioners' (HCPs) attention. This review aims to critically evaluate the latest evidence regarding mHealth devices and the future possible patient's uses in everyday life.

Expert Opinion: The patients are the first to be informed of the rhythm anomaly, leading to the urgency of increasing the patients' AF self-management. Furthermore, HCPs need to update themselves about mHealth devices use in clinical practice. Nevertheless, these are promising instruments in specific populations, such as post-stroke patients, to promote an early arrhythmia diagnosis in the post-ablation/cardioversion period, allowing checks on the efficacy of the treatment or intervention.
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http://dx.doi.org/10.1080/17434440.2022.2070005DOI Listing
April 2022

Clinical utility and prognostic implications of the novel 4S-AF scheme to characterize and evaluate patients with atrial fibrillation: a report from ESC-EHRA EORP-AF Long-Term General Registry.

Europace 2022 05;24(5):721-728

Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.

Aims: The 4S-AF classification scheme comprises of four domains: stroke risk (St), symptoms (Sy), severity of atrial fibrillation (AF) burden (Sb), and substrate (Su). We sought to examine the implementation of the 4S-AF scheme in the EORP-AF General Long-Term Registry and compare outcomes in AF patients according to the 4S-AF-led decision-making process.

Methods And Results: Atrial fibrillation patients from 250 centres across 27 European countries were included. A 4S-AF score was calculated as the sum of each domain with a maximum score of 9. Of 6321 patients, 8.4% had low (St), 47.5% EHRA I (Sy), 40.5% newly diagnosed or paroxysmal AF (Sb), and 5.1% no cardiovascular risk factors or left atrial enlargement (Su). Median follow-up was 24 months. Using multivariable Cox regression analysis, independent predictors of all-cause mortality were (St) [adjusted hazard ratio (aHR) 8.21, 95% confidence interval (CI): 2.60-25.9], (Sb) (aHR 1.21, 95% CI: 1.08-1.35), and (Su) (aHR 1.27, 95% CI: 1.14-1.41). For CV mortality and any thromboembolic event, only (Su) (aHR 1.73, 95% CI: 1.45-2.06) and (Sy) (aHR 1.29, 95% CI: 1.00-1.66) were statistically significant, respectively. None of the domains were independently linked to ischaemic stroke or major bleeding. Higher 4S-AF score was related to a significant increase in all-cause mortality, CV mortality, any thromboembolic event, and ischaemic stroke but not major bleeding. Treatment of all 4S-AF domains was associated with an independent decrease in all-cause mortality (aHR 0.71, 95% CI: 0.55-0.92). For each 4S-AF domain left untreated, the risk of all-cause mortality increased substantially (aHR 1.35, 95% CI: 1.16-1.56).

Conclusion: Implementation of the novel 4S-AF scheme is feasible, and treatment decisions based on this scheme improve mortality rates in AF.
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http://dx.doi.org/10.1093/europace/euab280DOI Listing
May 2022

The value of wearable cardioverter defibrillator in adult patients with recent myocardial infarction: Economic and clinical implications from a health technology assessment perspective.

Int J Cardiol 2022 06 5;356:12-18. Epub 2022 Apr 5.

Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy.

Aims: Sudden cardiac death (SCD) causes high mortality and substantial societal burdens for healthcare systems (HSs). The risk of SCD is significantly increased in patients with reduced left ventricular ejection fraction after myocardial infarction (MI). Current guidelines recommend re-evaluation of cardioverter-defibrillator implantation 40 days post-MI, earliest. Medical therapy alone does not provide sufficient protection against SCD, especially in the first month post-MI, and needs time. Consequently, there is a gap in care of high-risk patients upon hospital discharge. The wearable cardioverter defibrillator (WCD) is a proven safe, effective therapy, which temporarily protects from SCD. Little information on WCD cost-effectiveness exists. We conducted this research to demonstrate the medical need of the device in the post-MI setting defining WCD cost-effectiveness.

Methods & Results: Based on a randomized clinical trials (RCTs) and Italian and international data, we developed a Markov-model comparing costs, patient survival, and quality-of-life, and calculated the Incremental Cost-Effectiveness Ratio (ICER) of a WCD vs. current standard of care in post-MI patients. The rather conservative base case analysis - based on the RCT intention-to-treat results - produced an ICER of €47,709 per Quality Adjusted Life Year (QALY) gained, which is far lower than the accepted threshold of €60,000 in the Italian National HS. The ICER per Life Year (LY) gained was €38,276.

Conclusion: WCD utilization in post-MI patients is clinically beneficial and cost-effective. While improving guideline directed patient care, the WCD can also contribute to a more efficient use of resources in the Italian HS, and potentially other HSs as well.
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http://dx.doi.org/10.1016/j.ijcard.2022.04.003DOI Listing
June 2022

Case Report: Free-Floating Intracoronary Thrombus: Who Is the Convict?

Front Oncol 2022 8;12:825711. Epub 2022 Mar 8.

Department of Cardiology, Policlinico Hospital, Modena and Reggio Emilia University, Modena, Italy.

In young patients, especially with no traditional coronary risk factors, hypercoagulable states may always be considered as an alternative cause of acute coronary syndromes. The concomitant thrombotic and bleeding risk associated with myeloproliferative disorders complicates the decision-making, particularly regarding long-term dual antiplatelet therapy. The chosen therapy may need to be frequently revisited, depending on the patient's bleeding complications. We reported the case of a 49-year-old woman with acute myocardial infarction with no traditional risk factors for coronary artery disease where a myeloproliferative neoplasm was diagnosed.
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http://dx.doi.org/10.3389/fonc.2022.825711DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8957839PMC
March 2022

Atrial High-Rate Episodes Detected by Cardiac Implantable Electronic Devices: Dynamic Changes in Episodes and Predictors of Incident Atrial Fibrillation.

Biology (Basel) 2022 Mar 15;11(3). Epub 2022 Mar 15.

Department of Biomedical, Metabolic and Neural Sciences, Cardiology Division, University of Modena and Reggio Emilia, Policlinico di Modena, 41125 Modena, Italy.

Background: Atrial high rate episodes (AHRE) detected by cardiac implantable electronic devices (CIEDs) may be associated with a risk of progression towards long-lasting episodes (≥24 h) and clinical atrial fibrillation (AF).

Methods: Consecutive CIED patients presenting AHRE (with confirmation of an arrhythmia lasting 5 min-23 h 59 min, atrial rate ≥175/min, with no AF at 12-lead ECG and no prior clinical AF) were retrospectively enrolled. The aims of this study were to describe patients' characteristics and the incidence of adverse events, and second, to identify potential predictors of the composite outcome of clinical AF and/or AHRE episodes lasting ≥24 h.

Results: 104/107 (97.2%) patients (median age 79.7 (74.0-84.2), 33.7% female) had available follow-up data. Over a median follow-up of 24.3 (10.6-40.3) months, 31/104 (29.8%) patients experienced the composite outcome of clinical AF or AHRE episodes lasting ≥24 h. Baseline CHADS-VASc score and the longest AHRE episode at enrollment lasting 12 h-23 h 59 min were independently associated with the composite outcome (Hazard ratio (HR); 95% CI: 1.40; 1.07-1.83 and HR: 8.15; 95% CI 2.32-28.65, respectively). Baseline CHADS-VASc score and the longest AHRE episode at enrollment lasting 12 h-23 h 59 min were the only independent predictors of incident clinical AF (HR: 1.45; 95% CI 1.06-2.00 and HR: 4.25; 95% CI 1.05-17.20, respectively).

Conclusions: In patients with AHRE, the incidence of clinical AF or AHRE episodes lasting ≥24 h is high in a two-year follow-up. Baseline patients' characteristics (CHADS-VASc score) and AHRE duration may help to intensify monitoring and decision-making, being independently associated with clinical AF at follow-up.
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http://dx.doi.org/10.3390/biology11030443DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8945035PMC
March 2022

Impact of malignancy on outcomes in European patients with atrial fibrillation: A report from the ESC-EHRA EURObservational research programme in atrial fibrillation general long-term registry.

Eur J Clin Invest 2022 Jul 28;52(7):e13773. Epub 2022 Mar 28.

Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy.

Background: The management of patients with atrial fibrillation (AF) and malignancy is challenging given the paucity of evidence supporting their appropriate clinical management.

Purpose: To evaluate the outcomes of patients with active or prior malignancy in a contemporary cohort of European AF patients.

Methods: Patients enrolled in the EURObservational Research Programme in AF General Long-Term Registry were categorized into 3 categories: No Malignancy (NoMal), Prior Malignancy (PriorMal) and Active Malignancy (ActiveMal). The primary outcomes were all-cause death and the composite outcome MACE.

Results: A total of 10 383 patients were analysed. Of these, 9597 (92.4%) were NoMal patients, 577 (5.6%) PriorMal and 209 (2%) ActiveMal. Lack of any antithrombotic treatment was more prevalent in ActiveMal patients (12.4%) as compared to other groups (5.0% vs 6.3% for PriorMal and NoMal, p < .001). After a median follow-up of 730 days, there were 982 (9.5%) deaths and 950 (9.7%) MACE events. ActiveMal was independently associated with a higher risk for all-cause death (HR 2.90, 95% CI 2.23-3.76) and MACE (HR 1.54, 95% CI 1.03-2.31), as well as any haemorrhagic events and major bleeding (OR 2.42, 95% CI 1.49-3.91 and OR 4.18, 95% CI 2.49-7.01, respectively). Use of oral anticoagulants was not significantly associated with a higher risk for all-cause death or bleeding in ActiveMal patients.

Conclusions: In a large contemporary cohort of AF patients, active malignancy was independently associated with all-cause death, MACE and haemorrhagic events. Use of anticoagulants was not associated with a higher risk of all-cause death in patients with active malignancies.
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http://dx.doi.org/10.1111/eci.13773DOI Listing
July 2022

Arrhythmias in COVID-19/SARS-CoV-2 Pneumonia Infection: Prevalence and Implication for Outcomes.

J Clin Med 2022 Mar 7;11(5). Epub 2022 Mar 7.

Cardiology Division, Parma University Hospital, 43125 Parma, Italy.

Arrhythmias (ARs) are potential cardiovascular complication of COVID-19 but may also have a prognostic role. The aim of this study was to explore the prevalence and impact of cardiac ARs in hospitalized COVID-19 patients. All-comer patients admitted to the emergency department of Modena University Hospital from 16 March to 31 December 2020 and diagnosed with COVID-19 pneumonia infection were included in the study. The primary endpoint was 30-day mortality. Out of 902 patients, 637 (70.6%) presented a baseline 12-lead ECG registration; of these, 122 (19.2%) were diagnosed with ARs. Atrial fibrillation (AF, 40.2%) was the most frequent AR detected. The primary endpoint (30-day mortality) occurred in 33.6% ( < 0.001). AR-patients presented an almost 3-fold risk of mortality compared to non-AR-patients at 30d (Adj. OR = 2.8, 95%CI: 1.8-4.3, < 0.001). After adjustment for significant baseline characteristics selected by a stepwise backward selection, AR-patients remained at increased risk of mortality (Adj. HR = 2.0, 95%CI: 1.9-2.3, < 0.001). Sub-group analysis revealed that among ARs patients, those with AF at admission presented the highest risk of 30-day mortality (Adj. HR = 3.1, 95%CI: 2.0-4.9, < 0.001). In conclusion, ARs are a quite common manifestation in COVID-19 patients, who are burdened by even worse prognosis. AR patients with AF presented the highest risk of mortality; thus, these patients may benefit from a more aggressive secondary preventive therapy and a closer follow up.
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http://dx.doi.org/10.3390/jcm11051463DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8911084PMC
March 2022

AIM-AF: A Physician Survey in the United States and Europe.

J Am Heart Assoc 2022 03 4;11(6):e023838. Epub 2022 Mar 4.

Columbia University New York NY.

Background Guideline recommendations are the accepted reference for selection of therapies for rhythm control of atrial fibrillation (AF). This study was designed to understand physicians' treatment practices and adherence to guidelines. Methods and Results The AIM-AF (Antiarrhythmic Medication for Atrial Fibrillation) study was an online survey of clinical cardiologists and electrophysiologists that was conducted in the United States and Europe (N=629). Respondents actively treated ≥30 patients with AF who received drug therapy, and had received or were referred for ablation every 3 months. The survey comprised 96 questions on physician demographics, AF types, and treatment practices. Overall, 54% of respondents considered guidelines to be the most important nonpatient factor influencing treatment choice. Across most queried comorbidities, amiodarone was selected by 60% to 80% of respondents. Other nonadherent usage included sotalol by 21% in patients with renal impairment; dofetilide initiation (16%, United States only) outside of hospital; class Ic agents by 6% in coronary artery disease; and dronedarone by 8% in patients with heart failure with reduced ejection fraction. Additionally, rhythm control strategies were frequently chosen in asymptomatic AF (antiarrhythmic drugs [AADs], 35%; ablation, 8%) and subclinical AF (AADs, 38%; ablation, 13%). Despite guideline algorithms emphasizing safety first, efficacy (48%) was selected as the most important consideration for AAD choice, followed by safety (34%). Conclusions Despite surveyed clinicians recognizing the importance of guidelines, nonadherence was frequently observed. While deviation may be reasonable in selected patients, in general, nonadherence has the potential to compromise patient safety. These findings highlight an underappreciation of the safe use of AADs, emphasizing the need for interventions to support optimal AAD selection.
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http://dx.doi.org/10.1161/JAHA.121.023838DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9075271PMC
March 2022

Vascular Accesses in Cardiac Stimulation and Electrophysiology: An Italian Survey Promoted by AIAC (Italian Association of Arrhythmias and Cardiac Pacing).

Biology (Basel) 2022 Feb 8;11(2). Epub 2022 Feb 8.

Department of Biomedical, Metabolic and Neural Sciences, Cardiology Division, University of Modena and Reggio Emilia, Policlinico Di Modena, 41121 Modena, Italy.

Cardiac implantable electronic device (CIED) implants and electrophysiological procedures share a common step: vascular access. On behalf of the AIAC Ricerca Investigators' Network, we conducted a survey to outline Italian common practice regarding vascular access in EP-lab. All Italian physicians with experience in CIED implantation and electrophysiology were invited to answer an online questionnaire (from May 2020 to November 2020) featuring 20 questions. In total, 103 cardiologists (from 92 Italian hospitals) answered the survey. Vascular access during CIED implants was considered the most complex step following lead placement by 54 (52.4%) respondents and the most complex for 35 (33.9%). In total, 54 (52.4%) and 49 (47.6%) respondents considered the cephalic and subclavian vein the first option, respectively (intrathoracic and extrathoracic subclavian/axillary vein by 22 and 27, respectively). In total, 45 (43.7%) respondents performed close arterial femoral accesses manually; only 12 (11.7%) respondents made extensive use of vascular closure devices. A total of 46 out of 103 respondents had experience in ultrasound-guided vascular accesses, but only 10 (22%) used it for more than 50% of the accesses. In total, 81 (78.6%) respondents wanted to increase their ultrasound-guided vascular access skills. Reducing complications is a goal to reach in cardiac stimulation and electrophysiological procedures. Our survey shows the heterogeneity of the vascular approaches used in Italian centres. Some vascular accesses were proved to be superior to others in terms of complications, with ultrasound-guided puncture as an emerging technique. More effort to produce the standardization of vascular accesses could be made by scientific societies.
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http://dx.doi.org/10.3390/biology11020265DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8869488PMC
February 2022

Cardiac troponins and adverse outcomes in European patients with atrial fibrillation: A report from the ESC-EHRA EORP atrial fibrillation general long-term registry.

Eur J Intern Med 2022 05 15;99:45-56. Epub 2022 Feb 15.

Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Via del Pozzo, 71, Modena 41124, Italy. Electronic address:

Background: Cardiac troponins (cTn) have been reported to be predictors for adverse outcomes in atrial fibrillation (AF), patients, but their actual use is still unclear.

Aim: To assess the factors associated with cTn testing in routine practice and evaluate the association with outcomes.

Methods: Patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry were stratified into 3 groups according to cTn levels as (i) cTn not tested, (ii) cTn in range (≤99th percentile), (iii) cTn elevated (>99th percentile). The composite outcome of any thromboembolism /any acute coronary syndrome/cardiovascular (CV) death, defined as Major Adverse Cardiovascular Events (MACE) and all-cause death were the main endpoints.

Results: Among 10 445 AF patients (median age 71 years, 40.3% females) cTn were tested in 2834 (27.1%). cTn was elevated in 904/2834 (31.9%) and in-range in 1930/2834 (68.1%) patients. Female sex, in-hospital enrollment, first-detected AF, CV risk factors, history of coronary artery disease, and atypical AF symptoms were independently associated with cTn testing. Elevated cTn were independently associated with a higher risk for MACE (Model 1, hazard ratio [HR] 1.74, 95% confidence interval [CI] 1.40-2.16, Model 2, HR 1.62, 95% CI 1.28-2.05; Model 3 HR 1.76, 95% CI 1.37-2.26) and all-cause death (Model 1, HR 1.45, 95% CI 1.21-1.74; Model 2, HR 1.36, 95% CI 1.12-1.66; Model 3, HR 1.38, 95% CI 1.12-1.71).

Conclusions: Elevated cTn levels were associated with an increased risk of all-cause mortality and adverse CV events. Clinical factors that might enhance the need to rule out CAD were associated with cTn testing.
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http://dx.doi.org/10.1016/j.ejim.2022.01.025DOI Listing
May 2022

Ten-year follow-up of cardiac resynchronization therapy patients with non-ischemic dilated cardiomyopathy assessed by radionuclide angiography: a single-center cohort study.

J Interv Card Electrophysiol 2022 Feb 17. Epub 2022 Feb 17.

Department of Cardiology, IRCCS, Azienda Ospedaliero Universitaria Di Bologna, Policlinico Di S.Orsola, Via Massarenti 9, 40138, Bologna, Italy.

Purpose: Relatively few data are available on long-term survival and incidence of ventricular arrhythmias in cardiac resynchronization therapy (CRT) patients. We investigated long-term outcomes of CRT patients with non-ischemic dilated cardiomyopathy stratified as responders or non-responders according to radionuclide angiography.

Methods: Fifty patients with non-ischemic dilated cardiomyopathy undergoing CRT were assessed by equilibrium Tc radionuclide angiography with bicycle exercise at baseline and after 3 months. Intra- and interventricular dyssynchrony were derived by Fourier phase analysis. Patient clinical outcome was assessed after 10 years.

Results: At 3 months, 50% of patients were identified as CRT responders according to an increase in LV ejection fraction ≥ 5%. During a follow-up of 109 ± 48 months, 30% of patients died and 6% underwent heart transplantation. Age and history of paroxysmal atrial fibrillation were found to be predictors of all-cause mortality. CRT responders showed lower risk of death from cardiac causes than non-responders. At follow-up, 38% of patients presented at least one episode of sustained ventricular tachycardia, with a similar percentage between responders and non-responders.

Conclusion: At long-term follow-up, non-ischemic CRT recipients identified as responders by radionuclide angiography were found to be at lower risk of worsening heart failure death than non-responders. Long-term risk for sustained ventricular arrhythmia was similar between CRT responders and non-responders.
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http://dx.doi.org/10.1007/s10840-022-01117-zDOI Listing
February 2022

Kidney Function According to Different Equations in Patients Admitted to a Cardiology Unit and Impact on Outcome.

J Clin Med 2022 Feb 8;11(3). Epub 2022 Feb 8.

Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, 41125 Modena, Italy.

Background: This paper aims to evaluate the concordance between the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula and alternative equations and to assess their predictive power for all-cause mortality in unselected patients discharged alive from a cardiology ward.

Methods: We retrospectively included patients admitted to our Cardiology Division independently of their diagnosis. The total population was classified according to Kidney Disease: Improving Global Outcomes (KDIGO) categories, as follows: G1 (estimated glomerular filtration rate (eGFR) ≥90 mL/min/1.73 m); G2 (eGFR 89-60 mL/min/1.73 m); G3a (eGFR 59-45 mL/min/1.73 m); G3b (eGFR 44-30 mL/min/1.73 m); G4 (eGFR 29-15 mL/min/1.73 m); G5 (eGFR <15 mL/min/1.73 m). Cockcroft-Gault (CG), CG adjusted for body surface area (CG-BSA), Modification of Diet in Renal Disease (MDRD), Berlin Initiative Study (BIS-1), and Full Age Spectrum (FAS) equations were also assessed.

Results: A total of 806 patients were included. Good agreement was found between the CKD-EPI formula and CG-BSA, MDRD, BIS-1, and FAS equations. In subjects younger than 65 years or aged ≥85 years, CKD-EPI and MDRD showed the highest agreement (Cohen's kappa (K) 0.881 and 0.588, respectively) while CG showed the lowest. After a median follow-up of 407 days, overall mortality was 8.2%. The risk of death was higher in lower eGFR classes (G3b HR4.35; 95%CI 1.05-17.80; G4 HR7.13; 95%CI 1.63-31.23; G5 HR25.91; 95%CI 6.63-101.21). The discriminant capability of death prediction tested with ROC curves showed the best results for BIS-1 and FAS equations.

Conclusion: In our cohort, the concordance between CKD-EPI and other equations decreased with age, with the MDRD formula showing the best agreement in both younger and older patients. Overall, mortality rates increased with the renal function decreasing. In patients aged ≥75 years, the best discriminant capability for death prediction was found for BIS-1 and FAS equations.
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http://dx.doi.org/10.3390/jcm11030891DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8837128PMC
February 2022
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