ISSN 1671-5411 CN 11-5329/R

2021 Vol. 18, No. 11

Blood lead level in Chinese adults with and without coronary artery disease
Shi-Hong LI, Hong-Ju ZHANG, Xiao-Dong LI, Jian CUI, Yu-Tong CHENG, Qian WANG, Su WANG, Chayakrit Krittanawong, Edward A El-Am, Rody G. Bou Chaaya, Xiang-Yu WU, Wei GU, Hong-Hong LIU, Xian-Liang YAN, Zhi-Zhong LI, Shi-Wei YANG, Tao SUN
2021, 18(11): 857-866. doi: 10.11909/j.issn.1671-5411.2021.11.004
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 BACKGROUND  The Trial to Assess Chelation Therapy study found that edetate disodium (disodium ethylenediaminetetraacetic acid) chelation therapy significantly reduced the incidence of cardiac events in stable post-myocardial infarction patients, and a body of epidemiological data has shown that accumulation of biologically active metals, such as lead and cadmium, is an important risk factor for cardiovascular disease. However, limited studies have focused on the relationship between angiographically diagnosed coronary artery disease (CAD) and lead exposure. This study compared blood lead level (BLL) in Chinese patients with and without CAD.  METHODS  In this prospective, observational study, 450 consecutive patients admitted to Beijing Anzhen Hospital with suspected CAD from November 1, 2018, to January 30, 2019, were enrolled. All patients underwent coronary angiography, and an experienced heart team calculated the SYNTAX scores (SXscore) for all available coronary angiograms. BLLs were determined with atomic absorption spectrophotometry and compared between patients with angiographically diagnosed CAD and those without CAD.  RESULTS  In total, 343 (76%) patients had CAD, of whom 42% had low (0−22), 22% had intermediate (23−32), and 36% had high (≥ 33) SXscore. BLLs were 36.8 ± 16.95 μg/L in patients with CAD and 31.2 ± 15.75 μg/L in those without CAD (P = 0.003). When BLLs were categorized into three groups (low, middle, high), CAD prevalence increased with increasing BLLs (P < 0.05). In the multivariate regression model, BLLs were associated with CAD (odds ratio (OR): 1.023, 95% confidence interval (CI): 1.008−1.039; P = 0.0017). OR in the high versus low BLL group was 2.36 (95% CI: 1.29−4.42, P = 0.003). Furthermore, BLLs were independently associated with intermediate and high SXscore (adjusted OR: 1.050, 95% CI: 1.036–1.066; P < 0.0001).  CONCLUSION  BLLs were significantly associated with angiographically diagnosed CAD. Furthermore, BLLs showed excellent predictive value for SXscore, especially for complex coronary artery lesions.
Chronic kidney disease and risks of adverse clinical events in patients with atrial fibrillation
Si-Tong LI, Chao JIANG, Liu HE, Qi-Fan LI, Zuohan DING, Jia-Hui WU, Rong HU, Qiang LV, Xu LI, Chang-Qi JIA, Yan-Fei RUAN, Man NING, Li FENG, Rong BAI, Ri-Bo TANG, Xin DU, Jian-Zeng DONG, Chang-Sheng MA
2021, 18(11): 867-876. doi: 10.11909/j.issn.1671-5411.2021.11.002
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 BACKGROUND  Chronic kidney disease (CKD) is highly prevalent in patients with atrial fibrillation (AF). However, the association between CKD and clinical consequences in AF patients is still under debate.  METHODS  We included 19,079 nonvalvular AF patients with available estimated glomerular filtration rate (eGFR) values in the Chinese Atrial Fibrillation Registry from 2011 to 2018. Patients were classified into no CKD (eGFR ≥ 90 mL/min per 1.73 m2), mild CKD (60 ≤ eGFR < 90 mL/min per 1.73 m2), moderate CKD (30 ≤ eGFR < 60 mL/min per 1.73 m2), and severe CKD (eGFR < 30 mL/min per 1.73 m2) groups. The risks of thromboembolism, major bleeding, and cardiovascular mortality were estimated with Fine-Gray regression analysis according to CKD status. Cox regression was performed to assess the risk of all-cause mortality associated with CKD.  RESULTS Over a mean follow-up of 4.1 ± 1.9 years, there were 985 thromboembolic events, 414 major bleeding events, 956 cardiovascular deaths, and 1,786 all-cause deaths. After multivariate adjustment, CKD was not an independent risk factor of thromboembolic events. As compared to patients with no CKD, those with mild CKD, moderate CKD, and severe CKD had a 45%, 47%, and 133% higher risk of major bleeding, respectively. There was a graded increased risk of cardiovascular mortality associated with CKD status compared with no CKD group: adjusted hazard ratio [HR] was 1.34 (95% CI: 1.07−1.68, P = 0.011) for mild CKD group, 2.17 (95% CI: 1.67−2.81, P < 0.0001) for moderate CKD group, and 2.95 (95% CI: 1.97−4.41, P < 0.0001) for severe CKD group, respectively. Risk of all-cause mortality also increased among patients with moderate or severe CKD.  CONCLUSIONS CKD status was independently associated with progressively higher risks of major bleeding and mortality, but didn’t seem to be an independent predictor of thromboembolism in AF patients.
Minimally invasive thoracoscopic left atrial appendage occlusion compared with transcatheter left atrial appendage closure for stroke prevention in recurrent nonvalvular atrial fibrillation patients after radiofrequency ablation: a prospective cohort study
Jian-Long WANG, Kuo ZHOU, Zheng QIN, Wan-Jun CHENG, Ling-Zhi ZHANG, Yu-Jie ZHOU
2021, 18(11): 877-885. doi: 10.11909/j.issn.1671-5411.2021.11.001
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 BACKGROUND  Tanscatheter left atrial appendage (LAA) closure and minimally invasive thoracoscopic LAA occlusion are local interventions of LAA for stroke prevention in patients with nonvalvular atrial fibrillation (NVAF). However, the safety and efficacy of these methods have not been compared. This prospective cohort study aimed to assess the safety and efficacy of those two treatment approaches for stroke prevention in NVAF patients.  METHODS  Two hundred and nine recurrent NVAF patients who received radiofrequency ablation were enrolled. These patients were treated with transcatheter LAA closure or thoracoscopic LAA occlusion. The patients were followed up from the first postoperative day and evaluated for efficacy endpoints (stroke/transient ischemic attack (TIA), systemic embolism (SE), and death) and a safety endpoint (bleeding events). Perioperative complications were recorded.  RESULTS After a median follow-up of 1.8 years (383 patient-years), the overall rate of the composite efficacy endpoints was similar between the two groups (3.8 vs. 2.7 events per 100 patient-years; HR = 0.71; 95% CI: 0.225−2.237; P = 0.559). However, regarding primary safety endpoint, there were 1.5 bleeding events per 100 patient-years in the thoracoscopic LAA occlusion group, compared with 6.4 in transcatheter LAA closure group (HR = 0.246; 95% CI: 0.074−0.819; P = 0.022). The incidence of operative complications was 3/138 (2.17%) in thoracoscopic LAA occlusion group and 1/71 (1.41%) in transcatheter LAA closure group.  CONCLUSIONS  Thoracoscopic LAA occlusion and transcatheter LAA closure have similar efficacy in preventing stroke in NVAF patients. However, the thoracoscopic group had fewer bleeding events than the transcatheter group, but the former group required a longer hospital stay.
Clinical benefit of left atrial appendage closure in octogenarians
Yamen Mohrez, Steffen Gloekler, Steffen Schnupp, Wasim Allakkis, Xiao-Xia Liu, Monika Fuerholz, Johannes Brachmann, Stephan Windecker, Stephan Achenbach, Bernhard Meier, Caroline Kleinecke
2021, 18(11): 886-896. doi: 10.11909/j.issn.1671-5411.2021.11.003
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 OBJECTIVES  Whether left atrial appendage closure (LAAC) in octogenarians yield similar net clinical benefit compared to younger patients, was the purpose of the present study.  METHODS Two real-world LAAC registries, enrolling 744 consecutive Amplatzer and Watchman patients from 2009 to 2018, were retrospectively analyzed.  RESULTS  All events are reported per 100 patient-years. Two hundred and sixty one octogenarians and 483 non-octogenarians with a mean follow-up of 1.7 ± 1.3 and 2.3 ± 1.6 years, and a total of 1,502 patient-years were included. Octogenarians had a higher risk for stroke (CHA2DS2-VASc score: 5.2 ± 1.2 vs. 4.3 ± 1.7, P < 0.0001) and bleeding (HAS-BLED score: 3.3 ± 0.8 vs. 3.1 ± 1.1, P = 0.001). The combined safety endpoint of major periprocedural complications and major bleeding events at follow-up was comparable (30/446, 6.7% vs. 47/1056, 4.4%; hazard ratio [HR] = 1.2; 95% confidence interval [CI]: 0.73−1.98; P = 0.48) between the groups. The efficacy endpoint of all-cause stroke, systemic embolism, and cardiovascular/unexplained death occurred more often in octogenarians (61/446, 13.7% vs. 80/1056, 7.6%; HR = 7.0; 95% CI: 4.53−10.93; P < 0.0001). Overall, octogenarians had a lower net clinical benefit, i.e., the composite of all above mentioned hazards, from LAAC compared to younger patients (82/446, 18.4% vs. 116/1056, 11.0%; HR = 4.6; 95% CI: 3.11−7.0; P < 0.0001). Compared to the anticipated stroke rate, the observed rate decreased by 41% in octogenarians and 53% in non-octogenarians. The observed bleeding rate was reduced by 10% octogenarians and 41% non-octogenarians.  CONCLUSIONS LAAC can be performed with similar safety in octogenarians as compared to younger patients. On the long-term, it both reduces stroke and bleeding events, although to a lesser extent than in non-octogenarians.
Periprocedural complications and one-year outcomes after catheter ablation for treatment of atrial fibrillation in elderly patients: a nationwide Danish cohort study
Jesper Nielsen, Kristian Hay Kragholm, Sofie Brix Christensen, Arne Johannessen, Christian Torp-Pedersen, Steen Buus Kristiansen, Peter Karl Jacobsen, Peter Steen Hansen, Mogens Stig Djurhus, Christoffer Polcwiartek, Peter Søgaard, Anna Margrethe Thøgersen, Uffe Jakob Ortved Gang, Ole Dan Jørgensen, Filip Lyng Lindgren, Sam Riahi
2021, 18(11): 897-907. doi: 10.11909/j.issn.1671-5411.2021.11.005
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 OBJECTIVES  To investigate complications within 30-days following first-time ablation for atrial fibrillation (AF), including a composite of cardiac tamponade, hematoma requiring intervention, stroke or death, in patients ≥ 75 years of age, compared to patients aged 65−74 years. In addition, one-year all-cause mortality and AF relapse were compared.  METHODS & RESULTS  All patients receiving their first catheter ablation for AF between 2012 and 2016 were identified using Danish nationwide registries. Patients aged 65−74 years served as the reference group for patients ≥ 75 years. Relapse of AF within one year was defined as cardioversion following a three-month blanking period, re-ablation or confirmed relapse within follow-up. The composite complication outcome did not differ between the two age groups, with 39/1554 (2.8%) in patients 65−74 years of age, versus 5/199 (2.5%) in older patients (adjusted HR = 0.94), 95% CI: 0.37−2.39, P = 0.896). Patients ≥ 75 years or older had no increased hazard of death within 30 days after the procedure, with an incidence of 3/1554 (0.2%) in younger patients and 2/199 (1.0%) in patients ≥ 75 years of age (adjusted HR = 4.71, 95% CI: 0.78−28.40, P = 0.091). There was no difference in relapse of AF after one year between age groups (≥ 75 years adjusted HR = 1.00, 95% CI: 0.78-1.26, P = 0.969).  CONCLUSION In patients ≥ 75 years of age selected for catheter ablation for AF, the incidence of periprocedural complications, as well as one-year freedom from AF showed no statistical difference, when compared to patients 65−74 years of age.
Biomarkers in the clinical management of patients with atrial fibrillation and heart failure
Ioanna Koniari, Eleni Artopoulou, Dimitrios Velissaris, Mark Ainslie, Virginia Mplani, Georgia Karavasili, Nicholas Kounis, Grigorios Tsigkas
2021, 18(11): 908-951. doi: 10.11909/j.issn.1671-5411.2021.11.010
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Atrial fibrillation (AF) and heart failure (HF) are two cardiovascular diseases with an increasing prevalence worldwide. These conditions share common pathophysiologiesand frequently co-exit. In fact, the occurrence of either condition can ‘cause’ the development of the other, creating a new patient group that demands different management strategies to that if they occur in isolation. Regardless of the temproral association of the two conditions, their presence is linked with adverse cardiovascular outcomes, increased rate of hospitalizations, and increased economic burden on healthcare systems. The use of low-cost, easily accessible and applicable biomarkers may hasten the correct diagnosis and the effective treatment of AF and HF. Both AF and HF effect multiple physiological pathways and thus a great number of biomarkers can be measured that potentially give the clinician important diagnostic and prognostic information. These will then guide patient centred therapeutic management. The current biomarkers that offer potential for guiding therapy, focus on the physiological pathways of miRNA, myocardial stretch and injury, oxidative stress, inflammation, fibrosis, coagulation and renal impairment. Each of these has different utility in current clinincal practice.
COVID-19 vaccine safety surveillance and emerging concerns of vaccine-induced immune thrombotic thrombocytopenia
Shyh Poh Teo
2021, 18(11): 952-956. doi: 10.11909/j.issn.1671-5411.2021.11.006
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Endovascular interventions may save limbs in elderly subjects with severe lower extremity arterial disease
Min-I SU, Cheng-Wei LIU
2021, 18(11): 957-967. doi: 10.11909/j.issn.1671-5411.2021.11.007
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Coronary stent fracture in an octogenarian patient: from bad to worse
Andreas S. Triantafyllis, Petros N. Fountoulakis, Georgios Charalampidis, Konstantinos Kotinas, Pavlos Tsinivizov, Dimitrios Varvarousis, Andreas Giannakopoulos, Sofia Apollonatou, Areti Stefanidou, Stamatios Chatzopoulos, Dimitrios Tsiptsios, Konstantinos Tsamakis, Konstantinos Kyfnidis, Leonidas E. Poulimenos
2021, 18(11): 968-972. doi: 10.11909/j.issn.1671-5411.2021.11.009
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Gastroprotection during long-term dual antiplatelet therapy: to give or not to give?
Francesco Sbrana, Andrea Ripoli, Beatrice Dal Pino
2021, 18(11): 973-974. doi: 10.11909/j.issn.1671-5411.2021.11.008
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