To evaluate the long-term frequency and severity of anemia and selected vitamin and mineral deficiencies after gastric exclusion surgery for morbid obesity, the authors prospectively examined hematologic and nutritional parameters in 150 consecutive patients. These patients underwent a standardized gastric exclusion procedure during a six-year period (1976-1982) and were closely followed for up to seven years (mean, 33.2 months). Anemia developed in 36.8% of the population at a mean time from operation of 20 months. It was more frequent in women than in men (p less than 0.01), and it required transfusions in 3.5% of the population. A low serum iron concentration developed in 48.6%, iron deficiency in 47.2%, a low serum vitamin B12 concentration in 70.1%, vitamin B12 deficiency in 39.6%, and RBC folate deficiency in 18% of the population. Both iron and folate deficiencies responded to oral replacement. As a result of the high frequency and severity of anemia and nutritional deficiencies noted, all gastric exclusion patients should, as a minimum, be placed on oral multivitamin preparations containing iron, folate and vitamin B12. In addition, it is imperative that these patients be followed closely for the remainder of their lives with appropriate studies and replacement as necessary.

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Background Clinical complexity is increasingly prevalent among patients with atrial fibrillation (AF). The ‘Atrial fibrillation Better Care’ (ABC) pathway approach has been proposed to streamline a more holistic and integrated approach to AF care; however, there are limited data on its usefulness among clinically complex patients. We aim to determine the impact of ABC pathway in a contemporary cohort of clinically complex AF patients. Methods From the ESC-EHRA EORP-AF General Long-Term Registry, we analysed clinically complex AF patients, defined as the presence of frailty, multimorbidity and/or polypharmacy. A K-medoids cluster analysis was performed to identify different groups of clinical complexity. The impact of an ABC-adherent approach on major outcomes was analysed through Cox-regression analyses and delay of event (DoE) analyses. Results Among 9966 AF patients included, 8289 (83.1%) were clinically complex. Adherence to the ABC pathway in the clinically complex group reduced the risk of all-cause death (adjusted HR [aHR]: 0.72, 95%CI 0.58–0.91), major adverse cardiovascular events (MACEs; aHR: 0.68, 95%CI 0.52–0.87) and composite outcome (aHR: 0.70, 95%CI: 0.58–0.85). Adherence to the ABC pathway was associated with a significant reduction in the risk of death (aHR: 0.74, 95%CI 0.56–0.98) and composite outcome (aHR: 0.76, 95%CI 0.60–0.96) also in the high-complexity cluster; similar trends were observed for MACEs. In DoE analyses, an ABC-adherent approach resulted in significant gains in event-free survival for all the outcomes investigated in clinically complex patients. Based on absolute risk reduction at 1 year of follow-up, the number needed to treat for ABC pathway adherence was 24 for all-cause death, 31 for MACEs and 20 for the composite outcome. Conclusions An ABC-adherent approach reduces the risk of major outcomes in clinically complex AF patients. Ensuring adherence to the ABC pathway is essential to improve clinical outcomes among clinically complex AF patients.

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