BackgroundAtrial fibrillation is associated with higher mortality. Identification of causes of death and contemporary risk factors for all‐cause mortality may guide interventions.Methods and ResultsIn the Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation (ROCKET AF) study, patients with nonvalvular atrial fibrillation were randomized to rivaroxaban or dose‐adjusted warfarin. Cox proportional hazards regression with backward elimination identified factors at randomization that were independently associated with all‐cause mortality in the 14 171 participants in the intention‐to‐treat population. The median age was 73 years, and the mean CHADS
2 score was 3.5. Over 1.9 years of median follow‐up, 1214 (8.6%) patients died. Kaplan–Meier mortality rates were 4.2% at 1 year and 8.9% at 2 years. The majority of classified deaths (1081) were cardiovascular (72%), whereas only 6% were nonhemorrhagic stroke or systemic embolism. No significant difference in all‐cause mortality was observed between the rivaroxaban and warfarin arms (P=0.15). Heart failure (hazard ratio 1.51, 95% CI 1.33–1.70, P<0.0001) and age ≥75 years (hazard ratio 1.69, 95% CI 1.51–1.90, P<0.0001) were associated with higher all‐cause mortality. Multiple additional characteristics were independently associated with higher mortality, with decreasing creatinine clearance, chronic obstructive pulmonary disease, male sex, peripheral vascular disease, and diabetes being among the most strongly associated (model C‐index 0.677).ConclusionsIn a large population of patients anticoagulated for nonvalvular atrial fibrillation, ≈7 in 10 deaths were cardiovascular, whereas <1 in 10 deaths were caused by nonhemorrhagic stroke or systemic embolism. Optimal prevention and treatment of heart failure, renal impairment, chronic obstructive pulmonary disease, and diabetes may improve survival.Clinical Trial Registration
URL: https://www.clinicaltrials.gov/. Unique identifier: NCT00403767.
SummaryBackground: Evaluation of chest pain accounts for millions of costly Emergency Department (ED) visits and hospital admissions annually. Of these, approximately 10-20% are myocardial infarctions (MI).Hypothesis: Patients with chest pain whose initial electrocardiogram (ECG) is normal do not require hospital admission for evaluation and management of a possible myocardial infarction.Methods: The medical records of a consecutive cohort of 250 patients who presented to the ED with chest pain and were admitted by the ED physician to a cardiology inpatient service of an academic tertiary care medical center were reviewed. Reasons for admission to hospital was to rule out an acute coronary syndrome, specifically, myocardial infarction. The initial ECG of each patient was evaluated for abnormalities and compared with the final diagnosis.Results: Of the 75 patients presenting with normal ECGs (normal, upright T waves and isoelectric ST segments), 1 (1.3%) was subsequently diagnosed with a myocardial infarction by Troponin I elevation alone. Of the 55 patients presenting with abnormal ECGs but no clear evidence of ischemia [i.e., left bundle branch block (LBBB), right bundle branch block (RBBB), left anterior
Catheter ablation has become an important and widely used treatment modality for patients with symptomatic atrial fibrillation. The superior efficacy of catheter ablation over antiarrhythmic therapy has been well established. The understanding of the pathophysiology of atrial fibrillation has led to the development of catheter-based ablation techniques. The development of techniques for catheter ablation of atrial fibrillation has rapidly progressed over the last 15 years. As our knowledge of this arrhythmia expands the strategies for ablation treatment continue to evolve. New technologies aim to improve the safety, efficacy, and speed of catheter ablation for atrial fibrillation.
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