No abstract

Improved medical care of congenital heart disease patients increased survival into adulthood from 15% in the 1960s to over 85% in the current era. As a consequence, the prevalence of adult congenital heart disease (ACHD) increased rapidly, 1 which is estimated to be .1 million ACHD patients in North America and 1.2 million in Europe. The growing number and aging of ACHD patients led to an overall increase in hospitalizations over the last decade and a substantial increase in patients presenting with heart failure (HF) ( 20%). 2 The incidence of first HF-admission was 1.2 per 1000 patientyears in the Dutch national 'CONCOR' registry. Patients admitted with HF had a five-fold higher risk of death than those not admitted. From the same registry, the mortality was 2.8% during a follow-up period of 24 865 patient-years. Chronic HF (26%) and sudden death (19%) were recorded most frequently. The median age at death from HF was 51.0 years (range: 20.3 -91.2 years). 3 In another ACHD cohort, sudden death (26%) was the most common cause of death, followed by progressive HF (21%) and perioperative death (18%). 4 Although patients with ACHD may not readily report symptoms, clinical HF is documented in 22.2% of patients with a Mustard

Background— The risk of systemic thromboemboli associated with transvenous leads in the presence of an intracardiac shunt is currently unknown. Methods and Results— To define this risk, we conducted a multicenter, retrospective cohort study of 202 patients with intracardiac shunts: Sixty-four had transvenous leads (group 1), 56 had epicardial leads (group 2), and 82 had right-to-left shunts but no pacemaker or implantable cardioverter defibrillator leads (group 3). Patient-years were accrued until the occurrence of systemic thromboemboli or study termination. Censoring occurred in the event of complete shunt closure, death, or loss to follow-up. Mean ages for groups 1, 2, and 3 were 33.9±18.0, 22.2±12.6, and 22.9±15.0 years, respectively. Respective oxygen saturations were 91.2±9.1%, 88.1±8.1%, and 79.7±6.7%. During respective median follow-ups of 7.3, 9.3, and 17.0 years, 24 patients had at least 1 systemic thromboembolus: 10 (15.6%), 5 (8.9%), and 9 (11.0%) in groups 1, 2, and 3, respectively. Univariate risk factors were older age (hazard ratio [HR], 1.05; P =0.0001), ongoing phlebotomy (HR, 3.1; P =0.0415), and an transvenous lead (HR, 2.4; P =0.0421). In multivariate, stepwise regression analyses, transvenous leads remained an independent predictor of systemic thromboemboli (HR, 2.6; P =0.0265). In patients with transvenous leads, independent risk factors were older age (HR, 1.05; P =0.0080), atrial fibrillation or flutter (HR, 6.7; P =0.0214), and ongoing phlebotomy (HR, 14.4; P =0.0349). Having had aspirin or warfarin prescribed was not protective. Epicardial leads were, however, associated with higher atrial ( P =0.0407) and ventricular ( P =0.0270) thresholds and shorter generator longevity (HR, 1.9; P =0.0176). Conclusions— Transvenous leads incur a >2-fold increased risk of systemic thromboemboli in patients with intracardiac shunts.

Evidence from randomized controlled trials (RCTs) supports the use of antihypertensive agents in the secondary prevention of patients with ischemic stroke (IS) or transient ischemic attack (TIA).1,2 However, since heterogeneity is present for several outcomes among these trials, current recommendations do not specifically address the intensity of blood pressure (BP) lowering for secondary stroke prevention. 1,2This heterogeneity has been attributed to both a potential class effect of antihypertensive drugs used (related also to the reduction of BP variability) 3 and differences in the degree of BP reduction using standard and aggressive antihypertensive strategies. 4 Moreover, the majority of RCTs of secondary stroke prevention did not specifically evaluate the association between the extent of BP reduction and long-term outcomes in patients with stroke or TIA, leading to increasing uncertainty about the optimal BP levels that should be aimed and achieved during secondary stroke prevention. 5,6 In view of the former considerations, we conducted a systematic review and metaregression analysis on the association of BP reduction with recurrent stroke and cardiovascular events using available RCT data on secondary stroke prevention. Methods Trial Identification and Data AbstractionThis meta-analysis has adopted the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) for systematic reviews and meta-analyses.7 Eligible RCTs of all antihypertensive treatments used in the secondary prevention of IS/TIA Abstract-Current recommendations do not specifically address the optimal blood pressure (BP) reduction for secondary stroke prevention in patients with previous cerebrovascular events. We conducted a systematic review and metaregression analysis on the association of BP reduction with recurrent stroke and cardiovascular events using data from randomized controlled clinical trials of secondary stroke prevention. For all reported events during each eligible study period, we calculated the corresponding risk ratios to express the comparison of event occurrence risk between patients randomized to antihypertensive treatment and those randomized to placebo. The extent of BP reduction is linearly associated with the magnitude of risk reduction in recurrent cerebrovascular and cardiovascular events. Strict and aggressive BP control seems to be essential for effective secondary stroke prevention.

TCD is more sensitive but less specific compared to TTE for the detection of PFO in patients with cryptogenic cerebral ischemia. The overall diagnostic yield of TCD appears to outweigh that of TTE.