Background— Nonvalvular atrial fibrillation is the most common arrhythmia. Patients with nonvalvular atrial fibrillation are at increased risk of stroke; therefore, we evaluated the efficacy and safety of different approaches to prevent this major complication. Methods and Results— We conducted electronic database searches of phase III randomized controlled trials. The groups were novel oral anticoagulants, Watchman left atrial appendage occlusion device (DEVICE), and warfarin. Efficacy outcomes were stroke or systemic embolism, and all-cause mortality. Safety outcome was major bleeding and procedure-related complications. A subgroup analysis of the elderly population was done. We used random-effects model to compare pooled outcomes and tested for heterogeneity. Odds ratios (ORs) and 95% confidence intervals (CIs) were computed for each outcome. Seven randomized controlled trials (n=73 978) were included. There was a significant difference favoring novel oral anticoagulants for systemic embolism (OR, 0.84; 95% CI, 0.72–0.97; P =0.01), all-cause mortality (OR, 0.89; 95% CI, 0.84–0.94; P <0.001), and safety outcomes (OR, 0.79; 95% CI, 0.65–0.97; P =0.026) compared with warfarin. No difference was seen between DEVICE and warfarin for efficacy end points; however, DEVICE had more complications (OR, 1.85; 95% CI, 1.14–3.01; P =0.012). In the elderly (6 randomized controlled trials, n=30 699), systemic embolism was favored with novel oral anticoagulants over warfarin (OR, 0.77; 95% CI, 0.68–0.87; P ≤0.001). No evidence of significant publication bias was found. Conclusions— Novel oral anticoagulants is superior to warfarin for stroke prevention in nonvalvular atrial fibrillation. This benefit was also observed in the elderly population. DEVICE is a reasonable noninferior alternative to warfarin for stroke prevention, but cautious use is essential given safety concerns.

Apoptosis is a type of programmed cell death that is evident during embryonic development and normal tissue turnover. When the apoptotic activity extends beyond physiologic limits, it can determine and/or contribute to those pathologic states characterized by excessive cell loss and impairment of organ function. The clinical development of caspase inhibitors may represent a potential therapeutic strategy for influencing the onset and progression of ventricular dysfunction to terminal failure. This article focuses on the caspase cascade, a fundamental enzymatic system for apoptotic cell death. Caspases do not constitute the death signals, but are implicated in their transmission. These cytoplasmic cysteine proteases have a dual role in apoptosis. Caspases can operate as initiators, activating an endonuclease that catalyzes deoxyribonucleic acid fragmentation. Alternatively, caspases can act as effectors, participating in the total disassembly of cell structures. For example, apoptosis represents the principal form of myocyte death in the region of an acute myocardial infarction. In addition, apoptosis in the region bordering the infarct can influence the development of ischemic cardiomyopathy and ventricular dilation.

In takotsubo cardiomyopathy, the clinical appearance is that of an acute myocardial infarction T akotsubo cardiomyopathy (TC) is characterized by the clinical appearance of an acute myocardial infarction and by left ventricular (LV) apical ballooning in a patient who has no obstructive coronary artery disease.1 Patients typically present after a precipitating physical or emotional stressor. However, the mechanism by which these stimuli lead to cardiac decompensation is unclear-proposed factors include catecholamine excess and coronary vasospasm.2 We present the case of a patient whose TC was precipitated by elective direct-current (DC) cardioversion for atrial fibrillation. Case ReportIn January 2012, a 67-year-old woman was admitted to our hospital after a syncopal episode. She had been cooking breakfast and was able to catch herself before falling. During the event, her shirt caught on fire, but she was not burned. She reported no palpitations or chest pain; however, she had experienced dizziness and diaphoresis minutes after the event.The patient's medical history included paroxysmal atrial fibrillation and hypertension, treated with spironolactone and metoprolol succinate. Two years before the patient's current presentation, a computed tomographic angiogram had revealed normal coronary arteries. Her metoprolol succinate dose had recently been increased from 12.5 mg/d to 50 mg/d, and her warfarin therapy had recently been discontinued because of hematuria in the presence of a supratherapeutic international normalized ratio.Upon the patient's presentation, examination revealed an irregular pulse of 126 beats/min and a blood pressure of 106/72 mmHg. An electrocardiogram showed atrial fibrillation and low voltage (Fig. 1A). Laboratory values, including cardiac troponin I levels, were within normal limits. Echocardiograms showed normal LV function, normal wall motion, and a mildly dilated left atrium.The decision was made to establish sinus rhythm by means of DC cardioversion. The patient was sedated with propofol, and electrical cardioversion via biphasic energy at 200 J was performed, with a resultant rhythm of sinus bradycardia at 30 beats/min. After cardioversion, the patient was hypotensive and lethargic, despite the correction of the bradycardia with atropine and epinephrine. She was intubated for respiratory Case Reports

This international survey suggests that, while there are little clinical data to support or discourage such practice, the usage of antimicrobial agent pocket irrigation for CIED infection prophylaxis is widely used in current practice.