Purpose: We evaluated the performance of the newly proposed radiomics of multiparametric MRI (RMM), developed and validated based on a multicenter dataset adopting a radiomic strategy, for pretreatment prediction of pathologic complete response (pCR) to neoadjuvant chemotherapy (NAC) in breast cancer. Experimental Design: A total of 586 potentially eligible patients were retrospectively enrolled from four hospitals (primary cohort and external validation cohort 1-3). Quantitative imaging features were extracted from T2-weighted imaging, diffusion-weighted imaging, and contrast-enhanced T1-weighted imaging before NAC for each patient. With features selected using a coarse to fine feature selection strategy, four radiomic signatures were constructed based on each of the three MRI sequences and their combination. RMM was developed based on the best radiomic signature incorporating with independent clinicopathologic risk factors. The performance of RMM was assessed with respect to its discrimination and clinical usefulness, and compared with that of clinical information-based prediction model. Results: Radiomic signature combining multiparametric MRI achieved an AUC of 0.79 (the highest among the four radiomic signatures). The signature further achieved good performances in hormone receptor-positive and HER2negative group and triple-negative group. RMM yielded an AUC of 0.86, which was significantly higher than that of clinical model in two of the three external validation cohorts. Conclusions: The study suggested a possibility that RMM provided a potential tool to develop a model for predicting pCR to NAC in breast cancer.

Up to 40% of atrial fibrillation (AF) patients are asymptomatic. Despite this, scarce data are available about asymptomatic AF, with regard to its clinical profile and relationship to cerebrovascular and cardiovascular risks. Our objective was to conduct a systematic review and meta-analysis was to study the relationship between age and gender with asymptomatic AF and to establish whether patients with asymptomatic AF have a higher risk of death (all-cause and cardiovascular) and stroke/systemic thromboembolism, when compared to symptomatic AF patients. After a comprehensive search, 6 studies (2 randomized clinical trials and 4 observational studies) were entered in the meta-analysis. Despite significant heterogeneity, our data show that the prevalence of females amongst asymptomatic AF group was significantly less compared to the symptomatic AF group (RR, 0.57; 95% CI: 0.52-0.64). No difference in age between asymptomatic and symptomatic AF patients (P=0.72) was seen. No differences were found in all-cause death between patients with asymptomatic and symptomatic AF (RR, 1.38; 95% CI: 0.82-2.17), nor in cardiovascular death (RR, 0.85; 95% CI: 0.53-1.36) or stroke/thromboembolism (RR, 1.72 95% CI: 0.59-5.08). Asymptomatic AF is more associated with male sex, irrespective of age. Both general and cardiovascular death risks as well as thromboembolic risk do not seem to be affected by the asymptomatic clinical status. Symptomatic status should not determine our approach to stroke prevention and other cardiovascular prevention therapies, amongst patients with AF.

Background No pooled analysis has been undertaken to assess the efficacy and safety of the non‐vitamin K antagonist oral anticoagulants (NOACs) compared with warfarin in the subgroup of patients with atrial fibrillation (AF) and heart failure (HF), including edoxaban data from recent randomized controlled trials (RCTs). Methods Comprehensive literature searches were conducted using the Cochrane Library, MEDLINE, and Scopus databases from inception to April 2015. Statistical analyses were performed using RevMan 5.3 software. Results Four RCTs were included: 19 122 of 32 512 AF patients with HF were allocated to a NOAC (13 384 receiving single‐/high‐dose NOAC regimens), and 13 390 to warfarin. Among AF patients with HF, single/high‐dose NOACs significantly reduced the risk of stroke/systemic embolic (SE) events by 14% [odds ratio0.86, 95% confidence interval (CI) 0.76–0.98), and had a 24% lower risk of major bleeding(OR 0.76, 95% CI 0.67–0.86). For low‐dose NOAC regimens, comparable efficacy to warfarin for stroke or SE events (OR 1.02, 95% CI 0.86–1.21) and a non‐significant trend for lower major bleeding was observed. Regardless of high‐ or low‐dose NOAC, the incidences of both major bleeding and stroke/SE in AF patients with HF were similar to those without HF. Atrial fibrillation patients with HF on NOACs had a 41% lower risk of intracranial haemorrhage compared with those without HF (OR 0.59, 95% CI 0.40–0.87). Conclusion Among AF patients with HF, single‐/high‐dose NOAC regimens have a better efficacy and safety profile, but low‐dose regimens had similar efficacy and safety to warfarin. NOACs were similarly effective or even safer (less intracranial haemorrhage) in AF patients with HF compared with those without HF.

An association among the use of angiotensin converting enzyme (ACE) inhibitors and angiotensin‐receptor blockers (ARBs) with the clinical outcomes of coronavirus disease 2019 (COVID‐19) is unclear. PubMed, EMBASE, MedRxiv, and BioRxiv were searched for relevant studies that assessed the association between application of ACEI/ARB and risk of COVID‐19, inflammation level, severity COVID‐19 infection, and death in patients with COVID‐19. Eleven studies were included with 33 483 patients. ACEI/ARB therapy might be associated with the reduced inflammatory factor (interleukin‐6) and elevated immune cells counts (CD3, CD8). Meta‐analysis showed no significant increase in the risk of COVID‐19 infection (odds ratio [OR]: 0.95, 95%CI: 0.89‐1.05) in patients receiving ACEI/ARB therapy, and ACEI/ARB therapy was associated with a decreased risk of severe COVID‐19 (OR: 0.75, 95%CI: 0.59‐0.96) and mortality (OR: 0.52, 95%CI: 0.35‐0.79). Subgroup analyses showed among the general population, ACEI/ARB therapy was associated with reduced severe COVID‐19 infection (OR: 0.79, 95%CI: 0.60‐1.05) and all‐cause mortality (OR: 0.31, 95%CI: 0.13‐0.75), and COVID‐19 infection (OR: 0.85, 95% CI: 0.66‐1.08) were not increased. Among patients with hypertension, the use of an ACEI/ARB was associated with a lower severity of COVID‐19 (OR: 0.73, 95%CI: 0.51‐1.03) and lower mortality (OR: 0.57, 95%CI: 0.37‐0.87), without evidence of an increased risk of COVID‐19 infection (OR: 1.00). On the basis of the available evidence, ACEI/ARB therapy should be continued in patients who are at risk for, or have COVID‐19, either in general population or hypertension patients. Our results need to be interpreted with caution considering the potential for residual confounders, and more well‐designed studies that control the clinical confounders are necessary to confirm our findings.

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A trial fibrillation (AF), the cardiac arrhythmia most frequently identified in clinical practice, becomes more prevalent as patients age. This condition is characterized by several devastating sequelae, including stroke and systemic thromboembolism (TE).1,2 Atrial fibrillation is a leading cause of neurologic disability and death depending on the severity of cardioembolic stroke, so oral anticoagulation is crucial for high-risk patients who have AF. Nonetheless, hemorrhagic sequelae of long-term anticoagulation are often seen during stroke prevention in patients who have AF. To date, several risk-scoring systems have shown modest predictive ability for endpoint events and have been well validated in recent studies. Two of the most widely used scores for risk prediction, CHADS 2 and CHA 2 DS 2 -VASc, guide the optimization of therapy in patients who have AF, particularly if those patients are artificially categorized into low-, moderate-, and high-risk groups (Table I).3-6 The classical and revised CHADS 2 score is cumulative on the basis of 6 clinical features: congestive heart failure, hypertension, diabetes mellitus, and age ≥75 years (counted as 1 point each), and a history of stroke or transient ischemic attack (2 points). 4,5 In comparison, the CHA 2 DS 2 -VASc score, proposed as a complement to the CHADS 2 score, ranges from 0 to 9 points; the clinical features are congestive heart failure or left ventricular ejection fraction ≤0.40, hypertension, age 65-74 years, diabetes mellitus, vascular disease, and female sex (1 point each), and age ≥75 years and prior stroke, transient ischemic attack, or thromboembolism (2 points each). 6 In both systems, patient stratification into 3 risk categories-wherein a 0 score is low risk, 1 is intermediate risk, and ≥2 is high risk-has received particular attention in embolic risk evaluation and is widely included in guideline recommendations. 2 The likelihood of an embolic event is closely related to the total points recorded for a given patient, and anticoagulation is advisable for patients with a score of 2 or more points.7 However, it is unclear whether anticoagulation should be recommended for intermediate-risk patients. When comparing

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Left bundle branch area pacing (LBBAP) has developed in an effort to improve cardiac resynchronization therapy (CRT). We aimed to compare the long-term clinical outcomes between LBBAP and biventricular pacing (BIVP) in patients with heart failure (HF) and complete left bundle branch block (CLBBB). Consecutive patients with HF and CLBBB requiring CRT received either LBBAP or BIVP were recruited at the Second Affiliated Hospital of Nanchang University from February 2018 to May 2019. We assessed their implant parameters, electrocardiogram (ECG), clinical outcomes at implant and during follow-up at 1, 3, 6, 12, and 24 months. Forty-one patients recruited including 21 for LBBAP and 20 for BIVP. Mean follow-up duration was 23.71 ± 4.44 months. LBBAP produced lower pacing thresholds, shorter procedure time and fluoroscopy duration compared to BIVP. The QRS duration was significantly narrower after LBBAP than BIVP (129.29 ± 31.46 vs. 156.85 ± 26.37 ms, p = 0.005). Notably, both LBBAP and BIVP significantly improved LVEF, LVEDD, NYHA class, and BNP compared with baseline. However, LBBAP significantly lowered BNP compared with BIVP (416.69 ± 411.39 vs. 96.07 ± 788.71 pg/ml, p = 0.007) from baseline to 24-month follow-up. Moreover, patients who received LBBAP exhibited lower number of hospitalizations than those in the BIVP group (p = 0.019). In addition, we found that patients with moderately prolonged left ventricular activation time (LVAT) and QRS notching in limb leads in baseline ECG respond better to LBBAP for CLBBB correction. LBBAP might be a relative safe and effective resynchronization therapy and as a supplement to BIVP for patients with HF and CLBBB.