In the last 20 years, atrial fibrillation (AF) has become one of the most important public health problems and a significant cause of increasing health care costs in western countries. The prevalence of AF is increasing due to our greater ability to treat chronic cardiac and noncardiac diseases, and the improved ability to suspect and diagnose AF. At the present time, the prevalence of AF (2%) is double that reported in the last decade. The prevalence of AF varies with age and sex. AF is present in 0.12%–0.16% of those younger than 49 years, in 3.7%–4.2% of those aged 60–70 years, and in 10%–17% of those aged 80 years or older. In addition, it occurs more frequently in males, with a male to female ratio of 1.2:1. The incidence of AF ranges between 0.21 and 0.41 per 1,000 person/years. Permanent AF occurs in approximately 50% of patients, and paroxysmal and persistent AF in 25% each. AF is frequently associated with cardiac disease and comorbidities. The most common concomitant diseases are coronary artery disease, valvular heart disease, and cardiomyopathy. The most common comorbidities are hypertension, diabetes, heart failure, chronic obstructive pulmonary disease, renal failure, stroke, and cognitive disturbance. Paroxysmal AF occurs in younger patients and with a reduced burden of both cardiac disease and comorbidities. Generally, the history of AF is long, burdened by frequent recurrences, and associated with symptoms (in two thirds of patients). Patients with AF have a five-fold and two-fold higher risk of stroke and death, respectively. We estimate that the number of patients with AF in 2030 in Europe will be 14–17 million and the number of new cases of AF per year at 120,000–215,000. Given that AF is associated with significant morbidity and mortality, this increasing number of individuals with AF will have major public health implications.

BackgroundThe independent prognostic impact of diabetes mellitus (DM) and prediabetes mellitus (pre‐DM) on survival outcomes in patients with chronic heart failure has been investigated in observational registries and randomized, clinical trials, but the results have been often inconclusive or conflicting. We examined the independent prognostic impact of DM and pre‐DM on survival outcomes in the GISSI‐HF (Gruppo Italiano per lo Studio della Sopravvivenza nella Insufficienza Cardiaca‐Heart Failure) trial.Methods and ResultsWe assessed the risk of all‐cause death and the composite of all‐cause death or cardiovascular hospitalization over a median follow‐up period of 3.9 years among the 6935 chronic heart failure participants of the GISSI‐HF trial, who were stratified by presence of DM (n=2852), pre‐DM (n=2013), and non‐DM (n=2070) at baseline. Compared with non‐DM patients, those with DM had remarkably higher incidence rates of all‐cause death (34.5% versus 24.6%) and the composite end point (63.6% versus 54.7%). Conversely, both event rates were similar between non‐DM patients and those with pre‐DM. Cox regression analysis showed that DM, but not pre‐DM, was associated with an increased risk of all‐cause death (adjusted hazard ratio, 1.43; 95% CI, 1.28–1.60) and of the composite end point (adjusted hazard ratio, 1.23; 95% CI, 1.13–1.32), independently of established risk factors. In the DM subgroup, higher hemoglobin A1c was also independently associated with increased risk of both study outcomes (all‐cause death: adjusted hazard ratio, 1.21; 95% CI, 1.02–1.43; and composite end point: adjusted hazard ratio, 1.14; 95% CI, 1.01–1.29, respectively).ConclusionsPresence of DM was independently associated with poor long‐term survival outcomes in patients with chronic heart failure.Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT00336336.

Fifty-eight patients with transmural anterior myocardial infarction were prospectively studied with serial two-dimensional Circulation 72, No. 4, 774-780, 1985. TWO-DIMENSIONAL ECHOCARDIOGRAPHY has recently demonstrated that left ventricular thrombi are common in patients with acute anterior myocardial infarction.1-5 However, the clinical implications and prognostic significance of detection of thrombi during acute myocardial infarction, the incidence of systemic embolization, and the possible occurrence of spontaneous regression of left ventricular thrombus have not yet been investigated in prospective studies conducted

Left ventricular thrombus may develop both early and late after acute anterior myocardial infarction. To assess the possible prognostic implication of the time of thrombus appearance, 125 patients (87 males; age ranging from 35 to 92 years, mean: 65 +/- 10 years) consecutively admitted to our coronary care unit within 24 h of a first acute anterior myocardial infarction, untreated with antithrombotic drugs, underwent serial two-dimensional echocardiographic studies during hospitalization, then monthly for a follow-up of 1-48 (mean: 23 +/- 16) months among survivors. Left ventricular thrombi, detected in 71 patients (57%), appeared from 1 to 362 (mean: 13 +/- 44) days after acute infarction. In 40 patients (56%), early thrombus development, within 48 h of symptom onset, was noted. During the study period, 52 patients (42%) died. Global mortality rate was similar in patients with thrombi compared with those without thrombi (32/71: 45%, vs 20/54: 37%; P = ns). However, in-hospital mortality of patients who developed left ventricular thrombi within 48 h (17/40: 42.5%) was significantly higher compared with both patients with later thrombus appearance (4/31: 13%; P less than 0.008) and those without thrombi (10/54: 20%; P less than 0.01). Embolic events were more frequent in patients with thrombi (9/71, 13% vs 1/54, 2%; P less than 0.02), but there was no relationship with the time of thrombus appearance. The values of peak CPK levels and the degree of left ventricular wall motion abnormalities observed in patients with early left ventricular thrombus were significantly higher than the values detected in patients without thrombi, but similar to those obtained in patients with later thrombus occurrence.(ABSTRACT TRUNCATED AT 250 WORDS)

We conclude that 1) the rate of left ventricular thrombi does not differ in patients with acute myocardial infarction treated either with streptokinase or rt-PA, 2) subcutaneous heparin, when begun 12 hours after intravenous thrombolysis, does not appear to further reduce the occurrence of thrombi but seems to influence the shape of left ventricular thrombi, and 3) during the predischarge period, embolic events are rare in patients treated by thrombolysis.