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.
Left coronary artery arising from the right sinus of Valsalva is a rare congenital coronary anomaly. This anomaly is either benign or serious, depending on the relation of the anomalous left coronary artery to the aorta and pulmonary artery. Potentially serious anomaly is associated with sudden cardiac death and warrants prophylactic coronary bypass surgery. A rare case of anomalous left coronary artery arising from the right sinus of Valsalva is reported, documented by coronary angiography; however, it took a safer course between the aorta and pulmonary artery. Prophylactic surgery was not performed, for this benign anomaly may not carry the same risk of sudden cardiac death.
Acute aortic dissection may present a clinical picture simulating myocardial infarction, including electrocardiographic changes. The mechanism underlying this mode of presentation has not heretofore been documented during life. We present here for the first time, a patient with acute aortic dissection and the clinical picture of acute myocardial infarction, where the mechanism of infarction has been demonstrated, by preoperative angiographic studies, probably to be due to compression of the extramural portion of the right coronary artery by the false channel of the dissecting hematoma.
BACKGROUND: Disease management programs (DMP) issue frequent physician directed communications (PDC) to cardiology practices with the objective to assist the practitioners using an evidence-based approach. Although PDC have become widespread, the usefulness of this intervention in Cardiology is unknown. The objective of this study is to evaluate the effectiveness of established cardiology DMP-PDC in a general community cardiology practice. METHODS: A prospective cohort study evaluating all DMP-PDC received in a general cardiology practice from 6/2011 to 12/2012 was completed. The study included three fellowship trained board-certified cardiologist that examined the usefulness of DMP-PDC using a standardized questionnaire. Demographic data, pharmacological profile, type of DMP, general appropriateness based on current ACC/AHA guidelines, patient individual appropriateness, inappropriate recommendations and whether the DMP-PDC was effectively implemented in clinical practice was examined. RESULTS: 188 consecutive DMP-PDC were evaluated. Demographic characteristics (60% males / mean age: 67±13 Yr) of the cohort were as expected for a general cardiology practice. Recommendations were available from different DMP [Medco (30.3%), CVS Caremark (25.5%), Aetna Active (25.5%), United Healthcare (8.5%) and other (10.2%)]. 152 (81%) DMP-PDC were appropriate in the general clinical context but not implemented based on individualized appropriateness criteria: 35 (19%) directed to the wrong physician, 39 (21%) already implemented prior to the DMP-PDC, 45 (24%) considered to add no clinical benefit based on individual appropriateness, 14 (7%) based on outdated evidence-based information, 7 (4%) implemented in practice without success prior to the DMP-PDC, 5 (3%) directed to patients not in the practice, and 7 (4%) for other reasons. 28 (15%) DMP-PDC were inappropriate: 9 (5%) due to an incorrect patient diagnosis, 2 (1%) due to intolerance to the intervention proposed, 2 (1%) due to a pharmacological interactions with other medications, 7 (4%) due to compliance related-issues and 8 (5%) were DMP-PDC based on incorrect medications. Among all recommendations reviewed, only 15 (8%) were actually effectively applied in clinical practice. CONCLUSION: DMP-PDC can be useful in formulating general patient evidence-base recommendations, but are ineffective tools in clinical practice due to individual patient related factors that prevent implementation, and thus; unlikely to translate in improvement in health care delivery.
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