Background: Despite the publication of several randomized clinical trials comparing catheter ablation (CA) with medical therapy (MT) in patients with atrial fibrillation (AF), the superiority of one strategy over another is still questioned by many. In this meta-analysis of randomized controlled trials, we compared the efficacy and safety of CA with MT for AF. Methods: We systematically searched MEDLINE, EMBASE, and other online sources for randomized controlled trials of AF patients that compared CA with MT. The primary outcome was all-cause mortality. Secondary outcomes included cardiovascular hospitalizations and recurrence of atrial arrhythmia. Subgroup analyses stratified by the presence of heart failure with reduced ejection fraction, type of AF, age, and sex were performed. Risk ratios (RRs) with 95% CIs were calculated using a random effects model, and Mantel-Haenszel method was used to pool RR. Results: Eighteen randomized controlled trials comprising 4464 patients (CA, n=2286; MT, n=2178) were included. CA resulted in a significant reduction in all-cause mortality (RR, 0.69; 95% CI, 0.54–0.88; P =0.003) that was driven by patients with AF and heart failure with reduced ejection fraction (RR, 0.52; 95% CI, 0.35–0.76; P =0.0009). CA resulted in significantly fewer cardiovascular hospitalizations (hazard ratio, 0.56; 95% CI, 0.39–0.81; P =0.002) and fewer recurrences of atrial arrhythmias (RR, 0.42; 95% CI, 0.33–0.53; P <0.00001). Subgroup analyses suggested that younger patients (age, <65 years) and men derived more benefit from CA compared with MT. Conclusions: CA is associated with all-cause mortality benefit, that is driven by patients with AF and heart failure with reduced ejection fraction. CA reduces cardiovascular hospitalizations and recurrences of atrial arrhythmia for patients with AF. Younger patients and men appear to derive more benefit from CA.

Low-level transcutaneous vagus nerve stimulation at the tragus (LLTS) is anti-adrenergic. We aimed to evaluate the acute effects of LLTS on left ventricular (LV) function and autonomic tone. Patients with diastolic dysfunction and preserved LV ejection fraction were enrolled in a prospective, randomized, double-blind, 2×2 cross-over study. Patients received 2 separate, 1hour sessions, at least 1 day apart, of active LLTS (20Hz, 1mA below the discomfort threshold) and sham stimulation. Echocardiography was performed after LLTS or sham stimulation to assess cardiac function. A 5-minute ECG was performed to assess heart rate variability (HRV). Twentyfour patients were enrolled. LV global longitudinal strain improved by 1.8±0.9% during active LLTS compared to sham stimulation (p=0.001). Relative to baseline, HRV frequency domain components (low frequency, high frequency and their ratio) were favorably altered after LLTS compared to sham stimulation (all p<0.05). We concluded that LLTS acutely ameliorates cardiac mechanics by modulating the autonomic tone.

ICDs decrease total mortality and arrhythmic deaths in patients with NICM. The benefit of ICD appears to be dependent on age and concomitant use of CRT.

Obesity is associated with an increased risk of new-onset AF in susceptible individuals. This effect appears to be consistent in both genders. Further studies are warranted to examine the impact of weight loss interventions on the risk of developing AF.

Peripartum cardiomyopathy (PPCM) is a rare cause of heart failure. It is defined as cardiomyopathy that develops in the last month of pregnancy or within 5 months of the postpartum period without an identifiable cause. We conducted a systematic review of literature of prospective studies with a focus on echocardiographic and long-term clinical outcomes in PPCM. We searched MEDLINE and Embase up to October 1, 2017. Prospective studies (sample size ≥20) reporting all-cause mortality and follow-up duration of ≥1 year were included. Of the 956 studies identified, 7 met the inclusion criteria. A total of 445 patients with a mean age of 30 years (range, 27-32 years) were included. The mean follow-up duration was 41 months (range, 12-61 months). The majority of patients had New York Heart Association class III or IV symptoms at the time of diagnosis. Only 3 studies reported data on ethnicity where the majority of patients were non-Caucasian. Most of the patients (81%-93%) were on guideline-directed medical therapy, except 1 study (41%). Left ventricular ejection fraction at baseline ranged from 24% to 35% (mean, 28%) and at follow-up from 31% to 53% (mean, 44%). Recovery in systolic function was noted in 20% to 82% (mean, 50%) of patients. All-cause mortality ranged from 0% to 28% (mean, 16%). This systematic review summarizes the evidence to date on the clinical characteristics and outcomes of patients with PPCM. Multicenter registries with long-term follow-up will help shed further light on characteristics and outcomes of patients with this rare disease.

Background A systemic proinflammatory state plays a central role in the development of heart failure with preserved ejection fraction. Low‐level transcutaneous vagus nerve stimulation suppresses inflammation in humans. We conducted a sham‐controlled, double‐blind, randomized clinical trial to examine the effect of chronic low‐level transcutaneous vagus nerve stimulation on cardiac function, exercise capacity, and inflammation in patients with heart failure with preserved ejection fraction. Methods and Results Patients with heart failure with preserved ejection fraction and at least 2 additional comorbidities (obesity, diabetes, hypertension, or age ≥65 years) were randomized to either active (tragus) or sham (earlobe) low‐level transcutaneous vagus nerve stimulation (20 Hz, 1 mA below discomfort threshold), for 1 hour daily for 3 months. Echocardiography, 6‐minute walk test, quality of life, and serum cytokines were assessed at baseline and 3 months. Fifty‐two patients (mean age 70.4±9.2 years; 70% female) were included (active, n=26; sham, n=26). Baseline characteristics were balanced between the 2 arms. Adherence to the protocol of daily stimulation was >90% in both arms ( P >0.05). While the early mitral inflow Doppler velocity to the early diastolic mitral annulus velocity ratio did not differ between groups, global longitudinal strain and tumor necrosis factor‐α levels at 3 months were significantly improved in the active compared with the sham arm (−18.6%±2.5% versus −16.0%±2.4%, P =0.002; 8.9±2.8 pg/mL versus 11.3±2.9 pg/mL, P =0.007, respectively). The reduction in tumor necrosis factor‐α levels correlated with global longitudinal strain improvement (r=−0.73, P =0.001). Quality of life was better in the active arm. No device‐related side effects were observed. Conclusions Neuromodulation with low‐level transcutaneous vagus nerve stimulation over 3 months resulted in a significant improvement in global longitudinal strain, inflammatory cytokines, and quality of life in patients with heart failure with preserved ejection fraction. Registration URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03327649.

Background: The safety and efficacy of aspirin for the primary prevention of cardiovascular disease in patients with diabetes mellitus remains controversial. Design: A meta-analysis to investigate the effects of aspirin for the prevention of cardiovascular disease in diabetes mellitus. Methods: Ten randomized controlled trials were selected using MEDLINE, EMBASE and CENTRAL databases until 27 September 2018. Risk ratios (RRs) with 95% confidence intervals (CIs) and risk differences (RDs) reported as incident events per 1000 person-years were calculated. Results: In 33,679 patients, aspirin did not significantly reduce the risk of major adverse cardiovascular outcomes (RR 0.93, 95% CI 0.87-1.00, P = 0.06; RD −0.68 incident cases per 1000 person-years (95% CI −1.54, 0.17)), cardiovascular mortality (RR 0.95, 95% CI 0.83-1.09, P = 0.49; RD 0.11 incident cases per 1000 person-years (95% CI −0.80, 1.02)), myocardial infarction

Dissecting cellulitis is an inflammatory disease of the skin. We report a case of recurrent dissecting cellulitis in a patient with Crohn’s disease. A 31-year-old man with a history of purulent scalp lesions presented with night sweats, weight loss, abdominal pain, and hematochezia. Colonoscopy revealed a diffuse friable mucosa with extensive pseudopolyps. Scalp biopsy demonstrated epidermoid inclusion cysts with granulation tissue and chronic inflammatory cell infiltration, indicative of dissecting cellulitis. The incidence of dissecting cellulitis with Crohn’s disease is underreported. This dermatologic condition has a tendency to recur, and considering an underlying disease is key for its appropriate treatment.