RESUMEN
Background: The stress hyperglycemia ratio (SHR) has emerged as a potential prognostic indicator for various critical illnesses. However, its role in determining outcomes in patients with atrial fibrillation (AF) within the intensive care unit (ICU) remains unclear. This study aimed to elucidate the association between SHR and all-cause mortality in this clinical setting. Methods: We conducted a retrospective cohort study utilizing data from a large, retrospective database. Critically ill patients with documented AF were stratified based on quartiles of SHR. The primary outcome was 365-day all-cause mortality, with secondary outcomes including 90-day and 28-day mortality. COX proportional hazards models adjusted for confounders and Kaplan-Meier curve analyses were used to explore the relationship between SHR and mortality. Results: 2,679 patients with critical AF were enrolled in the final study. Among the patients studied, those in the highest SHR quartiles exhibited an increased risk of 365-day all-cause mortality (HR:1.32, 95%CI=1.06-1.65). Notably, in subgroup analyses, the prognostic value of SHR was particularly pronounced in patients with hypertension. Sensitivity analyses confirmed the persistence of these findings after excluding cohorts with malignant tumors, and heart failure. Conclusions: Our research discerns a positive association between SHR and all-cause mortality in critically ill patients with AF, highlighting the significance of acute glycemic dysregulation on patient outcomes. Longer follow-up is still needed in the future to study the association between SHR and all-cause mortality in critically ill patients with AF.
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Fibrilación Atrial , Enfermedad Crítica , Hiperglucemia , Humanos , Fibrilación Atrial/mortalidad , Fibrilación Atrial/sangre , Enfermedad Crítica/mortalidad , Masculino , Femenino , Anciano , Estudios Retrospectivos , Hiperglucemia/mortalidad , Hiperglucemia/sangre , Persona de Mediana Edad , Pronóstico , Glucemia/análisis , Glucemia/metabolismo , Unidades de Cuidados Intensivos/estadística & datos numéricos , Anciano de 80 o más AñosRESUMEN
OBJECTIVES: Atrial fibrillation (AF) is associated with increased mortality. Previous studies have reported conflicting results in temporal trends of mortality after AF diagnosis. We aim to address this disparity by investigating the 1-year mortality and causes of death in Finnish patients diagnosed with AF between 2010 and 2017. DESIGN: The Finnish AntiCoagulation in Atrial Fibrillation (FinACAF) study is a nationwide retrospective register-based cohort study. SETTING: The FinACAF study has gathered information on all Finnish AF patients between 2004 and 2018, with information from all national healthcare registers and data from all levels of care (primary, secondary and tertiary care). PARTICIPANTS: We included patients with an incident AF diagnosis (International Classification of Diseases, 10th Revision code I48) between 2010 and 2017. To ensure a cohort of only incident AF, we excluded patients who used any oral anticoagulant during the year before cohort entry as well as patients with a recorded use of warfarin between 2004 and 2006. Patients under 20 years of age were excluded, and patients with permanent migration abroad before 1 January 2019 were excluded, N=157 658. PRIMARY OUTCOME MEASURES: 1-year all-cause, cardiovascular (CV) and cause-specific mortality following AF diagnosis. RESULTS: The study cohort consisted of 157 658 incident AF cases (50.1% male, mean age 72.9 years). Both all-cause and CV mortality declined from cohort entry years 2010-2017 (from 12.9% to 10.6%, mortality rate ratio (MRR) 0.77; 95% CI 0.73 to 0.82 in cohort entry year 2017 with 2010 as reference; and from 7.4% to 5.2%, MRR 0.68; 95% CI 0.63 to 0.74, respectively). Overall mortality and CV mortality were lower in women than in men throughout the study period (MRR 0.66; 95% CI 0.63 to 0.69 and MRR 0.53; 95% CI 0.50 to 0.56, respectively). Deaths attributable to ischaemic heart disease decreased during the study period (from 30.7% to 21.6%, MRR 0.51; 95% CI 0.49 to 0.62 in 2017 vs 2010), whereas dementia and Alzheimer's disease increased as a cause of death over time (6.2% to 9.9%, MRR 1.19; 95% CI 0.96 to 1.48 in 2017 vs 2010). The CHA2DS2-VASc score associated strongly with 1-year survival (p<0.0001). CONCLUSIONS: Our study reiterates that mortality after diagnosis of AF has decreased. The CHA2DS2-VASc score highlights the need to treat comorbidities as it strongly associates with patient 1-year survival after initial AF diagnosis.
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Fibrilación Atrial , Causas de Muerte , Sistema de Registros , Humanos , Fibrilación Atrial/mortalidad , Fibrilación Atrial/epidemiología , Masculino , Femenino , Anciano , Finlandia/epidemiología , Causas de Muerte/tendencias , Estudios Retrospectivos , Persona de Mediana Edad , Anciano de 80 o más Años , Anticoagulantes/uso terapéuticoRESUMEN
Because earlier studies have proven a link between hemoglobin, albumin, lymphocyte, and platelet (HALP) and pan-immune-inflammation value (PIV) scores and inflammation, we examined if these 2 markers had predictive value in patients with atrial fibrillation (AF). In the intensive care unit, 444 patients with and without AF were retrospectively analyzed. Patients with and without AF were compared with regard to their HALP and PIV scores. High and low categories of HALP and PIV scores were established based on the cutoff values. Furthermore, using receiver operating characteristic analysis, the mortality predictive efficacy of these scores was assessed in 230 patients with AF. Patients with AF had a significantly higher PIV score than those without AF; however, the HALP score found to be lower (Pâ <â .05 for all groups). The receiver operating characteristic analysis revealed that the HALP score exhibited a sensitivity of 66.7% and a specificity of 75.3% at a cutoff value of 2.037 (AUC: 0.753, Pâ <â .001). The PIV score cutoff value was 1062.7, but the sensitivity and specificity were both 55.7% and 55.8%, respectively (AUC: 0.571, Pâ <â .05). The mechanical ventilation requirement and in-hospital mortality rate were significantly higher in the high PIV (PIVâ >â 1062.7) and low HALP (HALPâ ≤â 2.037) groups. There is a significant association between the HALP and PIV scores assessed upon admission and critically ill patients with AF. Although the HALP score serves as a powerful prognostic factor for these patients, the PIV lacks the capability to predict mortality.
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Fibrilación Atrial , Mortalidad Hospitalaria , Inflamación , Humanos , Fibrilación Atrial/mortalidad , Fibrilación Atrial/sangre , Fibrilación Atrial/inmunología , Masculino , Femenino , Estudios Retrospectivos , Anciano , Pronóstico , Persona de Mediana Edad , Inflamación/sangre , Biomarcadores/sangre , Curva ROC , Valor Predictivo de las Pruebas , Unidades de Cuidados Intensivos/estadística & datos numéricos , Hemoglobinas/análisis , Albúmina Sérica/análisisRESUMEN
BACKGROUND: COVID-19 infections can result in severe acute respiratory distress syndrome (ARDS) requiring admission to the intensive care unit (ICU). Cardiovascular manifestation or exacerbation of cardiovascular diseases could be another complication. Cardiac arrhythmias including New-Onset Atrial Fibrillation (NOAF), have been observed in hospitalized patients with COVID-19 infections. In this analysis, we aimed to systematically compare the complications associated with NOAF in critically ill COVID-19 patients admitted to the ICU. METHODS: MEDLINE, EMBASE, Web of Science, the Cochrane database, http://www. CLINICALTRIALS: gov , Google Scholar and Mendeley were searched for relevant publications based on COVID-19 patients with NOAF admitted to the ICU. Complications including in-hospital mortality, ICU mortality, patients requiring mechanical ventilation, acute myocardial infarction, acute kidney injury, renal replacement therapy and pulmonary embolism were assessed. This is a meta-analysis and the analytical tool which was used was the RevMan software version 5.4. Risk ratios (RR) and 95% confidence intervals (CIs) were used to represent the data post analysis. RESULTS: In critically ill COVID-19 patients with NOAF admitted to the ICU, the risks of ICU mortality (RR: 1.39, 95% CI: 1.07 - 1.80; P = 0.01), in-hospital mortality (RR: 1.56, 95% CI: 1.20 - 2.04; P = 0.001), patients requiring mechanical ventilation (RR: 1.32, 95% CI: 1.04 - 1.66; P = 0.02) were significantly higher when compared to the control group without AF. Acute myocardial infarction (RR: 1.54, 95% CI: 1.31 - 1.81; P = 0.00001), the risk for acute kidney injury (RR: 1.31, 95% CI: 1.11 - 1.55; P = 0.002) and patients requiring renal replacement therapy (RR: 1.83, 95% CI: 1.60 - 2.09; P = 0.00001) were also significantly higher in patients with NOAF. CONCLUSIONS: Critically ill COVID-19 patients with NOAF admitted to the ICU were at significantly higher risks of developing complications and death compared to similar patients without AF.
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Fibrilación Atrial , COVID-19 , Enfermedad Crítica , Mortalidad Hospitalaria , Unidades de Cuidados Intensivos , COVID-19/mortalidad , COVID-19/complicaciones , COVID-19/terapia , COVID-19/diagnóstico , Humanos , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/mortalidad , Fibrilación Atrial/terapia , Factores de Riesgo , Respiración Artificial , SARS-CoV-2 , Masculino , Femenino , Medición de Riesgo , Persona de Mediana Edad , Lesión Renal Aguda/mortalidad , Lesión Renal Aguda/terapia , Lesión Renal Aguda/etiología , Lesión Renal Aguda/diagnóstico , AncianoRESUMEN
BACKGROUND: Atrial fibrillation (AF) is common among intensive care unit (ICU) patients and significantly raises the in-hospital mortality rate. Existing scoring systems or models have limited predictive capabilities for AF patients in ICU. Our study developed and validated machine learning models to predict the risk of in-hospital mortality in ICU patients with AF. METHODS AND RESULTS: Medical Information Mart for Intensive Care (MIMIC)-IV dataset and eICU Collaborative Research Database (eICU-CRD) were analyzed. Among ten classifiers compared, adaptive boosting (AdaBoost) showed better performance in predicting all-cause mortality in AF patients. A compact model with 15 features was developed and validated. Both the all variable and compact models exhibited excellent performance with area under the receiver operating characteristic curves (AUCs) of 1(95%confidence interval [CI]: 1.0-1.0) in the training set. In the MIMIC-IV testing set, the AUCs of the all variable and compact models were 0.978 (95% CI: 0.973-0.982) and 0.977 (95% CI: 0.972-0.982), respectively. In the external validation set, the AUCs of all variable and compact models were 0.825 (95% CI: 0.815-0.834) and 0.807 (95% CI: 0.796-0.817), respectively. CONCLUSION: An AdaBoost-based predictive model was subjected to internal and external validation, highlighting its strong predictive capacity for assessing the risk of in-hospital mortality in ICU patients with AF.
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Fibrilación Atrial , Simulación por Computador , Mortalidad Hospitalaria , Aprendizaje Automático , Medición de Riesgo , Enfermedad Crítica , Fibrilación Atrial/mortalidad , Medición de Riesgo/métodos , Reproducibilidad de los Resultados , Humanos , Masculino , Femenino , Anciano , Anciano de 80 o más AñosRESUMEN
BACKGROUND: Patients with atrial fibrillation and severe chronic kidney disease have higher risks of bleeding, thromboembolism, and mortality. However, optimal anticoagulant choice in these high-risk patients remains unclear. METHODS AND RESULTS: Using deidentified electronic health records from the Optum Labs Data Warehouse, adults with atrial fibrillation and severe chronic kidney disease (estimated glomerular filtration rate <30 mL/min per 1.73 m2) initiating warfarin, apixaban, or rivaroxaban between 2011 and 2021 were included. Using inverse probability of treatment weighting, adjusted risks of major bleeding, stroke/systemic embolism, and death were compared among agents. A total of 6794 patients were included (mean age, 78.5 years; mean estimated glomerular filtration rate, 24.7 mL/min per 1.73 m2; 51% women). Apixaban versus warfarin was associated with a lower risk of major bleeding (incidence rate, 1.5 versus 2.9 per 100 person-years; subdistribution hazard ratio [sub-HR], 0.53 [95% CI, 0.39-0.70]), and similar risks for stroke/systemic embolism (incidence rate, 1.9 versus 2.4 per 100 person-years; sub-HR, 0.80 [95% CI, 0.59-1.09]) and death (incidence rate, 4.6 versus 4.5 per 100 person-years; HR, 1.03 [95% CI, 0.82-1.29]). Rivaroxaban versus warfarin was associated with a higher risk of major bleeding (incidence rate, 4.9 versus 2.9 per 100 person-years; sub-HR, 1.65 [95% CI, 1.10-2.48]), with no difference in risks for stroke/systemic embolism and death. Apixaban versus rivaroxaban was associated with a lower risk of major bleeding (sub-HR, 0.53 [95% CI, 0.36-0.78]). CONCLUSIONS: These real-world findings are consistent with potential safety advantages of apixaban over warfarin and rivaroxaban for patients with atrial fibrillation and severe chronic kidney disease. Further randomized trials comparing individual oral anticoagulants are warranted.
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Anticoagulantes , Fibrilación Atrial , Embolia , Hemorragia , Pirazoles , Piridonas , Insuficiencia Renal Crónica , Rivaroxabán , Accidente Cerebrovascular , Warfarina , Humanos , Fibrilación Atrial/tratamiento farmacológico , Fibrilación Atrial/complicaciones , Fibrilación Atrial/mortalidad , Femenino , Masculino , Anciano , Insuficiencia Renal Crónica/complicaciones , Insuficiencia Renal Crónica/mortalidad , Hemorragia/inducido químicamente , Hemorragia/epidemiología , Accidente Cerebrovascular/prevención & control , Accidente Cerebrovascular/epidemiología , Accidente Cerebrovascular/etiología , Accidente Cerebrovascular/mortalidad , Anticoagulantes/efectos adversos , Anticoagulantes/uso terapéutico , Anticoagulantes/administración & dosificación , Warfarina/efectos adversos , Warfarina/uso terapéutico , Rivaroxabán/efectos adversos , Rivaroxabán/uso terapéutico , Rivaroxabán/administración & dosificación , Embolia/prevención & control , Embolia/epidemiología , Embolia/etiología , Pirazoles/efectos adversos , Pirazoles/uso terapéutico , Piridonas/efectos adversos , Piridonas/uso terapéutico , Piridonas/administración & dosificación , Administración Oral , Medición de Riesgo , Anciano de 80 o más Años , Factores de Riesgo , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Incidencia , Inhibidores del Factor Xa/efectos adversos , Inhibidores del Factor Xa/uso terapéutico , Inhibidores del Factor Xa/administración & dosificaciónRESUMEN
AIMS: Physiological activation of the heart using algorithms to minimize right ventricular pacing (RVPm) may be an effective strategy to reduce adverse events in patients requiring anti-bradycardia therapies. This systematic review and meta-analysis aimed to evaluate current evidence on clinical outcomes for patients treated with RVPm algorithms compared to dual-chamber pacing (DDD). METHODS AND RESULTS: We conducted a systematic search of the PubMed database. The predefined endpoints were the occurrence of persistent/permanent atrial fibrillation (PerAF), cardiovascular (CV) hospitalization, all-cause death, and adverse symptoms. We also aimed to explore the differential effects of algorithms in studies enrolling a high percentage of atrioventricular block (AVB) patients. Eight studies (7229 patients) were included in the analysis. Compared to DDD pacing, patients using RVPm algorithms showed a lower risk of PerAF [odds ratio (OR) 0.74, 95% confidence interval (CI) 0.57-0.97] and CV hospitalization (OR 0.77, 95% CI 0.61-0.97). No significant difference was found for all-cause death (OR 1.01, 95% CI 0.78-1.30) or adverse symptoms (OR 1.03, 95% CI 0.81-1.29). No significant interaction was found between the use of the RVPm strategy and studies enrolling a high percentage of AVB patients. The pooled mean RVP percentage for RVPm algorithms was 7.96% (95% CI 3.13-20.25), as compared with 45.11% (95% CI 26.64-76.38) of DDD pacing. CONCLUSION: Algorithms for RVPm may be effective in reducing the risk of PerAF and CV hospitalization in patients requiring anti-bradycardia therapies, without an increased risk of adverse symptoms. These results are also consistent for studies enrolling a high percentage of AVB patients.
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Algoritmos , Fibrilación Atrial , Estimulación Cardíaca Artificial , Anciano , Femenino , Humanos , Masculino , Fibrilación Atrial/terapia , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/fisiopatología , Fibrilación Atrial/mortalidad , Bloqueo Atrioventricular/diagnóstico , Bloqueo Atrioventricular/mortalidad , Bloqueo Atrioventricular/fisiopatología , Bloqueo Atrioventricular/terapia , Bradicardia/terapia , Bradicardia/prevención & control , Bradicardia/mortalidad , Bradicardia/diagnóstico , Estimulación Cardíaca Artificial/efectos adversos , Estimulación Cardíaca Artificial/métodos , Frecuencia Cardíaca , Ventrículos Cardíacos/fisiopatología , Hospitalización/estadística & datos numéricos , Marcapaso Artificial/efectos adversos , Factores de Riesgo , Resultado del Tratamiento , Función Ventricular DerechaAsunto(s)
Fibrilación Atrial , Procedimientos Quirúrgicos Cardíacos , Complicaciones Posoperatorias , Humanos , Fibrilación Atrial/mortalidad , Femenino , Masculino , Procedimientos Quirúrgicos Cardíacos/mortalidad , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Procedimientos Quirúrgicos Cardíacos/estadística & datos numéricos , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/epidemiología , Anciano , Factores Sexuales , Persona de Mediana Edad , Factores de RiesgoRESUMEN
BACKGROUND: The increasing prevalence of frailty has gained considerable attention due to its profound influence on clinical outcomes. However, our understanding of the progression of frailty and long-term clinical outcomes in older individuals with atrial fibrillation remains scarce. METHODS: Using data from 2012 to 2018 from a comprehensive claims database incorporating primary and hospital care records in Shizuoka, Japan, we selected patients aged ≥65 years with atrial fibrillation who initiated oral anticoagulant therapy. The trajectory of frailty was plotted using Sankey plots, illustrating the annual changes in their frailty according to the electronic frailty index during a 3-year follow-up after oral anticoagulant initiation, along with the incidence of clinical adverse outcomes. For deceased patients, we assessed their frailty status in the year preceding their death. RESULTS: Of 6247 eligible patients (45.1% women; mean age, 79.3±8.0 years) at oral anticoagulant initiation, 7.7% were categorized as fit (electronic frailty index, 0-0.12), 30.1% as mildly frail (>0.12-0.24), 35.4% as moderately frail (>0.24-0.36), and 25.9% as severely frail (>0.36). Over the 3-year follow-up, 10.4% of initially fit patients transitioned to moderately frail or severely frail. Conversely, 12.5% of severely frail patients improved to fit or mildly frail. Death, stroke, and major bleeding occurred in 23.4%, 4.1%, and 2.2% of patients, respectively. Among the mortality cases, 74.8% (N=1183) and 3.5% (N=55) had experienced moderately or severely frail and either a stroke or major bleeding in the year preceding their death, respectively. CONCLUSIONS: In a contemporary era of atrial fibrillation management, a minor fraction of older patients on oral anticoagulants died following a stroke or major bleeding. However, their frailty demonstrated a dynamic trajectory, and a substantial proportion of death was observed after transitioning to a moderately or severely frail state.
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Anticoagulantes , Fibrilación Atrial , Bases de Datos Factuales , Anciano Frágil , Fragilidad , Evaluación Geriátrica , Humanos , Fibrilación Atrial/tratamiento farmacológico , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/mortalidad , Anciano , Femenino , Masculino , Fragilidad/diagnóstico , Fragilidad/mortalidad , Anciano de 80 o más Años , Anticoagulantes/efectos adversos , Anticoagulantes/administración & dosificación , Anticoagulantes/uso terapéutico , Japón/epidemiología , Factores de Riesgo , Factores de Tiempo , Administración Oral , Medición de Riesgo , Factores de Edad , Resultado del Tratamiento , Accidente Cerebrovascular/mortalidad , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/epidemiología , Estudios Retrospectivos , Hemorragia/inducido químicamente , Hemorragia/epidemiología , Incidencia , PrevalenciaRESUMEN
Importance: There are limited data on the association of sex with the incidence of postoperative atrial fibrillation (poAF) and subsequent long-term mortality after cardiac surgery. Objective: To evaluate whether the incidence of poAF and associated long-term mortality after cardiac surgery differ by sex. Design, Setting, and Participants: This retrospective cohort study was conducted at 2 tertiary care centers in Massachusetts from January 1, 2002, until October 1, 2016, with follow-up until December 1, 2022. Adult (aged >20 years) women and men undergoing coronary artery bypass graft surgery, aortic valve surgery, mitral valve surgery, and combined procedures with cardiopulmonary bypass were examined using medical records. Patients who had data on poAF were included in data analyses. Exposures: Sex and poAF. Main Outcomes and Measures: Primary outcomes were the incidence of poAF and all-cause mortality. poAF was defined as any atrial fibrillation detected on electrocardiogram (EKG) during the index hospitalization in patients presenting for surgery in normal sinus rhythm. Data on poAF were obtained from EKG reports and supplemented by information from the Society of Thoracic Surgeons Adult Cardiac Surgery Database. All-cause mortality was assessed via hospital records. The hypotheses were formulated prior to data analysis. Results: Among 21â¯568 patients with poAF data (mean [SD] age, 66.5 [12.4] years), 2694 of 6601 women (40.8%) and 5805 of 14â¯967 men (38.8%) developed poAF. In a multivariable logistic regression model, women had lower risk of poAF (odds ratio [OR], 0.85; 95% CI, 0.79-0.91; P < .001). During the follow-up study period, 1294 women (50.4%) and 2376 men (48.9%) in the poAF group as well as 1273 women (49.6%) and 2484 men (51.1%) in the non-poAF group died. Cox proportional hazards analysis found that the association between poAF and mortality was significantly moderated (ie, effect modified) by sex. Compared with same-sex individuals without poAF, men with poAF had a 17% higher mortality hazard (hazard ratio [HR], 1.17; 95% CI, 1.11-1.25; P < .001), and women with poAF had a 31% higher mortality hazard (HR, 1.31; 95% CI, 1.21-1.42; P < .001). Conclusions and Relevance: In this retrospective cohort study of 21â¯568 patients who underwent cardiac surgery, women were less likely to develop poAF than men when controlling for other relevant characteristics; however, women who did develop poAF had a higher risk of long-term mortality than men who developed poAF. This observed elevated risk calls for a tailored approach to perioperative care in women undergoing cardiac surgery.
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Fibrilación Atrial , Procedimientos Quirúrgicos Cardíacos , Complicaciones Posoperatorias , Humanos , Fibrilación Atrial/epidemiología , Fibrilación Atrial/etiología , Fibrilación Atrial/mortalidad , Masculino , Femenino , Estudios Retrospectivos , Persona de Mediana Edad , Anciano , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Procedimientos Quirúrgicos Cardíacos/mortalidad , Factores Sexuales , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/epidemiología , Incidencia , Factores de Riesgo , Massachusetts/epidemiologíaRESUMEN
BACKGROUND: Direct oral anticoagulants (DOACs) have been the drug of choice for preventing ischemic stroke in patients with atrial fibrillation since 2014. In previous studies, the stroke risk while taking warfarin was 2 per 100 patient-years and 1.5% per year while taking DOACs. We hypothesized that even if ischemic stroke occurred during anticoagulation therapy with DOACs, the prognosis was likely to be better than that with warfarin. METHODS AND RESULTS: Data from 2002 to 2019, sourced from a nationwide claims database, were used to identify atrial fibrillation patients using International Classification of Diseases codes. Patients who experienced an ischemic stroke during anticoagulation were categorized by the drugs used (warfarin, dabigatran, apixaban, rivaroxaban, and edoxaban). The primary outcome was mortality within 3 months and 1 year after the ischemic stroke. Among the 9578 patients with ischemic stroke during anticoagulation, 3343 received warfarin, and 6235 received DOACs (965 dabigatran, 2320 apixaban, 1702 rivaroxaban, 1248 edoxaban). The DOACs group demonstrated lower risks of 3-month (adjusted hazard ratio [HR], 0.550, [95% CI, 0.473-0.639]; P<0.0001) and 1-year mortality (adjusted HR, 0.596 [95% CI, 0.536-0.663]; P<0.0001) than the warfarin group. Apixaban and edoxaban within the DOAC group exhibited particularly reduced 1-year mortality risk compared with other DOACs (P<0.0001). CONCLUSIONS: Our study confirmed that DOACs have a better prognosis than warfarin after ischemic stroke. The apixaban and edoxaban groups had a lower risk of death after ischemic stroke than the other DOAC groups.
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Anticoagulantes , Fibrilación Atrial , Inhibidores del Factor Xa , Accidente Cerebrovascular Isquémico , Warfarina , Humanos , Warfarina/uso terapéutico , Warfarina/efectos adversos , Accidente Cerebrovascular Isquémico/prevención & control , Accidente Cerebrovascular Isquémico/mortalidad , Accidente Cerebrovascular Isquémico/diagnóstico , Masculino , Femenino , Anciano , Anticoagulantes/efectos adversos , Anticoagulantes/uso terapéutico , Anticoagulantes/administración & dosificación , Fibrilación Atrial/tratamiento farmacológico , Fibrilación Atrial/complicaciones , Fibrilación Atrial/mortalidad , Pronóstico , Administración Oral , Inhibidores del Factor Xa/uso terapéutico , Inhibidores del Factor Xa/efectos adversos , Inhibidores del Factor Xa/administración & dosificación , Persona de Mediana Edad , Anciano de 80 o más Años , Piridonas/efectos adversos , Piridonas/uso terapéutico , Piridonas/administración & dosificación , Estudios Retrospectivos , Pirazoles/uso terapéutico , Pirazoles/efectos adversos , Dabigatrán/uso terapéutico , Dabigatrán/efectos adversos , Dabigatrán/administración & dosificación , Rivaroxabán/uso terapéutico , Rivaroxabán/efectos adversos , Rivaroxabán/administración & dosificación , Factores de Riesgo , Medición de Riesgo , Taiwán/epidemiología , Piridinas , TiazolesRESUMEN
The clinical characteristics and long-term outcomes of patients with ischemic stroke (IS) and atrial fibrillation detected after stroke (AFDAS) have not been clearly established. Previous studies evaluating patients with AFDAS were limited by the low prescription rates of anticoagulants and short follow-up periods. Consecutive patients hospitalized for IS between 2014 and 2017 were identified from a National Health Insurance Research Database. The included patients were categorized into three groups: (1) known diagnosis of AF (KAF) before the index stroke, (2) AFDAS, and (3) without AF (non-AF). Univariable and multivariable Cox regression analyses were performed to estimate the hazard ratio (HR) for independent variables and recurrent IS, hemorrhagic stroke, or all-cause mortality. We identified 158,909 patients with IS of whom 16,699 (10.5%) had KAF and 7,826 (4.9%) had AFDAS. The patients with AFDAS were younger, more often male, and had lower CHA2DS2-VASc scores (3.8 ± 1.9 versus 4.9 ± 1.8, p < 0.001) than the patients with KAF. Anticoagulant treatment significantly reduced the risks of all outcomes. The standardized mortality rates were 40.4, 28.6, and 18.4 (per 100 person-years) for the patients with KAF, AFDAS, and non-AF, respectively. Compared with AFDAS, KAF was associated with lower risks of recurrent IS [hazard ratio (HR): 0.91, 95% confidence interval (CI): 0.86-0.97, p < 0.01] and hemorrhagic stroke (HR: 0.88, 95% CI: 0.79-0.99, p < 0.01) and a higher risk of all-cause mortality (HR: 1.11, 95% CI: 1.07-1.16, p < 0.001). The risks of recurrent IS and hemorrhagic stroke were higher and of all-cause mortality was lower for patients with AFDAS than with KAF. There is a strong need to refine treatment modalities to reduce the high mortality in patients with KAF and AFDAS.
Asunto(s)
Anticoagulantes , Fibrilación Atrial , Accidente Cerebrovascular , Humanos , Fibrilación Atrial/mortalidad , Fibrilación Atrial/complicaciones , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/tratamiento farmacológico , Masculino , Femenino , Anciano , Persona de Mediana Edad , Anticoagulantes/uso terapéutico , Accidente Cerebrovascular/mortalidad , Accidente Cerebrovascular/complicaciones , Accidente Cerebrovascular Isquémico/mortalidad , Accidente Cerebrovascular Isquémico/complicaciones , Accidente Cerebrovascular Isquémico/diagnóstico , Anciano de 80 o más Años , Estudios de Cohortes , Factores de Riesgo , Modelos de Riesgos Proporcionales , Accidente Cerebrovascular Hemorrágico/mortalidad , Accidente Cerebrovascular Hemorrágico/epidemiología , Accidente Cerebrovascular Hemorrágico/diagnósticoRESUMEN
BACKGROUND: Patients treated with left atrial appendage occlusion (LAAO) are at high bleeding risk. Intensive antithrombotic treatment is recommended after the procedure to prevent device-related thrombosis. OBJECTIVES: This study sought to evaluate the incidence, consequences, and predictors of early nonprocedural bleeding after LAAO. METHODS: This was a multicenter study including 1,649 patients undergoing LAAO in 9 centers. Early nonprocedural bleeding was defined as bleeding unrelated to the procedure occurring within 3 months after device implantation. The severity of bleeding was defined by the Valve Academic Research Consortium-2 classification. A sensitivity analysis was performed at 45 days. RESULTS: A total of 121 (7.3%) patients experienced early nonprocedural bleeding events, and 69 (57.0%) were classified as major bleeding (4.2% of patients). Independent predictors of early nonprocedural bleeding were dual antiplatelet therapy (DAPT) at discharge (adjusted HR [aHR]: 1.61; 95% CI: 1.12-2.33; P = 0.01), prior gastrointestinal bleeding (aHR: 2.15; 95% CI: 1.38-3.35; P < 0.001), and multiple locations of prior bleeding (aHR: 2.33; 95% CI: 1.34-4.05; P < 0.001). DAPT at discharge was predictive of both all and major nonprocedural bleeding at 3 months and 45 days. After a median follow-up of 2.3 years (Q1-Q3: 1.1-4.1 years), early nonprocedural bleeding was independently associated with an increased risk of all-cause death (aHR: 1.53; 95% CI: 1.15-2.06; P < 0.001). This heightened mortality risk was similar at 45 days. CONCLUSIONS: Early nonprocedural bleeding after LAAO occurred in â¼7% of patients within 3 months, with more than one-half being classified as major bleeding. Regardless of severity, early nonprocedural bleeding was associated with increased mortality. DAPT at discharge determined an increased risk of early nonprocedural bleeding after LAAO. These results emphasize the importance of bleeding risk for determining antithrombotic strategies after LAAO.
Asunto(s)
Apéndice Atrial , Fibrilación Atrial , Cateterismo Cardíaco , Hemorragia , Inhibidores de Agregación Plaquetaria , Humanos , Apéndice Atrial/fisiopatología , Apéndice Atrial/diagnóstico por imagen , Masculino , Femenino , Anciano , Factores de Riesgo , Factores de Tiempo , Fibrilación Atrial/mortalidad , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/complicaciones , Resultado del Tratamiento , Medición de Riesgo , Inhibidores de Agregación Plaquetaria/efectos adversos , Inhibidores de Agregación Plaquetaria/uso terapéutico , Hemorragia/etiología , Incidencia , Anciano de 80 o más Años , Cateterismo Cardíaco/efectos adversos , Cateterismo Cardíaco/instrumentación , Cateterismo Cardíaco/mortalidad , Terapia Antiplaquetaria Doble/efectos adversos , Estados Unidos/epidemiología , Persona de Mediana Edad , Fibrinolíticos/efectos adversos , Fibrinolíticos/administración & dosificación , Estudios Retrospectivos , Europa (Continente) , Anticoagulantes/efectos adversos , Anticoagulantes/uso terapéutico , Anticoagulantes/administración & dosificaciónRESUMEN
BACKGROUND: Preclinical animal studies have suggested that myeloid cell-synthesized coagulation factor X dampens antitumor immunity and that rivaroxaban, a direct factor Xa inhibitor, can be used to promote tumor immunity. This study was aimed at assessing whether patients with atrial fibrillation taking direct factor Xa inhibitors have lower risk of cancer and cancer-related mortality than patients taking the direct thrombin inhibitor dabigatran. METHODS AND FINDINGS: This nationwide population-based cohort study in Denmark included adult patients with atrial fibrillation and without a history of cancer, who started taking a factor Xa inhibitor or dabigatran between 2011 and 2015. Data on medical history, outcomes, and drug use were acquired through Danish healthcare registries. The primary outcome was any cancer. Secondary outcomes were cancer-related mortality and all-cause mortality. Outcome events were assessed during 5 years of follow-up in an intention-to-treat analysis. The propensity score-based inverse probability of treatment weighting was used to compute cumulative incidence and subdistribution hazard ratios (SHRs) and corresponding 95% confidence intervals (CIs), with death as a competing event. Propensity scores were estimated using logistic regression and including in the model sex, age group at index date, comorbidities, and use of comedications. A total of 11,742 patients with atrial fibrillation starting a factor Xa inhibitor and 11,970 patients starting dabigatran were included. Mean age was 75.2 years (standard deviation [SD] 11.2) in the factor Xa cohort and 71.7 years (SD 11.1) in the dabigatran cohort. On the basis of the propensity score-weighted models, after 5 years of follow-up, no substantial difference in the cumulative incidence of cancer was observed between the factor Xa inhibitor (2,157/23,711; 9.11%, 95% CI [8.61%,9.63%]) and dabigatran (2,294/23,715; 9.68%, 95% CI [9.14%,10.25%]) groups (SHR 0.94, 95% CI [0.89,1.00], P value 0.0357). We observed no difference in cancer-related mortality (factor Xa inhibitors cohort 1,028/23,711; 4.33%, 95% CI [4.02%,4.68%]. Dabigatran cohort 1,001/23,715; 4.22%, 95% CI [3.83%,4.66%]; SHR 1.03, 95% CI [0.94,1.12]), but all-cause mortality was higher in the factor Xa inhibitor cohort (factor Xa inhibitors cohort 7,416/23,711; 31.31%, 95% CI [30.37%,32.29%]. Dabigatran cohort 6,531/23,715; 27.56%, 95% CI [26.69%,28.45%]; HR 1.17, 95% CI [1.13,1.21]). The main limitations of the study were the possibility of residual confounding and the short follow-up period. CONCLUSIONS: In this population based cohort study, factor Xa inhibitor use was not associated with an overall lower incidence of cancer or cancer-related mortality when compared to dabigatran. We did observe an increase in all-cause mortality in the factor Xa inhibitor cohort.
Asunto(s)
Fibrilación Atrial , Dabigatrán , Inhibidores del Factor Xa , Neoplasias , Humanos , Inhibidores del Factor Xa/uso terapéutico , Inhibidores del Factor Xa/efectos adversos , Neoplasias/mortalidad , Neoplasias/epidemiología , Dinamarca/epidemiología , Masculino , Femenino , Anciano , Fibrilación Atrial/tratamiento farmacológico , Fibrilación Atrial/mortalidad , Fibrilación Atrial/epidemiología , Persona de Mediana Edad , Anciano de 80 o más Años , Dabigatrán/uso terapéutico , Dabigatrán/efectos adversos , Estudios de Cohortes , Sistema de Registros , Rivaroxabán/uso terapéutico , Rivaroxabán/efectos adversos , Factores de Riesgo , Incidencia , Antitrombinas/uso terapéutico , Antitrombinas/efectos adversosRESUMEN
BACKGROUND: Mounting evidence indicates that even device-detected subclinical atrial fibrillation is associated with a higher risk of heart failure (HF). However, the potential impact of atrial fibrillation screening on HF remains unknown. METHODS: The LOOP Study (Atrial Fibrillation detected by Continuous ECG Monitoring using Implantable Loop Recorder to prevent Stroke in High-risk Individuals) evaluated the effects of atrial fibrillation screening on stroke prevention using an implantable loop recorder (ILR) versus usual care in older individuals with additional stroke risk factors. In this secondary analysis, we explored the following HF end points: (1) HF event or cardiovascular death; (2) HF event; (3) event with HF with reduced ejection fraction (HFrEF); and (4) HFrEF event or cardiovascular death. Outcomes were assessed in a Cox model both as time-to-first events and as total (first and recurrent) events analyzed using the Andersen-and-Gill method. RESULTS: Of 6004 participants (mean age 74.7 and 52.7% men), 1501 were randomized to ILR screening and 4503 to the control group. In total, 77 (5.1%) in the ILR group versus 295 (6.6%) in the control group experienced the primary outcome of an HF event or cardiovascular death. Compared with usual care, ILR screening was associated with a nonsignificant reduction in the primary outcome for the time-to-first event analysis (hazard ratio, 0.78 [95% CI, 0.61-1.01]) and the total event analysis (hazard ratio, 0.77 [95% CI, 0.59-1.01]). Similar results were obtained for the HF event. A significant risk reduction in total events was observed in the ILR group for the composite of HFrEF event or cardiovascular death and for HFrEF event (hazard ratio, 0.74 [95% CI, 0.56-0.98] and 0.65 [95% CI, 0.44-0.97], respectively). CONCLUSIONS: In an older population with additional stroke risk factors, ILR screening for atrial fibrillation tended to be associated with a lower rate of total HF events and cardiovascular death, particularly those related to HFrEF. These findings should be considered hypothesis-generating and warrant further investigation. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02036450.
Asunto(s)
Fibrilación Atrial , Insuficiencia Cardíaca , Humanos , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/fisiopatología , Fibrilación Atrial/mortalidad , Masculino , Femenino , Anciano , Insuficiencia Cardíaca/diagnóstico , Insuficiencia Cardíaca/mortalidad , Insuficiencia Cardíaca/fisiopatología , Factores de Riesgo , Factores de Tiempo , Medición de Riesgo , Volumen Sistólico , Electrocardiografía Ambulatoria , Anciano de 80 o más Años , Accidente Cerebrovascular/prevención & control , Accidente Cerebrovascular/etiología , Accidente Cerebrovascular/epidemiología , Accidente Cerebrovascular/mortalidad , Accidente Cerebrovascular/diagnóstico , Tamizaje Masivo/métodos , Valor Predictivo de las Pruebas , Frecuencia CardíacaRESUMEN
BACKGROUND: Left atrial appendage closure (LAAC) represents an alternative to oral anticoagulation for stroke prevention in patients with non-valvular atrial fibrillation (AF). While transoesophageal echocardiography is the current standard for guiding LAAC procedures, several centers have employed fluoroscopic guidance alone. However, data on long-term outcomes are lacking. METHODS: A total of 536 patients with AF undergoing LAAC and with available data on long-term follow-up were included in the retrospective, single-center analysis. Outcomes of patients undergoing fluoroscopy-guided LAAC were compared with those undergoing echocardiography guided LAAC. Time-dependent analysis was performed with the Kaplan-Meier method. RESULTS: A total of 234 (44%) and 302 (56%) patients were treated with echocardiography and fluoroscopy guidance, respectively. Baseline characteristics did not differ between the two groups. Procedural success rates were high in both groups (97% of fluoroscopy vs. 98% of echocardiography guided procedures; p = 0.92) and rates of relevant peri-device leaks (p = 0.50) and device-related thrombus formation (p = 0.22) did not differ between groups. Median clinical follow-up time was 48 (IQR 19-73) months. Rates of all-cause mortality (p = 0.15, HR 0.83, CI 0.64-1.07) and stroke (p = 0.076, HR 2.23, CI 0.90-5.54) were comparable among groups. CONCLUSION: LAAC with fluoroscopy guidance alone is equally safe and leads to similar clinical outcome compared to LAAC with additional echocardiography guidance.
Asunto(s)
Fibrilación Atrial , Ecocardiografía Transesofágica , Cierre del Apéndice Auricular Izquierdo , Radiografía Intervencional , Accidente Cerebrovascular , Ultrasonografía Intervencional , Humanos , Apéndice Atrial/diagnóstico por imagen , Apéndice Atrial/fisiopatología , Fibrilación Atrial/complicaciones , Fibrilación Atrial/diagnóstico por imagen , Fibrilación Atrial/mortalidad , Fibrilación Atrial/terapia , Fluoroscopía , Cierre del Apéndice Auricular Izquierdo/efectos adversos , Cierre del Apéndice Auricular Izquierdo/instrumentación , Valor Predictivo de las Pruebas , Radiografía Intervencional/efectos adversos , Estudios Retrospectivos , Factores de Riesgo , Accidente Cerebrovascular/prevención & control , Accidente Cerebrovascular/etiología , Factores de Tiempo , Resultado del Tratamiento , Ultrasonografía Intervencional/efectos adversosRESUMEN
AIMS: Recommendations on cardiac resynchronization therapy (CRT) in patients with atrial fibrillation or flutter (AF) are based on less robust evidence than those in sinus rhythm (SR). We aimed to assess the efficacy of CRT upgrade in the BUDAPEST-CRT Upgrade trial population by their baseline rhythm. METHODS AND RESULTS: Heart failure patients with reduced ejection fraction (HFrEF) and previously implanted pacemaker (PM) or implantable cardioverter defibrillator (ICD) and ≥20% right ventricular (RV) pacing burden were randomized to CRT with defibrillator (CRT-D) upgrade (n = 215) or ICD (n = 145). Primary [HF hospitalization (HFH), all-cause mortality, or <15% reduction of left ventricular end-systolic volume] and secondary outcomes were investigated. At enrolment, 131 (36%) patients had AF, who had an increased risk for HFH as compared with those with SR [adjusted hazard ratio (aHR) 2.99; 95% confidence interval (CI) 1.26-7.13; P = 0.013]. The effect of CRT-D upgrade was similar in patients with AF as in those with SR [AF adjusted odds ratio (aOR) 0.06; 95% CI 0.02-0.17; P < 0.001; SR aOR 0.13; 95% CI 0.07-0.27; P < 0.001; interaction P = 0.29] during the mean follow-up time of 12.4 months. Also, it decreased the risk of HFH or all-cause mortality (aHR 0.33; 95% CI 0.16-0.70; P = 0.003; interaction P = 0.17) and improved the echocardiographic response (left ventricular end-diastolic volume difference -49.21 mL; 95% CI -69.10 to -29.32; P < 0.001; interaction P = 0.21). CONCLUSION: In HFrEF patients with AF and PM/ICD with high RV pacing burden, CRT-D upgrade decreased the risk of HFH and improved reverse remodelling when compared with ICD, similar to that seen in patients in SR.
Asunto(s)
Fibrilación Atrial , Terapia de Resincronización Cardíaca , Desfibriladores Implantables , Insuficiencia Cardíaca , Volumen Sistólico , Humanos , Fibrilación Atrial/terapia , Fibrilación Atrial/fisiopatología , Fibrilación Atrial/mortalidad , Fibrilación Atrial/complicaciones , Fibrilación Atrial/diagnóstico , Masculino , Femenino , Terapia de Resincronización Cardíaca/métodos , Anciano , Insuficiencia Cardíaca/fisiopatología , Insuficiencia Cardíaca/terapia , Insuficiencia Cardíaca/mortalidad , Resultado del Tratamiento , Persona de Mediana Edad , Función Ventricular Derecha , Función Ventricular Izquierda , Dispositivos de Terapia de Resincronización Cardíaca , Factores de Riesgo , Hospitalización/estadística & datos numéricos , Cardioversión Eléctrica/efectos adversos , Cardioversión Eléctrica/instrumentación , Factores de Tiempo , Anciano de 80 o más AñosRESUMEN
BACKGROUND: PINNACLE FLX (Protection Against Embolism for Nonvalvular AF Patients: Investigational Device Evaluation of the WATCHMAN FLX LAA Closure Technology) demonstrated improved outcomes and low incidence of adverse events with the WATCHMAN FLX device in a controlled setting. The National Cardiovascular Disease Registry's Left Atrial Appendage Occlusion Registry was utilized to assess the safety and effectiveness of WATCHMAN FLX in contemporary clinical practice in the United States. METHODS: The WATCHMAN FLX Device Surveillance Post Approval Analysis Plan used data from the Left Atrial Appendage Occlusion registry to identify patients undergoing WATCHMAN FLX implantation between August 2020 and September 2022. The key safety end point was defined as all-cause death, ischemic stroke, systemic embolism, or device or procedure-related events requiring open cardiac surgery or major endovascular intervention between device implantation and hospital discharge. Major adverse events were reported at hospital discharge, 45 days, and 1 year. RESULTS: Among 97 185 patients in the Left Atrial Appendage Occlusion registry undergoing WATCHMAN FLX, successful implantation occurred in 97.5% (n=94 784) of patients. The key safety end point occurred in 0.45% of patients. At 45 days post-procedure, all-cause death occurred in 0.81% patients, ischemic stroke in 0.23%, major bleeding in 3.1%, pericardial effusion requiring intervention in 0.50%, device-related thrombus in 0.44%, and device embolism in 0.04% patients. No peri-device leak was observed in 83.1% of patients at 45 days. At 1 year, the rate of all-cause death was 8.2%, the rate of any stroke was 1.5% (ischemic stroke, 1.2%), and major bleeding occurred in 6.4% of patients. CONCLUSIONS: In a large contemporary cohort of patients with the WATCHMAN FLX device, the rates of implant success and clinical outcomes through 1 year were comparable with the PINNACLE FLX study, demonstrating that favorable outcomes achieved in the pivotal approval study can be replicated in routine clinical practice.
Asunto(s)
Apéndice Atrial , Fibrilación Atrial , Sistema de Registros , Humanos , Apéndice Atrial/fisiopatología , Femenino , Masculino , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/terapia , Fibrilación Atrial/mortalidad , Fibrilación Atrial/fisiopatología , Anciano , Resultado del Tratamiento , Estados Unidos , Factores de Tiempo , Factores de Riesgo , Anciano de 80 o más Años , Cateterismo Cardíaco/efectos adversos , Cateterismo Cardíaco/instrumentación , Cateterismo Cardíaco/mortalidad , Medición de Riesgo , Vigilancia de Productos Comercializados , Dispositivos de Protección Embólica , Accidente Cerebrovascular Isquémico/prevención & control , Accidente Cerebrovascular Isquémico/mortalidad , Accidente Cerebrovascular Isquémico/etiología , Diseño de Prótesis , Persona de Mediana EdadRESUMEN
BACKGROUND: Intravenous digoxin is still used in emergency departments (EDs) to treat patients with acute heart failure (AHF), especially in those with rapid atrial fibrillation. Nonetheless, many emergency physicians are reluctant to use intravenous digoxin in patients with advanced age, impaired renal function, and potassium disturbances due to its potential capacity to increase adverse outcomes. OBJECTIVE: We investigated whether intravenous digoxin used to treat rapid atrial fibrillation in patients with AHF may influence mortality in patients with specific age, estimated glomerular filtration rate (eGFR), and serum potassium classes. DESIGN: A secondary analysis of patients included in in the Spanish EAHFE cohort, which includes patients diagnosed with AHF in the ED. SETTING: 45 Spanish EDs. PARTICIPANTS: Two thousand one hundred ninety-four patients with AHF and rapid atrial fibrillation (heart rate ≥100â bpm) not receiving digoxin at home, divided according to whether they were or were not treated with intravenous digoxin in the ED. OUTCOME: The relationships between age, eGFR, and potassium with 30-day mortality were investigated using restricted cubic spline (RCS) models adjusted for relevant patient and episode variables. The impact of digoxin use on such relationships was assessed by checking interaction. MAIN RESULTS: The median age of the patients was 82â years [interquartile range (IQR)â =â 76-87], 61.4% were women, 65.2% had previous episodes of atrial fibrillation, and the median heart rate at ED arrival was 120â bpm (IQRâ =â 109-135). Digoxin and no digoxin groups were formed by 864 (39.4%) and 1330 (60.6%) patients, respectively. There were 191 deaths within the 30-day follow-up period (8.9%), with no differences between patients receiving or not receiving digoxin (8.5 vs. 9.1%, P â =â 0.636). Although analysis of RCS curves showed that death was associated with advanced age, worse renal function, and hypo- and hyperkalemia, use of intravenous digoxin did not interact with any of these relationships ( P â =â 0.156 for age, P â =â 0.156 for eGFR; P â =â 0.429 for potassium). CONCLUSION: The use of intravenous digoxin in the ED was not associated with significant changes in 30-day mortality, which was confirmed irrespective of patient age or the existence of renal dysfunction or serum potassium disturbances.