Cause of Death and Predictors of All-Cause Mortality in Anticoagulated Patients With Nonvalvular Atrial Fibrillation : Data From ROCKET AF

M. Kaste on työryhmän ROCKET AF Steering Comm jäsen.Background-Atrial fibrillation is associated with higher mortality. Identification of causes of death and contemporary risk factors for all-cause mortality may guide interventions. Methods and Results-In 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= 75 years (hazard ratio 1.69, 95% CI 1.51-1.90, P Conclusions-In a large population of patients anticoagulated for nonvalvular atrial fibrillation, approximate to 7 in 10 deaths were cardiovascular, whereasPeer reviewe

Evacetrapib and Cardiovascular Outcomes in High-Risk Vascular Disease

BACKGROUND: The cholesteryl ester transfer protein inhibitor evacetrapib substantially raises the high-density lipoprotein (HDL) cholesterol level, reduces the low-density lipoprotein (LDL) cholesterol level, and enhances cellular cholesterol efflux capacity. We sought to determine the effect of evacetrapib on major adverse cardiovascular outcomes in patients with high-risk vascular disease. METHODS: In a multicenter, randomized, double-blind, placebo-controlled phase 3 trial, we enrolled 12,092 patients who had at least one of the following conditions: an acute coronary syndrome within the previous 30 to 365 days, cerebrovascular atherosclerotic disease, peripheral vascular arterial disease, or diabetes mellitus with coronary artery disease. Patients were randomly assigned to receive either evacetrapib at a dose of 130 mg or matching placebo, administered daily, in addition to standard medical therapy. The primary efficacy end point was the first occurrence of any component of the composite of death from cardiovascular causes, myocardial infarction, stroke, coronary revascularization, or hospitalization for unstable angina. RESULTS: At 3 months, a 31.1% decrease in the mean LDL cholesterol level was observed with evacetrapib versus a 6.0% increase with placebo, and a 133.2% increase in the mean HDL cholesterol level was seen with evacetrapib versus a 1.6% increase with placebo. After 1363 of the planned 1670 primary end-point events had occurred, the data and safety monitoring board recommended that the trial be terminated early because of a lack of efficacy. After a median of 26 months of evacetrapib or placebo, a primary end-point event occurred in 12.9% of the patients in the evacetrapib group and in 12.8% of those in the placebo group (hazard ratio, 1.01; 95% confidence interval, 0.91 to 1.11; P=0.91). CONCLUSIONS: Although the cholesteryl ester transfer protein inhibitor evacetrapib had favorable effects on established lipid biomarkers, treatment with evacetrapib did not result in a lower rate of cardiovascular events than placebo among patients with high-risk vascular disease. (Funded by Eli Lilly; ACCELERATE ClinicalTrials.gov number, NCT01687998 .)

Onychoptosis: a forgotten sign in syphilis infection

Onychoptosis is the periodic shedding and falling of one or more nails, in whole or part. It can be seen after fever, trauma, adverse reaction to medications, and in systemic illnesses including syphilis (syphilitic onychia). We report a case of 38-year-old man presented with subacute bilateral retrobulbar optic neuritis. Physical examination revealed diffuse onychoptosis which lead into the diagnosis of neurosyphilis. Symptoms significantly improved with appropriate treatment with intravenous penicillin G for 14 days

1003-2 Left and Right Atrial Systolic Function After the Maze Procedure: A Long-term Echo-Doppler Follow-up Study

The Maze procedure for atrial arrhythmias is designed to eliminate atrial fibrillation, and preserve atrial function. Initial data after short-term follow-up indicates that 60% patients show restoration of atrial systolic function. The long-term evaluation by echo-Doppler of left and right atrial function has not been well studied. We performed pulsed Doppler and two dimensional echocardiographyon 19 patients (16 males, mean age 54 years) who underwent the Maze procedure for atrial fibrillation and who had a follow-up study greater than 3 months (mean duration=17 months) after the procedure. Measurements included the peak left ventricular (LV) inflow and right ventricular (RV) inflow A-wave velocity, maximum (Max) and minimum (Min) off-line digitized left atrial (LA) and right atrial (RA) areas and fractional area change (FAC).Left AtriumRight AtriumPrePostPrePostMax (cm2)26.123.120.821.7Min (cm2)19.618.116.017.6FAC (%)27.022.023.20.0Twelve patients (63%) had evidence of LA function, while 16 patients (84%) had evidence of RA function. The LV inflow A-wave velocity (33±9cm/s) and the RV inflow A-wave velocity (35±12cm/s) did not differ significantly; however, the LA inflow A-wave was significantly lower than agematched controls (59±14, p<0.001). Both the mean LA FAC and the RA FAC tended to decrease at follow-up (p=0.13).Conclusions1) In long-term follow-up of 17 months after the Maze procedure, left atrial systolic function is preserved in 63% of patients, while the right atrial systolic function is preserved in 86% of patients. 21 LA peak A-wave velocity post Maze is considerably less than that shown in agematched controls. These findings suggest that the Maze procedure is only partially successful in achieving its goals of preserving atrial function