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    • br Discussion This study shows that

    2019-04-20


    Discussion This study shows that the risk of all-cause mortality in patients with atrial fibrillation is directly associated with RDW in a dose-response manner. This association was independent of known risk factors of mortality. Notably, RDW is associated with all-cause mortality regardless of anemia status. In addition, this study shows that the dynamic changes in RDW are strongly associated with the risk of all-cause mortality; in patients with elevated RDW, the risk of mortality decreased when RDW declined to normal levels, and in patients with normal RDW, the risk of mortality increased with RDW elevation. Changes in RDW over time were also found to be associated with all-cause mortality in patients with CHF [15]. RDW is well known as a marker associated with increased risk of mortality in multiple cardiovascular settings [2–8]. RDW was also found to be associated with increased mortality and poor clinical outcome in patients with stroke, regardless of atrial fibrillation [16,17]. Furthermore, we recently demonstrated that RDW is an independent risk factor for stroke in patients with atrial fibrillation [11]. Hence, it may be suggested that the increased risk of mortality associated with RDW in patients with atrial fibrillation may be attributed to stroke mortality. Unfortunately, we did not have data related to cause of death; therefore, we were not able to confirm this hypothesis or to assess the relationship of RDW with specific causes of mortality. Few previous small studies have assessed the association between RDW and all-cause mortality in patients with atrial fibrillation, and these studies have presented conflicting results [18,19]. Wan et al. studied 300 patients with atrial fibrillation and showed that RDW was independently associated with all-cause mortality and major adverse events [18]. Lee et al. studied 567 patients with paroxysmal atrial fibrillation and showed that RDW was significantly associated with composite clinical outcomes of death, hospitalization due to bace inhibitor failure, and new-onset stroke; however, RDW was not associated with mortality when death was considered as a single outcome [19]. Compared to previous studies, our work more accurately represents everyday real-life scenarios of patients with atrial fibrillation, as it includes a large number of patients from a population-based database. Furthermore, this study was able to examine the association of change in RDW over time and mortality. The exact biological mechanisms underlying the association of RDW and mortality in patients with atrial fibrillation cannot be gleaned by this cohort study. Furthermore, this cohort study is observational in nature and residual confounding may still exist. Hence, whether RDW has a causal effect in leading to mortality or is simply a marker of other comorbidities or biological mechanisms cannot be proven from this study. In this regard, a potential role may be played by systemic factors that alter erythrocyte hemostasis leading to anisocytosis, such as inflammation and oxidative stress [20,21]. Both decreased serum antioxidant levels (selenium, carotenoids, and vitamin E), and increased inflammatory biomarkers (IL-6, CRP, soluble TNF receptor I and II) were correlated with increased RDW [22–25]. Although this explanation seems to be plausible, adjustment for CRP and antioxidant levels did not meaningfully attenuate the association between RDW and mortality [25,26].
    Conclusion
    Conflicts of interest
    Introduction The entirely subcutaneous implantable cardioverter-defibrillator (ICD) system (S-ICD™, Boston Scientific Corp., Marlborough, MA, USA), was developed to provide life-saving defibrillation therapy that does not affect the heart and vasculature, and thus these can overcome transvenous lead-associated complications [1]. The subcutaneous ICD system is preferred over the transvenous ICD for active patients, or for those having a history of recurrent transvenous lead positioning, those without or limited vascular access, or those with congenital heart disease, ion channelopathies or primary electrical disease with ventricular fibrillation presenting with major life-threatening rhythms. This system was approved for use in Japan in February 2016.