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Boriani G, Gerra L, Mei DA, Bonini N, Vitolo M, Proietti M, Imberti JF. Detection of subclinical atrial fibrillation with cardiac implanted electronic devices: What decision making on anticoagulation after the NOAH and ARTESiA trials? Eur J Intern Med 2024; 123:37-41. [PMID: 38281819 DOI: 10.1016/j.ejim.2024.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Accepted: 01/04/2024] [Indexed: 01/30/2024]
Abstract
Atrial fibrillation (AF) may be asymptomatic and the extensive monitoring capabilities of cardiac implantable electronic devices (CIEDs) revealed asymptomatic atrial tachi-arrhythmias of short duration (minutes-hours) occurring in patients with no prior history of AF and without AF detection at a conventional surface ECG. Both the terms "AHRE" (Atrial High-Rate Episodes) and subclinical AF were used in a series of prior studies, that evidenced the association with an increased risk of stroke. Two randomized controlled studies were planned in order to assess the risk-benefit profile of anticoagulation in patients with AHRE/subclinical AF: the NOAH and ARTESiA trials. The results of these two trials (6548 patients enrolled, overall) show that the risk of stroke/systemic embolism associated with AHRE/subclinical AF is in the range of 1-1.2 % per patient-year, but with an important proportion of severe/fatal strokes occurring in non-anticoagulated patients. The apparent discordance between ARTESiA and NOAH results may be approached by considering the related study-level meta-analysis, which highlights a consistent reduction of ischemic stroke with oral anticoagulants vs. aspirin/placebo (relative risk [RR] 0.68, 95 % CI 0.50-0.92). Oral anticoagulation was found to increase major bleeding (RR 1.62, 95 % CI 1.05-2.5), but no difference was found in fatal bleeding (RR 0.79, 95 % CI 0.37-1.69). Additionally, no difference was found in cardiovascular death or all-cause mortality. Taking into account these results, clinical decision-making for patients with AHRE/subclinical AF at risk of stroke, according to CHA2DS2-VASc, can now be evidence-based, considering the benefits and related risks of oral anticoagulants, to be shared with appropriately informed patients.
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Affiliation(s)
- Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, Italy University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy.
| | - Luigi Gerra
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, Italy University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Davide A Mei
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, Italy University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy; Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Niccolo' Bonini
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, Italy University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy; Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Marco Vitolo
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, Italy University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy; Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Marco Proietti
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy; Division of Subacute Care IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy
| | - Jacopo F Imberti
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, Italy University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy; Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
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2
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Boriani G, Tartaglia E, Imberti JF. A call to action: The need to apply guidelines recommendations with ABC or SOS to improve stroke prevention and cardiovascular outcomes in patients with atrial fibrillation. Eur J Intern Med 2024; 122:42-44. [PMID: 38310009 DOI: 10.1016/j.ejim.2024.01.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 01/24/2024] [Indexed: 02/05/2024]
Affiliation(s)
- Giuseppe Boriani
- Department of Biomedical, Cardiology Division, Metabolic and Neural Sciences, Italy University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy.
| | - Enrico Tartaglia
- Department of Biomedical, Cardiology Division, Metabolic and Neural Sciences, Italy University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Jacopo F Imberti
- Department of Biomedical, Cardiology Division, Metabolic and Neural Sciences, Italy University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy; Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
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3
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Mathew J, Mehawej J, Wang Z, Orwig T, Ding E, Filippaios A, Naeem S, Otabil EM, Hamel A, Noorishirazi K, Radu I, Saczynski J, McManus DD, Tran KV. Health behavior outcomes in stroke survivors prescribed wearables for atrial fibrillation detection stratified by age. J Geriatr Cardiol 2024; 21:323-330. [PMID: 38665288 PMCID: PMC11040051 DOI: 10.26599/1671-5411.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND Smartwatches have become readily accessible tools for detecting atrial fibrillation (AF). There remains limited data on how they affect psychosocial outcomes and engagement in older adults. We examine the health behavior outcomes of stroke survivors prescribed smartwatches for AF detection stratified by age. METHODS We analyzed data from the Pulsewatch study, a randomized controlled trial that enrolled patients (≥ 50 years) with a history of stroke or transient ischemic attack and CHA2DS2-VASc ≥ 2. Intervention participants were equipped with a cardiac patch monitor and a smartwatch-app dyad, while control participants wore the cardiac patch monitor for up to 44 days. We evaluated health behavior parameters using standardized tools, including the Consumer Health Activation Index, the Generalized Anxiety Disorder questionnaire, the 12-Item Short Form Health Survey, and wear time of participants categorized into three age groups: Group 1 (ages 50-60), Group 2 (ages 61-69), and Group 3 (ages 70-87). We performed statistical analysis using a mixed-effects repeated measures linear regression model to examine differences amongst age groups. RESULTS Comparative analysis between Groups 1, 2 and 3 revealed no significant differences in anxiety, patient activation, perception of physical health and wear time. The use of smartwatch technology was associated with a decrease in perception of mental health for Group 2 compared to Group 1 (β = -3.29, P = 0.046). CONCLUSION Stroke survivors demonstrated a willingness to use smartwatches for AF monitoring. Importantly, among these study participants, the majority did not experience negative health behavior outcomes or decreased engagement as age increased.
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Affiliation(s)
- Joanne Mathew
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Chan Medical School, Lake Avenue North, Worcester, USA
- Department of Internal Medicine, Central Michigan University, Mount Pleasant, USA
| | - Jordy Mehawej
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Chan Medical School, Lake Avenue North, Worcester, USA
| | - Ziyue Wang
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Chan Medical School, Lake Avenue North, Worcester, USA
| | - Taylor Orwig
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Chan Medical School, Lake Avenue North, Worcester, USA
| | - Eric Ding
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Chan Medical School, Lake Avenue North, Worcester, USA
| | - Andreas Filippaios
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Chan Medical School, Lake Avenue North, Worcester, USA
| | - Syed Naeem
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Chan Medical School, Lake Avenue North, Worcester, USA
| | - Edith Mensah Otabil
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Chan Medical School, Lake Avenue North, Worcester, USA
| | - Alex Hamel
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Chan Medical School, Lake Avenue North, Worcester, USA
| | - Kamran Noorishirazi
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Chan Medical School, Lake Avenue North, Worcester, USA
| | - Irina Radu
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Chan Medical School, Lake Avenue North, Worcester, USA
| | - Jane Saczynski
- Department of Pharmacy and Health Systems Sciences, School of Pharmacy, Northeastern University, Boston, USA
| | - David D. McManus
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Chan Medical School, Lake Avenue North, Worcester, USA
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Lake Avenue North, Worcester, USA
| | - Khanh-Van Tran
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Chan Medical School, Lake Avenue North, Worcester, USA
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Leung ANW, Bhat A. Use of Anticoagulation for Thromboembolic Prophylaxis in Patients With Atrial High-Rate Episodes on Device Monitoring: A Narrative Review. Am J Cardiol 2024; 211:183-190. [PMID: 37944778 DOI: 10.1016/j.amjcard.2023.11.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 10/21/2023] [Accepted: 11/01/2023] [Indexed: 11/12/2023]
Abstract
Ischemic stroke and systemic thromboembolism are primary drivers of significant morbidity and mortality in patients with atrial fibrillation (AF). Although stroke is commonly the first index presentation of clinically silent AF, the growing use of continuous rhythm monitoring through cardiac implanted electronic devices has enabled earlier and increased detection of AF in patients who are otherwise asymptomatic before stroke development. Atrial high-rate episodes (AHREs) are atrial tachyarrhythmias frequently detected by cardiac implanted electronic devices; these events represent subclinical AF and other atrial tachyarrhythmias that can lead to stroke development and AF. Although the presence of AHREs increases the risk of developing both clinical AF and stroke compared with absence of AHREs, there has been a significant clinical variability in anticoagulation initiation in these subjects. In this narrative review, we explore the current evidence and published research surrounding the association between AHREs and stroke development in addition to the utility of anticoagulation in this population for thromboembolic prophylaxis.
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Affiliation(s)
- Alice Ngar Wing Leung
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales, Australia; School of Medicine, Western Sydney University, Sydney, New South Wales, Australia
| | - Aditya Bhat
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales, Australia; School of Medicine, Western Sydney University, Sydney, New South Wales, Australia; School of Public Health and Community Medicine, University of New South Wales, Sydney, New South Wales, Australia.
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Spartalis M, Kontogiannis C, Spartalis E, Iliopoulos DC, Siasos G. Anticoagulation in Patients with Atrial High-rate Episodes Detected by Cardiac Implantable Electronic Devices. Curr Pharm Des 2024; 30:485-488. [PMID: 38343055 DOI: 10.2174/0113816128291822240131063712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Accepted: 01/22/2024] [Indexed: 05/18/2024]
Abstract
Atrial high-rate episodes (AHRE) are atrial tachyarrhythmias that are identified by the use of continuous rhythm monitoring devices such as pacemakers, defibrillators, or implantable cardiac monitors. Nevertheless, the therapeutic implications of these rhythm disturbances remain uncertain. The presence of AHRE is associated with an increased risk of stroke as compared to patients who do not exhibit AHRE. The utilisation of oral anticoagulation has the ability to mitigate the likelihood of stroke occurrence in patients with AHRE. However, it is important to note that this treatment approach is also linked to a severe bleeding rate of approximately 2% per year. The stroke rate among individuals diagnosed with AHRE appears to be comparatively lower when compared to patients diagnosed with atrial fibrillation. The efficacy and safety of anticoagulation in patients with AHRE have yet to be definitively established. Further research is required to provide a comprehensive understanding of the effectiveness and safety of oral anticoagulation in individuals with AHRE.
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Affiliation(s)
- Michael Spartalis
- 3rd Department of Cardiology, Sotiria Thoracic Diseases General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Christos Kontogiannis
- Department of Clinical Therapeutics, Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Eleftherios Spartalis
- Laboratory of Experimental Surgery and Surgical Research 'N.S. Christeas', Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios C Iliopoulos
- Laboratory of Experimental Surgery and Surgical Research 'N.S. Christeas', Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Gerasimos Siasos
- 3 rd Department of Cardiology, Sotiria Thoracic Diseases General Hospital, National and Kapodistrian University of Athens, Athens, Greece
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Lip GYH, Proietti M, Potpara T, Mansour M, Savelieva I, Tse HF, Goette A, Camm AJ, Blomstrom-Lundqvist C, Gupta D, Boriani G. Atrial fibrillation and stroke prevention: 25 years of research at EP Europace journal. Europace 2023; 25:euad226. [PMID: 37622590 PMCID: PMC10451006 DOI: 10.1093/europace/euad226] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 07/17/2023] [Indexed: 08/26/2023] Open
Abstract
Stroke prevention in patients with atrial fibrillation (AF) is one pillar of the management of this common arrhythmia. Substantial advances in the epidemiology and associated pathophysiology underlying AF-related stroke and thrombo-embolism are evident. Furthermore, the introduction of the non-vitamin K antagonist oral anticoagulants (also called direct oral anticoagulants) has clearly changed our approach to stroke prevention in AF, such that the default should be to offer oral anticoagulation for stroke prevention, unless the patient is at low risk. A strategy of early rhythm control is also beneficial in reducing strokes in selected patients with recent onset AF, when compared to rate control. Cardiovascular risk factor management, with optimization of comorbidities and attention to lifestyle factors, and the patient's psychological morbidity are also essential. Finally, in selected patients with absolute contraindications to long-term oral anticoagulation, left atrial appendage occlusion or exclusion may be considered. The aim of this state-of-the-art review article is to provide an overview of the current status of AF-related stroke and prevention strategies. A holistic or integrated care approach to AF management is recommended to minimize the risk of stroke in patients with AF, based on the evidence-based Atrial fibrillation Better Care (ABC) pathway, as follows: A: Avoid stroke with Anticoagulation; B: Better patient-centred, symptom-directed decisions on rate or rhythm control; C: Cardiovascular risk factor and comorbidity optimization, including lifestyle changes.
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Affiliation(s)
- Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Marco Proietti
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy
| | - Tatjana Potpara
- School of Medicine, Belgrade University, Belgrade, Serbia
- Cardiology Clinic, University Clinical Centre of Serbia, Belgrade, Serbia
| | | | - Irina Savelieva
- Clinical Academic Group, Molecular and Clinical Sciences Institute, St. George’s University of London, Cranmer Terrace London SW17 0RE, UK
| | - Hung Fat Tse
- Cardiology Division, Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, University of Hong Kong, Hong Kong, China
| | - Andreas Goette
- Medizinische Klinik II: Kardiologie und Intensivmedizin, St. Vincenz-Krankenhaus Paderborn, Am Busdorf 2, 33098 Paderborn, Germany
| | - A John Camm
- Clinical Academic Group, Molecular and Clinical Sciences Institute, St. George’s University of London, Cranmer Terrace London SW17 0RE, UK
| | - Carina Blomstrom-Lundqvist
- Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Cardiology, Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, via del Pozzo 71, 41125 Modena, Italy
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7
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Boriani G, Auricchio A, Botto GL, Joseph JM, Roberts GJ, Grammatico A, Nabutovsky Y, Piccini JP. Insertable cardiac monitoring results in higher rates of atrial fibrillation diagnosis and oral anticoagulation prescription after ischaemic stroke. Europace 2023; 25:euad212. [PMID: 37490349 PMCID: PMC10403249 DOI: 10.1093/europace/euad212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 06/20/2023] [Indexed: 07/27/2023] Open
Abstract
AIMS After an ischaemic stroke, atrial fibrillation (AF) detection allows for improved secondary prevention strategies. This study aimed to compare AF detection and oral anticoagulant (OAC) initiation in patients with an insertable cardiac monitor (ICM) vs. external cardiac monitor (ECM) after ischaemic stroke. METHODS AND RESULTS Medicare Fee-for-Service (FFS) insurance claims and Abbott Labs device registration data were used to identify patients hospitalized with an ischaemic stroke in 2017-2019 who received an ICM or ECM within 3 months. Patients with continuous Medicare FFS insurance and prescription drug enrolment in the prior year were included. Patients with prior AF, atrial flutter, cardiac devices, or OAC were excluded. Insertable cardiac monitor and ECM patients were propensity score matched 1:4 on demographics, comorbidities, and stroke hospitalization characteristics. The outcomes of interest were AF detection and OAC initiation evaluated with Kaplan-Meier and Cox proportional hazard regression analyses. A total of 5702 Medicare beneficiaries (ICM, n = 444; ECM, n = 5258) met inclusion criteria. The matched cohort consisted of 2210 Medicare beneficiaries (ICM, n = 442; ECM, n = 1768) with 53% female, mean age 75 years, and mean CHA₂DS₂-VASc score 4.6 (1.6). Insertable cardiac monitor use was associated with a higher probability of AF detection [(hazard ratio (HR) 2.88, 95% confidence interval (CI) (2.31, 3.59)] and OAC initiation [HR 2.91, CI (2.28, 3.72)] compared to patients monitored only with ECM. CONCLUSION Patients with an ischaemic stroke monitored with an ICM were almost three times more likely to be diagnosed with AF and to be prescribed OAC compared to patients who received ECM only.
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Affiliation(s)
- Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Via del Pozzo, 71, Modena 41124, Italy
| | - Angelo Auricchio
- Division of Cardiology, Cardiocentro Ticino, Lugano, Switzerland
| | - Giovanni Luca Botto
- Department of Cardiology—Electrophysiology, ASST Rhodense, Civile Hospital Rho and Salvini Hospital Garbagnate Milanese Hospital, Milan, Italy
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Dai Q, Li P, Bose A, Cai P, Jin L, Pan S, Dixon RAF, Laidlaw D, Liu Q. Association of atrial fibrillation burden with in-hospital outcomes in patients with Takotsubo cardiomyopathy. Am J Med Sci 2023; 365:345-352. [PMID: 35793734 DOI: 10.1016/j.amjms.2022.06.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 04/15/2022] [Accepted: 06/28/2022] [Indexed: 01/03/2023]
Abstract
BACKGROUND The effects of atrial fibrillation (AF) and its burden on in-hospital mortality in patients with Takotsubo cardiomyopathy (TCM) are unclear. Here, we examined the effect of AF and paroxysmal AF on in-hospital outcomes in patients with TCM. METHODS We used ICD-10 codes to retrospectively identify patients with a primary diagnosis of TCM in the National Inpatient Sample database 2016-2018. We compared in-hospital outcomes in TCM patients with and without AF before and after propensity score matching. The effect of AF burden on outcomes was assessed in patients with paroxysmal AF and no AF. RESULTS Of the 4,733 patients with a primary diagnosis of TCM, 650 (13.7%) had AF, and 4,083 (86.3%) did not. Of TCM patients with AF, 368 (56.6%) had paroxysmal AF. In-hospital mortality was higher in patients with AF before (3.4% vs 1.2%, P < 0.001) and after propensity matching (3.4% vs 1.7%, P = 0.021) but did not differ between the paroxysmal AF and the no AF groups (P = 0.205). In the matched cohorts, both AF and paroxysmal AF groups were associated with a higher rate of cardiogenic shock (AF, P < 0.001; paroxysmal AF, P < 0.001), ventricular arrhythmia (AF, P = 0.002; paroxysmal AF, P = 0.02), acute kidney injury (AF, P = 0.007; paroxysmal AF, P = 0.008), and acute respiratory failure (AF, P < 0.001; paroxysmal AF, P < 0.001) compared with the no AF group. CONCLUSIONS Although AF was associated with increased in-hospital mortality, paroxysmal AF did not affect in-hospital mortality, suggesting a higher AF burden is associated with worse clinical outcome in patients with TCM.
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Affiliation(s)
- Qiying Dai
- Division of Cardiology, Saint Vincent Hospital, Worcester, MA, USA.
| | - Pengyang Li
- Division of Cardiology, Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Abhishek Bose
- Division of Cardiology, Saint Vincent Hospital, Worcester, MA, USA
| | - Peng Cai
- Department of Mathematical Sciences, Worcester Polytechnic Institute, Worcester, MA, USA
| | - Ling Jin
- Department of Medicine, Metrowest Medical Center, Framingham, MA, USA
| | - Su Pan
- Molecular Cardiology Research, Texas Heart Institute, Houston, TX, USA
| | - Richard A F Dixon
- Molecular Cardiology Research, Texas Heart Institute, Houston, TX, USA
| | - Douglas Laidlaw
- Division of Cardiology, Saint Vincent Hospital, Worcester, MA, USA
| | - Qi Liu
- Molecular Cardiology Research, Texas Heart Institute, Houston, TX, USA
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Kalarus Z, Mairesse GH, Sokal A, Boriani G, Średniawa B, Casado-Arroyo R, Wachter R, Frommeyer G, Traykov V, Dagres N, Lip GYH. Searching for atrial fibrillation: looking harder, looking longer, and in increasingly sophisticated ways. An EHRA position paper. Europace 2023; 25:185-198. [PMID: 36256580 PMCID: PMC10112840 DOI: 10.1093/europace/euac144] [Citation(s) in RCA: 37] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- Zbigniew Kalarus
- Department of Cardiology, DMS in Zabrze, Medical University of Silesia, Katowice, Poland
- Department of Cardiology, Silesian Center for Heart Diseases, Zabrze, Poland
| | - Georges H Mairesse
- Department of Cardiology and Electrophysiology, Cliniques du Sud Luxembourg—Vivalia, Arlon, Belgium
| | - Adam Sokal
- Department of Cardiology, Silesian Center for Heart Diseases, Zabrze, Poland
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Beata Średniawa
- Department of Cardiology, DMS in Zabrze, Medical University of Silesia, Katowice, Poland
- Department of Cardiology, Silesian Center for Heart Diseases, Zabrze, Poland
| | | | - Rolf Wachter
- Clinic and Policlinic for Cardiology, University Hospital Leipzig, Leipzig, Germany
| | - Gerrit Frommeyer
- Department of Cardiology II (Electrophysiology), University Hospital Münster, Münster, Germany
| | - Vassil Traykov
- Department of Invasive Electrophysiology and Cardiac Pacing, Acibadem City Clinic Tokuda Hospital, Sofia, Bulgaria
| | - Nikolaos Dagres
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, UK
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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10
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Hennings E, Coslovsky M, Paladini RE, Aeschbacher S, Knecht S, Schlageter V, Krisai P, Badertscher P, Sticherling C, Osswald S, Kühne M, Zuern CS. Assessment of the atrial fibrillation burden in Holter ECG recordings using artificial intelligence. CARDIOVASCULAR DIGITAL HEALTH JOURNAL 2023; 4:41-47. [PMID: 37101946 PMCID: PMC10123500 DOI: 10.1016/j.cvdhj.2023.01.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Background Emerging evidence indicates that a high atrial fibrillation (AF) burden is associated with adverse outcome. However, AF burden is not routinely measured in clinical practice. An artificial intelligence (AI)-based tool could facilitate the assessment of AF burden. Objective We aimed to compare the assessment of AF burden performed manually by physicians with that measured by an AI-based tool. Methods We analyzed 7-day Holter electrocardiogram (ECG) recordings of AF patients included in the prospective, multicenter Swiss-AF Burden cohort study. AF burden was defined as percentage of time in AF, and was assessed manually by physicians and by an AI-based tool (Cardiomatics, Cracow, Poland). We evaluated the agreement between both techniques by means of Pearson correlation coefficient, linear regression model, and Bland-Altman plot. Results We assessed the AF burden in 100 Holter ECG recordings of 82 patients. We identified 53 Holter ECGs with 0% or 100% AF burden, where we found a 100% correlation. For the remaining 47 Holter ECGs with an AF burden between 0.01% and 81.53%, Pearson correlation coefficient was 0.998. The calibration intercept was -0.001 (95% CI -0.008; 0.006), and the calibration slope was 0.975 (95% CI 0.954; 0.995; multiple R2 0.995, residual standard error 0.017). Bland-Altman analysis resulted in a bias of -0.006 (95% limits of agreement -0.042 to 0.030). Conclusion The assessment of AF burden with an AI-based tool provided very similar results compared to manual assessment. An AI-based tool may therefore be an accurate and efficient option for the assessment of AF burden.
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11
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Schwab AC, Anic A, Farkowski MM, Guerra J, Iliodromitis KE, Jubele K, Providencia R, Chun JKR, Boveda S. Rhythm monitoring, success definition, recurrence, and anticoagulation after atrial fibrillation ablation: results from an EHRA survey. Europace 2022; 25:676-681. [PMID: 36372986 PMCID: PMC9934999 DOI: 10.1093/europace/euac194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 10/05/2022] [Indexed: 11/15/2022] Open
Abstract
Atrial fibrillation (AF) is a major challenge for the healthcare field. Pulmonary vein isolation is the most effective treatment for the maintenance of sinus rhythm. However, clinical endpoints for the procedure vary significantly among studies. There is no consensus on the definition of recurrence and no clear roadmap on how to deal with recurrences after a failed ablation. The purpose of this study was to perform a survey in order to show how clinicians currently approach this knowledge gap. An online survey, supported by the European Heart Rhythm Association (EHRA) Scientific Initiatives Committee, was conducted between 1 April 2022 and 8 May 2022. An anonymous questionnaire was disseminated via social media and EHRA newsletters, for clinicians to complete. This consisted of 18 multiple-choice questions regarding rhythm monitoring, definitions of a successful ablation, clinical practices after a failed AF ablation, and the continuance of anticoagulation. A total of 107 replies were collected across Europe. Most respondents (82%) perform routine monitoring for AF recurrences after ablation, with 51% of them preferring a long-term monitoring strategy. Cost was reported to have an impact on the choice of monitoring strategy. Self-screening was recommended by most (71%) of the respondents. The combination of absence of symptoms and recorded AF was the definition of success for most (83%) of the respondents. Cessation of anticoagulation after ablation was an option mostly for patients with paroxysmal AF and a low CHA2DS2-VASc score. The majority of physicians perform routine monitoring after AF ablation. For most physicians, the combination of the absence of symptoms and electrocardiographic endpoints defines a successful result after AF ablation.
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Affiliation(s)
| | - Ante Anic
- Department for Cardiovascular Diseases, University Hospital Center Split, Split, Croatia
| | - Michal M Farkowski
- II Department of Heart Arrhythmia, National Institute of Cardiology, Alpejska 42, 04-628 Warsaw, Poland
| | - Jose Guerra
- Department of Cardiology, Hospital de la Santa Creu I Sant Pau, IIB SANT PAU, CIBERCV, Universitat Autonòma de Barcelona, Barcelona, Spain
| | | | - Kristine Jubele
- Arrhythmia Department, P. Stradins Clinical University Hospital, Riga, Latvia,Arrhythmia Department, Riga Stradins University Riga, Latvia
| | - Rui Providencia
- St Bartholomew’s Hospital, Barts Heart Centre, Barts Health NHS Trust, London, UK,Institute of Health Informatics, University College of London, London, UK
| | - Julian K R Chun
- CCB, Cardiology, Med. Klinik III, Markuskrankenhaus Frankfurt, Germany
| | - Serge Boveda
- Heart Rhythm Department, Clinique Pasteur, 31076 Toulouse, France,Universitair Ziekenhuis Brussel - VUB, Heart Rhythm Management Centre, Brussels, Belgium,Paris Cardiovascular Research Center, INSERM U970, 75908 Paris Cedex 15, France
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Campo D, Elie V, de Gallard T, Bartet P, Morichau-Beauchant T, Genain N, Fayol A, Fouassier D, Pasteur-Rousseau A, Puymirat E, Nahum J. Atrial Fibrillation Detection With an Analog Smartwatch: Prospective Clinical Study and Algorithm Validation. JMIR Form Res 2022; 6:e37280. [PMID: 35481559 PMCID: PMC9675016 DOI: 10.2196/37280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 04/26/2022] [Accepted: 04/28/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Atrial fibrillation affects approximately 4% of the world's population and is one of the major causes of stroke, heart failure, sudden death, and cardiovascular morbidity. It can be difficult to diagnose when asymptomatic or in the paroxysmal stage, and its natural history is not well understood. New wearables and connected devices offer an opportunity to improve on this situation. OBJECTIVE We aimed to validate an algorithm for the automatic detection of atrial fibrillation from a single-lead electrocardiogram taken with a smartwatch. METHODS Eligible patients were recruited from 4 sites in Paris, France. Electrocardiograms (12-lead reference and single lead) were captured simultaneously. The electrocardiograms were reviewed by independent, blinded board-certified cardiologists. The sensitivity and specificity of the algorithm to detect atrial fibrillation and normal sinus rhythm were calculated. The quality of single-lead electrocardiograms (visibility and polarity of waves, interval durations, heart rate) was assessed in comparison with the gold standard (12-lead electrocardiogram). RESULTS A total of 262 patients (atrial fibrillation: n=100, age: mean 74.3 years, SD 12.3; normal sinus rhythm: n=113, age: 61.8 years, SD 14.3; other arrhythmia: n=45, 66.9 years, SD 15.2; unreadable electrocardiograms: n=4) were included in the final analysis; 6.9% (18/262) were classified as Noise by the algorithm. Excluding other arrhythmias and Noise, the sensitivity for atrial fibrillation detection was 0.963 (95% CI lower bound 0.894), and the specificity was 1.000 (95% CI lower bound 0.967). Visibility and polarity accuracies were similar (1-lead electrocardiogram: P waves: 96.9%, QRS complexes: 99.2%, T waves: 91.2%; 12-lead electrocardiogram: P waves: 100%, QRS complexes: 98.8%, T waves: 99.5%). P-wave visibility accuracy was 99% (99/100) for patients with atrial fibrillation and 95.7% (155/162) for patients with normal sinus rhythm, other arrhythmias, and unreadable electrocardiograms. The absolute values of the mean differences in PR duration and QRS width were <3 ms, and more than 97% were <40 ms. The mean difference between the heart rates from the 1-lead electrocardiogram calculated by the algorithm and those calculated by cardiologists was 0.55 bpm. CONCLUSIONS The algorithm demonstrated great diagnostic performance for atrial fibrillation detection. The smartwatch's single-lead electrocardiogram also demonstrated good quality for physician use in daily routine care. TRIAL REGISTRATION ClinicalTrials.gov NCT04351386; http://clinicaltrials.gov/ct2/show/NCT04351386.
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Affiliation(s)
| | | | | | | | | | | | - Antoine Fayol
- Cardiology Intensive Care Unit, Hopital Europeen Georges Pompidou, Paris, France
| | | | | | - Etienne Puymirat
- Cardiology Intensive Care Unit, Hopital Europeen Georges Pompidou, Paris, France
| | - Julien Nahum
- Intensive Care Unit, Centre Cardiologique du Nord, Sainte-Denis, France
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Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia despite substantial efforts to understand the pathophysiology of the condition and develop improved treatments. Identifying the underlying causative mechanisms of AF in individual patients is difficult and the efficacy of current therapies is suboptimal. Consequently, the incidence of AF is steadily rising and there is a pressing need for novel therapies. Research has revealed that defects in specific molecular pathways underlie AF pathogenesis, resulting in electrical conduction disorders that drive AF. The severity of this so-called electropathology correlates with the stage of AF disease progression and determines the response to AF treatment. Therefore, unravelling the molecular mechanisms underlying electropathology is expected to fuel the development of innovative personalized diagnostic tools and mechanism-based therapies. Moreover, the co-creation of AF studies with patients to implement novel diagnostic tools and therapies is a prerequisite for successful personalized AF management. Currently, various treatment modalities targeting AF-related electropathology, including lifestyle changes, pharmaceutical and nutraceutical therapy, substrate-based ablative therapy, and neuromodulation, are available to maintain sinus rhythm and might offer a novel holistic strategy to treat AF.
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Affiliation(s)
- Bianca J J M Brundel
- Department of Physiology, Amsterdam University Medical Centers, VU Universiteit, Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands.
| | - Xun Ai
- Department of Physiology and Cell Biology, College of Medicine/Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | | | - Myrthe F Kuipers
- AFIPonline.org, Atrial Fibrillation Innovation Platform, Amsterdam, Netherlands
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Vitolo M, Imberti JF, Proietti M, Lip GYH, Boriani G. Atrial high rate episodes as a marker of atrial cardiomyopathy: In the quest of the Holy Grail. Author's reply. Eur J Intern Med 2022; 98:115-116. [PMID: 35074244 DOI: 10.1016/j.ejim.2022.01.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 01/19/2022] [Indexed: 12/13/2022]
Affiliation(s)
- Marco Vitolo
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy; Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy; Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Jacopo F Imberti
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy; Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy; Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Marco Proietti
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy; Geriatric Unit, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy.
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15
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Cao M, Guo H, Zhao X, Li X, Sun C. Refinement of CHADS2 and CHA2DS2-VASc scores predict left atrial thrombus or spontaneous echo contrast in nonvalvular atrial fibrillation patients. J Int Med Res 2022; 50:3000605221074520. [PMID: 35196885 PMCID: PMC8883313 DOI: 10.1177/03000605221074520] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Objective To investigate the risk factors of left atrial thrombus (LAT)/spontaneous echo contrast (SEC) in patients with nonvalvular atrial fibrillation (AF). Methods This retrospective study analysed the data from consecutive patients with nonvalvular AF that underwent transoesophageal echocardiography. Logistic regression analysis was performed to identify risk factors of LAT/SEC. Receiver operating characteristic curve analysis was undertaken compare the new scales with CHADS2 and CHA2DS2-VASc scores. Results A total of 558 patients with AF were included in the study. LAT/SEC was detected in 137 (24.6%) patients. The independent risk factors of LAT/SEC beyond CHADS2 or CHA2DS2-VASc scores included non-paroxysmal AF and left atrial diameter >37.5 mm. These two variables were added into the CHADS2 or CHA2DS2-VASc score to build new scales. Areas under the curve for the new scales based on CHADS2 and CHA2DS2-VASc scores were significantly higher than the CHADS2 or CHA2DS2-VASc score both in the overall study cohort and in patients at a high risk of thromboembolism. Conclusions Non-paroxysmal AF and increased left atrial diameter beyond the CHADS2 or CHA2DS2-VASc score were independent risk factors of LAT/SEC and may help to improve the current risk stratification, especially for patients with nonvalvular AF at a high risk of thromboembolism.
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Affiliation(s)
- Miaomiao Cao
- Department of Cardiovascular Medicine, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
| | - Huihui Guo
- Department of Cardiovascular Medicine, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
| | - Xiao Zhao
- Department of Cardiovascular Medicine, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
| | - Xiyang Li
- Department of Cardiovascular Medicine, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
| | - Chaofeng Sun
- Department of Cardiovascular Medicine, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
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16
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Vitolo M, Imberti JF, Maisano A, Albini A, Bonini N, Valenti AC, Malavasi VL, Proietti M, Healey JS, Lip GY, Boriani G. Device-detected atrial high rate episodes and the risk of stroke/thrombo-embolism and atrial fibrillation incidence: a systematic review and meta-analysis. Eur J Intern Med 2021; 92:100-106. [PMID: 34154879 DOI: 10.1016/j.ejim.2021.05.038] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 05/18/2021] [Accepted: 05/26/2021] [Indexed: 01/09/2023]
Abstract
BACKGROUND Atrial High Rate Episodes (AHRE) are asymptomatic atrial tachy-arrhythmias detected through continuous monitoring with a cardiac implantable electronic device. The risks of stroke/Thromboembolic (TE) events and incident clinical Atrial Fibrillation (AF) associated with AHRE varies markedly. OBJECTIVES To assess the relationship between AHRE and TE events, and between AHRE and incident clinical AF. METHODS This systematic review and meta-analysis was conducted following the PRISMA recommendations. PubMed, Scopus, and Google Scholar were searched from inception to 18/02/2021 for studies reporting TE events and incident clinical AF in patients with AHRE, as compared with patients without. RESULTS Ten out of 8081 records fulfilled the inclusion criteria, for a total of 37 266 patients. Seven out of ten studies excluded patients with prior history of clinical AF (4961 patients), embracing the most recent definition of AHRE. The risk ratio (RR) for TE events in AHRE patients was 2.13 (95% CI: 1.53-2.95, I2: 0%). The incidence of clinical AF was reported in four studies excluding patients with a history of clinical AF (3574 patients). The RR for incident clinical AF was 3.34 (95%CI: 1.89-5.90, I2: 73%). CONCLUSIONS AHRE are significantly associated with systemic thromboembolism and incident clinical AF. Further studies are needed to improve patients' risk stratification and management.
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Affiliation(s)
- Marco Vitolo
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy.; Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy; Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Jacopo F Imberti
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy.; Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Anna Maisano
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Alessandro Albini
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Niccolò Bonini
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Anna Chiara Valenti
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Vincenzo L Malavasi
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Marco Proietti
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy; Geriatric Unit, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy
| | - Jeff S Healey
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Gregory Yh Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy..
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Li RJ, Caughey GE, Shakib S. Appropriateness of inpatient dosing of direct oral anticoagulants for atrial fibrillation. J Thromb Thrombolysis 2021; 53:425-435. [PMID: 34302286 DOI: 10.1007/s11239-021-02528-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/14/2021] [Indexed: 12/22/2022]
Abstract
Direct oral anticoagulant (DOAC) use for stroke prevention in atrial fibrillation (AF) has dose reduction criteria including age, weight, serum creatinine, and creatinine clearance. There is a paucity of data for rates of inappropriate inpatient DOAC dosing in Australia. The objective was to determine the rates of inappropriate inpatient DOAC dosing in AF and identifying its associated underlying factors. We conducted a retrospective cross-sectional study from December 2013 to November 2019 across six South Australian public hospitals utilising a centralised electronic health record. Multivariate analysis was used to identify factors associated with underdosing of patients prescribed apixaban. Of 1882 inpatients, 544 (28.9 %) were inappropriately dosed. Underdosing was the most common form of inappropriate dosing with rates of 22.9 % (n = 295), 7.1 % (n = 7), and 25.1 % (n = 124) for apixaban, dabigatran, and rivaroxaban, respectively. Independent factors predictive of apixaban underdosing included higher age (adjusted odds ratio (aOR) 1.63 [95 % Confidence Interval (CI): 1.47-1.81]), higher serum creatinine (aOR 1.13 [95 % CI: 1.08-1.19]), higher total number of drugs on discharge (aOR 1.08 [95 % CI: 1.04-1.11]), and being already prescribed a DOAC on admission (aOR 1.63 [95 % CI: 1.12-2.38]). Nearly one quarter of all apixaban prescribing was inappropriately underdosed. Older patients with multimorbidity, frailty and polypharmacy present a challenge for clinicians in balancing risks of thromboembolism and bleeding. It is likely prescribers are more conservative in their apixaban dosing in this population. Clinicians should consider alternative drug regimens to avoid DOAC use at inappropriate doses at unknown safety and efficacy.
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Affiliation(s)
- Ray J Li
- Department of Clinical Pharmacology, Royal Adelaide Hospital, Adelaide, 5000, Australia.
- Discipline of Pharmacology, Adelaide Medical School, The University of Adelaide, 5000, Adelaide, Australia.
| | - Gillian E Caughey
- Department of Clinical Pharmacology, Royal Adelaide Hospital, Adelaide, 5000, Australia
- Discipline of Pharmacology, Adelaide Medical School, The University of Adelaide, 5000, Adelaide, Australia
- Registry of Senior Australians, South Australian Health and Medical Research Institute, Adelaide, 5000, Australia
- Division of Health Sciences, University of South Australia, 5000, Adelaide, Australia
| | - Sepehr Shakib
- Department of Clinical Pharmacology, Royal Adelaide Hospital, Adelaide, 5000, Australia
- Discipline of Pharmacology, Adelaide Medical School, The University of Adelaide, 5000, Adelaide, Australia
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Botto GL, Tortora G, Casale MC, Canevese FL, Brasca FAM. Impact of the Pattern of Atrial Fibrillation on Stroke Risk and Mortality. Arrhythm Electrophysiol Rev 2021; 10:68-76. [PMID: 34401178 PMCID: PMC8335885 DOI: 10.15420/aer.2021.01] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 03/15/2021] [Indexed: 12/22/2022] Open
Abstract
Thromboembolism is the most serious complication of AF, and oral anticoagulation is the mainstay therapy. Current guidelines place all AF types together in terms of anticoagulation with the major determinants being associated comorbidities translated into risk marker. Among patients in large clinical trials, those with non-paroxysmal AF appear to be at higher risk of stroke than those with paroxysmal AF. Higher complexity of the AF pattern is also associated with higher risk of mortality. Moreover, continuous monitoring of AF through cardiac implantable devices provided us with the concept of 'AF burden'. Usually, the larger the AF burden, the higher the risk of stroke; however, the relationship is not well characterised with respect to the threshold value above which the risk increases. The picture is more complex than it appears: AF and underlying disorders must act synergically respecting the magnitude of its own characteristics, which are the amount of time a patient stays in AF and the severity of associated comorbidities.
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Affiliation(s)
- Giovanni Luca Botto
- Department of Cardiology - Electrophysiology, ASST Rhodense, Civile Hospital Rho and Salvini Hospital Garbagnate Milanese Hospital, Milan, Italy
| | - Giovanni Tortora
- Department of Cardiology - Electrophysiology, ASST Rhodense, Civile Hospital Rho and Salvini Hospital Garbagnate Milanese Hospital, Milan, Italy
| | - Maria Carla Casale
- Department of Cardiology - Electrophysiology, ASST Rhodense, Civile Hospital Rho and Salvini Hospital Garbagnate Milanese Hospital, Milan, Italy
| | - Fabio Lorenzo Canevese
- Department of Cardiology - Electrophysiology, ASST Rhodense, Civile Hospital Rho and Salvini Hospital Garbagnate Milanese Hospital, Milan, Italy
| | - Francesco Angelo Maria Brasca
- Department of Cardiology - Electrophysiology, ASST Rhodense, Civile Hospital Rho and Salvini Hospital Garbagnate Milanese Hospital, Milan, Italy
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Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, Boriani G, Castella M, Dan GA, Dilaveris PE, Fauchier L, Filippatos G, Kalman JM, Meir ML, Lane DA, Lebeau JP, Lettino M, Lip GY, Pinto FJ, Neil Thomas G, Valgimigli M, Van Gelder IC, Van Putte BP, Watkins CL. Guía ESC 2020 sobre el diagnóstico y tratamiento de la fibrilación auricular, desarrollada en colaboración de la European Association of Cardio-Thoracic Surgery (EACTS). Rev Esp Cardiol 2021. [DOI: 10.1016/j.recesp.2020.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Boriani G, Vitolo M, Diemberger I, Proietti M, Valenti AC, Malavasi VL, Lip GYH. Optimizing indices of AF susceptibility and burden to evaluate AF severity, risk and outcomes. Cardiovasc Res 2021; 117:1-21. [PMID: 33913486 PMCID: PMC8707734 DOI: 10.1093/cvr/cvab147] [Citation(s) in RCA: 63] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 03/15/2021] [Accepted: 04/29/2021] [Indexed: 02/06/2023] Open
Abstract
Atrial fibrillation (AF) has heterogeneous patterns of presentation concerning symptoms,
duration of episodes, AF burden, and the tendency to progress towards the terminal step of
permanent AF. AF is associated with a risk of stroke/thromboembolism traditionally
considered dependent on patient-level risk factors rather than AF type, AF burden, or
other characterizations. However, the time spent in AF appears related to an incremental
risk of stroke, as suggested by the higher risk of stroke in patients with clinical AF vs.
subclinical episodes and in patients with non-paroxysmal AF vs. paroxysmal AF. In patients
with device-detected atrial tachyarrhythmias, AF burden is a dynamic process with
potential transitions from a lower to a higher maximum daily arrhythmia burden, thus
justifying monitoring its temporal evolution. In clinical terms, the appearance of the
first episode of AF, the characterization of the arrhythmia in a specific AF type, the
progression of AF, and the response to rhythm control therapies, as well as the clinical
outcomes, are all conditioned by underlying heart disease, risk factors, and
comorbidities. Improved understanding is needed on how to monitor and modulate the effect
of factors that condition AF susceptibility and modulate AF-associated outcomes. The
increasing use of wearables and apps in practice and clinical research may be useful to
predict and quantify AF burden and assess AF susceptibility at the individual patient
level. This may help us reveal why AF stops and starts again, or why AF episodes, or
burden, cluster. Additionally, whether the distribution of burden is associated with
variations in the propensity to thrombosis or other clinical adverse events. Combining the
improved methods for data analysis, clinical and translational science could be the basis
for the early identification of the subset of patients at risk of progressing to a longer
duration/higher burden of AF and the associated adverse outcomes.
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Affiliation(s)
- Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Marco Vitolo
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy.,Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom.,Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Igor Diemberger
- Department of Experimental, Diagnostic and Specialty Medicine, Institute of Cardiology, University of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy
| | - Marco Proietti
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.,Geriatric Unit, IRCCS Istituti Clinico Scientifici Maugeri, Milan, Italy
| | - Anna Chiara Valenti
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Vincenzo Livio Malavasi
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Ooi PC, Ramayah G, Omar SR, Rajadorai V, Nadarajah T, Ting CH, Teng CL. Knowledge, attitude, and practice regarding atrial fibrillation among primary care physicians: the potential role of postgraduate training. MALAYSIAN FAMILY PHYSICIAN : THE OFFICIAL JOURNAL OF THE ACADEMY OF FAMILY PHYSICIANS OF MALAYSIA 2021; 16:39-49. [PMID: 33948141 PMCID: PMC8088736 DOI: 10.51866/oa0002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
INTRODUCTION Atrial fibrillation (AF) is known to lead to stroke and thromboembolism, causing a five-fold increase in the risk of stroke and almost doubling the mortality rate. Optimal anticoagulant therapy is effective in reducing AF-related death. However, prescription of anticoagulants in AF in East Asian countries has been low, ranging from 0.5% to 28%. This study aimed to determine whether vocational training in family medicine improves primary care physicians' knowledge, attitude, and practice in the management of AF. METHOD This investigation was a cross-sectional study carried out during centralized workshops for two groups of trainees using a validated questionnaire: (i) junior trainees were newly enrolled postgraduate trainees in the Graduate Certificate in Family Medicine (GCFM) program, and (ii) senior trainees were postgraduate trainees in Advance Training in Family Medicine (ATFM) programs of the Academy of Family Physicians of Malaysia (AFPM). RESULTS A total of 223 trainees (127 junior and 96 senior) participated in this study. Only 55.2% of the trainees passed the knowledge test; senior trainees were more likely to pass the knowledge test compared to junior trainees (69.8% vs. 44.1%, p < 0.001). Female trainees were significantly more likely to pass the knowledge test than male trainees. While the attitude of senior and junior trainees was similar, more of the latter group worked in public clinic that provide better support where there is better support for outpatient anticoagulation treatment (e.g., same-day INR test, direct access echocardiogram, and warfarin in in-house pharmacy). CONCLUSION Vocational training in family medicine appears to improve primary care physicians' knowledge regarding the management of AF. Better knowledge will help vocationally trained primary care physicians to provide anticoagulation treatment for AF within primary care clinics. More optimal AF management within primary care can take place if the identified barriers are addressed and a shared care plan can be implemented.
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Affiliation(s)
- Phaik Choo Ooi
- MBBS (UM), MAFP/FRACGP, Community Based Department Universiti Kuala Lumpur, Royal College of Medicine Perak, Ipoh, Perak, Malaysia.
| | | | | | | | | | - Chung Hui Ting
- MD, MAFP/FRACGP, Gunung Rapat Health Clinic, Ipoh, Perak, Malaysia
| | - Cheong Lieng Teng
- MFamMed (UM), FRACGP, FAMM. Professor, Department of Family Medicine, International Medical University, Seremban Campus, Seremban, Negeri Sembilan, Malaysia
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Boriani G, Imberti JF, Vitolo M. The challenge to improve knowledge on the interplay between subclinical atrial fibrillation, atrial cardiomyopathy, and atrial remodeling. J Cardiovasc Electrophysiol 2021; 32:1364-1366. [PMID: 33694284 DOI: 10.1111/jce.14992] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 03/03/2021] [Indexed: 01/13/2023]
Affiliation(s)
- Giuseppe Boriani
- Division of Cardiology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Jacopo F Imberti
- Division of Cardiology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Marco Vitolo
- Division of Cardiology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy.,Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
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23
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Boriani G, Palmisano P, Malavasi VL, Fantecchi E, Vitolo M, Bonini N, Imberti JF, Valenti AC, Schnabel RB, Freedman B. Clinical Factors Associated with Atrial Fibrillation Detection on Single-Time Point Screening Using a Hand-Held Single-Lead ECG Device. J Clin Med 2021; 10:729. [PMID: 33673209 PMCID: PMC7917757 DOI: 10.3390/jcm10040729] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 02/05/2021] [Accepted: 02/08/2021] [Indexed: 02/07/2023] Open
Abstract
Our aim was to assess the prevalence of unknown atrial fibrillation (AF) among adults during single-time point rhythm screening performed during meetings or social recreational activities organized by patient groups or volunteers. A total of 2814 subjects (median age 68 years) underwent AF screening by a handheld single-lead ECG device (MyDiagnostick). Overall, 56 subjects (2.0%) were diagnosed with AF, as a result of 12-lead ECG following a positive/suspected recording. Screening identified AF in 2.9% of the subjects ≥ 65 years. None of the 265 subjects aged below 50 years was found positive at AF screening. Risk stratification for unknown AF based on a CHA2DS2VASc > 0 in males and >1 in females (or CHA2DS2VA > 0) had a high sensitivity (98.2%) and a high negative predictive value (99.8%) for AF detection. A slightly lower sensitivity (96.4%) was achieved by using age ≥ 65 years as a risk stratifier. Conversely, raising the threshold at ≥75 years showed a low sensitivity. Within the subset of subjects aged ≥ 65 a CHA2DS2VASc > 1 in males and >2 in females, or a CHA2DS2VA > 1 had a high sensitivity (94.4%) and negative predictive value (99.3%), while age ≥ 75 was associated with a marked drop in sensitivity for AF detection.
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Affiliation(s)
- Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, 41125 Modena, Italy; (V.L.M.); (E.F.); (M.V.); (N.B.); (J.F.I.); (A.C.V.)
| | - Pietro Palmisano
- Cardiology Unit, “Card. G. Panico” Hospital, 73039 Tricase, Italy;
| | - Vincenzo Livio Malavasi
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, 41125 Modena, Italy; (V.L.M.); (E.F.); (M.V.); (N.B.); (J.F.I.); (A.C.V.)
| | - Elisa Fantecchi
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, 41125 Modena, Italy; (V.L.M.); (E.F.); (M.V.); (N.B.); (J.F.I.); (A.C.V.)
| | - Marco Vitolo
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, 41125 Modena, Italy; (V.L.M.); (E.F.); (M.V.); (N.B.); (J.F.I.); (A.C.V.)
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, 41125 Modena, Italy
| | - Niccolo’ Bonini
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, 41125 Modena, Italy; (V.L.M.); (E.F.); (M.V.); (N.B.); (J.F.I.); (A.C.V.)
| | - Jacopo F. Imberti
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, 41125 Modena, Italy; (V.L.M.); (E.F.); (M.V.); (N.B.); (J.F.I.); (A.C.V.)
| | - Anna Chiara Valenti
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, 41125 Modena, Italy; (V.L.M.); (E.F.); (M.V.); (N.B.); (J.F.I.); (A.C.V.)
| | - Renate B. Schnabel
- German Cardiovascular Research Center (DZHK), Partner Site Hamburg/Kiel/Lübeck, University Heart and Vascular Centre, 20251 Hamburg, Germany;
| | - Ben Freedman
- Heart Research Institute, Charles Perkins Centre, and Concord Hospital Cardiology, University of Sydney, Sydney 2006, Australia;
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Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, Boriani G, Castella M, Dan GA, Dilaveris PE, Fauchier L, Filippatos G, Kalman JM, La Meir M, Lane DA, Lebeau JP, Lettino M, Lip GYH, Pinto FJ, Thomas GN, Valgimigli M, Van Gelder IC, Van Putte BP, Watkins CL. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J 2021; 42:373-498. [PMID: 32860505 DOI: 10.1093/eurheartj/ehaa612] [Citation(s) in RCA: 5463] [Impact Index Per Article: 1821.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Patel UK, Malik P, Patel N, Patel P, Mehta N, Urhoghide E, Aedma S, Chakinala RC, Shah S, Arumaithurai K. Newer Diagnostic and Cost-Effective Ways to Identify Asymptomatic Atrial Fibrillation for the Prevention of Stroke. Cureus 2021; 13:e12437. [PMID: 33552757 PMCID: PMC7854334 DOI: 10.7759/cureus.12437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 01/02/2021] [Indexed: 12/02/2022] Open
Abstract
Atrial fibrillation (Afib) is the most common and underestimated cardiac arrhythmia with a lifetime risk of >35% after the age of 55 years and the risk continues to rise exponentially. Afib leads to stasis of blood within the atria allowing clot formation and increasing the risk for systemic embolization leading to strokes. Outcomes due to Afib can improve significantly with appropriate treatment. Thus, the need for convenient, well-tolerated, cost-effective cardiac monitoring for Afib is needed. The study aims to evaluate the various newer devices and compare them with traditional Holter monitoring, keeping diagnostic yield, cost-effectiveness, and patients' convenience in mind. Though Holter monitoring is simple and non-expensive, it has major limitations including limited recording capacity, inability for real-time recordings, and inconvenience to patients. Zio Patch (iRhythm Technologies, Inc; San Francisco, CA) and other loop recording devices are patient-friendly, inexpensive, and can offer real-time data for longer days. More prospective studies are needed to evaluate the sensitivity, specificity, and the actual number of patients getting benefits from newer devices by diagnosing Afib sooner and start early prevention therapy.
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Affiliation(s)
- Urvish K Patel
- Neurology and Public Health, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Preeti Malik
- Public Health, Icahn School of Medicine at Mount Sinai, New York, USA
- Neurology, Massachusetts General Hospital, Andover, USA
| | - Nidhi Patel
- Medicine, Drexel University College of Medicine, Philadelphia, USA
| | | | - Neev Mehta
- Epidemiology and Biostatistics, Boston University School of Public Health, Boston, USA
| | | | - Surya Aedma
- Internal Medicine, Carle Foundation Hospital, Urbana, USA
| | - Raja Chandra Chakinala
- Medicine, Geisinger Commonwealth School of Medicine, Danville, USA
- Medicine, Guthrie Robert Packer Hospital, Sayre, USA
| | - Shamik Shah
- Neurology, Stormont Vail Health, Topeka, USA
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Henry M, Wosnitza M, Thate-Waschke IM, Bauersachs R, Ueng KC, Chang KC, Wilke T. Country-based Comparison of Atrial Fibrillation Patients' Preferences for Oral Anticoagulation: An Evaluation of Discrete Choice Experiments in Five Different Countries. J Cardiovasc Pharmacol 2021; 77:100-106. [PMID: 33165142 DOI: 10.1097/fjc.0000000000000936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 09/13/2020] [Indexed: 11/26/2022]
Abstract
ABSTRACT The aim of this study was to examine atrial fibrillation (AF) patients' preferences regarding oral anticoagulation (OAC) characteristics and to investigate differences across 5 different countries. A multicenter discrete choice experiment was conducted in Germany, Sweden, Switzerland, Spain, and Taiwan. Study sites enrolled patients with nonvalvular AF who received continuous OAC therapy. The discrete choice experiment design considered the following 4 attributes with 2 attribute levels each: need for bridging (yes/no), interactions with food/alcohol (yes/no), need for regular international normalized ratio (INR) assessments, and frequency of intake (once/twice daily). Generally, patients (n = 1391) preferred treatment alternatives that were characterized by "no need of bridging," "no need for regular INR controls," "no interactions with food/alcohol," and "once daily intake." For this desired treatment regimen, patients were willing to accept a substantially higher travel distance/time. German patients with AF were strongly impacted in their hypothetical treatment decision by the frequency of intake (37.5%). Swedish patients on the other hand gave little importance to intake frequency (12.6%). In Switzerland, patients were especially concerned with food/alcohol interactions of the medication (34.7%), whereas this was the least important attribute for Taiwanese patients (18.9%), who ascribed the most homogenous importance to the different treatment attributes overall. In Spain, the need for regular INR assessments especially impacted the patient's treatment decision (31.9%). Patients of all countries attributed a moderate importance to the need for bridging (25.9%-34.2%). These findings may facilitate country-specific consideration of patients' preferences regarding OAC therapy, potentially increasing treatment acceptance on the patient's side with the ultimate goal of improving treatment adherence and persistence.
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Abstract
Atrial high rate episodes (AHREs) are defined as asymptomatic atrial tachyarrhythmias detected by cardiac implantable electronic devices with atrial sensing, providing automated continuous monitoring and tracings storage, occurring in subjects with no previous clinical atrial fibrillation (AF) and with no AF detected at conventional electrocardiogram recordings. AHREs are associated with an increased thrombo-embolic risk, which is not negligible, although lower than that of clinical AF. The thrombo-embolic risk increases with increasing burden of AHREs, and moreover, AHREs burden shows a dynamic pattern, with tendency to progression along with time, with potential transition to clinical AF. The clinical management of AHREs, in particular with regard to prophylactic treatment with oral anticoagulants (OACs), remains uncertain and heterogeneous. At present, in patients with confirmed AHREs, as a result of device tracing analysis, an integrated, individual and clinically-guided assessment should be applied, taking into account the patients' risk of stroke (to be reassessed regularly) and the AHREs burden. The use of OACs, preferentially non-vitamin K antagonists OACs, may be justified in selected patients, such as those with longer AHREs durations (in the range of several hours or ≥24 h), with no doubts on AF diagnosis after device tracing analysis and with an estimated high/very high individual risk of stroke, accounting for the anticipated net clinical benefit, and informed patient's preferences. Two randomized clinical trials on this topic are currently ongoing and are likely to better define the role of anticoagulant therapy in patients with AHREs.
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Affiliation(s)
- Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Via del Pozzo, 71, 41124 Modena, Italy
| | - Marco Vitolo
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Via del Pozzo, 71, 41124 Modena, Italy
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, William Henry Duncan Building, 6 West Derby Street, Liverpool, L7 8TX, UK
| | - Jacopo Francesco Imberti
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Via del Pozzo, 71, 41124 Modena, Italy
| | - Tatjana S Potpara
- School of Medicine, Belgrade University, dr Subotica 8, 11000 Belgrade, Serbia
- Cardiology Clinic, Clinical Centre of Serbia, Visegradska 26, 11000 Belgrade, Serbia
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, William Henry Duncan Building, 6 West Derby Street, Liverpool, L7 8TX, UK
- Department of Clinical Medicine, Aalborg University, Søndre Skovvej 15, 9000 Aalborg, Denmark
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Vesa ŞC, Vlaicu SI, Sabin O, Văcăraș V, Crișan S, Istratoaie S, Samantar F, Popa DE, Macarie AE, Buzoianu AD. Evaluating Physician Adherence to Antithrombotic Recommendations in Patients with Atrial Fibrillation: A Pathway to Better Medical Education. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E4008. [PMID: 32512937 PMCID: PMC7312043 DOI: 10.3390/ijerph17114008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 05/25/2020] [Accepted: 06/02/2020] [Indexed: 05/04/2023]
Abstract
BACKGROUND Atrial fibrillation is a major health problem due to the stroke risk associated with it. To reduce stroke risk, oral anticoagulants (OAC) are prescribed using the CHA2DS2-VASc (Congestive heart failure; Hypertension; Age ≥75 years; Diabetes Mellitus; Stroke; Vascular disease; Age 65-74 years; Sex category) risk score, a clinical probability assessment that includes a combination of risk factors predicting the probability of a stroke. Not all patients with high risk are receiving this treatment. The aim of this study was to assess physician adherence to clinical guidelines concerning the OAC treatment and to identify the factors that were associated with the decision to prescribe it. METHODS Registry data from 784 patients with non-valvular atrial fibrillation were evaluated in this retrospective cross-sectional study. Demographic data, subtype of AF, comorbidities associated with higher stroke and bleeding risk, and antithrombotic treatment received were recorded. We compared stroke and bleeding risk in patients with and without OAC treatment to determine if the clinicians followed guidelines: prescribed when necessary and abstained when not needed. RESULTS OAC treatment was administered in 617 (78.7%) patients. Of the 167 patients who did not receive OAC, 161 (96.4%) were undertreated according to their risk score, as opposed to those who received OAC in which the percentage of overtreated was 3.2%. Most undertreated patients (60.5%, p < 0.001) were with paroxysmal atrial fibrillation subtype. CONCLUSIONS The decision to use anticoagulants for stroke prevention was based on the type of atrial fibrillation, rather than on the risk of stroke as quantified by CHA2DS2-VASc as per the recommended guidelines.
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Affiliation(s)
- Ştefan Cristian Vesa
- Department of Pharmacology, Toxicology and Clinical Pharmacology, “Iuliu Haţieganu” University of Medicine and Pharmacy, 400337 Cluj-Napoca, Romania; (Ş.C.V.); (S.I.); (A.D.B.)
| | - Sonia Irina Vlaicu
- Department of Internal Medicine, 1st Medical Clinic, “Iuliu Haţieganu” University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania;
| | - Octavia Sabin
- Department of Pharmacology, Toxicology and Clinical Pharmacology, “Iuliu Haţieganu” University of Medicine and Pharmacy, 400337 Cluj-Napoca, Romania; (Ş.C.V.); (S.I.); (A.D.B.)
| | - Vitalie Văcăraș
- Department of Neurology, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Sorin Crișan
- Department of Internal Medicine, 5th Medical Clinic, “Iuliu Haţieganu” University of Medicine and Pharmacy, 400139 Cluj-Napoca, Romania;
| | - Sabina Istratoaie
- Department of Pharmacology, Toxicology and Clinical Pharmacology, “Iuliu Haţieganu” University of Medicine and Pharmacy, 400337 Cluj-Napoca, Romania; (Ş.C.V.); (S.I.); (A.D.B.)
| | - Fatuma Samantar
- Graduate of “Iuliu Haţieganu” Faculty of Medicine, University of Medicine and Pharmacy, 400337 Cluj-Napoca, Romania;
| | - Daciana Elena Popa
- Department of Cardiology, “Niculae Stăncioiu” Heart Institute, 400001 Cluj-Napoca, Romania;
| | - Antonia Eugenia Macarie
- Department of Geriatrics-Gerontology, “Iuliu Haţieganu” University of Medicine and Pharmacy, 400139 Cluj-Napoca, Romania;
| | - Anca Dana Buzoianu
- Department of Pharmacology, Toxicology and Clinical Pharmacology, “Iuliu Haţieganu” University of Medicine and Pharmacy, 400337 Cluj-Napoca, Romania; (Ş.C.V.); (S.I.); (A.D.B.)
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Cho S, Kim J, Kim JB, Park J, Park JK, Kang KW, Shim J, Choi EK, Lee YS, Park HW, Joung B. The difference of burden of ectopic beats in different types of atrial fibrillation and the effect of atrial fibrillation type on stroke risk in a prospective cohort of patients with atrial fibrillation (CODE-AF registry). Sci Rep 2020; 10:6319. [PMID: 32286428 PMCID: PMC7156648 DOI: 10.1038/s41598-020-63370-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Accepted: 03/30/2020] [Indexed: 11/09/2022] Open
Abstract
The relationship between atrial fibrillation (AF) type and stroke risk is still controversial. We investigated the difference of burden of atrial ectopic beats in different types of AF and the effect of the AF type on stroke risk in patients with non-valvular AF. In the prospective, multicenter observational registry with more than about 10,000 AF patients, 8883 non-valvular AF patients (mean age, 67.0 years; 36% were women) with eligible follow-up visits participated. We compared the burden of ectopic beats and stroke risk between patients with paroxysmal AF (n = 5,808) and non-paroxysmal AF (n = 3,075). The patients with a non-paroxysmal type of AF were older, male-predominant and had a higher prevalence of comorbidities and had more anticoagulation and rhythm control treatment than those with paroxysmal AF. In terms of the difference in burden of ectopic beats, patients with non-paroxysmal AF had a higher proportion of atrial premature beats (APBs) (paroxysmal vs. non-paroxysmal, median 3% vs. 5%; p = 0.001) in 24 hours Holter monitoring. During a median follow-up period of 16.8 months (Interquartile range [IQR], 11.67-20.52), a total of 82 (0.92%) patients experienced ischemic stroke with incidence rates of 0.50 and 1.09 events per 100 person-year for paroxysmal and non-paroxysmal AF, respectively. The cumulative incidence of stroke events was significantly higher in non-paroxysmal AF than in paroxysmal AF (p < 0.001). The risk of ischemic stroke was higher in non-paroxysmal AF with an adjusted hazard ratio (HR) of 2.08 (95% confidence interval [CI], 1.33-3.25; p = 0.001) than in paroxysmal AF. The type of AF was associated with an increased risk of stroke, along with the difference of burden of ectopic beats (specially in APBs) in different types of AF. These results suggest that the type of AF should be considered in stroke prevention and decision-making for oral anticoagulation in AF patients.
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Affiliation(s)
- Seunghoon Cho
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jun Kim
- Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jin-Bae Kim
- Division of Cardiology, Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University, Seoul, Republic of Korea
| | - Junbeom Park
- Department of Cardiology, School of Medicine, Ewha Womans University, Seoul, Republic of Korea
| | - Jin-Kyu Park
- Department of Cardiology, Hanyang University Seoul Hospital, Seoul, Republic of Korea
| | - Ki-Woon Kang
- Division of Cardiology, Eulji University Hospital, Daejeon, Republic of Korea
| | - Jaemin Shim
- Division of Cardiology, Department of Internal Medicine, Korea University Medical Center, Seoul, Republic of Korea
| | - Eue-Keun Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Young Soo Lee
- Division of Cardiology, Department of Internal Medicine, Daegu Catholic University Medical Center, Daegu, Republic of Korea
| | - Hyung Wook Park
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Hospital, Chonnam National University School of Medicine, Gwangju, Republic of Korea.
| | - Boyoung Joung
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.
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Zanotto G, Melissano D, Baccillieri S, Campana A, Caravati F, Maines M, Platania F, Zuccaro L, Landolina M, Berisso MZ, Boriani G, Ricci RP. Intrahospital organizational model of remote monitoring data sharing, for a global management of patients with cardiac implantable electronic devices. J Cardiovasc Med (Hagerstown) 2020; 21:171-181. [DOI: 10.2459/jcm.0000000000000912] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Strano S, Toni D, Ammirati F, Sanna T, Tomaino M, Brignole M, Mazza A, Nguyen BL, Di Bonaventura C, Ricci RP, Boriani G. Neuro-arrhythmology: a challenging field of action and research: a review from the Task Force of Neuro-arrhythmology of Italian Association of Arrhythmias and Cardiac Pacing. J Cardiovasc Med (Hagerstown) 2020; 20:731-744. [PMID: 31567632 DOI: 10.2459/jcm.0000000000000866] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
: There is a growing interest in the study of the mechanisms of heart and brain interactions with the aim to improve the management of high-impact cardiac rhythm disorders, first of all atrial fibrillation. However, there are several topics to which the scientific interests of cardiologists and neurologists converge constituting the basis for enhancing the development of neuro-arrhythmology. This multidisciplinary field should cover a wide spectrum of diseases, even beyond the classical framework corresponding to stroke and atrial fibrillation and include the complex issues of seizures as well as loss of consciousness and syncope. The implications of a more focused interaction between neurologists and cardiologists in the field of neuro-arrhythmology should include in perspective the institution of research networks specifically devoted to investigate 'from bench to bedside' the complex pathophysiological links of the abovementioned diseases, with involvement of scientists in the field of biochemistry, genetics, molecular medicine, physiology, pathology and bioengineering. An investment in the field could have important implications in the perspectives of a more personalized approach to patients and diseases, in the context of 'precision'medicine. Large datasets and electronic medical records, with the approach typical of 'big data' could enhance the possibility of new findings with potentially important clinical implications. Finally, the interaction between neurologists and cardiologists involved in arrythmia management should have some organizational implications, with new models of healthcare delivery based on multidisciplinary assistance, similarly to that applied in the case of syncope units.
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Affiliation(s)
| | - Danilo Toni
- Emergency Department Stroke Unit, Department of Human Neurosciences, Sapienza University of Rome
| | | | - Tommaso Sanna
- Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Institute of Cardiology, Rome
| | - Marco Tomaino
- Department of Cardiology, Ospedale di Bolzano, Bolzano
| | - Michele Brignole
- Department of Cardiology, Arrhythmologic Centre, Ospedali del Tigullio, Lavagna
| | - Andrea Mazza
- Cardiology Division, Santa Maria della Stella Hospital, Orvieto
| | | | | | | | - Giuseppe Boriani
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena University Hospital, Modena, Italy
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32
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Boriani G, Healey JS, Schnabel RB, Lopes RD, Calkins H, Camm JA, Freedman B. Oral anticoagulation for subclinical atrial tachyarrhythmias detected by implantable cardiac devices: an international survey of the AF-SCREEN Group. Int J Cardiol 2019; 296:65-70. [DOI: 10.1016/j.ijcard.2019.07.039] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 07/09/2019] [Accepted: 07/10/2019] [Indexed: 11/28/2022]
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Wang Z, Korantzopoulos P, Liu T. Carotid Atherosclerosis in Patients with Atrial Fibrillation. Curr Atheroscler Rep 2019; 21:55. [PMID: 31781980 DOI: 10.1007/s11883-019-0808-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW This review aims to explore the relationship between AF and carotid atherosclerosis, and the impact on the outcomes of cardiovascular and cerebrovascular events. Also, our aim is to critically review current knowledge and delineate future directions for effective treatment or prevention as well as strategies for improvement of the quality of life and survival. RECENT FINDINGS Atrial fibrillation (AF) is the most common arrhythmia, increasing the risk of stroke and cardiovascular morbidity and mortality representing a significant worldwide public health problem. On the other hand, carotid artery atherosclerosis can also significantly increase the risk of stroke, transient ischemic attack (TIA), and death. Firstly, we report epidemiological data on AF patients in different countries and regions having carotid artery abnormalities such as carotid artery plaque formation, atherosclerotic, and even stenosis. Despite geographical variations, these abnormalities were more frequent in AF patients and correlated with the duration of AF and the value of CHA2DS2-VASc score. Moreover, it is evident that AF patients with carotid artery abnormalities have significantly increased risk of adverse outcomes from the heart and brain. According to the CHA(2)DS2 (-VASc) score, AF patients are managed with anticoagulation therapy. Reviewing existing data on the treatment for stroke prevention in patients with AF, carotid artery disease, or both, we found that antiplatelet therapy could be combined with anticoagulant therapy appropriately in certain circumstances. In addition, some emerging technologies, such as the percutaneous permanent carotid filter, may be used safely and effectively to prevent the occurrence of stroke in patients both with AF and carotid artery atherosclerosis.
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Affiliation(s)
- Zhaojia Wang
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, The Second Hospital of Tianjin Medical University, Tianjin, China
| | | | - Tong Liu
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, The Second Hospital of Tianjin Medical University, Tianjin, China.
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Lessons from the current European Heart Rhythm Association consensus document on screening for atrial fibrillation. Anatol J Cardiol 2019. [PMID: 29521317 PMCID: PMC5864773 DOI: 10.14744/anatoljcardiol.2018.37043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
In this paper, we reviewed the atrial fibrillation screening strategies in a stepwise manner and discussed the uncertainties in the assessment of the need for anticoagulation in light of the recently published European Heart Rhythm Association consensus document. We reviewed not only the methods and tools but also the role of health care professionals and patient organizations in addition to cost-effectiveness issues.
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Abstract
PURPOSE Ischemic stroke significantly contributes to morbidity and mortality in heart failure (HF). The risk of stroke increases significantly, with coexisting atrial fibrillation (AF). An aggravating factor could be asymptomatic paroxysms of AF (so-called silent AF), and therefore, the risk stratification in these patients remains difficult. This review provides an overview of stroke risk in HF, its risk stratification, and stroke prevention in these patients. RECENT FINDINGS Stroke risk stratification in HF patients remains an important issue. Recently, the CHA2DS2-VASc score, originally developed to predict stroke risk in AF patients, had been reported to be a predictive for strokes in HF patients regardless of AF being present. Furthermore, there are several independent risk factors (e.g., hypertension, diabetes mellitus, prior stroke) described. Based on the current evidence, HF should be considered as an independent risk factor for stroke. The CHA2DS2-VASc score might be useful to predict stroke risk in HF patients with or without AF in clinical routine. However, there is only a recommendation for the oral anticoagulation use in patients with concomitant HF and AF, while in patients with HF and no AF, individualized risk stratification is preferred. Current guidelines recommend to prefer non-vitamin Kantagonist anticoagulants over warfarin.
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Affiliation(s)
- Katja Schumacher
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK.,Heart Center, Department of Electrophysiology, University of Leipzig, Leipzig, Germany
| | - Jelena Kornej
- Heart Center, Department of Electrophysiology, University of Leipzig, Leipzig, Germany.,Institute for Medical Informatics, Statistics and Epidemiology (IMISE), Leipzig University, Leipzig, Germany
| | - Eduard Shantsila
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK.
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Patel AR, Patel AR, Singh S, Singh S, Khawaja I. The Association Between Obstructive Sleep Apnea and Arrhythmias. Cureus 2019; 11:e4429. [PMID: 31245216 PMCID: PMC6559391 DOI: 10.7759/cureus.4429] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 04/10/2019] [Indexed: 11/05/2022] Open
Abstract
Obstructive sleep apnea (OSA) is caused by intermittent episodes of partial or complete closure of the upper airway, leading to apneic episodes while the patient is asleep. Atrial fibrillation (AF) leads to more than 750,000 hospitalizations per year and accounts for an estimated 130,000 deaths each year. The death rate from AF as the primary or a contributing cause of death has been rising for more than two decades. The material reviewed in this paper focuses on the association between OSA and arrhythmias. It goes into the details of the epidemiology, pathophysiology, and types of arrhythmias and the therapies seen in association with OSA.
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Affiliation(s)
- Avani R Patel
- Internal Medicine, Northern California Kaiser Permanente, Fremont, USA
| | - Amar R Patel
- Internal Medicine, Northern California Kaiser Permanente, Fremont, USA
| | - Shivank Singh
- Internal Medicine, Maoming People's Hospital, Maoming, CHN
| | - Shantanu Singh
- Pulmonary Medicine, Marshall University School of Medicine, Huntington, USA
| | - Imran Khawaja
- Pulmonary Medicine, Marshall University School of Medicine, Huntington, USA
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Arnar DO, Mairesse GH, Boriani G, Calkins H, Chin A, Coats A, Deharo JC, Svendsen JH, Heidbüchel H, Isa R, Kalman JM, Lane DA, Louw R, Lip GYH, Maury P, Potpara T, Sacher F, Sanders P, Varma N, Fauchier L, Haugaa K, Schwartz P, Sarkozy A, Sharma S, Kongsgård E, Svensson A, Lenarczyk R, Volterrani M, Turakhia M, Obel IWP, Abello M, Swampillai J, Kalarus Z, Kudaiberdieva G, Traykov VB, Dagres N, Boveda S, Vernooy K, Kalarus Z, Kudaiberdieva G, Mairesse GH, Kutyifa V, Deneke T, Hastrup Svendsen J, Traykov VB, Wilde A, Heinzel FR. Management of asymptomatic arrhythmias: a European Heart Rhythm Association (EHRA) consensus document, endorsed by the Heart Failure Association (HFA), Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society (APHRS), Cardiac Arrhythmia Society of Southern Africa (CASSA), and Latin America Heart Rhythm Society (LAHRS). Europace 2019; 21:844–845. [DOI: 10.1093/europace/euz046] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 02/24/2019] [Indexed: 12/22/2022] Open
Abstract
AbstractAsymptomatic arrhythmias are frequently encountered in clinical practice. Although studies specifically dedicated to these asymptomatic arrhythmias are lacking, many arrhythmias still require proper diagnostic and prognostic evaluation and treatment to avoid severe consequences, such as stroke or systemic emboli, heart failure, or sudden cardiac death. The present document reviews the evidence, where available, and attempts to reach a consensus, where evidence is insufficient or conflicting.
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Affiliation(s)
- David O Arnar
- Department of Medicine, Landspitali - The National University Hospital of Iceland and University of Iceland, Reykjavik, Iceland
| | | | - Giuseppe Boriani
- Division of Cardiology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Hugh Calkins
- Department of Arrhythmia Services, Johns Hopkins Medical Institutions Baltimore, MD, USA
| | - Ashley Chin
- Division of Cardiology, Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Andrew Coats
- Department of Cardiology, University of Warwick, Warwickshire, UK
| | - Jean-Claude Deharo
- Department of Rhythmology, Hôpital Universitaire La Timone, Marseille, France
| | - Jesper Hastrup Svendsen
- Department of Cardiology, The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Hein Heidbüchel
- Antwerp University Hospital, University of Antwerp, Edegem, Belgium
| | - Rodrigo Isa
- Clínica RedSalud Vitacura and Hospital el Carmen de Maipú, Santiago, Chile
| | - Jonathan M Kalman
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
| | - Ruan Louw
- Department Cardiology (Electrophysiology), Mediclinic Midstream Hospital, Centurion, South Africa
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
| | - Philippe Maury
- Cardiology, University Hospital Rangueil, Toulouse, France
| | - Tatjana Potpara
- Cardiology Clinic, Clinical Center of Serbia, School of Medicine, University of Belgrade, Serbia
| | - Frederic Sacher
- Service de Cardiologie, Institut Lyric, CHU de Bordeaux, Bordeaux, France
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Niraj Varma
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Laurent Fauchier
- Service de Cardiologie et Laboratoire d'Electrophysiologie Cardiaque, Centre Hospitalier Universitaire Trousseau et Université François Rabelais, Tours, France
| | - Kristina Haugaa
- Department of Cardiology, Center for Cardiological Innovation and Institute for Surgical Research, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Peter Schwartz
- Istituto Auxologico Italiano, IRCCS, Center for Cardiac Arrhythmias of Genetic Origin, Milan, Italy
| | - Andrea Sarkozy
- Heart Rhythm Management Centre, UZ Brussel-VUB, Brussels, Belgium
| | | | - Erik Kongsgård
- Department of Cardiology, OUS-Rikshospitalet, Oslo, Norway
| | - Anneli Svensson
- Department of Cardiology, University Hospital of Linkoping, Sweden
| | | | | | - Mintu Turakhia
- Stanford University, Cardiac Arrhythmia & Electrophysiology Service, Stanford, USA
| | | | | | - Janice Swampillai
- Electrophysiologist & Cardiologist, Waikato Hospital, University of Auckland, New Zealand
| | - Zbigniew Kalarus
- SMDZ in Zabrze, Medical University of Silesia, Katowice, Poland
- Department of Cardiology, Silesian Center for Heart Diseases, Zabrze
| | | | - Vassil B Traykov
- Department of Invasive Electrophysiology and Cardiac Pacing, Clinic of Cardiology, Acibadem City Clinic Tokuda Hospital, Sofia, Bulgaria
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Hyman DA, Siebert V, Jia X, Alam M, Levine GN, Virani SS, Birnbaum Y. Risk Assessment of Stroke in Patients with Atrial Fibrillation: Current Shortcomings and Future Directions. Cardiovasc Drugs Ther 2019; 33:105-117. [PMID: 30684116 DOI: 10.1007/s10557-018-06849-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Atrial fibrillation is a well-known risk factor for cardioembolic stroke; a number of risk stratification scoring systems have been developed to help differentiate which patients would stand to benefit from anticoagulation. However, these scoring systems cannot be utilized in patients whose atrial fibrillation has not been diagnosed. As implantable cardiac monitors become more prevalent, it becomes possible to identify occult, subclinical atrial fibrillation. With this data, it is also possible to examine the relationship between episodes of paroxysmal atrial fibrillation and thromboembolism and the total burden of paroxysmal atrial fibrillation and thromboembolic risk. The data gleaned from these devices provides insight and raises questions regarding the underlying mechanism of thromboembolism in atrial fibrillation, and in doing so, exposes shortcomings in the present clinical use of current risk scoring systems, specifically, the inability to account for atrial fibrillation burden and to apply scores at all in subclinical atrial fibrillation.
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Affiliation(s)
- Daniel A Hyman
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA.
| | - Vincent Siebert
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Xiaoming Jia
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Mahboob Alam
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Glenn N Levine
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA.,Michael E. Debakey VA Medical Center, Houston, TX, USA
| | - Salim S Virani
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA.,Michael E. Debakey VA Medical Center, Houston, TX, USA
| | - Yochai Birnbaum
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
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39
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Maltoni S, Negro A, Camerlingo MD, Pecoraro V, Sassone B, Biffi M, Boriani G. Comparison of cryoballoon and radiofrequency ablation techniques for atrial fibrillation. J Cardiovasc Med (Hagerstown) 2018; 19:725-738. [DOI: 10.2459/jcm.0000000000000725] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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40
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Mazza A, Bendini MG, De Cristofaro R, Lovecchio M, Valsecchi S, Boriani G. Pacemaker-detected severe sleep apnoea predicts new-onset atrial fibrillation: Author’s reply. Europace 2018; 20:2047-2048. [DOI: 10.1093/europace/euy068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Andrea Mazza
- Cardiology Division, S. Maria della Stella Hospital, Orvieto, Italy
| | | | | | | | | | - Giuseppe Boriani
- Cardiology Division, Department of Diagnostics, Clinical and Public Health Medicine, University of Modena and Reggio Emilia, Policlinico di Modena, Via del Pozzo 71, Modena, Italy
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Boriani G, Proietti M, Laroche C, Diemberger I, Popescu MI, Riahi S, Shantsila A, Dan GA, Tavazzi L, Maggioni AP, Lip GY. Changes to oral anticoagulant therapy and risk of death over a 3-year follow-up of a contemporary cohort of European patients with atrial fibrillation final report of the EURObservational Research Programme on Atrial Fibrillation (EORP-AF) pilot general registry. Int J Cardiol 2018; 271:68-74. [DOI: 10.1016/j.ijcard.2018.05.034] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 04/22/2018] [Accepted: 05/10/2018] [Indexed: 12/20/2022]
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Lip GY, Banerjee A, Boriani G, Chiang CE, Fargo R, Freedman B, Lane DA, Ruff CT, Turakhia M, Werring D, Patel S, Moores L. Antithrombotic Therapy for Atrial Fibrillation. Chest 2018; 154:1121-1201. [DOI: 10.1016/j.chest.2018.07.040] [Citation(s) in RCA: 481] [Impact Index Per Article: 80.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 07/11/2018] [Accepted: 07/24/2018] [Indexed: 02/08/2023] Open
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Mairesse GH, Moran P, Van Gelder IC, Elsner C, Rosenqvist M, Mant J, Banerjee A, Gorenek B, Brachmann J, Varma N, Glotz de Lima G, Kalman J, Claes N, Lobban T, Lane D, Lip GYH, Boriani G. Screening for atrial fibrillation: a European Heart Rhythm Association (EHRA) consensus document endorsed by the Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulación Cardíaca y Electrofisiología (SOLAECE). Europace 2018; 19:1589-1623. [PMID: 29048522 DOI: 10.1093/europace/eux177] [Citation(s) in RCA: 182] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 05/06/2017] [Indexed: 01/21/2023] Open
Affiliation(s)
- Georges H Mairesse
- Department of Cardiology, Cliniques du Sud-Luxembourg, 137 rue des déportés, B6700 Arlon, Belgium
| | - Patrick Moran
- Health Information and Quality Authority, George's Lane, Dublin 7, D07 E98Y, Ireland
| | - Isabelle C Van Gelder
- University of Groningen, University Medical Center Groningen, Hanzeplein 1, Groningen, 9713 GZ, The Netherlands
| | - Christian Elsner
- University Clinic Of Schleswig Holstein, Maria Goeppert Strasse 7a-b, Luebeck, 23538, Germany
| | | | - Jonathan Mant
- Primary Care Unit, University of Cambridge, Strangeways Research Laboratory, Wort's Causeway, Cambridge, CB1 8RN, United Kingdom
| | - Amitava Banerjee
- University College London, Farr Institute of Health Informatics Research, 222 Euston Road, London, West Midlands NW1 2DA, United Kingdom
| | - Bulent Gorenek
- Eskisehir Osmangazi University, ESOGÜ Meselik Yerleskesi, 26480 ESKISEHIR, Turkey
| | - Johannes Brachmann
- Klinikum Coburg, Chefarzt der II. Medizinischen Klinik, Ketschendorfer Str. 33, Coburg, DE-96450, Germany
| | - Niraj Varma
- Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, Ohio 44195, USA
| | - Gustavo Glotz de Lima
- Instituto de Cardiologia do RS / FUC, Eletrofisiologia Dept., Av. Princesa Isabel 370, Porto Alegre, 90620-001, Brazil
| | - Jonathan Kalman
- The Royal Melbourne Hospital, Melbourne Heart Center, Royal Parade Suite 1, Parkville, Victoria, 3050, Australia
| | - Neree Claes
- University of Hasselt, Patient Safety in General Practice and Hospitals, Diepenbeek, Belgium, Antwerp Management School, Clinical Leadership, Antwerp, Belgium
| | - Trudie Lobban
- Arrhythmia Alliance & AF Association, Unit 6B, Essex House, Cromwell Business Park, Chipping Norton, Oxfordshire OX7 5SR, UK
| | - Deirdre Lane
- Institute of Cardiovascular Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, United Kingdom; and Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Fredrik Bajers Vej 5, 9100 Aalborg, Denmark
| | - Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, United Kingdom; and Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Fredrik Bajers Vej 5, 9100 Aalborg, Denmark
| | - Giuseppe Boriani
- Cardiology Division, Department of Diagnostics, Clinical and Public Health Medicine, University of Modena and Reggio Emilia, Policlinico di Modena, Largo del Pozzo, 71, 41125 Modena, Italy
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Atrial fibrillation in athletes: From epidemiology to treatment in the novel oral anticoagulants era. J Cardiol 2018; 72:269-276. [DOI: 10.1016/j.jjcc.2018.04.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Revised: 04/09/2018] [Accepted: 04/23/2018] [Indexed: 12/17/2022]
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Bierig SM, Arnold A, Einbinder LC, Armbrecht E, Burroughs T. Cardiovascular Ultrasound Combined With Non-invasive Screening for the Detection of Undiagnosed Cardiovascular Disease: A Literature Review. JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY 2018. [DOI: 10.1177/8756479317737764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Non-invasive screenings have been widely utilized in the United States and worldwide to provide early identification of cardiovascular disease, allowing for earlier diagnosis and treatment. Screening sonography detects valve disease, cardiac dysfunction, and carotid disease in 5% to 20% of the population. This review discusses the current data regarding cardiovascular screening, the methodologies, and the resources required for performance of screenings. Cardiac and carotid sonography is highly accurate and discovers cardiovascular diseases that impact quality of life and risk of future events. Screenings are performed in a variety of settings and accuracy depends on the quality of personnel performing the non-invasive testing, the equipment utilized, and the personnel interpreting the studies. Despite the potential benefit for disease detection, population screening to detect cardiovascular disease is not widely supported by national organizations due to the theoretical cost of further testing and lack of cost versus benefit data. Additional studies are necessary to compare costs and benefits of non-invasive cardiovascular screening in the community setting.
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Affiliation(s)
| | | | | | - Eric Armbrecht
- Saint Louis University Center for Outcomes Research, Saint Louis, MO, USA
| | - Thomas Burroughs
- Saint Louis University Center for Outcomes Research, Saint Louis, MO, USA
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Cloutier JM, Khoo C, Hiebert B, Wassef A, Seifer CM. Physician decision making in anticoagulating atrial fibrillation: a prospective survey of a physician notification system for atrial fibrillation detected on cardiac implantable electronic devices of patients at increased risk of stroke. Ther Adv Cardiovasc Dis 2018; 12:113-122. [PMID: 29528778 PMCID: PMC5941669 DOI: 10.1177/1753944717749739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 11/14/2017] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES The objectives of this study were to evaluate the effectiveness of a physician notification system for atrial fibrillation (AF) detected on cardiac devices, and to assess predictors of anticoagulation in patients with device-detected AF. METHODS In 2013, a physician notification system for AF detected on a patient's CIED [including pacemakers, implantable cardioverter defibrillators (ICD) or cardiac resynchronization therapy (CRT) devices] was implemented, with a recommendation to consider oral anticoagulation in high-risk patients. We prospectively investigated the effectiveness of this system, and evaluated both patient and physician predictors of anticoagulation, as well as factors influencing physician decision making in prescribing anticoagulation. Both uni- and multivariable analysis as well as descriptive statistics were used in the analysis. RESULTS We identified 177 patients with device-detected AF, 126 with a CHADS2 ⩾2. Only 41% were prescribed anticoagulation at any point within 12 months. On multivariable analysis, stroke risk as predicted by CHADS2 was not a predictor of anticoagulation. ASA use predicted a lower rate of anticoagulation (OR 0.39, 95% CI 0.16-0.97, p = 0.04); physicians in practice for <20 years were more likely to prescribe anticoagulation (OR 3.39, 95% CI 1.28-8.93, p = 0.01); and physicians who believed both cardiologist and family doctor should be involved in managing anticoagulation were more likely to prescribe anticoagulation (OR 3.28, 95% CI 1.02-10.5, p = 0.05). CONCLUSIONS Patients on aspirin were less likely to be anticoagulated. Physicians in practice for <20 years and who believed that both the general practitioner and cardiologist should be involved in managing anticoagulants were more likely to prescribe anticoagulation.
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Affiliation(s)
- Justin M. Cloutier
- Section of Cardiology, University of Manitoba, Winnipeg, MB, Canada Cardiac Sciences Program, St. Boniface Hospital, Winnipeg, MB, Canada
| | - Clarence Khoo
- Section of Cardiology, University of Manitoba, Winnipeg, MB, Canada Cardiac Sciences Program, St. Boniface Hospital, Winnipeg, MB, Canada
| | - Brett Hiebert
- Cardiac Sciences Program, St. Boniface Hospital, Winnipeg, MB, Canada
| | - Anthony Wassef
- Division of Cardiology, University of Toronto, Toronto, ON, Canada
| | - Colette M. Seifer
- WRHA Cardiac Sciences Program, Section of Cardiology, University of Manitoba and Cardiac Sciences Program, St. Boniface Hospital, Y3019 St Boniface Hospital, Winnipeg, Manitoba, R2H 2A6, Canada
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Boriani G, Glotzer TV, Ziegler PD, De Melis M, Mangoni di S. Stefano L, Sepsi M, Landolina M, Lunati M, Lewalter T, Camm AJ. Detection of new atrial fibrillation in patients with cardiac implanted electronic devices and factors associated with transition to higher device-detected atrial fibrillation burden. Heart Rhythm 2018; 15:376-383. [DOI: 10.1016/j.hrthm.2017.11.007] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Indexed: 11/30/2022]
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Boriani G, Laroche C, Diemberger I, Fantecchi E, Meeder J, Kurpesa M, Baluta MM, Proietti M, Tavazzi L, Maggioni AP, Lip GYH. Overweight and obesity in patients with atrial fibrillation: Sex differences in 1-year outcomes in the EORP-AF General Pilot Registry. J Cardiovasc Electrophysiol 2018; 29:566-572. [DOI: 10.1111/jce.13428] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 11/13/2017] [Accepted: 01/02/2018] [Indexed: 12/31/2022]
Affiliation(s)
- Giuseppe Boriani
- Cardiology Department; University of Modena and Reggio Emilia, Policlinico di Modena; Modena Italy
| | - Cécile Laroche
- EURObservational Research Programme Department; European Society of Cardiology; Sophia Antipolis France
| | - Igor Diemberger
- Institute of Cardiology, Department of Experimental, Diagnostic and Specialty Medicine; University of Bologna, S. Orsola-Malpighi University Hospital; Bologna Italy
| | - Elisa Fantecchi
- Cardiology Department; University of Modena and Reggio Emilia, Policlinico di Modena; Modena Italy
| | - Joan Meeder
- Department of Cardiology; VieCuri Medical Center; Venlo the Netherlands
| | | | - Monica Mariana Baluta
- Cardiology Department; Carol Davila University of Medicine and Pharmacy, St. Pantelimon Emergency Hospital; Bucharest Romania
| | - Marco Proietti
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital; Birmingham United Kingdom
| | - Luigi Tavazzi
- Maria Cecilia Hospital; GVM Care&Research. E.S. Health Science Foundation; Cotignola Italy
| | - Aldo P. Maggioni
- EURObservational Research Programme Department; European Society of Cardiology; Sophia Antipolis France
- ANMCO Research Center; Firenze Italy
| | - Gregory Y. H. Lip
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital; Birmingham United Kingdom
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine; Aalborg University; Aalborg Denmark
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Kucukseymen S, Cekin AH, Bayar N, Arslan S, Uygur Kucukseymen E, Mercan T, Ozdemir S. A novel biomarker for prediction of atrial fibrillation susceptibility in patients with celiac disease. PLoS One 2018; 13:e0190382. [PMID: 29315324 PMCID: PMC5760044 DOI: 10.1371/journal.pone.0190382] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Accepted: 12/13/2017] [Indexed: 12/13/2022] Open
Abstract
Background Celiac disease (CD), a serious autoimmune disorder that occurs in people who are genetically predisposed, is induced by dietary gluten intake and affects primarily the small intestine. Many studies have identified an increased risk of cardiovascular problems in patients with CD. Moreover, these patients are susceptible to certain liver diseases, as well as fibrosis. Objective The aim of this study was to assess the presence of fibrosis using the De Ritis ratio, determining its effect on the electromechanical features of the left atrium and its susceptibility to atrial fibrillation (AF) in patients with CD. Methods A total of 97 patients diagnosed with CD by antibody test and biopsy were included in this prospective study. Two groups were created from these patients, a fibrosis-prone (FP) group and a non-fibrosis-prone (NFP) group, according to the cut-off value, as defined in previously published reports, for the AST/ALT ratio. Electrocardiographic and echocardiographic examinations were performed as part of the study. Results There were no differences in the baseline characteristics and conventional echocardiographic parameters of the defined groups. However, the patients in the FP group, as compared to those in the NFP group, had significantly increased PWD (56.68±6.48 ms vs. 37.49±6.22 ms, P<0.001). Additionally, significantly higher interatrial (60.50±13.05 ms vs. 29.40±11.55 ms, P<0.001), intra-left atrial (44.18±14.12 ms vs. 21.02±11.99 ms, P<0.001), and intra-right atrial (15.61±8.91 ms vs. 8.38±4.50 ms, P<0.001) EMD was found among the patients in the FP group compared to that of the NFP group. Conclusion It is believed that the susceptibility to AF cited in previous studies may be related to fibrosis. Our study is the first to examine the possible effects of fibrosis on AF susceptibility in patients with CD, whereby we propose a new biomarker for prediction of AF susceptibility of these patients.
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Affiliation(s)
- Selcuk Kucukseymen
- Department of Cardiology, University of Health Sciences, Antalya Education and Research Hospital, Antalya, Turkey
- Department of Biophysics, Akdeniz University Faculty of Medicine, Antalya, Turkey
- * E-mail:
| | - Ayhan Hilmi Cekin
- Department of Gastroenterology, University of Health Sciences, Antalya Education and Research Hospital, Antalya, Turkey
| | - Nermin Bayar
- Department of Cardiology, University of Health Sciences, Antalya Education and Research Hospital, Antalya, Turkey
| | - Sakir Arslan
- Department of Cardiology, University of Health Sciences, Antalya Education and Research Hospital, Antalya, Turkey
| | - Elif Uygur Kucukseymen
- Department of Neurology, University of Health Sciences, Antalya Education and Research Hospital, Antalya, Turkey
| | - Tanju Mercan
- Department of Biophysics, Akdeniz University Faculty of Medicine, Antalya, Turkey
| | - Semir Ozdemir
- Department of Biophysics, Akdeniz University Faculty of Medicine, Antalya, Turkey
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The complexity of atrial fibrillation newly diagnosed after ischemic stroke and transient ischemic attack: advances and uncertainties. Curr Opin Neurol 2018; 30:28-37. [PMID: 27984303 PMCID: PMC5321114 DOI: 10.1097/wco.0000000000000410] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Purpose of review Atrial fibrillation is being increasingly diagnosed after ischemic stroke and transient ischemic attack (TIA). Patient characteristics, frequency and duration of paroxysms, and the risk of recurrent ischemic stroke associated with atrial fibrillation detected after stroke and TIA (AFDAS) may differ from atrial fibrillation already known before stroke occurrence. We aim to summarize major recent advances in the field, in the context of prior evidence, and to identify areas of uncertainty to be addressed in future research. Recent findings Half of all atrial fibrillations in ischemic stroke and TIA patients are AFDAS, and most of them are asymptomatic. Over 50% of AFDAS paroxysms last less than 30 s. The rapid initiation of cardiac monitoring and its duration are crucial for its timely and effective detection. AFDAS comprises a heterogeneous mix of atrial fibrillation, possibly including cardiogenic and neurogenic types, and a mix of both. Over 25 single markers and at least 10 scores have been proposed as predictors of AFDAS. However, there are considerable inconsistencies across studies. The role of AFDAS burden and its associated risk of stroke recurrence have not yet been investigated. Summary AFDAS may differ from atrial fibrillation known before stroke in several clinical dimensions, which are important for optimal patient care strategies. Many questions remain unanswered. Neurogenic and cardiogenic AFDAS need to be characterized, as it may be possible to avoid some neurogenic cases by initiating timely preventive treatments. AFDAS burden may differ in ischemic stroke and TIA patients, with distinctive diagnostic and treatment implications. The prognosis of AFDAS and its risk of recurrent stroke are still unknown; therefore, it is uncertain whether AFDAS patients should be treated with oral anticoagulants.
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