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Hemels MEW, Van Noord T, Crijns HJGM, Van Veldhuisen DJ, Veeger NJGM, Bosker HA, Wiesfeld ACP, Van den Berg MP, Ranchor AV, Van Gelder IC. Verapamil versus digoxin and acute versus routine serial cardioversion for the improvement of rhythm control for persistent atrial fibrillation. J Am Coll Cardiol 2006; 48:1001-9. [PMID: 16949494 DOI: 10.1016/j.jacc.2006.05.043] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2006] [Revised: 04/10/2006] [Accepted: 05/02/2006] [Indexed: 10/24/2022]
Abstract
OBJECTIVES The VERDICT (Verapamil Versus Digoxin and Acute Versus Routine Serial Cardioversion Trial) is a prospective, randomized study to investigate whether: 1) acutely repeated serial electrical cardioversions (ECVs) after a relapse of atrial fibrillation (AF); and 2) prevention of intracellular calcium overload by verapamil, decrease intractability of AF. BACKGROUND Rhythm control is desirable in patients suffering from symptomatic AF. METHODS A total of 144 patients with persistent AF were included. Seventy-four (51%) patients were randomized to the acute (within 24 h) and 70 (49%) patients to the routine serial ECVs, and 74 (51%) patients to verapamil and 70 (49%) patients to digoxin for rate control before ECV and continued during follow-up (2 x 2 factorial design). Class III antiarrhythmic drugs were used after a relapse of AF. Follow-up was 18 months. RESULTS At baseline, there were no significant differences between the groups, except for beta-blocker use in the verapamil versus digoxin group (38% vs. 60%, respectively, p = 0.01). At follow-up, no difference in the occurrence of permanent AF between the acute and the routine cardioversion groups was observed (32% [95% confidence intervals (CI)] 22 to 44) vs. 31% [95% CI 21 to 44], respectively, p = NS), and also no difference between the verapamil- and the digoxin-randomized patients (28% [95% CI 19 to 40] vs. 36% [95% CI 25 to 48] respectively, p = NS). Multivariate Cox regression analysis revealed that lone digoxin use was the only significant predictor of failure of rhythm control treatment (hazard ratio 2.2 [95% CI 1.1 to 4.4], p = 0.02). CONCLUSIONS An acute serial cardioversion strategy does not improve long-term rhythm control in comparison with a routine serial cardioversion strategy. Furthermore, verapamil has no beneficial effect in a serial cardioversion strategy.
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Affiliation(s)
- Martin E W Hemels
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Chen PS. Douglas P. Zipes Lecture. Neural mechanisms of atrial fibrillation. Heart Rhythm 2006; 3:1373-7. [PMID: 17074648 DOI: 10.1016/j.hrthm.2006.08.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2006] [Accepted: 08/06/2006] [Indexed: 12/15/2022]
Affiliation(s)
- Peng-Sheng Chen
- Division of Cardiology, Department of Medicine, Cedars-Sinai Medical Center and David Geffen School of Medicine, UCLA, Los Angeles, California 90048, USA.
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454
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Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA, Halperin JL, Le Heuzey JY, Kay GN, Lowe JE, Olsson SB, Prystowsky EN, Tamargo JL, Wann S, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Hunt SA, Nishimura R, Ornato JP, Page RL, Riegel B, Priori SG, Blanc JJ, Budaj A, Camm AJ, Dean V, Deckers JW, Despres C, Dickstein K, Lekakis J, McGregor K, Metra M, Morais J, Osterspey A, Zamorano JL. ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation—Executive Summary. J Am Coll Cardiol 2006; 48:854-906. [PMID: 16904574 DOI: 10.1016/j.jacc.2006.07.009] [Citation(s) in RCA: 714] [Impact Index Per Article: 39.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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455
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Singh SN, Tang XC, Singh BN, Dorian P, Reda DJ, Harris CL, Fletcher RD, Sharma SC, Atwood JE, Jacobson AK, Lewis HD, Lopez B, Raisch DW, Ezekowitz MD. Quality of Life and Exercise Performance in Patients in Sinus Rhythm Versus Persistent Atrial Fibrillation. J Am Coll Cardiol 2006; 48:721-30. [PMID: 16904540 DOI: 10.1016/j.jacc.2006.03.051] [Citation(s) in RCA: 142] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2005] [Revised: 02/28/2006] [Accepted: 03/07/2006] [Indexed: 10/24/2022]
Abstract
OBJECTIVES The purpose of this study was to determine quality of life (QOL) and exercise performance (EP) in patients with persistent atrial fibrillation (AF) converted to sinus rhythm (SR) compared with those remaining in or reverting to AF. BACKGROUND Restoration of SR in patients with AF improving QOL and EP remains controversial. METHODS Patients with persistent AF were randomized double-blind to amiodarone, sotalol, or placebo. Those not achieving SR at day 28 were cardioverted and classified into SR or AF groups at 8 weeks (n = 624) and 1 year (n = 556). The QOL (SF-36), symptom checklist (SCL), specific activity scale (SAS), AF severity scale (AFSS), and EP were assessed. RESULTS Favorable changes were seen in SR patients at 8 weeks in physical functioning (p < 0.001), physical role limitations (p = 0.03), general health (p = 0.002), and vitality (p < 0.001), and at 1 year in general health (p = 0.007) and social functioning (p = 0.02). Changes in the scores for SCL severity (p = 0.01), functional capacity (p = 0.003), and AFSS symptom burden (p < 0.001) at 8 weeks and in SCL severity (p < 0.01) and AF symptom burden (p < 0.001) at 1 year showed significant improvements in SR versus AF. Symptomatic patients were more likely to have improvement. The EP in SR versus AF was greater from baseline to 8 weeks (p = 0.01) and to 1 year (p = 0.02). The EP correlated with physical functioning and functional capacity except in the AF group at 1 year. CONCLUSIONS In patients with persistent AF, restoration and maintenance of SR was associated with improvements in QOL measures and EP. There was a strong correlation between QOL measures and EP.
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Affiliation(s)
- Steven N Singh
- Department of Veterans Affairs Medical Center, Washington, DC 20422, USA.
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Kato T, Yamashita T, Sekiguchi A, Sagara K, Takamura M, Takata S, Kaneko S, Aizawa T, Fu LT. What are arrhythmogenic substrates in diabetic rat atria? J Cardiovasc Electrophysiol 2006; 17:890-4. [PMID: 16759295 DOI: 10.1111/j.1540-8167.2006.00528.x] [Citation(s) in RCA: 102] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Diabetes mellitus is one of the significant independent risk factors for the development of atrial fibrillation (AF). However, the pathophysiological mechanisms of the relationship have not been fully elucidated. METHODS AND RESULTS The genetic type II diabetes (GK) rats and their original (Wistar) ones were subjected to electrophysiological (n = 8 per group) and histological (n = 7 per group) studies. At 40 weeks old, when GK rats had significantly (P < 0.01) more increased plasma glucose and HbA(1c) values than Wistar rats, atrial electrical stimuli in the isolated-perfused hearts induced significantly greater number of repetitive atrial responses in GK rats than in Wistar rats (47.9 +/- 17.5 vs 3.1 +/- 1.3 beats, respectively, P < 0.01). GK rats showed significantly longer intra-atrial activation time than Wistar rats (18.3 +/- 0.4 ms vs 15.9 +/- 0.5 ms, P < 0.01) without any significant difference in the atrial refractoriness. The histological examination revealed significantly increased diffuse fibrotic deposition in GK rats atria compared with Wistar ones (P < 0.01). CONCLUSION The present diabetic GK rat showed increased atrial arrhythmogenicity with intra-atrial conduction disturbance, and thus indicated that the structural remodeling of atrium characterized by diffuse interstitial fibrosis would be a major substrate for diabetes-related AF.
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459
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Hagens VE, Van Veldhuisen DJ, Crijns HJGM, Van Gelder IC. Implication from randomized trials of rate and rhythm controls on management of patients with persistent atrial fibrillation. Ann Noninvasive Electrocardiol 2006; 11:170-86. [PMID: 16630092 PMCID: PMC6932388 DOI: 10.1111/j.1542-474x.2006.00099.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Recently, several randomized trials were published on the issue of rate or rhythm control for patients with atrial fibrillation (AF). Patients were typically minor symptomatic, relatively old, with age above 70, presenting with a recurrence of AF and suffering from only mild to moderate underlying heart disease. The main outcome of these trials is that rate control is not inferior to rhythm control for the management of patients with AF concerning morbidity and mortality. Also patients' quality of life did not differ significantly in follow-up in these trials. However, rhythm control is not redundant in the treatment of AF. Focus is now on subgroups of patients who could still have benefit being in sinus rhythm. For severely symptomatic patients, patients presenting with the first episode of AF and probably those with severe congestive heart failure, to restore and maintain sinus rhythm should still be the goal. With the failure of antiarrhythmic therapy, nonpharmacological approaches such as pulmonary vein isolation can be performed. Another finding of the randomized trials is that being in sinus rhythm does not prevent from the occurrence of thromboembolic complications. This means that for patients with AF, with risk factors for thromboembolic events, adequate anticoagulant therapy is indicated irrespective of the current heart rhythm. As with antiarrhythmic therapy, the search for new and safer anticoagulant therapy is underway. This review will focus on the key aspects we have learned from the randomized trials on rate and rhythm controls for patients with AF.
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Affiliation(s)
- Vincent E. Hagens
- Department of Cardiology, University Medical Center Groningen, the Netherlands
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460
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Wyse DG. Pharmacologic approaches to rhythm versus rate control in atrial fibrillation—where are we now? Int J Cardiol 2006; 110:301-12. [PMID: 16516313 DOI: 10.1016/j.ijcard.2005.12.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2005] [Revised: 12/02/2005] [Accepted: 12/14/2005] [Indexed: 11/30/2022]
Abstract
Until recently, contemporary drug treatment of atrial fibrillation (AF) focused primarily on restoration and maintenance of sinus rhythm, predicated on the belief that if AF is abolished then problems associated with AF would be abolished too. Recently completed clinical trials using drug therapy and comparing maintenance of sinus rhythm with control of ventricular rate have challenged this assumption, showing that simple control of ventricular rate with anticoagulation is an acceptable primary therapy, notably in older patients with persistent AF, minimally symptomatic or asymptomatic, and at increased risk for thromboembolic events. However, rate control and anticoagulation is not a panacea; existing trial results should not be interpreted to mean all patients should be treated with the rate control approach. Despite the limited efficacy and poor safety of current antiarrhythmic drugs, strategies for maintenance of sinus rhythm remain justified in many patients, such as those with first-episode AF, highly symptomatic patients, younger patients, and those with a history of congestive heart failure (CHF). Commonly used current and some investigational agents designated for "rhythm control" have enough pharmacologic overlap with rate control agents to be considered to have a dual mode of action, simultaneously addressing both rhythm and rate control. Furthermore, there is much interest in non-pharmacologic therapies, such as radiofrequency ablation, for rhythm control. The lack of appropriately designed and controlled trials at this time makes it difficult to determine the place of radiofrequency ablation and its impact on the rhythm versus rate question.
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Affiliation(s)
- D George Wyse
- Libin Cardiovascular Institute of Alberta, Department of Cardiac Sciences, University of Calgary/Calgary Health Region, Calgary, Alberta, Canada.
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461
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Zellerhoff S, Goette A, Kirchhof P. [Anticoagulation with atrial fibrillation]. Herzschrittmacherther Elektrophysiol 2006; 17:89-94. [PMID: 16786467 DOI: 10.1007/s00399-006-0515-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2006] [Accepted: 05/10/2006] [Indexed: 05/10/2023]
Abstract
Atrial fibrillation is associated with a relevant risk for ischemic stroke: Observational studies suggest that one in four to five strokes is due to atrial fibrillation. Depending on the risk profile of an individual patient, the yearly risk for a stroke is between 2% and 14%. Continuous oral anticoagulation is indicated if atrial fibrillation is accompanied by at least one additional risk factor for thromboembolic complications. This recommendation is supported by several large randomized trials. Due to their low therapeutic range, vitamin K antagonists (phenprocoumon, warfarin, and others), the most commonly used oral anticoagulants, require regular anticoagulation monitoring. If well-controlled (international normalized ratio 2-3, in elderly patients preferably 2-2.5), oral anticoagulation prevents more than half of ischemic strokes related to atrial fibrillation, while bleeding complications are rare. In the follow-up of low risk patients (CHADS2-Score 0), oral anticoagulation becomes necessary when risk factors for thromboembolic complications develop. If a stroke occurs during oral anticoagulation and an INR>2 in a patient with atrial fibrillation, other causes than thromboembolic events should be considered. New anticoagulants--especially direct thrombin antagonists--are currently evaluated in clinical trials and may in the future facilitate anticoagulation in patients with atrial fibrillation.
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Affiliation(s)
- S Zellerhoff
- Medizinische Klinik und Poliklinik C, Kardiologie und Angiologie, Kompetenznetz Vorhofflimmern, Universitätsklinikum Münster, Albert-Schweitzer-Strasse 33, 48149, Münster, Germany
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462
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Linhart M, Lewalter T. [Electrical and pharmacological strategies for early cardioversion of atrial fibrillation]. Herzschrittmacherther Elektrophysiol 2006; 17:81-8. [PMID: 16786466 DOI: 10.1007/s00399-006-0514-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2006] [Accepted: 05/09/2006] [Indexed: 05/10/2023]
Abstract
Cardioversion of atrial fibrillation as an element of rhythm control strategy is indicated in patients with first episode of atrial fibrillation, hemodynamic instability, recurrent atrial fibrillation with low probability of spontaneous conversion, or severe symptoms. Early cardioversion is performed within 48 h of onset of atrial fibrillation. The best point in time is still unknown. It can be performed by pharmacological, or, preferentially, by electrical cardioversion. The advantages of electrical cardioversion are higher efficacy and no proarrhythmic risk, however, short time general anaesthesia is needed. Electrical cardioversion is most effective when biphasic shocks are delivered. For pharmacological cardioversion, several antiarrhythmic drugs are available which have to be considered individually. Thromboembolic risk does not differ between the two methods. Early cardioversion and maintenance of sinus rhythm is most effective in atrial fibrillation of short duration, normal left atrial size and no or only mild structural heart disease.
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Affiliation(s)
- M Linhart
- Medizinische Klinik und Poliklinik II, Universitätsklinikum Bonn, Sigmund-Freud-Str. 25, 53105, Bonn, Germany.
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463
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Li H. Can we use a pacemaker to identify the trigger and substrate of atrial fibrillation? Heart Rhythm 2006; 3:689-90. [PMID: 16731471 DOI: 10.1016/j.hrthm.2006.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2006] [Indexed: 11/19/2022]
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464
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Abstract
Although the maintenance of sinus rhythm would be the ideal scenario for patients with atrial fibrillation (AF), recent randomised trials have questioned the value of this approach. A careful interpretation of their results showed the limited efficacy of currently available antiarrhythmic drugs in maintaining sinus rhythm, as well as their potentially serious side effects. Therefore, it is imperative to develop safer and more effective drugs for AF. Based on our improved understanding of the pathophysiology of AF and the mechanism of action of antiarrhythmic drugs, significant efforts are being made to develop new antiarrhythmic agents that would prevent electrophysiological remodelling, would be selective for the atria and, therefore, would not prolong ventricular repolarisation, thus lacking any proarrhythmic effect.
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Affiliation(s)
- Panos E Vardas
- Department of Cardiology, Heraklion University Hospital, 71000, Voutes, Heraklion, Crete, Greece.
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465
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Jolobe O. Inadvertent Toxic Drug Reaction in the Management of Atrial Fibrillation. Med Chir Trans 2006; 99:220. [PMID: 16672751 PMCID: PMC1457752 DOI: 10.1177/014107680609900509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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466
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Vijayalakshmi K, Whittaker VJ, Sutton A, Campbell P, Wright RA, Hall JA, Harcombe AA, Linker NJ, Stewart MJ, Davies A, de Belder MA. A randomized trial of prophylactic antiarrhythmic agents (amiodarone and sotalol) in patients with atrial fibrillation for whom direct current cardioversion is planned. Am Heart J 2006; 151:863.e1-6. [PMID: 16569550 DOI: 10.1016/j.ahj.2005.09.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2004] [Accepted: 09/14/2005] [Indexed: 11/17/2022]
Abstract
UNLABELLED Antiarrhythmic agents enhance maintenance of sinus rhythm (SR) after direct current cardioversion (DCC) for atrial fibrillation but there are few comparative trials. BACKGROUND The aims of the study were (1) to establish whether patients successfully cardioverted to SR are more likely to stay in SR over 6 months if taking amiodarone or sotalol, and if so, to establish whether one agent is better than the other; (2) to establish whether taking amiodarone or sotalol is better at achieving chemical cardioversion within the 6 weeks before DCC; and (3) to establish whether DCC is more likely to be successful on a drug. METHODS Randomized, prospective, nonblinded, controlled study of treatment with either amiodarone (n = 27), sotalol (n = 36), or no antiarrhythmic agent (n = 31). RESULTS Chemical cardioversion occurred in 7 patients in the amiodarone group (A), 7 patients in the sotalol group (S), but none in the no-antiarrhythmic group (N). A total of 33 (92%) patients in the sotalol group, 22 (81%) patients in the amiodarone group, and 23 (74%) patients in the no-antiarrhythmic group were in SR after cardioversion. Of the original cohort of patients, 17 (63%) patients in the amiodarone group remained in SR at 6-month follow-up, compared with 14 (39%) in the sotalol group and 5 (16%) in the no-antiarrhythmic group (A vs N, P < .0002, P < .0006B [after Bonferroni correction]; A vs S, P = .05, P = .15B; and S vs N, P = .03, P = .09B). CONCLUSIONS Amiodarone and sotalol achieved chemical cardioversion before planned electrical cardioversion in 26% and 19% of patients, respectively. After successful cardioversion, amiodarone appears better than sotalol at maintaining SR at 6 months.
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Affiliation(s)
- Kunadian Vijayalakshmi
- Department of Cardiology, The James Cook University Hospital, Middlesbrough, United Kingdom
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467
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Scheinman MM, Keung E. The Year in Clinical Electrophysiology. J Am Coll Cardiol 2006; 47:1207-13. [PMID: 16545653 DOI: 10.1016/j.jacc.2005.12.043] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2005] [Accepted: 12/21/2005] [Indexed: 11/24/2022]
Affiliation(s)
- Melvin M Scheinman
- Cardiac Electrophysiology, University of California San Francisco, San Francisco, California 94143, USA.
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468
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Affiliation(s)
- Susannah K Leaver
- Knight Centre for Cystic Fibrosis, Frimley Park Hospital NHS Foundation Trust, Camberley, Surrey GU16 7UJ, UK
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469
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Fujiki A. [Present status in and prospects for anti-arrhythmic drug therapy: How to use type III anti-arrhythmic agents]. NIHON NAIKA GAKKAI ZASSHI. THE JOURNAL OF THE JAPANESE SOCIETY OF INTERNAL MEDICINE 2006; 95:253-60. [PMID: 16536075 DOI: 10.2169/naika.95.253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
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Abstract
Atrial fibrillation is the most common sustained cardiac arrhythmia, and contributes greatly to cardiovascular morbidity and mortality. Many aspects of the management of atrial fibrillation remain controversial. We address nine specific controversies in atrial fibrillation management, briefly focusing on the relations between mechanisms and therapy, the roles of rhythm and rate control, the definition of optimum rate control, the need for early cardioversion to prevent remodelling, the comparison of electrical with pharmacological cardioversion, the selection of patients for long-term oral anticoagulation, the roles of novel long-term anticoagulation approaches and ablation therapy, and the potential usefulness of upstream therapy targeting substrate development. The background of every controversy is reviewed and our opinions expressed. Here, we hope to inform physicians about the most important controversies in this specialty and stimulate investigators to address unresolved issues.
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Affiliation(s)
- Stanley Nattel
- Department of Medicine and Research Centre, Montreal Heart Institute, University of Montreal, Montreal, Quebec H1T 1C8, Canada.
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471
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Abstract
Supraventricular tachycardias consist of AV-nodal-reentrant-tachycardias, atrioventricular tachycardias with accessory pathways (WPW-syndrome), atrial tachycardias, atrial fibrillation and atrial flutter. Only specific ECG interpretation with an exact arrhythmia classification offers the way to perform modern differential therapy including drug treatment and also interventional therapy modalities. In atrial fibrillation, drug treatment is still first-line therapy: physicians have to make a decision either to follow the rate or rhythm control concept. In case of rhythm control, drug therapy is tailored to the individual patient taking into account the patients symptomatology, left ventricular ejection fraction and nature and degree of an underlying cardiac disease. Drug refractory symptomatic atrial fibrillation patients should be considered for interventional treatment like pulmonary vein ablation. Recurrent typical right atrial flutter, AV-nodal-reentrant-tachycardia and all forms of atrioventricular tachycardias however are indications for catheter ablation; long-term drug treatment will only be performed in rare cases.
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Affiliation(s)
- T Lewalter
- Medizinische Klinik und Poliklinik II, Universitätsklinikum Bonn, Sigmund-Freud-Strasse 25, 53105 Bonn.
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472
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Fernández Lozano I, Merino Llorens JL. Temas de actualidad 2005: electrofisiología y arritmias. Rev Esp Cardiol 2006; 59 Suppl 1:20-30. [PMID: 16540017 DOI: 10.1157/13084445] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Cardiac electrophysiology laboratories deal with a wide range of pathological conditions, diagnostic techniques, and treatments. Since a huge quantity of material has been published in recent months, this article will be limited to discussion of the most significant developments in the prognostic evaluation of arrhythmias, hereditary disease, syncope, atrial fibrillation, implantable cardioverter-defibrillators, cardiac resynchronization therapy, and catheter ablation. Even within these areas, discussion will be restricted to specific concrete topics and to a limited number of publications that were judged to have important implications for clinical practice. Our principal aim was to provide clinical cardiologists with an overview of the latest developments in cardiac electrophysiology.
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473
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Heist EK, Ruskin JN. Atrial Fibrillation and Congestive Heart Failure: Risk Factors, Mechanisms, and Treatment. Prog Cardiovasc Dis 2006; 48:256-69. [PMID: 16517247 DOI: 10.1016/j.pcad.2005.09.001] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Atrial fibrillation (AF) and congestive heart failure (CHF) are commonly encountered together, and either condition predisposes to the other. Risk factors for AF and CHF include age, hypertension, valve disease, and myocardial infarction, as well as a variety of medical conditions and genetic variants. Congestive heart failure and AF share common mechanisms, including myocardial fibrosis and dysregulation of intracellular calcium and neuroendocrine function. Pharmacological treatments including beta-blockers, digoxin, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers can be useful in treating both of these conditions. Antiarrhythmic medications intended to achieve and maintain sinus rhythm may be beneficial in some patients with AF and CHF. Advances in pacemaker and defibrillator therapy, including cardiac resynchronization therapy, may also benefit patients with AF and CHF. Surgical and catheter-based ablation therapy can restore sinus rhythm in patients with AF, with proven benefit in patients with concommitant CHF. Investigational biologic therapy, including cell and gene based therapy, offers promise for the future of reversing the pathophysiological mechanisms that underlie AF and CHF.
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Affiliation(s)
- E Kevin Heist
- Cardiac Arrhythmia Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
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474
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Hu CL, Jiang H, Tang QZ, Zhang QH, Chen JB, Huang CX, Li GS. Comparison of rate control and rhythm control in patients with atrial fibrillation after percutaneous mitral balloon valvotomy: a randomised controlled study. Heart 2005; 92:1096-101. [PMID: 16387819 PMCID: PMC1861118 DOI: 10.1136/hrt.2005.080325] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To compare rate control and rhythm control strategies in patients with atrial fibrillation (AF) after percutaneous mitral balloon valvotomy (PMV). METHODS 183 patients with AF after successful PMV, with AF duration <or= 12 months and post-PMV left atrial (LA) size <or= 45 mm, were studied in a prospective, randomised trial. The primary end point was improvement in AF-related symptoms. Secondary study end points were 6 min walk tests, quality of life (QOL), normalisation of LA size, number of hospital admissions and duration of hospital stay. RESULTS Over one year, 2% patients in the rate control group had sinus rhythm, as compared with 96% of patients in the rhythm control group (p < 0.001). A greater proportion of patients reported improvement in symptoms in the rhythm control group than in the rate control group (p < 0.0001 at every visit time). Walking distance in a 6 min walk test, QOL and LA size normalisation were better in the rhythm control group than in the rate control group. The strategy of rhythm control was associated with similar numbers of hospital admissions but with longer duration of hospital admissions. Drug-related side effect did not differ between the rate control and rhythm control groups. During the follow-up period, no patients in either group had embolic or transitory ischaemic neurological events. CONCLUSIONS In patients with AF after PMV, AF duration <or= 12 months and post-PMV LA size <or= 45 mm, sinus rhythm was easy and safe to achieve and maintain. Moreover, patients benefited from restoration and maintenance of sinus rhythm in terms of improved AF-related symptoms, 6 min walk tests and QOL, and of LA size normalisation. Rhythm control should therefore be considered as the preferred initial therapy for this group of patients. The optimal strategy to treat AF after PMV should be individualised.
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Affiliation(s)
- C L Hu
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China.
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475
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Kirchhof P. Cardiovert!--or better wait a little? Systematic evidence that the initial hours of atrial fibrillation are a "special time". Heart Rhythm 2005; 2:1330-1. [PMID: 16360085 DOI: 10.1016/j.hrthm.2005.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2005] [Indexed: 11/24/2022]
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476
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Gerstenfeld EP. Does Rhythm Control Improve Functional Status in Patients With Atrial Fibrillation?**Editorials published in the Journal of the American College of Cardiologyreflect the views of the authors and do not necessarily represent the views of JACCor the American College of Cardiology. J Am Coll Cardiol 2005; 46:1900-1. [PMID: 16286178 DOI: 10.1016/j.jacc.2005.08.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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477
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Tse HF, Lau CP. Catheter Ablation for Persistent Atrial Fibrillation: Are We Ready for "Prime Time"? J Cardiovasc Electrophysiol 2005; 16:1148-9. [PMID: 16302894 DOI: 10.1111/j.1540-8167.2005.50573.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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478
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Kirchhof P, Fetsch T, Hanrath P, Meinertz T, Steinbeck G, Lehmacher W, Breithardt G. Targeted pharmacological reversal of electrical remodeling after cardioversion--rationale and design of the Flecainide Short-Long (Flec-SL) trial. Am Heart J 2005; 150:899. [PMID: 16290956 DOI: 10.1016/j.ahj.2005.07.020] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2005] [Accepted: 07/12/2005] [Indexed: 11/28/2022]
Abstract
Persistent atrial fibrillation (AF) causes relevant mortality and cardiovascular and noncardiovascular morbidity. Therefore, maintenance of sinus rhythm is an important clinical goal, especially when the patient is symptomatic, despite the fact that current treatment strategies are not sufficient to completely prevent recurrent AF. In addition to underlying atrial disease that predisposes to AF, AF in itself induces structural and electrical adaptations ("electrical remodeling" and "structural remodeling"). Underlying disease processes and parts of structural remodeling are not always reversible. Electrical remodeling, in contrast, is reversed by a few weeks of maintenance of sinus rhythm under experimental conditions. This corresponds to the period when most of the recurrent episodes of AF occur after cardioversion. Antiarrhythmic drugs that prolong the atrial action potential can assist in the prevention of recurrent AF by promoting the reversal of electrical remodeling. Such drugs, which are currently used over long periods after cardioversion, may only be needed until the physiological action potential duration is restored, for example, during the first few weeks after cardioversion of persistent AF. This treatment concept that we call "targeted pharmacological reversal of electrical remodeling" would limit both cost and drug-induced side effects of antiarrhythmic drug therapy after cardioversion. The Flec-SL trial, ISECTN62728743, therefore tests the main hypothesis that targeted pharmacological reversal of electrical remodeling by short-term antiarrhythmic drug therapy for 4 weeks after cardioversion is not inferior to standard long-term antiarrhythmic drug therapy for the prevention of recurrent AF after cardioversion in a parallel group, randomized, multicenter, open, blinded end point analysis design. Based on its effectiveness and pharmacokinetic profile, flecainide is used to test the study hypothesis. The trial uses daily transtelephonic electrocardiographic monitoring for all patients and will be conducted within the German Atrial Fibrillation Competence NETwork (AFNET) to facilitate inclusion of patients from electrophysiologically oriented cardiology centers, ordinary hospitals, and office-based physicians.
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Affiliation(s)
- Paulus Kirchhof
- Department of Cardiology and Angiology, Hospital of the University of Münster, Germany.
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479
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Wadhani N, Singh BN. Prolongation of repolarization as antifibrillatory action revisited: drug combination therapy in atrial fibrillation. J Cardiovasc Pharmacol Ther 2005; 10:149-52. [PMID: 16211202 DOI: 10.1177/107424840501000301] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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480
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Reynolds DW, Chen PS, Deal BJ, Donahue JK, Ellenbogen KA, Epstein AE, Friedman PA, Hammill SC, Hohnloser SH, Kanter RJ, Lindsay BD, Natale A, Saffitz J, Stevenson WG. Highlights of Heart Rhythm 2005, the Annual Scientific Sessions of the Heart Rhythm Society, May 4-7, 2005, New Orleans, Louisiana. Heart Rhythm 2005; 2:1025-33. [PMID: 16171766 DOI: 10.1016/j.hrthm.2005.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2005] [Indexed: 11/24/2022]
Affiliation(s)
- Dwight W Reynolds
- Cardiovascular Section, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma 73190, USA.
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481
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Affiliation(s)
- Laurie G. Futterman
- The Division of Cardiology, Department of Medicine, University of Miami School of Medicine, Miami, Fla
| | - Louis Lemberg
- The Division of Cardiology, Department of Medicine, University of Miami School of Medicine, Miami, Fla
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482
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Rubinstein J. Amiodarone versus sotalol for atrial fibrillation. N Engl J Med 2005; 353:627-30; author reply 627-30. [PMID: 16093474 DOI: 10.1056/nejm200508113530618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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483
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Generali J. Recent Publications on Medications and Pharmacy. Hosp Pharm 2005. [DOI: 10.1177/001857870504000711] [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
Hospital Pharmacy presents a new feature to keep pharmacists abreast of new publications in the medical/pharmacy literature. Articles of interest will be abstracted monthly regarding a broad scope of topics.
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Affiliation(s)
- Joyce Generali
- Drug Information Center, Kansas University Medical Center, Kansas City, KS
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484
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Singh BN. Atrial fibrillation: the rate or rhythm controversy can it be resolved on the basis of clinical trial data? J Cardiovasc Pharmacol Ther 2005; 10:81-3. [PMID: 15965558 DOI: 10.1177/107424840501000201] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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485
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486
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Abstract
DNA methylation is a stable but not irreversible epigenetic signal that silences gene expression. It has a variety of important functions in mammals, including control of gene expression, cellular differentiation and development, preservation of chromosomal integrity, parental imprinting and X-chromosome inactivation. In addition, it has been implicated in brain function and the development of the immune system. Somatic alterations in genomic methylation patterns contribute to the etiology of human cancers and ageing. It is tightly interwoven with the modification of histone tails and other epigenetic signals. Here we review our current understanding of the molecular enzymology of the mammalian DNA methyltransferases Dnmt1, Dnmt3a, Dnmt3b and Dnmt2 and the roles of the enzymes in the above-mentioned biological processes.
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Affiliation(s)
- A Hermann
- Institut für Biochemie, FB 8, Justus-Liebig-Universität, Heinrich-Buff-Ring 58, 35392, Giessen, Germany
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