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Smit MD, Maass AH, De Jong AM, Muller Kobold AC, Van Veldhuisen DJ, Van Gelder IC. Role of inflammation in early atrial fibrillation recurrence. Europace 2012; 14:810-7. [PMID: 22237586 DOI: 10.1093/europace/eur402] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
AIMS Outcome of rhythm control in atrial fibrillation (AF) is still poor due to various mechanisms involved in the initiation and perpetuation of AF. Differences in timing of AF recurrence may depend on different types of mechanisms. The aim of this study was to assess the mechanisms involved in early AF recurrence in patients with short-lasting AF. METHODS AND RESULTS Patients with short-lasting persistent AF undergoing rhythm control (n= 100) were included. Markers of mechanisms involved in the initiation and perpetuation of AF were assessed, including clinical factors, echocardiographic parameters, and biomarkers. Primary endpoint was early AF recurrence (recurrence <1 month). Secondary endpoint was progression to permanent AF. Median total AF history was short: 4.2 months. Early AF recurrences occurred in 30 patients (30%) after a median of 6 (inter-quartile range 2-14) days. Baseline log(2) interleukin (IL)-6 [adjusted hazard ratio (HR) 1.3, 95% confidence interval (CI) 1.0-1.7, P= 0.02] and present or previous smoking (adjusted HR 3.6, 95% CI 1.2-10.9, P= 0.03) were independently associated with early AF recurrence, suggesting that inflammation played an important role in early recurrences. Atrial fibrillation became permanent in 29 patients (29%). Baseline transforming growth factor-β1, left ventricular ejection fraction, and early AF recurrence were independently associated with progression to permanent AF. CONCLUSION In patients with short-lasting AF, early AF recurrence seemed to be associated with inflammation as represented by IL-6. Treatment aimed against inflammation may therefore prevent early AF recurrences, which can improve rhythm control outcome.
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Affiliation(s)
- Marcelle D Smit
- Department of Cardiology, Thoraxcenter, University Medical Center Groningen, University of Groningen, PO Box 30.001, 9700 RB Groningen, The Netherlands.
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Rasoli S, Kakouros N, Harling L, Gukop P, Soni M, Athanasiou T, Kourliouros A. Antioxidant vitamins in the prevention of atrial fibrillation: what is the evidence? Cardiol Res Pract 2011; 2011:164078. [PMID: 21876823 PMCID: PMC3162973 DOI: 10.4061/2011/164078] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2010] [Accepted: 05/19/2011] [Indexed: 12/22/2022] Open
Abstract
Atrial fibrillation (AF) is the most common sustained arrhythmia that is associated with significant morbidity and mortality. Current available therapies remain inadequate in symptom control and secondary prevention and are often associated with significant side effects. The mechanisms underlying the pathogenesis of AF are poorly understood, although electrophysiological remodeling has been described as an important initiating step. Recently, increasing evidence implicates oxidative stress and inflammation in the pathogenesis of AF. We searched the literature for evidence to support the use of antioxidant vitamins C and E in the prevention of AF. These vitamins, through their reactive-oxygen-species- (ROS-) scavenging effect, have shown a role in AF prevention in both animal and small clinical studies. The available evidence, however, is currently insufficient to support recommendations for their use in the wider patient population. Larger-scale clinical studies are required to confirm these preliminary results. Research is also required to further the understanding of the processes involved in the pathogenesis of AF and the role of antioxidant therapies to prevent the arrhythmia.
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Affiliation(s)
- Sonia Rasoli
- Department of Cardiothoracic Surgery, St George's Hospital, London SW17 0QT, UK
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Nodari S, Triggiani M, Campia U, Manerba A, Milesi G, Cesana BM, Gheorghiade M, Dei Cas L. n-3 polyunsaturated fatty acids in the prevention of atrial fibrillation recurrences after electrical cardioversion: a prospective, randomized study. Circulation 2011; 124:1100-6. [PMID: 21844082 DOI: 10.1161/circulationaha.111.022194] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND n-3 polyunsaturated fatty acids (n-3 PUFAs) exert antiarrhythmic effects and reduce sudden cardiac death. However, their role in the prevention of atrial fibrillation remains controversial. We aimed to determine the effect of n-3 PUFAs in addition to amiodarone and a renin-angiotensin-aldosterone system inhibitor on the maintenance of sinus rhythm after direct current cardioversion in patients with persistent atrial fibrillation. METHODS AND RESULTS We conducted a randomized, double-blind, placebo-controlled, parallel-arm trial in patients with persistent atrial fibrillation, with at least 1 relapse after cardioversion, and treated with amiodarone and a renin-angiotensin-aldosterone system inhibitor. Participants were assigned to placebo or n-3 PUFAs 2 g/d and then underwent direct current cardioversion 4 weeks later. The primary end point was the probability of maintenance of sinus rhythm at 1 year after cardioversion. Of 254 screened patients, 199 were found to be eligible and randomized. At the 1-year follow up, the probability of maintenance of sinus rhythm was significantly higher in the n-3 PUFAs-treated patients compared with the placebo group (hazard ratio, 0.62 [95% confidence interval, 0.52 to 0.72] and 0.36 [95% confidence interval, 0.26 to 0.46], respectively; P=0.0001). CONCLUSIONS In patients with persistent atrial fibrillation on amiodarone and a renin-angiotensin-aldosterone system inhibitor, the addition of n-3 PUFAs 2 g/d improves the probability of the maintenance of sinus rhythm after direct current cardioversion. Our data suggest that n-3 PUFAs may exert beneficial effects in the prevention of atrial fibrillation recurrence. Further studies are needed to confirm and expand our findings. Clinical Trial Registration- URL: http://www.clinicaltrials.gov. Unique identifier: NCT01198275.
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Affiliation(s)
- Savina Nodari
- Department of Experimental and Applied Medicine, Section of Cardiovascular Diseases, University of Brescia Medical School, P. le Spedali Civili, 1-25123 Brescia, Italy
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Alcaraz R, Hornero F, Rieta JJ. Noninvasive time and frequency predictors of long-standing atrial fibrillation early recurrence after electrical cardioversion. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2011; 34:1241-50. [PMID: 21605132 DOI: 10.1111/j.1540-8159.2011.03125.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Several clinical factors have been studied to predict atrial fibrillation (AF) recurrence after electrical cardioversion (ECV) with limited predictive value. METHODS A method able to predict robustly long-standing AF early recurrence by characterizing noninvasively the electrical atrial activity (AA) with parameters related to its time course and spectral features is presented. To this respect, 63 patients (20 men and 43 women; mean age 73.4 ± 9.0 years; under antiarrhythmic drug treatment with amiodarone) who were referred for ECV of persistent AF were studied. During a 4-week follow-up, AF recurrence was observed in 41 patients (65.1%). RESULTS RR variability and the studied AA spectral features, including dominant atrial frequency (DAF), its first harmonic and their amplitude, provided poor statistical differences between groups. On the contrary, f waves power (fWP) and Sample Entropy (SampEn) of the AA behaved as very good predictors. Patients who relapsed to AF presented lower fWP (0.036 ± 0.019 vs 0.081 ± 0.029 n.u.(2) , P < 0.001) and higher SampEn (0.107 ± 0.022 vs 0.086 ± 0.033, P < 0.01). Furthermore, fWP presented the highest predictive accuracy of 82.5%, whereas SampEn provided a 79.4%. The remaining features revealed accuracies lower than 70%. A stepwise discriminant analysis (SDA) provided a model based on fWP and SampEn with 90.5% of accuracy. CONCLUSIONS The fWP has proved to predict long-standing AF early recurrence after ECV and can be combined with SampEn to improve its diagnostic ability. Furthermore, a thorough analysis of the results allowed outlining possible associations between these two features and the concomitant status of atrial remodeling.
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Affiliation(s)
- Raúl Alcaraz
- Innovation in Bioengineering Research Group, University of Castilla-La Mancha, Cuenca, Spain.
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Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA, Halperin JL, Kay GN, Le Huezey JY, Lowe JE, Olsson SB, Prystowsky EN, Tamargo JL, Wann LS. 2011 ACCF/AHA/HRS Focused Updates Incorporated Into the ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation. Circulation 2011; 123:e269-367. [PMID: 21382897 DOI: 10.1161/cir.0b013e318214876d] [Citation(s) in RCA: 592] [Impact Index Per Article: 45.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA, Halperin JL, Kay GN, Le Huezey JY, Lowe JE, Olsson SB, Prystowsky EN, Tamargo JL, Wann LS. 2011 ACCF/AHA/HRS Focused Updates Incorporated Into the ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation. J Am Coll Cardiol 2011; 57:e101-98. [PMID: 21392637 DOI: 10.1016/j.jacc.2010.09.013] [Citation(s) in RCA: 642] [Impact Index Per Article: 49.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Schotten U, Verheule S, Kirchhof P, Goette A. Pathophysiological mechanisms of atrial fibrillation: a translational appraisal. Physiol Rev 2011; 91:265-325. [PMID: 21248168 DOI: 10.1152/physrev.00031.2009] [Citation(s) in RCA: 852] [Impact Index Per Article: 65.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Atrial fibrillation (AF) is an arrhythmia that can occur as the result of numerous different pathophysiological processes in the atria. Some aspects of the morphological and electrophysiological alterations promoting AF have been studied extensively in animal models. Atrial tachycardia or AF itself shortens atrial refractoriness and causes loss of atrial contractility. Aging, neurohumoral activation, and chronic atrial stretch due to structural heart disease activate a variety of signaling pathways leading to histological changes in the atria including myocyte hypertrophy, fibroblast proliferation, and complex alterations of the extracellular matrix including tissue fibrosis. These changes in electrical, contractile, and structural properties of the atria have been called "atrial remodeling." The resulting electrophysiological substrate is characterized by shortening of atrial refractoriness and reentrant wavelength or by local conduction heterogeneities caused by disruption of electrical interconnections between muscle bundles. Under these conditions, ectopic activity originating from the pulmonary veins or other sites is more likely to occur and to trigger longer episodes of AF. Many of these alterations also occur in patients with or at risk for AF, although the direct demonstration of these mechanisms is sometimes challenging. The diversity of etiological factors and electrophysiological mechanisms promoting AF in humans hampers the development of more effective therapy of AF. This review aims to give a translational overview on the biological basis of atrial remodeling and the proarrhythmic mechanisms involved in the fibrillation process. We pay attention to translation of pathophysiological insights gained from in vitro experiments and animal models to patients. Also, suggestions for future research objectives and therapeutical implications are discussed.
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Affiliation(s)
- Ulrich Schotten
- Department of Physiology, University Maastricht, Maastricht, The Netherlands.
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Bhuriya R, Singh M, Sethi A, Molnar J, Bahekar A, Singh PP, Khosla S, Arora R. Prevention of recurrent atrial fibrillation with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers: a systematic review and meta-analysis of randomized trials. J Cardiovasc Pharmacol Ther 2011; 16:178-84. [PMID: 21285399 DOI: 10.1177/1074248410389045] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Controversy persists regarding the efficacy of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) in the prevention of recurrent atrial fibrillation (AF). We performed a meta-analysis of randomized controlled trials (RCTs), not designed a priori to test this hypothesis, to explore whether ACEs and ARBs reduce recurrent AF. METHODS We performed a systematic literature search for RCTs using ACEIs or ARBs and providing data on the outcome of recurrent AF. Statistical heterogeneity across the trials was tested using the Cochran Q statistic and I(2) was computed to quantify heterogeneity. A 2-sided α error of less than .05 was considered statistically significant (P < .05). RESULTS The analysis was based on 8 RCTs including 2323 patients. The Mantel-Haenszel random-effect model was used to calculate relative risk (RR) for studies using ACEIs or ARBs, and for studies using ARBs. The fixed-effect model was used to calculate RR for studies using ACEIs. Meta-analysis of the studies revealed that ACEIs or ARBs significantly reduced the incidence of recurrent AF (RR, 0.611; 95% CI, 0.441-0.847; P = .003). The RR for recurrent AF was 0.643 (95% CI, 0.439-0.941; P = .023) for studies using ARBs and 0.54 (95% CI, 0.377-0.80; P = .002) for studies using ACEIs. CONCLUSION In this meta-analysis of RCTs not designed a priori to test the hypothesis, ACEs and ARBs were associated with a significant reduction in recurrent AF. Large-scale randomized trials designed a priori to test the hypothesis are necessary to complete the totality of evidence.
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Affiliation(s)
- Rohit Bhuriya
- Division of Cardiology, Department of Medicine, The Chicago Medical School, North Chicago, IL 60064, USA.
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Koyama T, Tada H, Sekiguchi Y, Arimoto T, Yamasaki H, Kuroki K, Machino T, Tajiri K, Zhu XD, Kanemoto-Igarashi M, Sugiyasu A, Kuga K, Nakata Y, Aonuma K. Prevention of atrial fibrillation recurrence with corticosteroids after radiofrequency catheter ablation: a randomized controlled trial. J Am Coll Cardiol 2010; 56:1463-72. [PMID: 20951321 DOI: 10.1016/j.jacc.2010.04.057] [Citation(s) in RCA: 117] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2009] [Revised: 03/10/2010] [Accepted: 04/13/2010] [Indexed: 02/09/2023]
Abstract
OBJECTIVES We sought to clarify the efficacy of corticosteroid therapy for preventing atrial fibrillation (AF) recurrence after pulmonary vein isolation (PVI). BACKGROUND The inflammatory process may cause acute AF recurrence after PVI. However, no studies have examined the relationship between corticosteroid administration and AF recurrence after PVI. METHODS A total of 125 patients with paroxysmal AF were randomized to receive either corticosteroids (corticosteroid group) or a placebo (placebo group). In the corticosteroid group, intravenous hydrocortisone (2 mg/kg) was given the day of the procedure, and oral prednisolone (0.5 mg/kg/day) was administered for 3 days after the PVI. The body temperature and high-sensitivity C-reactive protein level were measured before and on each of the first 3 days after ablation. RESULTS The prevalence of immediate AF recurrence (≤3 days after the PVI) was significantly lower in the corticosteroid group (7%) than in the placebo group (31%). The maximum body temperature and C-reactive protein during the initial 3 days after ablation and the increase in the body temperature and C-reactive protein level from baseline were significantly lower in the corticosteroid group than in the placebo group. Corticosteroid treatment did not decrease AF recurrences between 4 and 30 days after ablation. The AF-free rate at 14 months post-ablation was greater in the corticosteroid group (85%) than in the placebo group (71%, p=0.032 by the log-rank test). CONCLUSIONS Transient use of small amounts of corticosteroids shortly after AF ablation may be effective and safe for preventing not only immediate AF recurrences but also AF recurrences during the mid-term follow-up period after PVI.
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Affiliation(s)
- Takashi Koyama
- Institute of Clinical Medicine, Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Japan.
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Nabauer M, Gerth A, Kirchhof P, Goette A, Limbourg T, Sprenger C, Hoffmann B, Willems S, Doll N, Schuchert A, Oeff M, Ravens U, Meinertz T, Steinbeck G, Breithardt G. [Registry and studies of the German Competence Network on Atrial Fibrillation (AFNET)]. Herzschrittmacherther Elektrophysiol 2010; 21:153-159. [PMID: 20676664 DOI: 10.1007/s00399-010-0097-7] [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] [Indexed: 05/29/2023]
Abstract
The German Competence Network on Atrial Fibrillation (AFNET) is a national interdisciplinary research network funded by the Federal Ministry of Education and Research (BMBF). AFNET was initiated in 2003 and aims at improving treatment of atrial fibrillation (AF), the most frequent sustained cardiac arrhythmia. AFNET has established a nationwide patient registry on diagnostics, therapy, course and complications of AF in Germany. The data analyzed to date demonstrate that patients with AF are likely to have multiple co-morbidities, such as hypertension, valvular heart disease, coronary artery disease, diabetes mellitus and advanced age. Oral anticoagulation is provided to the majority of patients in accordance with the recommendations given by guidelines. Further areas of research deal with the optimal duration of antiarrhythmic therapy following electrical cardioversion of atrial fibrillation and the value of strategies to prevent arrhythmogenic changes, such as fibrosis in the atria, for prevention of further episodes of atrial fibrillation. Additional registry projects were established for patients with catheter-based interventional therapy of atrial fibrillation and surgical ablation to define success, complications and long term results of these recently developed procedures more clearly. Data and insights gathered from these projects were used to further develop standards of care in two international conferences.
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Affiliation(s)
- M Nabauer
- Medizinischen Klinik und Poliklinik I, Ludwig-Maximilians-Universität - Campus Grosshadern, Marchioninistr. 15, 81377, München, Deutschland.
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Rondano E, Dell'Era G, De Luca G, Piccinino C, Bellomo G, Marino PN. Left atrial asynchrony is a major predictor of 1-year recurrence of atrial fibrillation after electrical cardioversion. J Cardiovasc Med (Hagerstown) 2010; 11:499-506. [DOI: 10.2459/jcm.0b013e32833757b5] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Dell'Era G, Rondano E, Franchi E, Marino PN. Atrial asynchrony and function before and after electrical cardioversion for persistent atrial fibrillation. EUROPEAN JOURNAL OF ECHOCARDIOGRAPHY 2010; 11:577-83. [DOI: 10.1093/ejechocard/jeq010] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Left Atrial Electromechanical Conduction Time Can Predict Six-Month Maintenance of Sinus Rhythm After Electrical Cardioversion in Persistent Atrial Fibrillation by Doppler Tissue Echocardiography. J Am Soc Echocardiogr 2010; 23:309-14. [DOI: 10.1016/j.echo.2009.12.019] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2009] [Indexed: 11/21/2022]
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Biosignalverarbeitung. BIOMED ENG-BIOMED TE 2010. [DOI: 10.1515/bmt.2010.705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Alcaraz R, Rieta J. A review on sample entropy applications for the non-invasive analysis of atrial fibrillation electrocardiograms. Biomed Signal Process Control 2010. [DOI: 10.1016/j.bspc.2009.11.001] [Citation(s) in RCA: 121] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Toutouzas K, Drakopoulou M, Stefanadi E, Tousoulis D, Synetos A, Stefanadis C, Lerakis S, Lerakis S. The Role of Inflammation in Atrial Fibrillation: A Myth or a Fact? Am J Med Sci 2009; 338:494-9. [DOI: 10.1097/maj.0b013e3181b271a9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Rennison JH, Van Wagoner DR. Impact of dietary fatty acids on cardiac arrhythmogenesis. Circ Arrhythm Electrophysiol 2009; 2:460-9. [PMID: 19808503 DOI: 10.1161/circep.109.880773] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Julie H Rennison
- Department of Molecular Cardiology, The Cleveland Clinic, Cleveland, Ohio 44195, USA
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Lan X, Su L, Ling Z, Liu Z, Wu J, Yang X, Zrenner B, Yin Y. Catheter ablation vs. amiodarone plus losartan for prevention of atrial fibrillation recurrence in patients with paroxysmal atrial fibrillation. Eur J Clin Invest 2009; 39:657-63. [PMID: 19490069 DOI: 10.1111/j.1365-2362.2009.02160.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Although amiodarone plus angiotensin II receptor blockers (ARBs) and catheter ablation may improve sinus rhythm maintenance of paroxysmal atrial fibrillation (AF), their clinical efficacies have not been compared. This prospective cohort study was designed to compare clinical efficacy of catheter ablation and amiodarone plus losartan on sinus rhythm maintenance in patients with paroxysmal AF. MATERIALS AND METHODS A total of 240 patients with paroxysmal AF were assigned to four groups. CPVA group (n = 60) was treated with circumferential pulmonary vein ablation (CPVA), SPVI group (n = 60) with segmental pulmonary vein isolation, AMIO group (n = 60) with amiodarone and AMIO + LO group (n = 60) with amiodarone plus losartan. The endpoint was documented recurrence of AF > 30 s by Holter or conventional 12-lead ECG in the 1-year follow-up period. RESULTS During 12 months of follow-up, the primary end point was reached in 28 patients in CPVA group, 14 patients in SPVI group, 25 patients in AMIO group and 13 patients in AMIO + LO group, respectively. The sinus rhythm in SPVI and AMIO + LO group were significant higher than that in CPVA and AMIO group (P < 0.01 and 0.025), and no difference between CPVA and AMIO group. The maintenance rate of sinus rhythm in SPVI group was similar to that in AMIO + LO group. CONCLUSIONS This study demonstrates that segmental pulmonary vein isolation in preventing AF recurrence is similar to amiodarone plus losartan, but it is superior to CPVA and amiodarone alone in patients with paroxysmal AF. Larger multicentre studies are needed to confirm its long-term outcomes.
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Affiliation(s)
- X Lan
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Dogan A, Akcay S, Karabacak M, Turker Y, Ozaydin M, Erdogan D. The effect of pretreatment with renin-angiotensin-aldosterone system blockers on cardioversion success and acute recurrence of atrial fibrillation. Int J Clin Pract 2009; 63:1017-23. [PMID: 19570119 DOI: 10.1111/j.1742-1241.2009.01997.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Renin-angiotensin-aldosterone system (RAS) may be activated during atrial fibrillation (AF). It is unclear whether RAS inhibition may facilitate cardioversion from AF and may prevent acute recurrence of AF (ARAF). We thus investigated the effect of pretreatment with RAS blockers on cardioversion success and ARAF in patients with AF scheduled for elective cardioversion. METHODS This observational study included 356 patients with AF undergoing elective pharmacological or electrical cardioversion. Of these patients, 135 were not included based on exclusion criteria and the remaining 221 patients were divided into RAS group (n = 116, 69 male) or non-RAS group (n = 105, 58 male) based on precardioversion use of any RAS blocker. RESULTS Hypertension, coronary heart disease and heart failure were more frequent in the RAS group. Cardioversion from AF was more successful in the RAS group than in the non-RAS group (%92 vs. %82, p = 0.026). The rate of ARAF was lower in RAS group compared with that in non-RAS group (17% vs. 31%, p = 0.026). In multivariate analysis, pretreatment with RAS blockers in addition to shock number and enlarged left atrium, independently predicted ARAF (OR: 0.33, 95% CI: 0.15-0.75, p = 0.008). Independent predictors of cardioversion success were shock number and left atrial dilatation, but not use of RAS blocker. CONCLUSION Precardioversion use of RAS blockers may reduce ARAF following successful cardioversion of AF, but did not improve electrical cardioversion.
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Affiliation(s)
- A Dogan
- Department of Cardiology, Medical School, Suleyman Demirel University, Isparta, Turkey.
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Mazza A, Bendini MG, Cristofori M, Nardi S, Leggio M, De Cristofaro R, Giordano A, Cozzari L, Giordano G, Cappato R. Baseline apnoea/hypopnoea index and high-sensitivity C-reactive protein for the risk of recurrence of atrial fibrillation after successful electrical cardioversion: a predictive model based upon the multiple effects of significant variables. Europace 2009; 11:902-9. [DOI: 10.1093/europace/eup107] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
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Koyama T, Sekiguchi Y, Tada H, Arimoto T, Yamasaki H, Kuroki K, Machino T, Tajiri K, Zhu XD, Kanemoto M, Sugiyasu A, Kuga K, Aonuma K. Comparison of characteristics and significance of immediate versus early versus no recurrence of atrial fibrillation after catheter ablation. Am J Cardiol 2009; 103:1249-54. [PMID: 19406267 DOI: 10.1016/j.amjcard.2009.01.010] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2008] [Revised: 01/05/2009] [Accepted: 01/05/2009] [Indexed: 02/09/2023]
Abstract
Atrial fibrillation (AF) recurrences after catheter ablation are common within the first month after AF ablation, and inflammatory processes may be related to AF genesis. This study aimed to clarify the relation between inflammatory processes and recurrence of AF after ablation and to characterize AF recurring within 3 days after ablation (immediate AF recurrence).The study included 186 patients with drug-refractory paroxysmal AF who underwent extensive pulmonary vein isolation. Body temperature and C-reactive protein level were measured before and consecutively on the first 3 days after ablation. Signs of pericarditis or atrial arrhythmias within 3 days after ablation were also monitored. Forty-five patients (24%) had immediate AF recurrence (immediate-AF-recurrence group), 27 (14%) had early recurrence 4 to 30 days after ablation (early-AF-recurrence group), and the remaining 114 (61%) had no AF recurrence within 1 month after ablation (no-AF-recurrence group). Increases in body temperature and C-reactive protein level from baseline in the immediate-AF-recurrence group were the highest among the 3 groups, and signs of pericarditis were observed in 15 of the 45 patients (33%) in the immediate-AF-recurrence group. Atrial premature contractions and nonsustained AF occurred most frequently in the early-AF-recurrence group. After 6-month follow-up, the AF-free rate was greater in the immediate-AF-recurrence group (76%) than in the early-AF-recurrence group (30%). In conclusion, immediate AF recurrence has an apparently different mechanism and impact on midterm outcomes than does early AF recurrence. Acute inflammatory changes after ablation may be responsible for immediate AF recurrence.
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Efremidis M, Alexanian IP, Oikonomou D, Manolatos D, Letsas KP, Pappas LK, Gavrielatos G, Vadiaka M, Mihas CC, Filippatos GS, Sideris A, Kardaras F. Predictors of atrial fibrillation recurrence in patients with long-lasting atrial fibrillation. Can J Cardiol 2009; 25:e119-24. [PMID: 19340356 DOI: 10.1016/s0828-282x(09)70070-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Limited data are available on the predictors of atrial fibrillation (AF) recurrence in patients with chronic AF. OBJECTIVES To evaluate potential clinical, echocardiographic and electrophysiological predictors of AF recurrence, after internal cardioversion for long-lasting AF. METHODS A total of 99 consecutive patients (63 men and 36 women, mean age 63.33+/-9.27 years) with long-standing AF (52.42+/-72.02 months) underwent internal cardioversion with a catheter that consisted of two defibrillating coils. Shocks were delivered according to a step-up protocol. Clinical follow-up and electrocardiographic recordings were performed on a monthly basis for a 12-month period or whenever patients experienced symptoms suggestive of recurrent AF. RESULTS Ninety-three patients (93.94%) underwent a successful uncomplicated cardioversion, with a mean atrial defibrillation threshold of 10.69+/-6.76 J. Immediate reinitiation of AF was observed in 15 patients (15.78%) of whom a repeated cardioversion restored sinus rhythm in 13 cases. Early recurrence of AF (within one week) was observed in 12 of 93 patients (12.90%). At the end of the 12-month follow-up period, during which seven patients were lost, 42 of the 86 remaining patients (48.84%) were still in sinus rhythm. Multivariate regression analysis showed that left atrial diameter (OR 1.126, 95% CI 1.015 to 1.249; P=0.025) and mitral A wave velocity (OR 0.972, 95% CI 0.945 to 0.999; P=0.044) were significant and independent predictors of AF recurrence, whereas age, left ventricular ejection fraction and AF cycle length were not predictive of arrhythmia recurrence. CONCLUSION The present study showed that the left atrial diameter and mitral A wave velocity are the only variables associated with AF recurrence after successful cardioversion.
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Affiliation(s)
- Michalis Efremidis
- Second Department of Cardiology, Evangelismos General Hospital of Athens, Athens, Greece.
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74
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Disertori M, Latini R, Barlera S, Franzosi MG, Staszewsky L, Maggioni AP, Lucci D, Di Pasquale G, Tognoni G. Valsartan for prevention of recurrent atrial fibrillation. N Engl J Med 2009; 360:1606-17. [PMID: 19369667 DOI: 10.1056/nejmoa0805710] [Citation(s) in RCA: 300] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Atrial fibrillation is the most common cardiac arrhythmia, and no current therapy is ideal for control of this condition. Experimental studies suggest that angiotensin II-receptor blockers (ARBs) can influence atrial remodeling, and some clinical studies suggest that they may prevent atrial fibrillation. METHODS We conducted a large, randomized, prospective, placebo-controlled, multicenter trial to test whether the ARB valsartan could reduce the recurrence of atrial fibrillation. We enrolled patients who were in sinus rhythm but had had either two or more documented episodes of atrial fibrillation in the previous 6 months or successful cardioversion for atrial fibrillation in the previous 2 weeks. To be eligible, patients also had to have underlying cardiovascular disease, diabetes, or left atrial enlargement. Patients were randomly assigned to receive valsartan or placebo. The two primary end points were the time to a first recurrence of atrial fibrillation and the proportion of patients who had more than one recurrence of atrial fibrillation over the course of 1 year. RESULTS A total of 1442 patients were enrolled in the study. Atrial fibrillation recurred in 371 of the 722 patients (51.4%) in the valsartan group, as compared with 375 of 720 (52.1%) in the placebo group (adjusted hazard ratio, 0.97; 96% confidence interval [CI], 0.83 to 1.14; P=0.73). More than one episode of atrial fibrillation occurred in 194 of 722 patients (26.9%) in the valsartan group and in 201 of 720 (27.9%) in the placebo group (adjusted odds ratio, 0.89; 99% CI, 0.64 to 1.23; P=0.34). The results were similar in all predefined subgroups of patients, including those who were not receiving angiotensin-converting-enzyme inhibitors. CONCLUSIONS Treatment with valsartan was not associated with a reduction in the incidence of recurrent atrial fibrillation. (ClinicalTrials.gov number, NCT00376272.)
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75
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Alcaraz R, Rieta JJ. Time and frequency recurrence analysis of persistent atrial fibrillation after electrical cardioversion. Physiol Meas 2009; 30:479-89. [PMID: 19369714 DOI: 10.1088/0967-3334/30/5/005] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Electrical cardioversion (ECV) has become a mainstay of therapy for the treatment of persistent atrial fibrillation (AF), which is an arrhythmia that affects up to 1% of the general population. The procedure is initially effective, but it is also characterized by a high rate of AF recurrence. As a consequence, it would be clinically useful to predict normal sinus rhythm (NSR) maintenance after ECV before it is attempted. In this respect, several clinical, echocardiographic and demographic parameters have been analyzed by other authors. However, these indices are weak predictors of ECV outcome. In this work, surface electrocardiographic (ECG) recordings were used to extract the atrial activity (AA) signal and parametrize the fibrillatory (f) waves, both in time and frequency, to obtain AF recurrence predictors. Parameters as f waves amplitude (fWA), AA mean power, dominant atrial frequency (DAF), its first harmonic, etc were studied. Obtained results showed that fWA was the most significant predictor of AF recurrence 1 month later. Concretely, 72.73% of the patients resulting in NSR, 83.87% relapsing to AF and 80.0% with unsuccessful ECV, were correctly identified. Therefore, fWA classified satisfactorily 79.37% of the analyzed patients. In addition, a forward stepwise discriminant analysis, with a leave-one-out cross validation approach, proved that fWA and DAF combination provided an improved diagnostic ability of 85.71%. In this case 86.36%, 83.87% and 90% of the patients who resulted in NSR, relapsed to AF and with unsuccessful ECV, were correctly discerned, respectively. In conclusion, fWA could be considered as a promising predictor of ECV outcome during the first month following the procedure. Additionally, time and frequency indices could yield complementary information useful to predict the cardioversion outcome. Finally, further studies are needed to validate the robustness of these parameters and the repeatability of the obtained results on wider databases.
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Affiliation(s)
- Raúl Alcaraz
- Innovation in Bioengineering Research Group, University of Castilla-La Mancha, Campus Universitario, 16071 Cuenca, Spain.
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76
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Tse HF, Wang Q, Yu CM, Ayers GM, Lau CP. Effect of verapamil on prevention of atrial fibrillation in patients implanted with an implantable atrial defibrillator. Clin Cardiol 2009; 24:503-5. [PMID: 11450689 PMCID: PMC6655226 DOI: 10.1002/clc.4960240717] [Citation(s) in RCA: 5] [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] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The role of verapamil in the prevention of atrial fibrillation (AF) in patients with recurrent AF is unknown. HYPOTHESIS The aim of this study was to evaluate the effect of verapamil on the prevention of AF in patients implanted with an implantable atrial defibrillator (IAD). METHODS The effects of verapamil (240 mg/day) on the total duration of AF, number of AF recurrences, and number of cardioversions were prospectively evaluated in a randomized, crossover fashion over an 8-week period in 11 patients (9 men, 2 women; mean age: 60 +/- 6 years) implanted with an IAD. RESULTS Implantable atrial defibrillators successfully converted 13 of 14 (93%) spontaneous episodes of AF. There was no significant difference in the efficacy of cardioversion (86 vs. 100%, p = 0.8), the total duration of AF (173 +/- 198 vs. 270 +/- 241 h, p = 0.5), the number of AF episodes (8.5 +/- 9.0 vs. 9.3 +/- 10.2, p = 0.3), and the number of cardioversions (1.7 +/- 2.4 vs. 1.8 +/- 2.1 p = 0.7) with or without treatment with verapamil. CONCLUSIONS The results of the present study suggest that treatment with verapamil has no significant effect on the prevention of AF in patients treated with an LAD.
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Affiliation(s)
- H F Tse
- Division of Cardiology, Department of Medicine, University of Hong Kong, Queen Mary Hospital, Hong Kong, China
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77
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78
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A randomized study on the efficacy of intravenous cibenzoline and pilsicainide administered prior to electrical cardioversion in patients with lone paroxysmal and persistent atrial fibrillation. J Cardiol 2009; 53:35-42. [DOI: 10.1016/j.jjcc.2008.08.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2008] [Revised: 07/04/2008] [Accepted: 08/18/2008] [Indexed: 11/22/2022]
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79
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Sörnmo L, Stridh M, Husser D, Bollmann A, Olsson SB. Analysis of atrial fibrillation: from electrocardiogram signal processing to clinical management. PHILOSOPHICAL TRANSACTIONS. SERIES A, MATHEMATICAL, PHYSICAL, AND ENGINEERING SCIENCES 2009; 367:235-253. [PMID: 18952548 DOI: 10.1098/rsta.2008.0162] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
The analysis of atrial fibrillation in non-invasive ECG recordings has received considerable attention in recent years, spurring the development of signal processing techniques for more advanced characterization of the atrial waveforms than previously available. The present paper gives an overview of different approaches to the extraction of atrial activity in the ECG and to the characterization of the resulting atrial signal with respect to its spectral properties. So far, the repetition rate of the atrial waves is the most studied parameter and its significance in clinical management is briefly considered, including the identification of pathomechanisms and prediction of therapy efficacy.
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Affiliation(s)
- Leif Sörnmo
- Department of Electrical and Information Technology, Lund University, 221 00 Lund, Sweden.
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80
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Hirayama Y, Atarashi H, Kobayashi Y, Iwasaki Y, Miyauchi Y, Ohara T, Yashima M, Katoh T, Mizuno K. Long-Term Effects of Upstream Therapy on Paroxysmal Atrial Fibrillation in Patients Without Overt Heart Diseases. Int Heart J 2009; 50:141-51. [DOI: 10.1536/ihj.50.141] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Yoshiyuki Hirayama
- Division of Cardiology, Department of Internal Medicine, Nippon Medical School
| | - Hirotsugu Atarashi
- Division of Cardiology, Department of Internal Medicine, Nippon Medical School
| | - Yoshinori Kobayashi
- Division of Cardiology, Department of Internal Medicine, Nippon Medical School
| | - Yuuki Iwasaki
- Division of Cardiology, Department of Internal Medicine, Nippon Medical School
| | - Yasushi Miyauchi
- Division of Cardiology, Department of Internal Medicine, Nippon Medical School
| | - Toshihiko Ohara
- Division of Cardiology, Department of Internal Medicine, Nippon Medical School
| | - Masaaki Yashima
- Division of Cardiology, Department of Internal Medicine, Nippon Medical School
| | - Takao Katoh
- Division of Cardiology, Department of Internal Medicine, Nippon Medical School
| | - Kyoichi Mizuno
- Division of Cardiology, Department of Internal Medicine, Nippon Medical School
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81
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Michael G, Xiao L, Qi XY, Dobrev D, Nattel S. Remodelling of cardiac repolarization: how homeostatic responses can lead to arrhythmogenesis. Cardiovasc Res 2008; 81:491-9. [PMID: 18826964 DOI: 10.1093/cvr/cvn266] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Cardiac action potentials (APs) are driven by ionic currents flowing through specific channels and exchangers across cardiomyocyte membranes. Once initiated by rapid Na(+) entry during phase 0, the AP time course is determined by the balance between inward depolarizing currents, carried mainly by Na(+) and Ca(2+), and outward repolarizing currents carried mainly by K(+). K(+) currents play a major role in repolarization. The loss of a K(+) current can impair repolarization, but there is a redundancy of K(+) currents so that when one K(+) current is dysfunctional, other K(+) currents increase to compensate, a phenomenon called 'repolarization reserve'. Repolarization reserve protects repolarization under conditions that increase inward current or reduce outward current, threatening the balance that governs AP duration. This protection comes at the expense of reduced repolarization reserve, potentially resulting in unexpectedly large AP prolongation and arrhythmogenesis, when an additional repolarization-suppressing intervention is superimposed. The critical role of appropriate repolarization is such that cardiac rhythm stability can be impaired with either abnormally slow or excessively rapid repolarization. In cardiac disease states such as heart failure and atrial fibrillation (AF), changes in ion channel properties appear as part of an adaptive response to maintain function in the face of disease-related stress on the cardiovascular system. However, if the stress is maintained the adaptive ion channel changes may themselves lead to dysfunction, in particular cardiac arrhythmias. The present article reviews ionic remodelling of cardiac repolarization, and focuses on how potentially adaptive repolarization changes with congestive heart failure and AF can have arrhythmogenic consequences.
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Affiliation(s)
- Georghia Michael
- Department of Medicine, Montreal Heart Institute, 5000 Belanger Street East, Montreal, Quebec, Canada H1T 1C8
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82
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Lombardi F, Tundo F, Belletti S, Mantero A, Melzi D'eril GV. C-reactive protein but not atrial dysfunction predicts recurrences of atrial fibrillation after cardioversion in patients with preserved left ventricular function. J Cardiovasc Med (Hagerstown) 2008; 9:581-8. [PMID: 18475126 DOI: 10.2459/jcm.0b013e3282f3524d] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Maintenance of sinus rhythm after cardioversion of atrial fibrillation is a major clinical challenge also in patients with preserved left ventricular function. Subclinical inflammation and atrial strain have been recognized as important contributors to atrial fibrillation onset and perpetuation. Aim of the study was to compare the predictive role of C-reactive protein (CRP) and indices of atrial dysfunction in relation to subacute arrhythmic recurrence rate in patients with persistent atrial fibrillation and normal left ventricular ejection fraction (LVEF). METHODS We studied 53 patients with a mean LVEF of 58.7 +/- 6%. Left atrial diameter and area, left atrial auricle emptying velocity, N-terminal pro-b-type natriuretic peptide (NT-proBNP) and CRP levels were determined few hours before electrical cardioversion. NT-proBNP and CRP levels were also measured 1 h and 3 weeks after cardioversion. RESULTS Subacute atrial fibrillation recurrences were documented in 18 (33.9%) patients. Whereas none of the parameters reflecting atrial dysfunction predicted arrhythmic outcome, higher CRP levels (>3.0 mg/l) were significantly associated with atrial fibrillation recurrences [odds ratio (OR): 1.6; 95% confidence interval (CI): 1.4-2.5; P = 0.031]. No changes in CRP levels were evident after cardioversion independently of underlying rhythm. On the contrary, NT-proBNP levels, which were correlated with left atrial auricle emptying velocity, significantly decreased only in patients who maintained sinus rhythm (from 638 +/- 329 to 295 +/- 261 pg/ml; P < 0.001). CONCLUSION The present study demonstrates that in patients with persistent atrial fibrillation and preserved LVEF, CRP level is an independent predictor of atrial fibrillation subacute recurrence rate, whereas none of the indices of atrial dysfunction is associated with arrhythmic outcome. NT-proBNP levels reflect, instead, the hemodynamic alterations secondary to arrhythmia presence.
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Affiliation(s)
- Federico Lombardi
- Cardiology Laboratory, Department of Medicine, Surgery and Odontoiatry, Hospital San Paolo, University of Milan, Italy.
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83
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Kezerashvili A, Krumerman AK, Fisher JD. Sinus Node Dysfunction in Atrial Fibrillation: Cause or Effect? J Atr Fibrillation 2008; 1:30. [PMID: 28496586 DOI: 10.4022/jafib.30] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2008] [Revised: 04/27/2008] [Accepted: 07/16/2008] [Indexed: 11/10/2022]
Affiliation(s)
- Anna Kezerashvili
- Department of Medicine, Cardiology Division, Arrhythmia Service, Montefiore Medical Center and the Albert Einstein College of Medicine
| | - Andrew K Krumerman
- Department of Medicine, Cardiology Division, Arrhythmia Service, Montefiore Medical Center and the Albert Einstein College of Medicine
| | - John D Fisher
- Department of Medicine, Cardiology Division, Arrhythmia Service, Montefiore Medical Center and the Albert Einstein College of Medicine
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84
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Zhang W, Zhong M, Yang GR, Li JP, Guo C, Wang Z, Zhang Y. Matrix metalloproteinase-9/tissue inhibitors of metalloproteinase-1 expression and atrial structural remodeling in a dog model of atrial fibrillation: inhibition with angiotensin-converting enzyme. Cardiovasc Pathol 2008; 17:399-409. [PMID: 18706834 DOI: 10.1016/j.carpath.2008.02.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2007] [Revised: 11/01/2007] [Accepted: 02/27/2008] [Indexed: 10/21/2022] Open
Abstract
INTRODUCTION Matrix metalloproteinases and tissue inhibitors of metalloproteinases regulate extracellular matrix turnover in cardiac tissues. However, alteration of matrix metalloproteinases and tissue inhibitors of metalloproteinases during atrial fibrillation is unclear. This study aims to determine (a) the relationship between altered expressions of matrix metalloproteinases and tissue inhibitors of metalloproteinases and atrial structural remodeling; (b) the role of changes in the atrial angiotensin system and in calcium concentration; and (c) the effect of captopril on the expressions of matrix metalloproteinase-9/tissue inhibitors of metalloproteinase-1 and atrial structural remodeling. METHODS In left atrial tissue samples, the mRNA expression of angiotensin-converting enzyme, matrix metalloproteinase-9, and tissue inhibitors of metalloproteinase-1; the protein expression of matrix metalloproteinase-9 and tissue inhibitors of metalloproteinase-1; and Ca(2+) concentration and angiotensin II were measured. RESULTS Compared with controls, dogs under atrial fibrillation showed significantly increased contents of Ca(2+), angiotensin II , and interstitial fibrous tissue (P<.05-.001). The mRNA levels of angiotensin-converting enzyme, matrix metalloproteinase-9, and tissue inhibitors of metalloproteinase-1 were significantly increased as compared with controls (P<.05-.01). The protein level of matrix metalloproteinase-9 was higher, and that of tissue inhibitors of metalloproteinase-1 was lower, in dogs with atrial fibrillation than in controls (P<.01-.001). All findings highlighted above were reversed by treatment with captopril. CONCLUSIONS Altered expression of matrix metalloproteinase-9 and tissue inhibitors of metalloproteinase-1 contributes to atrial extracellular matrix remodeling and atrial dilatation. Angiotensin-II-mediated intracellular Ca(2+) overload may be the mechanism of altered expression of matrix metalloproteinase-9 and tissue inhibitors of metalloproteinase-1. Angiotensin-converting enzyme inhibitor treatment may attenuate atrial structural remodeling by normalizing the balance between matrix metalloproteinase-9 and tissue inhibitors of metalloproteinase-1.
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Affiliation(s)
- Wei Zhang
- Department of Cardiology, Qilu Hospital of Shandong University, Ji'nan 250012, PR China
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85
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XIA WEI, QU XIUFEN, YU YANG, ZHANG XUELI, FENG WEI, SONG YING. Asymmetric Dimethylarginine Concentration and Early Recurrence of Atrial Fibrillation after Electrical Cardioversion. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2008; 31:1036-40. [DOI: 10.1111/j.1540-8159.2008.01131.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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86
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A non-invasive method to predict electrical cardioversion outcome of persistent atrial fibrillation. Med Biol Eng Comput 2008; 46:625-35. [DOI: 10.1007/s11517-008-0348-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2007] [Accepted: 04/04/2008] [Indexed: 10/22/2022]
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87
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Abstract
In this article, electrical and pharmacologic cardioversion for atrial fibrillation is described in detail. Indications for cardioversion and management of pericardioversion anticoagulation also are discussed. Finally, management strategies for immediate recurrence of atrial fibrillation and cardioversion failure are offered.
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Affiliation(s)
- Susan S Kim
- Clinical Cardiac Electrophysiology, Section of Cardiology, Department of Medicine, University of Chicago Hospitals, University of Chicago, 5758 South Maryland Avenue MC9024, Chicago, IL 60637, USA
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88
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Kirchhof P, Goette A, Hindricks G, Hohnloser S, Kuck KH, Meinertz T, Ravens U, Steinbeck G, Breithardt G. [Outcome parameters for AF trials--executive summary of an AFNET-EHRA consensus conference]. Herzschrittmacherther Elektrophysiol 2007; 18:259-268. [PMID: 18084800 DOI: 10.1007/s00399-007-0581-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Affiliation(s)
- P Kirchhof
- Medizinische Klinik und Poliklinik C, Kardiologie und Angiologie, Universitätsklinikum Münster, Albert-Schweitzer-Strasse 33, 48149 Münster, Germany.
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89
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Laszlo R, Winkler C, Wöhrl S, Wessel RE, Laszlo S, Busch MC, Schreieck J, Bosch RF. Effect of verapamil on tachycardia-induced early cellular electrical remodeling in rabbit atrium. Naunyn Schmiedebergs Arch Pharmacol 2007; 376:231-40. [PMID: 17874072 DOI: 10.1007/s00210-007-0188-0] [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: 03/05/2007] [Accepted: 08/29/2007] [Indexed: 10/22/2022]
Abstract
We investigated the effects of a 7-day verapamil pretreatment (VPT, 7.5 mg/kg bodyweight subcutaneously every 12 h) on ionic currents and molecular mechanisms underlying tachycardia-induced early electrical remodeling after 24-h rapid atrial pacing (RAP, 600 bpm) in rabbit atrium. Animals were divided into four groups (n = 6 each group): control (not paced, no verapamil), paced only, verapamil only and verapamil and paced, respectively. VPT doubled ICa,L [7.0 +/- 0.7 pA/pF (control) vs 14.2 +/- 0.6 pA/pF (verapamil only)]. RAP reduced ICa,L by 48% to 3.6 +/- 0.7 pA/pF (paced only). RAP did not affect ICa,L in verapamil-treated animals and averaged 15.3 +/- 0.2 pA/pF (paced and verapamil). RAP resulted in a significant decrease of the expression of the alpha1c subunit (-24.7%) and the beta2A subunit (-13.3%), respectively. VPT led to a similar alteration of subunit expression as RAP ["control" vs "verapamil only", decrease of alpha1c subunit (-25.4%), but no significant change in beta2A subunit expression]. However, after VPT, further diminishment of alpha1c and beta2A subunit expression after rapid atrial pacing was absent. ("verapamil" vs "verapamil and paced", n = 6 both groups). RAP decreased Ito [-45%, 51.5 +/- 3.9 pA/pF (control) vs 26.8 +/- 1.5 pA/pF (paced only)] and was not influenceable by VPT. IK1 was neither affected by RAP nor verapamil pretreatment. Downregulation of alpha1c and beta2A subunit expression and the resulting decay of ICa,L current densities were prevented by verapamil. However, these effects are abolished by multiple other adverse effects of verapamil on atrial electrophysiology.
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Affiliation(s)
- Roman Laszlo
- Department of Cardiology, University of Tübingen, Otfried-Müller-Strasse 10, 72076, Tübingen, Germany.
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90
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Husser O, Husser D, Stridh M, Sörnmo L, Corino VDA, Mainardi LT, Lombardi F, Klein HU, Olsson SB, Bollmann A. Exercise testing for non-invasive assessment of atrial electrophysiological properties in patients with persistent atrial fibrillation. ACTA ACUST UNITED AC 2007; 9:627-32. [PMID: 17595231 DOI: 10.1093/europace/eum124] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
AIMS Experimental studies suggest that the autonomic nervous system modulates atrial refractoriness and conduction velocity in atrial fibrillation (AF). These modulatory effects are, however, difficult to assess in the clinical setting. This study sought to non-invasively characterize in patients with persistent AF, the influence of autonomic modulation induced by exercise on atrial fibrillatory rate as marker of atrial refractoriness and to identify clinical and electrocardiographic predictors of atrial rate response. METHODS AND RESULTS In 24 patients (16 males, mean age 60 +/- 13 years) with persistent AF (16 +/- 25 months), continuous ECGs were recorded during bicycle exercise testing. Fibrillatory rate (in fibrillations per minute, fpm) was assessed at baseline and immediately after termination of exercise with spatiotemporal QRST cancellation and time-frequency analysis. Ventricular response was characterized by time-domain HRV indices. Exercise had no influence on mean fibrillatory rate (409 +/- 42 vs. 414 +/- 43 fpm, P = NS). Seven patients responded to exercise with an increase in fibrillatory rate (26 +/- 10 fpm, P < 0.001 and three with a decrease (-21 +/- 8 fpm, P < 0.001), while the remaining 14 patients did not show a response. Responders' HRV indices changed in response to exercise similarly to that of non-responders. Their baseline fibrillatory rate was, however, lower than that of non-responders (387 +/- 18 vs. 425 +/- 48 fpm, P = 0.028). No other clinical or echocardiographic variable was associated with fibrillatory rate response. Twelve weeks after cardioverson, responders were more likely to remain in sinus rhythm than non-responders (88 vs. 46 %, P = 0.04). CONCLUSIONS Exercise-induced autonomic activation produces changes in atrial electrophysiological properties that can be detected by time-frequency analysis. Higher baseline fibrillatory rates are associated with an impaired atrial response to exercise that suggests advanced electrical remodelling and reduced sensitivity to autonomic stimuli.
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Affiliation(s)
- Oliver Husser
- Department of Cardiology, Otto-von-Guericke University, University Hospital, Leipziger Str. 44, 39120 Magdeburg, Germany
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91
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Turco P, De Simone A, La Rocca V, Iuliano A, Capuano V, Astarita C, Di Napoli T, Messina V, Baldi S, Stabile G. Antiarrhythmic drug therapy after radiofrequency catheter ablation in patients with atrial fibrillation. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2007; 30 Suppl 1:S112-5. [PMID: 17302684 DOI: 10.1111/j.1540-8159.2007.00618.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The use of antiarrhythmic drugs after ablation is a controversial issue when evaluating the efficacy of atrial fibrillation (AF) ablation. This study compares in a prospective and randomized fashion the impact of an antiarrhythmic drug in preventing AF recurrence after AF ablation. METHODS From February 2004 to May 2005, 107 consecutive patients (mean age 57 +/- 10 years, 69 men), with paroxysmal (60%) or persistent (40%) drug refractory AF, were randomly assigned to ablation alone (Group A, 53 patients) or combined with the best antiarrhythmic therapy, preferably amiodarone (Group B, 54 patients). All patients underwent cavo-tricuspid and left inferior pulmonary vein (PV)-mitral isthmus ablation plus circumferential PV ablation, using a guided electro-anatomical approach. Standard electrocardiograms (ECG), and ambulatory and transtelephonic ECG monitoring were used to assess AF recurrences. Recurrences during the first month after ablation were excluded from this analysis. RESULTS At 12 months of follow-up, no significant difference was observed in the rates of AF recurrences between Group A (18/53 patients, 34%) and Group B (16/54 patients, 30%). The percentage of patients with >/= 1 asymptomatic AF episode was higher in Group B than in Group A (10/16 patients, 63%, vs 5/18 patients, 28%, P = 0.04). CONCLUSIONS Continuing antiarrhythmic drug therapy in patients who undergo catheter ablation for AF did not lower the rate of AF recurrences. Antiarrhythmic drugs increased the proportion of patients with asymptomatic AF episodes.
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92
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Varounis C, Dagres N, Maounis T, Panagiotakos D, Cokkinos DV. Atrial premature complexes and heart rate have prognostic significance in 1-month atrial fibrillation recurrence after electrical cardioversion. Europace 2007; 9:633-7. [PMID: 17507365 DOI: 10.1093/europace/eum090] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
AIMS The aim of this study was to investigate the significance of simple 24-h Holter (24H) data after electrical cardioversion (CV) for atrial fibrillation (AF) recurrence. METHODS We prospectively studied 47 consecutive patients subjected to CV, who successfully converted to sinus rhythm. All underwent echocardiography and 24H after CV. AF recurrence was studied at 14 days and 1 month by second 24H or by interim report of AF. RESULTS About 53.2% remained in sinus rhythm (group I) and the rest recurred to AF (group II). Group I had fewer atrial premature complexes per hour (APC/h) (P = 0.002) and lower maximum (max HR), average, and minimum heart rates compared with group II (all Ps < 0.05). The optimal value of APC/h and max HR with best sensitivity and specificity was 32 APC/h and 90 bpm, respectively. These findings were the predictors of AF recurrence [hazard ratio (HR) = 4.5 with 95% CI = 1.7-11.7 and HR = 4.3 with 95% CI = 1.7-10.9, respectively]. Patients with the combination of both predictors had greater HR of AF recurrence compared with those with < 32 APC/h and max HR < 90 bpm (HR = 8.8 with 95% CI = 2.5-31.4). CONCLUSION Patients with frequent APC/h and high max HR are at high risk for 1-month AF recurrence after electrical CV.
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Affiliation(s)
- Christos Varounis
- 1st Department of Cardiology, Onassis Cardiac Surgery Center, Syngrou Avenue 356, Kallithea 17674, Athens, Greece.
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93
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Loricchio ML, Cianfrocca C, Pasceri V, Bianconi L, Auriti A, Calo L, Lamberti F, Castro A, Pandozi C, Palamara A, Santini M. Relation of C-reactive protein to long-term risk of recurrence of atrial fibrillation after electrical cardioversion. Am J Cardiol 2007; 99:1421-4. [PMID: 17493472 DOI: 10.1016/j.amjcard.2006.12.074] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2006] [Revised: 12/21/2006] [Accepted: 12/21/2006] [Indexed: 10/23/2022]
Abstract
The aim of this study is to assess the role of C-reactive protein (CRP) in predicting long-term risk of atrial fibrillation (AF) recurrence after electrical cardioversion. CRP levels are associated with the presence of AF and failure of electrical or pharmacologic cardioversion, but no previous study has assessed their predictive role in long-term follow-up after successful electrical cardioversion. One hundred two consecutive patients (age 67 +/- 11 years; 58 men) with nonvalvular persistent AF who underwent successful biphasic electrical cardioversion were studied. High-sensitivity CRP was measured immediately before cardioversion. Follow-up was performed up to 1 year in all cases. Patients were divided into 4 groups according to CRP quartiles. Patients in the lowest CRP quartile (<1.9 mg/L) had significantly lower rates of AF recurrence (4% vs 33% at 3 months in the other 3 groups combined, p = 0.007, and 28% vs 60% at 1 year, p = 0.01). The 4 groups were similar in age, gender, ejection fraction, and left atrial size. Survival analysis confirmed that patients in the lowest CRP quartile had a lower recurrence rate (p = 0.02). Cox regression analyses using age, gender, hypertension, diabetes, ejection fraction, left atrial diameter, use of antiarrhythmic drugs, angiotensin-converting enzyme inhibitors or angiotensin II antagonists, and statins, and CRP quartiles as covariates showed that only CRP was independently associated with AF recurrence during follow-up (hazard ratio 4.98, 95% confidence interval 1.75 to 14.26, p = 0.003). In conclusion, low CRP is associated with long-term maintenance of sinus rhythm after cardioversion for nonvalvular AF.
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94
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Petrutiu S, Sahakian AV, Swiryn S. Short-term dynamics in fibrillatory wave characteristics at the onset of paroxysmal atrial fibrillation in humans. J Electrocardiol 2007; 40:155-60. [PMID: 17349458 DOI: 10.1016/j.jelectrocard.2006.10.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2006] [Accepted: 10/05/2006] [Indexed: 11/20/2022]
Abstract
INTRODUCTION The purpose of this study was to investigate the magnitude and time course of fibrillatory wave dynamics during spontaneous onset of paroxysmal atrial fibrillation (AF). METHODS We studied fibrillatory waves in Holter recordings of paroxysmal AF with regard to the fibrillation-free interval (FFI) preceding each episode. RESULTS For 38 episodes of paroxysmal AF in 20 patients, dominant frequency (DF) ranged from 4.4 to 6.8 Hz (5.5 +/- 0.5 Hz). Long-FFI episodes showed a gradual increase in DF over the first 4 minutes (P < .0001). Short-FFI episodes showed an increase only from the first to the second minute (P < .003). For all 7 patients exhibiting both long-FFI and short-FFI episodes, short-FFI episodes had a higher initial DF (P < .002). CONCLUSION The dynamics during onset and their relation to the FFI are consistent with the influence of short-term electrophysiological changes and their reversal. These findings have implications for the timing of antifibrillatory interventions.
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Affiliation(s)
- Simona Petrutiu
- Department of Electrical Engineering and Computer Science, Northwestern University, Evanston, IL, USA
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95
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Liu T, Li G, Li L, Korantzopoulos P. Association between C-reactive protein and recurrence of atrial fibrillation after successful electrical cardioversion: a meta-analysis. J Am Coll Cardiol 2007; 49:1642-1648. [PMID: 17433956 DOI: 10.1016/j.jacc.2006.12.042] [Citation(s) in RCA: 215] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2006] [Revised: 12/04/2006] [Accepted: 12/19/2006] [Indexed: 02/06/2023]
Abstract
OBJECTIVES We conducted a systematic review and meta-analysis of observational studies to examine the association between baseline C-reactive protein (CRP) levels and the recurrence of atrial fibrillation (AF) after successful electrical cardioversion (EC). BACKGROUND Current evidence links AF to the inflammatory state. Inflammatory indexes such as CRP have been related to the development and persistence of AF. However, inconsistent results have been published with regard to the role of CRP in predicting sinus rhythm maintenance after successful EC. METHODS Using PubMed, the Cochrane clinical trials database, and EMBASE, we searched for literature published June 2006 or earlier. In addition, a manual search was performed using all review articles on this topic, reference lists of papers, and abstracts from conference reports. Of the 225 initially identified studies, 7 prospective observational studies with 420 patients (229 with and 191 without AF relapse) were finally analyzed. RESULTS Overall, baseline CRP levels were greater in patients with AF recurrence. The standardized mean difference in the CRP levels between the patients with, and those without AF was 0.35 units (95% confidence interval 0.01 to 0.69); test for overall effect z-score = 2.00 (p = 0.05). The heterogeneity test showed that there were significant differences between individual studies (p = 0.02; I(2) = 60.2%). Further analysis revealed that differences between the CRP assays possibly account for this heterogeneity. CONCLUSIONS Our meta-analysis suggests that increased CRP levels are associated with greater risk of AF recurrence, although there was significant heterogeneity across the studies. The use of CRP levels in predicting sinus rhythm maintenance appears promising but requires further study.
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Affiliation(s)
- Tong Liu
- Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, People's Republic of China
| | - Guangping Li
- Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, People's Republic of China.
| | - Lijian Li
- College of Graduate Students, Tianjin Medical University, Tianjin, People's Republic of China
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Gall NP, Murgatroyd FD. Electrical Cardioversion for AF?The State of the Art. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2007; 30:554-67. [PMID: 17437583 DOI: 10.1111/j.1540-8159.2007.00709.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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97
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Yoshida T, Niwano S, Niwano H, Imaki R, Satoh D, Masaki Y, Nakazato K, Soma K, Izumi T. Atrial natriuretic peptide (ANP) suppresses acute atrial electrical remodeling in the canine rapid atrial stimulation model. Int J Cardiol 2007; 123:147-54. [PMID: 17376550 DOI: 10.1016/j.ijcard.2006.12.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2006] [Revised: 11/06/2006] [Accepted: 12/11/2006] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Atrial electrical remodeling is considered to play an important role in the appearance of atrial fibrillation. The effect of atrial natriuretic peptide (ANP) on atrial electrical remodeling was evaluated in a canine atrial stimulation model. METHODS In 15 beagle dogs, electrodes for pacing and recording were fixed on the atrial surface. In 10/15 dogs, rapid atrial stimulation (400 bpm) was performed for 7 h at the right atrial appendage (RAA) and the remaining 5 were used as the sham without rapid pacing. In 5/10 dogs with rapid pacing, human atrial natriuretic peptide (ANP) was infused (1.0 microg/kg/min). The effective refractory period (ERP) and the monophasic action potential duration (MAP) were evaluated at 0, 3, and 7 h after rapid pacing. The expression levels of mRNAs of ion channels or transporters were evaluated from the atrial samples of sham and after a 7 hour pacing. RESULTS In the control group with rapid pacing (n=5), the atrial ERP and MAP duration were shortened at all atrial sites, e.g., ERP from 148+/-14 ms to 109+/-8 ms at RAA, P=0.006. In contrast in the ANP group, neither the ERP nor MAP duration showed a significant shortening and the effect of ANP on hemodynamic parameter was relatively small. Expression levels of the mRNA were not significantly different between the control and ANP groups. CONCLUSIONS Administration of ANP prevented the shortening of the ERP and MAP duration in the rapid atrial stimulation model. The effect of ANP on atrial electrical remodeling was considered to be due to its direct action on the myocardium.
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Affiliation(s)
- Toru Yoshida
- Department of Emergency and Critical Care Medicine, Kitasato University School of Medicine, 1-15-1, Kitasato, Sagamihara, Kanagawa, 228-8555, Japan.
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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. ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation-executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients with Atrial Fibrillation). Eur Heart J 2007; 27:1979-2030. [PMID: 16885201 DOI: 10.1093/eurheartj/ehl176] [Citation(s) in RCA: 362] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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99
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Atrial Fibrillation and Flutter. CARDIOVASCULAR MEDICINE 2007. [DOI: 10.1007/978-1-84628-715-2_95] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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100
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Abstract
There are multiple factors for the etiology of atrial fibrillation (AF), including stretch, autonomic imbalance, hyperthyroidism, and inflammation. Of these factors for AF, stretch and inflammation increase the angiotensin II level, thereby inducing calcium over load, and inducing ectopic focal activities that initiate AF. Angiotensin II activates the Erk cascade through the AT(1)R and induces interstitial fibrosis of the atria, which compromises intra-atrial conduction. Short atrial refractoriness and slow conduction form multiple re-entry, before maintaining AF. Anti-arrhythmic drugs used for downstream therapy can suppress the focal activities and re-entry, but cannot prevent the development of a structural substrate. In contrast, angiotensin-converting enzyme, angiotensin II type 1 receptor blocker and statins might constitute upstream therapy through the prevention of structural remodeling that promotes AF.
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Affiliation(s)
- Koichiro Kumagai
- Department of Cardiology, School of Medicine, Fukuoka University, Jonan-ku, Fukuoka 814-0180, Japan.
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