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Tsigkas G, Apostolos A, Despotopoulos S, Vasilagkos G, Kallergis E, Leventopoulos G, Mplani V, Davlouros P. Heart failure and atrial fibrillation: new concepts in pathophysiology, management, and future directions. Heart Fail Rev 2021; 27:1201-1210. [PMID: 34218400 DOI: 10.1007/s10741-021-10133-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/22/2021] [Indexed: 12/11/2022]
Abstract
A bidirectional pathophysiological link connects heart failure and atrial fibrillation, creating a frequent and challenging comorbidity, which includes neurohormonal hyperactivation, fibrosis development, and electrophysiologic remodeling, while they share mutual risk factors. Management for these devastating comorbidities includes most of the established treatment measures for heart failure as well as rhythm or rate control and anticoagulation mostly for atrial fibrillation, which can be achieved with either pharmaceutical or non-pharmaceutical approaches. The current manuscript aims to review the existing literature regarding the underlying pathophysiology, to present the novel trends of treatment, and to predict the future perspective of these two linked diseases with the numerous unanswered questions.
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Affiliation(s)
- Grigorios Tsigkas
- Department of Cardiology, University Hospital of Patras, Patras, Greece.
| | | | | | | | | | | | - Virginia Mplani
- Department of Cardiology, University Hospital of Patras, Patras, Greece
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Shah RL, Kapoor R, Bonnett C, Ottoboni LK, Tacklind C, Tsiperfal A, Perez MV. Antiarrhythmic drug loading at home using remote monitoring: a virtual feasibility study during COVID-19 social distancing. EUROPEAN HEART JOURNAL - DIGITAL HEALTH 2021; 2:259-262. [PMID: 37155657 PMCID: PMC8083679 DOI: 10.1093/ehjdh/ztab034] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 03/11/2021] [Accepted: 03/24/2021] [Indexed: 11/14/2022]
Abstract
The epidemiological necessity for distancing during the COVID-19 pandemic has resulted in postponement of non-emergent hospitalizations and increase use of telemedicine. The feasibility of virtual antiarrhythmic drug (AAD) loading specifically with digital QTc electrocardiographic monitoring (EM) in conjunction with telemedicine video visits is not well established. We tested the hypothesis that existing digital health technologies and virtual communication platforms could provide EM and support medically guided AAD loading for patients with symptomatic tachyarrhythmia in the ambulatory setting, while reducing physical contact between patient and healthcare system. A prospective pilot, case series approved by the institutional ethics committee, entailing three subjects with symptomatic arrhythmia during the COVID-19 pandemic who were enrolled for virtual AAD loading at home. Clinicians met with participants twice daily via video visits conducted after QTc analysis (Kardia 6L mobile sensor) and telemetry review (Mobile Cardiac Outpatient Telemetry of silent arrhythmias). Participants received direct instruction to either terminate the study or proceed with the next single dose of AAD. All participants completed contactless loading of 5 AAD doses, without untoward event. Scheduled video visits allowed dialogue and participant counseling where decision making was guided by remote review of EM. Participant adherence with transmissions and scheduled visits was 98.3%; a single electrocardiogram was delayed beyond the two-hours-post-dose schedule. This virtual approach reduced overall expenditures based on retrospective comparison with previous AAD load hospitalizations. We found that a ‘virtual hospitalization’ for AAD loading with remote electrocardiographic monitoring and twice daily virtual rounding is feasible using existing digital health technologies.
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Affiliation(s)
- Rajan L Shah
- Department of Medicine (Cardiovascular Medicine), Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA
- Section of Cardiac Electrophysiology, Stanford University Medical Partners, 365 Hawthorne Ave, Ste. 201, Oakland, CA 94609, USA
| | - Ridhima Kapoor
- Department of Medicine (Cardiovascular Medicine), Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA
| | - Colleen Bonnett
- Department of Medicine (Cardiovascular Medicine), Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA
- Stanford Center for Inherited Cardiovascular Diseases, Stanford University, 300 Pasteur Drive, A21 Heart Clinic, Palo Alto, CA 94305, USA
| | - Linda K Ottoboni
- Department of Medicine (Cardiovascular Medicine), Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA
| | - Christine Tacklind
- Department of Medicine (Cardiovascular Medicine), Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA
| | - Angela Tsiperfal
- Department of Medicine (Cardiovascular Medicine), Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA
| | - Marco V Perez
- Department of Medicine (Cardiovascular Medicine), Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA
- Stanford Center for Inherited Cardiovascular Diseases, Stanford University, 300 Pasteur Drive, A21 Heart Clinic, Palo Alto, CA 94305, USA
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Brandes A, Crijns HJGM, Rienstra M, Kirchhof P, Grove EL, Pedersen KB, Van Gelder IC. Cardioversion of atrial fibrillation and atrial flutter revisited: current evidence and practical guidance for a common procedure. Europace 2021; 22:1149-1161. [PMID: 32337542 PMCID: PMC7399700 DOI: 10.1093/europace/euaa057] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 02/25/2020] [Indexed: 12/17/2022] Open
Abstract
Cardioversion is widely used in patients with atrial fibrillation (AF) and atrial flutter when a rhythm control strategy is pursued. We sought to summarize the current evidence on this important area of clinical management of patients with AF including electrical and pharmacological cardioversion, peri-procedural anticoagulation and thromboembolic complications, success rate, and risk factors for recurrence to give practical guidance.
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Affiliation(s)
- Axel Brandes
- Department of Cardiology, Odense University Hospital, J.B. Winsløws Vej 4, 5000 Odense C, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Corresponding author. Tel: +45 30 43 36 50. E-mail address:
| | - Harry J G M Crijns
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Michiel Rienstra
- Department of Cardiology, University of Groningen, University Medical Centre, Groningen, The Netherlands
| | - Paulus Kirchhof
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, UHB and Sandwell & West Birmingham Hospitals, NHS Trusts, Birmingham, UK
| | - Erik L Grove
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Kenneth Bruun Pedersen
- Department of Cardiology, Odense University Hospital, J.B. Winsløws Vej 4, 5000 Odense C, Denmark
| | - Isabelle C Van Gelder
- Department of Cardiology, Odense University Hospital, J.B. Winsløws Vej 4, 5000 Odense C, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Department of Cardiology, University of Groningen, University Medical Centre, Groningen, The Netherlands
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Kany S, Brachmann J, Lewalter T, Kuck KH, Andresen D, Willems S, Hoffmann E, Eckardt L, Thomas D, Hochadel M, Senges J, Metzner A, Rillig A. Safety and patient-reported outcomes in index ablation versus repeat ablation in atrial fibrillation: insights from the German Ablation Registry. Clin Res Cardiol 2021; 110:841-850. [PMID: 33112998 PMCID: PMC8166687 DOI: 10.1007/s00392-020-01763-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 10/12/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND Pulmonary vein isolation is an established strategy for catheter ablation of atrial fibrillation (AF). However, in a significant number of patients, a repeat procedure is mandatory due to arrhythmia recurrence. In this study, we report safety data and procedural details of patients undergoing index ablation versus repeat ablation in a registry-based real-life setting. METHODS Patients from the German Ablation Registry, a prospective, multicentre registry of patients undergoing ablation between January 2007 and January 2010 were included. RESULTS A total of 4155 patients were enrolled in the study. Group I (index ablation) consisted of 3377/4155 (82.1%) and group II (repeat ablation) of 738/4155 (17.9%). Patients in group I had a significantly higher ratio of paroxysmal AF (69.3% vs 61.9%, p < 0.001) and significantly less persistent AF (30.7% vs 38.1%, p < 0.001). The repeat group showed significantly lower mean RF application duration (2580 s. vs 1960, p < 0.001), less fluoroscopy time (29 min. vs. 27 min., p < 0.001), less mean dose area product (DAP) (3744 cGy × cm2 vs 3325 cGy × cm2, p = 0.001), and shorter study duration (181.2 min. vs 163.6 min., p < 0.001). No statistical difference between the groups was found in terms of mortality (0.3% vs 0.1%, p = 0.39), MACE (0.4% vs 0.3%, p = 0.58), MACCE (0.8% vs 0.6%, p = 0.47), composite safety endpoint (1.5% vs 1.4%, p = 0.76), and arrhythmia recurrence (43.8% vs 41.9%, p = 0.37) during 1-year follow-up. Both groups reported to have improved or no symptoms (80.4% vs 77.8%, p = 0.13). CONCLUSION Repeat catheter ablation is safe and provides a symptomatic relief comparable to index ablation. Repeat procedures are significantly shorter and use less fluoroscopy.
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Affiliation(s)
- Shinwan Kany
- Department of Cardiology, University Heart and Vascular Center Hamburg-Eppendorf, Martinistraße 52, 20251, Hamburg, Germany
| | - Johannes Brachmann
- Department of Cardiology, Angiology and Pneumology, Coburg Hospital, Coburg, Germany
| | - Thorsten Lewalter
- Department of Medicine-Cardiology and Intensive Care, Hospital Munich-Thalkirchen, Munich, Germany
| | | | - Dietrich Andresen
- Department of Cardiology, Evangelisches Krankenhaus Hubertus, Berlin, Germany
| | - Stephan Willems
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
| | - Ellen Hoffmann
- Dept. of Cardiology and Internal Intensive Care Medicine, Heart Center Munich-Bogenhausen, Munich Clinic Bogenhausen, Munich, Germany
| | - Lars Eckardt
- Department of Cardiology (Electrophysiology), University Hospital Muenster, Muenster, Germany
| | - Dierk Thomas
- Department of Cardiology, University of Heidelberg, Heidelberg, Germany
| | | | - Jochen Senges
- Stiftung Für Herzinfarktforschung (IHF), Ludwigshafen, Germany
| | - Andreas Metzner
- Department of Cardiology, University Heart and Vascular Center Hamburg-Eppendorf, Martinistraße 52, 20251, Hamburg, Germany
| | - Andreas Rillig
- Department of Cardiology, University Heart and Vascular Center Hamburg-Eppendorf, Martinistraße 52, 20251, Hamburg, Germany.
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Hwang I, Jin Z, Park JW, Kwon OS, Lim B, Hong M, Kim M, Yu HT, Kim TH, Uhm JS, Joung B, Lee MH, Pak HN. Computational Modeling for Antiarrhythmic Drugs for Atrial Fibrillation According to Genotype. Front Physiol 2021; 12:650449. [PMID: 34054570 PMCID: PMC8155488 DOI: 10.3389/fphys.2021.650449] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 03/22/2021] [Indexed: 01/11/2023] Open
Abstract
Background: The efficacy of antiarrhythmic drugs (AAD) can vary in patients with atrial fibrillation (AF), and the PITX2 gene affects the responsiveness of AADs. We explored the virtual AAD (V-AAD) responses between wild-type and PITX2 +/--deficient AF conditions by realistic in silico AF modeling. Methods: We tested the V-AADs in AF modeling integrated with patients' 3D-computed tomography and 3D-electroanatomical mapping, acquired in 25 patients (68% male, 59.8 ± 9.8 years old, 32.0% paroxysmal type). The ion currents for the PITX2 +/- deficiency and each AAD (amiodarone, sotalol, dronedarone, flecainide, and propafenone) were defined based on previous publications. Results: We compared the wild-type and PITX2 +/- deficiency in terms of the action potential duration (APD90), conduction velocity (CV), maximal slope of restitution (Smax), and wave-dynamic parameters, such as the dominant frequency (DF), phase singularities (PS), and AF termination rates according to the V-AADs. The PITX2 +/--deficient model exhibited a shorter APD90 (p < 0.001), a lower Smax (p < 0.001), mean DF (p = 0.012), PS number (p < 0.001), and a longer AF cycle length (AFCL, p = 0.011). Five V-AADs changed the electrophysiology in a dose-dependent manner. AAD-induced AFCL lengthening (p < 0.001) and reductions in the CV (p = 0.033), peak DF (p < 0.001), and PS number (p < 0.001) were more significant in PITX2 +/--deficient than wild-type AF. PITX2 +/--deficient AF was easier to terminate with class IC AADs than the wild-type AF (p = 0.018). Conclusions: The computational modeling-guided AAD test was feasible for evaluating the efficacy of multiple AADs in patients with AF. AF wave-dynamic and electrophysiological characteristics are different among the PITX2-deficient and the wild-type genotype models.
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Kany S, Reissmann B, Metzner A, Kirchhof P, Darbar D, Schnabel RB. Genetics of atrial fibrillation-practical applications for clinical management: if not now, when and how? Cardiovasc Res 2021; 117:1718-1731. [PMID: 33982075 PMCID: PMC8208749 DOI: 10.1093/cvr/cvab153] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Indexed: 12/12/2022] Open
Abstract
The prevalence and economic burden of atrial fibrillation (AF) are predicted to more than double over the next few decades. In addition to anticoagulation and treatment of concomitant cardiovascular conditions, early and standardized rhythm control therapy reduces cardiovascular outcomes as compared with a rate control approach, favouring the restoration, and maintenance of sinus rhythm safely. Current therapies for rhythm control of AF include antiarrhythmic drugs (AADs) and catheter ablation (CA). However, response in an individual patient is highly variable with some remaining free of AF for long periods on antiarrhythmic therapy, while others require repeat AF ablation within weeks. The limited success of rhythm control therapy for AF is in part related to incomplete understanding of the pathophysiological mechanisms and our inability to predict responses in individual patients. Thus, a major knowledge gap is predicting which patients with AF are likely to respond to rhythm control approach. Over the last decade, tremendous progress has been made in defining the genetic architecture of AF with the identification of rare mutations in cardiac ion channels, signalling molecules, and myocardial structural proteins associated with familial (early-onset) AF. Conversely, genome-wide association studies have identified common variants at over 100 genetic loci and the development of polygenic risk scores has identified high-risk individuals. Although retrospective studies suggest that response to AADs and CA is modulated in part by common genetic variation, the development of a comprehensive clinical and genetic risk score may enable the translation of genetic data to the bedside care of AF patients. Given the economic impact of the AF epidemic, even small changes in therapeutic efficacy may lead to substantial improvements for patients and health care systems.
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Affiliation(s)
- Shinwan Kany
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg Eppendorf, Martinistraße 52, 20251 Hamburg, Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Martinistraße 52, 20251 Hamburg, Hamburg, Germany
| | - Bruno Reissmann
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg Eppendorf, Martinistraße 52, 20251 Hamburg, Hamburg, Germany
| | - Andreas Metzner
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg Eppendorf, Martinistraße 52, 20251 Hamburg, Hamburg, Germany
| | - Paulus Kirchhof
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg Eppendorf, Martinistraße 52, 20251 Hamburg, Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Martinistraße 52, 20251 Hamburg, Hamburg, Germany.,The Institute of Cardiovascular Sciences, University of Birmingham, Edgbaston Birmingham B15 2TT, UK
| | - Dawood Darbar
- Division of Cardiology, Departments of Medicine, University of Illinois at Chicago and Jesse Brown Veterans Administration, 840 South Wood Street, Suite 928 M/C 715, Chicago, IL 60612, USA
| | - Renate B Schnabel
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg Eppendorf, Martinistraße 52, 20251 Hamburg, Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Martinistraße 52, 20251 Hamburg, Hamburg, Germany
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57
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Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, Boriani G, Castella M, Dan GA, Dilaveris PE, Fauchier L, Filippatos G, Kalman JM, Meir ML, Lane DA, Lebeau JP, Lettino M, Lip GY, Pinto FJ, Neil Thomas G, Valgimigli M, Van Gelder IC, Van Putte BP, Watkins CL. Guía ESC 2020 sobre el diagnóstico y tratamiento de la fibrilación auricular, desarrollada en colaboración de la European Association of Cardio-Thoracic Surgery (EACTS). Rev Esp Cardiol 2021. [DOI: 10.1016/j.recesp.2020.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Al-Jazairi MIH, Nguyen BO, De With RR, Smit MD, Weijs B, Hobbelt AH, Alings M, Tijssen JGP, Geelhoed B, Hillege HL, Tieleman RG, Van Veldhuisen DJ, Crijns HJGM, Van Gelder IC, Blaauw Y, Rienstra M. Antiarrhythmic drugs in patients with early persistent atrial fibrillation and heart failure: results of the RACE 3 study. Europace 2021; 23:1359-1368. [PMID: 33899093 PMCID: PMC8427339 DOI: 10.1093/europace/euab062] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 03/02/2021] [Indexed: 01/22/2023] Open
Abstract
AIMS Maintaining sinus rhythm in patients with persistent atrial fibrillation (AF) is challenging. We explored the efficacy of class I and III antiarrhythmic drugs (AADs) in patients with persistent AF and mild to moderate heart failure (HF). METHODS AND RESULTS In the RACE 3 trial, patients with early persistent symptomatic AF and short history of mild to moderate HF with preserved or reduced left ventricular ejection fraction (LVEF) were randomized to targeted or conventional therapy. Both groups received AF and HF guideline-driven treatment. Additionally, the targeted-group received mineralocorticoid receptor antagonists, statins, angiotensin-converting enzyme inhibitors and/or receptor blockers, and cardiac rehabilitation. Class I and III AADs could be instituted in case of symptomatic recurrent AF. Eventually, pulmonary vein isolation could be performed. Primary endpoint was sinus rhythm on 7-day Holter after 1-year. Included were 245 patients, age 65 ± 9 years, 193 (79%) men, AF history was 3 (2-6) months, HF history 2 (1-4) months, 72 (29.4%) had HF with reduced LVEF. After baseline electrical cardioversion (ECV), 190 (77.6%) had AF recurrences; 108 (56.8%) received class I/III AADs; 19 (17.6%) flecainide, 36 (33.3%) sotalol, 3 (2.8%) dronedarone, 50 (46.3%) amiodarone. At 1-year 73 of 108 (68.0%) patients were in sinus rhythm, 44 (40.7%) without new AF recurrences. Maintenance of sinus rhythm was significantly better with amiodarone [n = 29/50 (58%)] compared with flecainide [n = 6/19 (32%)] and sotalol/dronedarone [n = 9/39 (23%)], P = 0.0064. Adverse events occurred in 27 (25.0%) patients, were all minor and reversible. CONCLUSION In stable HF patients with early persistent AF, AAD treatment was effective in nearly half of patients, with no serious adverse effects reported.
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Affiliation(s)
- Meelad I H Al-Jazairi
- Department of Cardiology, University of Groningen, Groningen, University Medical Center Groningen, The Netherlands
| | - Bao-Oanh Nguyen
- Department of Cardiology, University of Groningen, Groningen, University Medical Center Groningen, The Netherlands
| | - Ruben R De With
- Department of Cardiology, University of Groningen, Groningen, University Medical Center Groningen, The Netherlands
| | - Marcelle D Smit
- Department of Cardiology, Martini Hospital, Groningen, The Netherlands
| | - Bob Weijs
- Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, The Netherlands
| | - Anne H Hobbelt
- Department of Cardiology, University of Groningen, Groningen, University Medical Center Groningen, The Netherlands
| | - Marco Alings
- Department of Cardiology, Amphia Hospital Breda, Julius Clinical Zeist, The Netherlands
| | - Jan G P Tijssen
- Department of Clinical Epidemiology and Biostatistics, Academic Medical Centre, Amsterdam, The Netherlands
| | - Bastiaan Geelhoed
- Department of Cardiology, University of Groningen, Groningen, University Medical Center Groningen, The Netherlands
| | - Hans L Hillege
- Department of Cardiology, University of Groningen, Groningen, University Medical Center Groningen, The Netherlands
| | - Robert G Tieleman
- Department of Cardiology, Martini Hospital, Groningen, The Netherlands
| | - Dirk J Van Veldhuisen
- Department of Cardiology, University of Groningen, Groningen, University Medical Center Groningen, The Netherlands
| | - Harry J G M Crijns
- Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, The Netherlands
| | - Isabelle C Van Gelder
- Department of Cardiology, University of Groningen, Groningen, University Medical Center Groningen, The Netherlands
| | - Yuri Blaauw
- Department of Cardiology, University of Groningen, Groningen, University Medical Center Groningen, The Netherlands
| | - Michiel Rienstra
- Department of Cardiology, University of Groningen, Groningen, University Medical Center Groningen, The Netherlands
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Reissmann B, Breithardt G, Camm AJ, Van Gelder IC, Metzner A, Kirchhof P. The RACE to the EAST. In pursuit of rhythm control therapy for atrial fibrillation-a dedication to Harry Crijns. Europace 2021; 23:ii34-ii39. [PMID: 33837756 PMCID: PMC8035707 DOI: 10.1093/europace/euab023] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Indexed: 11/12/2022] Open
Abstract
The RACE trial was one of the first landmark trials to establish whether restoring and maintaining sinus rhythm could reduce morbidity and mortality in patients with atrial fibrillation (AF). Its neutral outcome shaped clinical decision-making for almost 20 years. However, there were two important treatment-related factors associated with mortality of rhythm control therapy at that time: One was safety of antiarrhythmic drug therapy, and the other one withdrawal of anticoagulation after restoration of sinus rhythm. Both concerns have been overcome, and, moreover, important knowledge considering the importance of time for the treatment of AF has been gained. These insights led to the concept of the EAST-AFNET 4 trial, and after more than two decades in the pursuit of ongoing therapeutic improvement, early rhythm control therapy has demonstrated to reduce a composite of cardiovascular death, stroke, and hospitalization for worsening of HF or acute coronary syndrome, by 21% (first primary outcome, absolute reduction 1.1 per 100 patient-years). For this entire period, Harry Crijns characterized the treatment of AF patients, and contributed decisively to realizing the benefit of rhythm control therapy. It is almost easier to list the clinical trials without Harry's involvement than to list those which he co-designed and led.
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Affiliation(s)
- Bruno Reissmann
- Department of Cardiology, University Heart Center Hamburg, Hamburg, Germany
| | - Günter Breithardt
- Department of Cardiology II (Electrophysiology), University Hospital Münster, Münster, Germany
| | - A John Camm
- Cardiology Clinical Academic Group Molecular & Clinical Sciences Institute, St George’s University of London, London, UK
| | - Isabelle C Van Gelder
- Department of Cardiology, Thoraxcenter, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Andreas Metzner
- Department of Cardiology, University Heart Center Hamburg, Hamburg, Germany
| | - Paulus Kirchhof
- Department of Cardiology, University Heart Center Hamburg, Hamburg, Germany
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
- German Center for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Germany
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Pajares MA, Margarit JA, García-Camacho C, García-Suarez J, Mateo E, Castaño M, López Forte C, López Menéndez J, Gómez M, Soto MJ, Veiras S, Martín E, Castaño B, López Palanca S, Gabaldón T, Acosta J, Fernández Cruz J, Fernández López AR, García M, Hernández Acuña C, Moreno J, Osseyran F, Vives M, Pradas C, Aguilar EM, Bel Mínguez AM, Bustamante-Munguira J, Gutiérrez E, Llorens R, Galán J, Blanco J, Vicente R. Guidelines for enhanced recovery after cardiac surgery. Consensus document of Spanish Societies of Anesthesia (SEDAR), Cardiovascular Surgery (SECCE) and Perfusionists (AEP). REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2021; 68:183-231. [PMID: 33541733 DOI: 10.1016/j.redar.2020.11.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 11/03/2020] [Accepted: 11/09/2020] [Indexed: 01/28/2023]
Abstract
The ERAS guidelines are intended to identify, disseminate and promote the implementation of the best, scientific evidence-based actions to decrease variability in clinical practice. The implementation of these practices in the global clinical process will promote better outcomes and the shortening of hospital and critical care unit stays, thereby resulting in a reduction in costs and in greater efficiency. After completing a systematic review at each of the points of the perioperative process in cardiac surgery, recommendations have been developed based on the best scientific evidence currently available with the consensus of the scientific societies involved.
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Affiliation(s)
- M A Pajares
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, España.
| | - J A Margarit
- Servicio de Cirugía Cardiaca, Hospital Universitari de La Ribera, Valencia, España
| | - C García-Camacho
- Unidad de Perfusión del Servicio de Cirugía Cardiaca, Hospital Universitario Puerta del Mar,, Cádiz, España
| | - J García-Suarez
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario Puerta de Hierro, Madrid, España
| | - E Mateo
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario de Valencia, Valencia, España
| | - M Castaño
- Servicio de Cirugía Cardiaca, Complejo Asistencial Universitario de León, León, España
| | - C López Forte
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, España
| | - J López Menéndez
- Servicio de Cirugía Cardiaca, Hospital Ramón y Cajal, Madrid, España
| | - M Gómez
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari de La Ribera, Valencia, España
| | - M J Soto
- Unidad de Perfusión, Servicio de Cirugía Cardiaca, Hospital Universitari de La Ribera, Valencia, España
| | - S Veiras
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Clínico Universitario de Santiago, Santiago de Compostela, España
| | - E Martín
- Servicio de Cirugía Cardiaca, Complejo Asistencial Universitario de León, León, España
| | - B Castaño
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Complejo Hospitalario de Toledo, Toledo, España
| | - S López Palanca
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario de Valencia, Valencia, España
| | - T Gabaldón
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario de Valencia, Valencia, España
| | - J Acosta
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - J Fernández Cruz
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari de La Ribera, Valencia, España
| | - A R Fernández López
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Virgen Macarena, Sevilla, España
| | - M García
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - C Hernández Acuña
- Servicio de Cirugía Cardiaca, Hospital Universitari de La Ribera, Valencia, España
| | - J Moreno
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario de Valencia, Valencia, España
| | - F Osseyran
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, España
| | - M Vives
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari Dr. Josep Trueta, Girona, España
| | - C Pradas
- Servicio de Cirugía Cardiaca, Hospital Universitari Dr. Josep Trueta, Girona, España
| | - E M Aguilar
- Servicio de Cirugía Cardiaca, Hospital Universitario 12 de Octubre, Madrid, España
| | - A M Bel Mínguez
- Servicio de Cirugía Cardiaca, Hospital Universitari i Politècnic La Fe, Valencia, España
| | - J Bustamante-Munguira
- Servicio de Cirugía Cardiaca, Hospital Clínico Universitario de Valladolid, Valladolid, España
| | - E Gutiérrez
- Servicio de Cirugía Cardiaca, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - R Llorens
- Servicio de Cirugía Cardiovascular, Hospiten Rambla, Santa Cruz de Tenerife, España
| | - J Galán
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - J Blanco
- Unidad de Perfusión, Servicio de Cirugía Cardiovascular, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España
| | - R Vicente
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, España
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El Amrani A, Viñolas X, Arias MA, Bazan V, Valdovinos P, Alegret JM. Pharmacological Cardioversion after Pre-Treatment with Antiarrythmic Drugs Prior to Electrical Cardioversion in Persistent Atrial Fibrillation: Impact on Maintenance of Sinus Rhythm. J Clin Med 2021; 10:1029. [PMID: 33802253 PMCID: PMC7958960 DOI: 10.3390/jcm10051029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 02/19/2021] [Accepted: 02/22/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Antiarrhythmic drugs (AADs) are frequently initiated in patients with persistent atrial fibrillation (AF) prior to electrical cardioversion (ECV), achieving pharmacological cardioversion (PCV) in some cases. Little is known about the mode of cardioversion and the effect of the type of AAD used in the maintenance of sinus rhythm (SR). METHODS From three national surveys of patients with persistent AF referred for ECV, we selected those who were pre-treated with AADs (amiodarone or group Ic AADs). We analyzed the effect of the type of cardioversion (pharmacological vs. electrical) and the AAD used in the maintenance of SR at three months. RESULTS Among the 665 patients selected, 151 had a successful PCV prior to the planned ECV. In the remaining 514 patients, 460 had a successful ECV. A successful PCV was related to a higher rate of SR maintenance than a successful ECV (77.9% vs. 57.5%; p < 0.0001). After a successful PCV, the maintenance of SR was identical in those patients treated with amiodarone and those treated with group Ic AADs (77.4% vs. 77.5%; p = 0.99), whereas after a successful ECV, amiodarone was clearly superior to group Ic AADs (61.3% vs. 43.0%; p = 0.001). Considering patients with successful PCV and ECV together, PCV was an independent factor related to the maintenance of SR. CONCLUSIONS In patients with persistent AF, successful PCV selects a subgroup with a high probability of maintenance of SR. With regard to drugs, amiodarone was superior to group Ic AADs in patients with ECV, whereas in PCV, no differences were observed.
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Affiliation(s)
- Amine El Amrani
- Department of Cardiology, Hospital Universitari de Sant Joan, IISPV, Universitat Rovira i Virgili, 43204 Reus, Spain; (A.E.A.); (P.V.)
| | - Xavier Viñolas
- Department of Cardiology, Hospital de la Sta. Creu i St. Pau, 08026 Barcelona, Spain;
| | - Miguel Angel Arias
- Department of Cardiology, Hospital Virgen de la Salud, 45004 Toledo, Spain;
| | - Victor Bazan
- Department of Cardiology, Hospital Universitari Germans Trias i Pujol, 08916 Badalona, Spain;
| | - Pilar Valdovinos
- Department of Cardiology, Hospital Universitari de Sant Joan, IISPV, Universitat Rovira i Virgili, 43204 Reus, Spain; (A.E.A.); (P.V.)
| | - Josep M. Alegret
- Department of Cardiology, Hospital Universitari de Sant Joan, IISPV, Universitat Rovira i Virgili, 43204 Reus, Spain; (A.E.A.); (P.V.)
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62
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Margarit JA, Pajares MA, García-Camacho C, Castaño-Ruiz M, Gómez M, García-Suárez J, Soto-Viudez MJ, López-Menéndez J, Martín-Gutiérrez E, Blanco-Morillo J, Mateo E, Hernández-Acuña C, Vives M, Llorens R, Fernández-Cruz J, Acosta J, Pradas-Irún C, García M, Aguilar-Blanco EM, Castaño B, López S, Bel A, Gabaldón T, Fernández-López AR, Gutiérrez-Carretero E, López-Forte C, Moreno J, Galán J, Osseyran F, Bustamante-Munguira J, Veiras S, Vicente R. Vía clínica de recuperación intensificada en cirugía cardiaca. Documento de consenso de la Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor (SEDAR), la Sociedad Española de Cirugía Cardiovascular y Endovascular (SECCE) y la Asociación Española de Perfusionistas (AEP). CIRUGIA CARDIOVASCULAR 2021. [DOI: 10.1016/j.circv.2020.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
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[2020 ESC guidelines on atrial fibrillation : Summary of the most relevant recommendations and innovations]. Herz 2021; 46:28-37. [PMID: 33289046 DOI: 10.1007/s00059-020-05005-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The new guidelines for the diagnosis and management of atrial fibrillation (AF) were published by the European Society of Cardiology (ESC) in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS) in August 2020. The 2020 guidelines of the ESC on AF summarize the current developments in this field and provide general recommendations for the management of patients with AF based on the principles of evidence-based medicine. Beside the general statements on definition, epidemiology and clinical features of AF, interesting new aspects in screening and diagnosis of AF are also presented. The main novelties of the 2020 guidelines are the proposal of the 4S-AF scheme for a structured characterization of AF that takes the stroke risk, severity of symptoms, severity of AF burden and substrate severity into account. Also new is the ABC approach for improvement of the structured management and treatment results. A further innovation is the introduction of the concept of major risk factors for recurrences in the decision for catheter ablation. This review focuses on the newest and most important recommendations taken from the 2020 ESC guidelines for the diagnosis and management of AF.
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64
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Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, Boriani G, Castella M, Dan GA, Dilaveris PE, Fauchier L, Filippatos G, Kalman JM, La Meir M, Lane DA, Lebeau JP, Lettino M, Lip GYH, Pinto FJ, Thomas GN, Valgimigli M, Van Gelder IC, Van Putte BP, Watkins CL. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J 2021; 42:373-498. [PMID: 32860505 DOI: 10.1093/eurheartj/ehaa612] [Citation(s) in RCA: 5483] [Impact Index Per Article: 1827.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Siemers LA, MacGillivray J, Andrade JG, Turgeon RD. Chronic Amiodarone Use and the Risk of Cancer: A Systematic Review and Meta-analysis. CJC Open 2021; 3:109-114. [PMID: 33458637 PMCID: PMC7801211 DOI: 10.1016/j.cjco.2020.09.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 09/11/2020] [Indexed: 11/16/2022] Open
Abstract
Background Observational studies have identified inconsistent associations between chronic use of amiodarone and cancer-related outcomes. We performed a systematic review and meta-analysis to evaluate cancer risk among patients receiving amiodarone. Methods We searched MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) to May 1, 2020. We included randomized controlled trials (RCTs) with follow-up ≥2 years that compared amiodarone (any dose) to any comparator (placebo, active pharmacologic or interventional comparator, or usual care), and reported ≥1 outcome of interest. We contacted authors of published chronic amiodarone trials for potentially unreported cancer outcomes. The primary outcome was cancer incidence. Secondary outcomes were cancer-related death and site-specific cancers. We determined risk ratios and 95% confidence intervals using a fixed-effect model, and statistical heterogeneity using I2. We conducted prespecified subgroup and sensitivity analyses for amiodarone indication, amiodarone dose, duration of therapy, and trial-level risk of bias. Results From 1439 articles, we included 5 RCTs (n = 4357). Mean follow-up duration ranged from 21 to 37 months. We included previously unpublished cancer outcome data from 1 RCT. Our primary outcome was not reported in any RCT. There was no significant difference in cancer-related death between amiodarone (1.69%) and the comparator (1.75%) (risk ratio 0.96, 95% confidence interval 0.57-1.63; I2 = 0%). There were no significant interactions from our subgroup or sensitivity analyses. Conclusions Chronic amiodarone use did not increase cancer-related deaths. Data from RCTs do not support an increased risk of cancer-related harms with amiodarone use, and these concerns should not deter use of amiodarone when indicated.
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Affiliation(s)
- Lauren A Siemers
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jenny MacGillivray
- Atrial Fibrillation Clinic, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Jason G Andrade
- Atrial Fibrillation Clinic, Vancouver General Hospital, Vancouver, British Columbia, Canada.,Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.,Centre for Cardiovascular Innovation, Vancouver, British Columbia, Canada
| | - Ricky D Turgeon
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
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66
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Chew D, Piccini JP. Long-term oral anticoagulant after catheter ablation for atrial fibrillation. Europace 2021; 23:1157-1165. [PMID: 33400774 DOI: 10.1093/europace/euaa365] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 11/11/2020] [Indexed: 11/14/2022] Open
Abstract
Catheter ablation is superior to antiarrhythmic therapy for the reduction of symptomatic atrial fibrillation (AF), recurrence, and burden. The possibility of a true 'rhythm' control strategy with catheter ablation has re-opened the debate on rate vs. rhythm control and the subsequent impact on stroke risk. Some observation studies suggest that successful AF catheter ablation and maintenance of sinus rhythm are associated with a decrease in stroke risk, while the CABANA trial had demonstrated no apparent reduction. Other observational studies have demonstrated increased stroke risk when oral anticoagulation (OAC) is discontinued after catheter ablation. When and in whom OAC can be discontinued after ablation will need to be determined in properly conducted randomized control trials. In this review article, we discuss our current understanding of the interactions between AF, stroke, and anticoagulation following catheter ablation. Specifically, we discuss the evidence for the long-term anticoagulation following successful catheter ablation, the potential for OAC discontinuation with restoration of sinus rhythm, and novel approaches to anticoagulation management post-ablation.
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Affiliation(s)
- Derek Chew
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Jonathan P Piccini
- Duke Clinical Research Institute, Duke University, Durham, NC, USA.,Division of Cardiology, Duke University Medical Center, 200 Morris Street, Durham, NC 27701, USA
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67
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Arora S, Jaswaney R, Jani C, Zuzek Z, Thakkar S, Patel HP, Patel M, Patel N, Tripathi B, Lahewala S, Arora N, Josephson R, Osman MN, Hoit BD, Kowlgi G, Mulpuru SK, DeSimone CV, Viles-Gonzalez J, Deshmukh A. Catheter Ablation for Atrial Fibrillation in Patients With Concurrent Heart Failure. Am J Cardiol 2020; 137:45-54. [PMID: 33002464 DOI: 10.1016/j.amjcard.2020.09.035] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 09/15/2020] [Accepted: 09/18/2020] [Indexed: 11/17/2022]
Abstract
Due to limited real-world data, the aim of this study was to explore the impact of catheter ablation (CA) for atrial fibrillation (AF) in heart failure (HF). This retrospective cohort study identified 119,694 patients with AF and HF from the Nationwide Readmissions Database (NRD) from 2016 to 2017. Propensity-matching was generated using demographics, comorbidities, hospital and other characteristics through multivariate logistic regression. Greedy's propensity score match (1:15) algorithm was used to create matched data. The primary end point was a composite of HF readmission and mortality at 1 year. Secondary outcomes include HF readmission, mortality, AF readmission, and any-cause readmission at 1 year. Of the 119,694 patients, 63,299 had HF with reduced ejection fraction (HFrEF), and 56,395 had HF with preserved ejection fraction (HFpEF). In the overall HFrEF cohort, the primary outcome was similar (HR, 95% confidence interval, p-value) (1.01, 0.91 to 1.13, 0.811). AF readmission (0.41, 0.33 to 0.49, <0.001) and any readmission (0.87, 0.82 to 0.93, <0.001) were reduced with CA. In the propensity-matched HFrEF cohort, results were unchanged (primary outcome: 1.10, 0.95 to 1.27, 0.189; AF readmission: 0.46, 0.36 to 0.59, <0.001; any readmission: 0.89, 0.82 to 0.98, 0.015). In the overall HFpEF cohort, the primary outcome was similar (0.90, 0.78 to 1.04, 0.154). AF readmission was reduced with CA (0.54, 0.44 to 0.65, <0.001). In the propensity-matched HFpEF cohort, results were unchanged (primary outcome 1.10, 0.92 to 1.31, 0.289; AF readmission 0.44, 0.33 to 0.57, <0.001). CA did not reduce mortality and HF readmission at one year irrespective of the type of HF, but significantly reduce readmission due to AF.
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Affiliation(s)
- Shilpkumar Arora
- Harrington Heart and Vascular Institute/Case Western Reserve University, Cleveland, Ohio.
| | - Rahul Jaswaney
- Harrington Heart and Vascular Institute/Case Western Reserve University, Cleveland, Ohio
| | - Chinmay Jani
- Mount Auburn Hospital-Harvard Medical School, Cambridge, Massachusetts
| | - Zachary Zuzek
- Harrington Heart and Vascular Institute/Case Western Reserve University, Cleveland, Ohio
| | | | | | - Mohini Patel
- Boston University School of Public Health, Boston, Massachusetts
| | - Nilay Patel
- University of Kansas Medical center, Kansas City, Kansas
| | | | | | | | - Richard Josephson
- Harrington Heart and Vascular Institute/Case Western Reserve University, Cleveland, Ohio
| | - Mohammed Najeeb Osman
- Harrington Heart and Vascular Institute/Case Western Reserve University, Cleveland, Ohio
| | - Brian D Hoit
- Harrington Heart and Vascular Institute/Case Western Reserve University, Cleveland, Ohio
| | | | | | | | - Juan Viles-Gonzalez
- Miami Cardiac and Vascular Institute/Baptist Health South Florida, Miami, Florida
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Kugamoorthy P, Spears DA. Management of tachyarrhythmias in pregnancy - A review. Obstet Med 2020; 13:159-173. [PMID: 33343692 PMCID: PMC7726166 DOI: 10.1177/1753495x20913448] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 02/16/2020] [Indexed: 11/16/2022] Open
Abstract
The most common arrhythmias detected during pregnancy include sinus tachycardia, sinus bradycardia, and sinus arrhythmia, identified in 0.1% of pregnancies. Isolated premature atrial or ventricular arrhythmias are observed in 0.03% of pregnancies. Arrhythmias may become more frequent during pregnancy or may manifest for the first time.
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Affiliation(s)
| | - Danna A Spears
- University Health Network – Toronto General Hospital, Toronto, Canada
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69
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Geng M, Lin A, Nguyen TP. Revisiting Antiarrhythmic Drug Therapy for Atrial Fibrillation: Reviewing Lessons Learned and Redefining Therapeutic Paradigms. Front Pharmacol 2020; 11:581837. [PMID: 33240090 PMCID: PMC7680856 DOI: 10.3389/fphar.2020.581837] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 09/17/2020] [Indexed: 12/12/2022] Open
Abstract
Since the clinical use of digitalis as the first pharmacological therapy for atrial fibrillation (AF) 235 years ago in 1785, antiarrhythmic drug therapy has advanced considerably and become a cornerstone of AF clinical management. Yet, a preventive or curative panacea for sustained AF does not exist despite the rise of AF global prevalence to epidemiological proportions. While multiple elevated risk factors for AF have been established, the natural history and etiology of AF remain incompletely understood. In the present article, the first section selectively highlights some disappointing shortcomings and current efforts in antiarrhythmic drug therapy to uncover reasons why AF is such a clinical challenge. The second section discusses some modern takes on the natural history of AF as a relentless, progressive fibro-inflammatory "atriomyopathy." The final section emphasizes the need to redefine therapeutic strategies on par with new insights of AF pathophysiology.
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Affiliation(s)
| | | | - Thao P. Nguyen
- Division of Cardiology, Department of Medicine, The Cardiovascular Research Laboratory, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
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Abstract
PURPOSE OF REVIEW To review the shared pathology of atrial fibrillation and heart failure with preserved ejection fraction (HFpEF) and the prognostic, diagnostic, and treatment challenges incurred by the co-occurrence of these increasingly prevalent diseases. RECENT FINDINGS Multiple risk factors and mechanisms have been proposed as potentially linking atrial fibrillation and HFpEF, with systemic inflammation more recently being invoked. Nonvitamin K oral anticoagulants, left atrial appendage occlusion devices, and catheter ablation have emerged as alternative treatment options. Other novel pharmacological agents, such as neprilysin inhibitors, need to be studied further in this patient population. SUMMARY Atrial fibrillation and HFpEF commonly co-occur because of their shared risk factors and pathophysiology and incur increased morbidity and mortality relative to either condition alone. Although the presence of both diseases can often make each diagnosis difficult, it is important to do so early in the disease course as there are now a variety of treatment options aimed at improving symptoms and quality of life, slowing disease progression, and improving prognosis. However, more research needs to be performed on the role of catheter ablation in this population. Novel pharmacologic and procedural treatment options appear promising and may further improve the treatment options available to this growing population.
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71
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Pharmacological rhythm versus rate control in patients with atrial fibrillation and heart failure: the CASTLE-AF trial. J Interv Card Electrophysiol 2020; 61:609-615. [DOI: 10.1007/s10840-020-00856-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 08/24/2020] [Indexed: 12/22/2022]
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Reyat JS, Chua W, Cardoso VR, Witten A, Kastner PM, Kabir SN, Sinner MF, Wesselink R, Holmes AP, Pavlovic D, Stoll M, Kääb S, Gkoutos GV, de Groot JR, Kirchhof P, Fabritz L. Reduced left atrial cardiomyocyte PITX2 and elevated circulating BMP10 predict atrial fibrillation after ablation. JCI Insight 2020; 5:139179. [PMID: 32814717 PMCID: PMC7455124 DOI: 10.1172/jci.insight.139179] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 07/08/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUNDGenomic and experimental studies suggest a role for PITX2 in atrial fibrillation (AF). To assess if this association is relevant for recurrent AF in patients, we tested whether left atrial PITX2 affects recurrent AF after AF ablation.METHODSmRNA concentrations of PITX2 and its cardiac isoform, PITX2c, were quantified in left atrial appendages (LAAs) from patients undergoing thoracoscopic AF ablation, either in whole LAA tissue (n = 83) or in LAA cardiomyocytes (n = 52), and combined with clinical parameters to predict AF recurrence. Literature suggests that BMP10 is a PITX2-repressed, atrial-specific, secreted protein. BMP10 plasma concentrations were combined with 11 cardiovascular biomarkers and clinical parameters to predict recurrent AF after catheter ablation in 359 patients.RESULTSReduced concentrations of cardiomyocyte PITX2, but not whole LAA tissue PITX2, were associated with AF recurrence after thoracoscopic AF ablation (16% decreased recurrence per 2-(ΔΔCt) increase in PITX2). RNA sequencing, quantitative PCR, and Western blotting confirmed that BMP10 is one of the most PITX2-repressed atrial genes. Left atrial size (HR per mm increase [95% CI], 1.055 [1.028, 1.082]); nonparoxysmal AF (HR 1.672 [1.206, 2.318]), and elevated BMP10 (HR 1.339 [CI 1.159, 1.546] per quartile increase) were predictive of recurrent AF. BMP10 outperformed 11 other cardiovascular biomarkers in predicting recurrent AF.CONCLUSIONSReduced left atrial cardiomyocyte PITX2 and elevated plasma concentrations of the PITX2-repressed, secreted atrial protein BMP10 identify patients at risk of recurrent AF after ablation.TRIAL REGISTRATIONClinicalTrials.gov NCT01091389, NL50069.018.14, Dutch National Registry of Clinical Research Projects EK494-16.FUNDINGBritish Heart Foundation, European Union (H2020), Leducq Foundation.
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Affiliation(s)
| | | | - Victor R. Cardoso
- Institute of Cardiovascular Sciences and
- Institute of Cancer and Genomics Sciences, College of Medical and Dental Sciences, Medical School, University of Birmingham, Birmingham, United Kingdom
| | - Anika Witten
- Institute of Human Genetics, Genetic Epidemiology, WWU Münster, Münster, Germany
| | | | | | - Moritz F. Sinner
- Department of Medicine I, University Hospital Munich, Ludwig Maximilian University of Munich (LMU), Munich, Germany
- German Centre for Cardiovascular Research (DZHK), partner site Munich Heart Alliance, Munich, Germany
| | - Robin Wesselink
- Department of Cardiology, Amsterdam University Medical Center (UMC), University of Amsterdam, Heart Center, Amsterdam, Netherlands
| | | | | | - Monika Stoll
- Institute of Human Genetics, Genetic Epidemiology, WWU Münster, Münster, Germany
- Cardiovascular Research Institute Maastricht, Genetic Epidemiology and Statistical Genetics, Maastricht University, Maastricht, Netherlands
| | - Stefan Kääb
- Department of Medicine I, University Hospital Munich, Ludwig Maximilian University of Munich (LMU), Munich, Germany
- Atrial Fibrillation NETwork (AFNET), Münster, Germany
| | - Georgios V. Gkoutos
- Institute of Cardiovascular Sciences and
- Institute of Cancer and Genomics Sciences, College of Medical and Dental Sciences, Medical School, University of Birmingham, Birmingham, United Kingdom
- Health Data Research Midlands, Birmingham, United Kingdom
| | - Joris R. de Groot
- Department of Cardiology, Amsterdam University Medical Center (UMC), University of Amsterdam, Heart Center, Amsterdam, Netherlands
| | - Paulus Kirchhof
- Institute of Cardiovascular Sciences and
- Atrial Fibrillation NETwork (AFNET), Münster, Germany
- Department of Cardiology, University Hospitals Birmingham (UHB) and Sandwell and West Birmingham (SWBH) NHS Trusts, Birmingham, United Kingdom
- University Heart and Vascular Center, Universitätsklinikum Hamburg-Eppendorf (UKE), Hamburg, Germany
- German Center for Cardiovascular Research, partner site Hamburg/Kiel/Lübeck, Germany
| | - Larissa Fabritz
- Institute of Cardiovascular Sciences and
- Atrial Fibrillation NETwork (AFNET), Münster, Germany
- Department of Cardiology, University Hospitals Birmingham (UHB) and Sandwell and West Birmingham (SWBH) NHS Trusts, Birmingham, United Kingdom
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Abstract
Atrial fibrillation (AF) is the most common sustained arrhythmia encountered in humans and is a significant source of morbidity and mortality. Despite its prevalence, our mechanistic understanding is incomplete, the therapeutic options have limited efficacy, and are often fraught with risks. A better biological understanding of AF is needed to spearhead novel therapeutic avenues. Although "natural" AF is nearly nonexistent in most species, animal models have contributed significantly to our understanding of AF and some therapeutic options. However, the impediments of animal models are also apparent and stem largely from the differences in basic physiology as well as the complexities underlying human AF; these preclude the creation of a "perfect" animal model and have obviated the translation of animal findings. Herein, we review the vast array of AF models available, spanning the mouse heart (weighing 1/1000th of a human heart) to the horse heart (10× heavier than the human heart). We attempt to highlight the features of each model that bring value to our understanding of AF but also the shortcomings and pitfalls. Finally, we borrowed the concept of a SWOT analysis from the business community (which stands for strengths, weaknesses, opportunities, and threats) and applied this introspective type of analysis to animal models for AF. We identify unmet needs and stress that is in the context of rapidly advancing technologies, these present opportunities for the future use of animal models.
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Affiliation(s)
- Dominik Schüttler
- From the Department of Medicine I, University Hospital Munich, Campus Großhadern, Ludwig-Maximilians University Munich (LMU), Germany (D.S., S.K., P.T., S.C.).,DZHK (German Centre for Cardiovascular Research), Partner Site Munich, Munich Heart Alliance (MHA), Germany (D.S., S.K., P.T., S.C.).,Walter Brendel Centre of Experimental Medicine, Ludwig-Maximilians University Munich (LMU), Germany (D.S., P.T., S.C.)
| | - Aneesh Bapat
- Cardiovascular Research Center, Massachusetts General Hospital, Harvard Medical School, Boston (A.B., K.L., W.J.H.).,Cardiac Arrhythmia Service, Division of Cardiology, Massachusetts General Hospital, Boston (A.B., W.J.H.)
| | - Stefan Kääb
- From the Department of Medicine I, University Hospital Munich, Campus Großhadern, Ludwig-Maximilians University Munich (LMU), Germany (D.S., S.K., P.T., S.C.).,DZHK (German Centre for Cardiovascular Research), Partner Site Munich, Munich Heart Alliance (MHA), Germany (D.S., S.K., P.T., S.C.)
| | - Kichang Lee
- Cardiovascular Research Center, Massachusetts General Hospital, Harvard Medical School, Boston (A.B., K.L., W.J.H.)
| | - Philipp Tomsits
- From the Department of Medicine I, University Hospital Munich, Campus Großhadern, Ludwig-Maximilians University Munich (LMU), Germany (D.S., S.K., P.T., S.C.).,DZHK (German Centre for Cardiovascular Research), Partner Site Munich, Munich Heart Alliance (MHA), Germany (D.S., S.K., P.T., S.C.).,Walter Brendel Centre of Experimental Medicine, Ludwig-Maximilians University Munich (LMU), Germany (D.S., P.T., S.C.)
| | - Sebastian Clauss
- From the Department of Medicine I, University Hospital Munich, Campus Großhadern, Ludwig-Maximilians University Munich (LMU), Germany (D.S., S.K., P.T., S.C.).,DZHK (German Centre for Cardiovascular Research), Partner Site Munich, Munich Heart Alliance (MHA), Germany (D.S., S.K., P.T., S.C.).,Walter Brendel Centre of Experimental Medicine, Ludwig-Maximilians University Munich (LMU), Germany (D.S., P.T., S.C.)
| | - William J Hucker
- Cardiovascular Research Center, Massachusetts General Hospital, Harvard Medical School, Boston (A.B., K.L., W.J.H.).,Cardiac Arrhythmia Service, Division of Cardiology, Massachusetts General Hospital, Boston (A.B., W.J.H.)
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75
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Kahale LA, Khamis AM, Diab B, Chang Y, Lopes LC, Agarwal A, Li L, Mustafa RA, Koujanian S, Waziry R, Busse JW, Dakik A, Hooft L, Guyatt GH, Scholten RJPM, Akl EA. Meta-Analyses Proved Inconsistent in How Missing Data Were Handled Across Their Included Primary Trials: A Methodological Survey. Clin Epidemiol 2020; 12:527-535. [PMID: 32547244 PMCID: PMC7266325 DOI: 10.2147/clep.s242080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Background How systematic review authors address missing data among eligible primary studies remains uncertain. Objective To assess whether systematic review authors are consistent in the way they handle missing data, both across trials included in the same meta-analysis, and with their reported methods. Methods We first identified 100 eligible systematic reviews that included a statistically significant meta-analysis of a patient-important dichotomous efficacy outcome. Then, we successfully retrieved 638 of the 653 trials included in these systematic reviews’ meta-analyses. From each trial report, we extracted statistical data used in the analysis of the outcome of interest to compare with the data used in the meta-analysis. First, we used these comparisons to classify the “analytical method actually used” for handling missing data by the systematic review authors for each included trial. Second, we assessed whether systematic reviews explicitly reported their analytical method of handling missing data. Third, we calculated the proportion of systematic reviews that were consistent in their “analytical method actually used” across trials included in the same meta-analysis. Fourth, among systematic reviews that were consistent in the “analytical method actually used” across trials and explicitly reported on a method for handling missing data, we assessed whether the “analytical method actually used” and the reported methods were consistent. Results We were unable to determine the “analytical method reviews actually used” for handling missing outcome data among 397 trials. Among the remaining 241, systematic review authors most commonly conducted “complete case analysis” (n=128, 53%) or assumed “none of the participants with missing data had the event of interest” (n=58, 24%). Only eight of 100 systematic reviews were consistent in their approach to handling missing data across included trials, but none of these reported methods for handling missing data. Among seven reviews that did explicitly report their analytical method of handling missing data, only one was consistent in their approach across included trials (using complete case analysis), and their approach was inconsistent with their reported methods (assumed all participants with missing data had the event). Conclusion The majority of systematic review authors were inconsistent in their approach towards reporting and handling missing outcome data across eligible primary trials, and most did not explicitly report their methods to handle missing data. Systematic review authors should clearly identify missing outcome data among their eligible trials, specify an approach for handling missing data in their analyses, and apply their approach consistently across all primary trials.
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Affiliation(s)
- Lara A Kahale
- Clinical Research Institute, American University of Beirut, Beirut, Lebanon
| | - Assem M Khamis
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Batoul Diab
- Clinical Research Institute, American University of Beirut, Beirut, Lebanon
| | - Yaping Chang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Luciane Cruz Lopes
- Pharmaceutical Sciences Post Graduate Course, University of Sorocaba, UNISO, Sorocaba, Sao Paulo, Brazil
| | - Arnav Agarwal
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ling Li
- Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Reem A Mustafa
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada.,Departments of Medicine and Biomedical & Health Informatics, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Serge Koujanian
- Department of Evaluative Clinical Sciences, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Reem Waziry
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Jason W Busse
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada.,Department of Anesthesia, McMaster University, Hamilton, Canada.,The Michael G. DeGroote National Pain Centre, McMaster University, Hamilton, Canada.,Chronic Pain Centre of Excellence for Canadian Veterans, Hamilton, Canada
| | - Abeer Dakik
- Clinical Research Institute, American University of Beirut, Beirut, Lebanon
| | - Lotty Hooft
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada.,Department of Medicine, McMaster University, Hamilton, Canada
| | - Rob J P M Scholten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Elie A Akl
- Clinical Research Institute, American University of Beirut, Beirut, Lebanon.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
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76
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Magliari RT, Neto JNDA. How to Manage Atrial Fibrillation in the Emergency Department: a Critical Appraisal. JOURNAL OF CARDIAC ARRHYTHMIAS 2020. [DOI: 10.24207/jca.v33i1.3390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Atrial fibrillation is the most common cardiac arrhythmia in emergency departments. There is growing evidence that certain patients with acute atrial fibrillation can be safely managed in the emergency room without the need for hospitalization, minimizing costs and reducing unnecessary exposures. This review addresses the emergency management of atrial fibrillation based on the latest updates on the subject with a focus on the assessment and prevention of thromboembolic phenomena, control of frequency x control of rhythm and strategies for cardioversion and restoration of sinus rhythm or for heart rate control.
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77
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Dretzke J, Chuchu N, Agarwal R, Herd C, Chua W, Fabritz L, Bayliss S, Kotecha D, Deeks JJ, Kirchhof P, Takwoingi Y. Predicting recurrent atrial fibrillation after catheter ablation: a systematic review of prognostic models. Europace 2020; 22:748-760. [PMID: 32227238 PMCID: PMC7203634 DOI: 10.1093/europace/euaa041] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 02/05/2020] [Indexed: 12/22/2022] Open
Abstract
AIMS We assessed the performance of modelsf (risk scores) for predicting recurrence of atrial fibrillation (AF) in patients who have undergone catheter ablation. METHODS AND RESULTS Systematic searches of bibliographic databases were conducted (November 2018). Studies were eligible for inclusion if they reported the development, validation, or impact assessment of a model for predicting AF recurrence after ablation. Model performance (discrimination and calibration) measures were extracted. The Prediction Study Risk of Bias Assessment Tool (PROBAST) was used to assess risk of bias. Meta-analysis was not feasible due to clinical and methodological differences between studies, but c-statistics were presented in forest plots. Thirty-three studies developing or validating 13 models were included; eight studies compared two or more models. Common model variables were left atrial parameters, type of AF, and age. Model discriminatory ability was highly variable and no model had consistently poor or good performance. Most studies did not assess model calibration. The main risk of bias concern was the lack of internal validation which may have resulted in overly optimistic and/or biased model performance estimates. No model impact studies were identified. CONCLUSION Our systematic review suggests that clinical risk prediction of AF after ablation has potential, but there remains a need for robust evaluation of risk factors and development of risk scores.
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Affiliation(s)
- Janine Dretzke
- Institute of Applied Health Research, University of Birmingham, Birmingham B15 2TT, UK
| | - Naomi Chuchu
- Institute of Applied Health Research, University of Birmingham, Birmingham B15 2TT, UK
| | - Ridhi Agarwal
- Institute of Applied Health Research, University of Birmingham, Birmingham B15 2TT, UK
| | - Clare Herd
- Institute of Applied Health Research, University of Birmingham, Birmingham B15 2TT, UK
| | - Winnie Chua
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - Larissa Fabritz
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham B15 2TT, UK
- University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, UK
| | - Susan Bayliss
- Institute of Applied Health Research, University of Birmingham, Birmingham B15 2TT, UK
| | - Dipak Kotecha
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham B15 2TT, UK
- University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, UK
| | - Jonathan J Deeks
- Institute of Applied Health Research, University of Birmingham, Birmingham B15 2TT, UK
| | - Paulus Kirchhof
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham B15 2TT, UK
- University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, UK
- Sandwell and West Birmingham Hospitals NHS Trust, Birmingham B18 7QH, UK
| | - Yemisi Takwoingi
- Institute of Applied Health Research, University of Birmingham, Birmingham B15 2TT, UK
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78
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Ting C, Malloy R, Knowles D. Assessment of Sotalol and Dofetilide Dosing at a Large Academic Medical Center. J Cardiovasc Pharmacol Ther 2020; 25:438-443. [PMID: 32347108 DOI: 10.1177/1074248420921740] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Patients initiated on sotalol and dofetilide require inpatient monitoring and dose adjustments due to risks of corrected QT (QTc) prolongation and Torsades de pointes (TdP). Patients may receive higher initial doses than recommended due to close monitoring by specialized practitioners. The objective of this study was to describe prescribing practices of sotalol and dofetilide and to compare safety outcomes between standard and nonstandard dosing strategies. METHODS This was a single-center retrospective analysis of adult inpatients who underwent sotalol or dofetilide initiation between June 1, 2015, and August 1, 2018. The end points of this study included the percentage of patients who received standard and nonstandard dosing, incidence of QTc prolongation (≥500 milliseconds or ≥15% from baseline), incidence of TdP, and dose reduction or medication discontinuation. RESULTS A total of 379 patients (195 sotalol and 184 dofetilide) were included in this analysis. There were 110 (56.4%) patients in the sotalol group and 111 (58.4%) patients in the dofetilide group that received nonstandard initial dosing. Nonstandard dosing was associated with a greater incidence of QTc prolongation compared to standard dosing (57.5% vs 43.0%, P = .005). Only one patient in the nonstandard dosing group experienced TdP. Patients initiated on nonstandard dosing required dose reduction or therapy discontinuation (37.6% vs 23.4%, P = .003) more frequently. CONCLUSION Higher than recommended initial doses of sotalol or dofetilide were associated with higher incidence of QTc prolongation and more frequent therapy modification.
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Affiliation(s)
- Clara Ting
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, MA, USA
| | - Rhynn Malloy
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, MA, USA
| | - Danielle Knowles
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, MA, USA
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79
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Son NKL, Park JW, Kim M, Yang SY, Yu HT, Kim TH, Uhm JS, Joung B, Lee MH, Pak HN. Efficacy and Safety of Outpatient Clinic-based Elective External Electrical Cardioversion in Patients with Atrial Fibrillation. Korean Circ J 2020; 50:511-523. [PMID: 32212425 PMCID: PMC7234846 DOI: 10.4070/kcj.2019.0310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 01/28/2020] [Accepted: 02/19/2020] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Little is known about the outcomes of outpatient clinic-based elective external cardioversion (OPC-ECV) for persistent atrial fibrillation (PeAF). We investigated the acute, short-term, and long-term elective external cardioversion (ECV) outcomes. METHODS We included 1,718 patients who underwent OPC-ECV (74% male, 61.1±11.0 years old, 90.9% long-standing PeAF, 9.1% after atrial fibrillation [AF] ablation) after excluding patients with atrial tachycardia or inappropriate antiarrhythmic drug medication, and in-patient ECV. Biphasic shocks were delivered sequentially until successful cardioversion was achieved (70-100-150-200-250 J). If ECV failed at 150 J, we administered intravenous amiodarone 150 mg and delivered 200 J. RESULTS ECV failed in 11.4%, and the complication rate was 0.47%. Within 3 months, AF recurred in 55.5% (44.7% as sustaining AF, 10.8% as paroxysmal AF), and the AF duration was independently associated (odds ratio [OR], 1.01 [1.00-1.02]; p=0.006), but amiodarone was independently protective (OR, 0.46 [0.27-0.76]; p=0.002, Log rank p<0.001) against an early recurrence. Regarding the long-term recurrence, pre-ECV heart failure was protective against an AF recurrence (hazard ratio, 0.63 [0.41-0.96], p=0.033) over 32 (9-66) months of follow-up. ECV energy (p<0.001) and early recurrence rate within 3 months (p=0.007, Log rank p=0.006) were significantly lower in post-ablation patients than in those with long-standing persistent AF. CONCLUSIONS The success rate of OPC-ECV was 88.6%, and the complication rate was low. However, AF recurred in 55.5% within 3 months. Amiodarone was protective against short-term AF recurrences, and long-term AF recurrences were less in patients with baseline heart failure.
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Affiliation(s)
- Nguyen Khac Le Son
- Division of Cardiology, Department of Internal Medicine, Yonsei University Health System, Seoul, Korea
| | - Je Wook Park
- Division of Cardiology, Department of Internal Medicine, Yonsei University Health System, Seoul, Korea
| | - Min Kim
- Division of Cardiology, Department of Internal Medicine, Yonsei University Health System, Seoul, Korea
| | - Song Yi Yang
- Division of Cardiology, Department of Internal Medicine, Yonsei University Health System, Seoul, Korea
| | - Hee Tae Yu
- Division of Cardiology, Department of Internal Medicine, Yonsei University Health System, Seoul, Korea
| | - Tae Hoon Kim
- Division of Cardiology, Department of Internal Medicine, Yonsei University Health System, Seoul, Korea
| | - Jae Sun Uhm
- Division of Cardiology, Department of Internal Medicine, Yonsei University Health System, Seoul, Korea
| | - Boyoung Joung
- Division of Cardiology, Department of Internal Medicine, Yonsei University Health System, Seoul, Korea
| | - Moon Hyoung Lee
- Division of Cardiology, Department of Internal Medicine, Yonsei University Health System, Seoul, Korea
| | - Hui Nam Pak
- Division of Cardiology, Department of Internal Medicine, Yonsei University Health System, Seoul, Korea.
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80
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Thind M, Crijns HJ, Naccarelli GV, Reiffel JA, Corp Dit Genti V, Wieloch M, Koren A, Kowey PR. Dronedarone treatment following cardioversion in patients with atrial fibrillation/flutter: A post hoc analysis of the EURIDIS and ADONIS trials. J Cardiovasc Electrophysiol 2020; 31:1022-1030. [PMID: 32083368 PMCID: PMC7318600 DOI: 10.1111/jce.14405] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 01/24/2020] [Accepted: 02/17/2020] [Indexed: 12/17/2022]
Abstract
INTRODUCTION The phase 3 EURIDIS and ADONIS studies evaluated dronedarone for atrial fibrillation (AF)/atrial flutter (AFL) recurrence in patients with nonpermanent AF. Here we assessed whether patient characteristics and/or treatment outcomes in these studies differed based on the need for cardioversion before randomization. METHODS Time to adjudicated first AF/AFL recurrence, symptomatic recurrence, cardiovascular hospitalization/death, and AF hospitalization, and safety were assessed by cardioversion status. RESULTS Of 1237 patients randomized (2:1 dronedarone:placebo), 364 required baseline cardioversion (dronedarone 243, placebo 121). Patients requiring cardioversion had a greater prevalence of cardiovascular comorbidities and shorter times to first AF/AFL recurrence compared with those not requiring cardioversion. Dronedarone was associated with longer median time to first AF/AFL recurrence vs placebo regardless of cardioversion status (cardioversion: 50 vs 15 days, hazard ratio [HR] 0.76; 95% confidence interval [CI], 0.59-0.97; P = .02; non-cardioversion: 150 vs 77 days, HR 0.76; 95% CI, 0.64-0.90; P < .01). Dronedarone was similarly associated with prolonged median time to symptomatic recurrence vs placebo in the cardioversion (347 vs 87 days, HR 0.65; 95% CI, 0.49-0.87) and non-cardioversion (288 vs 120 days, HR 0.74; 95% CI, 0.62-0.90) populations. Risk of cardiovascular hospitalization/death and first AF hospitalization was lower with dronedarone vs placebo regardless of cardioversion status, but differences were not statistically significant. The safety of dronedarone was similar in both groups. CONCLUSION Patients requiring baseline cardioversion represent a distinct population, having more underlying cardiovascular disease and experiencing a shorter time to AF/AFL recurrences. Dronedarone was associated with improved efficacy vs placebo regardless of cardioversion status.
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Affiliation(s)
- Munveer Thind
- Division of Cardiovascular Medicine, Lankenau Heart Institute, Wynnewood, Pennsylvania
| | - Harry J Crijns
- Department of Cardiology, Maastricht University Medical Center and CARIM, Maastricht, Netherlands
| | - Gerald V Naccarelli
- Department of Medicine, Division of Cardiology, Penn State University College of Medicine, Hershey, Pennsylvania
| | - James A Reiffel
- Department of Medicine, Division of Cardiology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | | | - Mattias Wieloch
- Sanofi-Aventis, Paris, France.,Department of Clinical Sciences Malmö, Lund University, Lund, Sweden
| | | | - Peter R Kowey
- Division of Cardiovascular Medicine, Lankenau Heart Institute, Wynnewood, Pennsylvania
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81
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Utility of Amiodarone Pre-Treatment as a Facilitator of the Acute Success of Electrical Cardioversion in Persistent Atrial Fibrillation. Cardiovasc Drugs Ther 2020; 34:89-94. [PMID: 32096001 DOI: 10.1007/s10557-019-06934-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
PURPOSE The usefulness and mechanisms of antiarrhythmic drug (AAD) pre-treatment as a facilitator of the acute success of electrical cardioversion (ECV) in atrial fibrillation (AF) remain controversial. We sought to analyze the role of AAD treatment with this purpose, differentiating its possible utility either facilitating the restoration of sinus rhythm (SR) or reducing immediate AF recurrences (IAFR). METHODS We analyzed 2962 consecutive patients with persistent AF undergoing ECV prospectively included in 3 national registries. The acute success of ECV was indicated by the reversion to SR without presenting an IAFR (< 2 h). RESULTS A total of 1410 patients (48%) received AAD treatment prior to ECV (80% amiodarone, 15% class Ic AAD, 2% other AAD). The rate of restoration of SR was similar between the patients treated with amiodarone (92%), class Ic AAD (91%) and who did not receive AAD pre-treatment (91%) (p = 0.92). However, those treated with amiodarone had fewer IAFR than those in the other two groups (amiodarone 3% vs class Ic 7% vs without treatment 6%; p = 0.002), so the ECV success rate was higher in the amiodarone group than in the other groups (amiodarone 89% vs Ic 84% vs without treatment 86%; p = 0.04). After adjusting for multiple variables, amiodarone remained as an independent predictor of a lower occurrence of IAFR (OR = 0.57; p = 0.01) and of a successful ECV (OR 1.37; p = 0.01). CONCLUSIONS For patients with persistent AF undergoing ECV, AAD has a neutral effect on the restoration of SR but amiodarone increases its effectiveness due to a lower incidence of IAFR.
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Grubb A, Mentz RJ. Pharmacological management of atrial fibrillation in patients with heart failure with reduced ejection fraction: review of current knowledge and future directions. Expert Rev Cardiovasc Ther 2020; 18:85-101. [PMID: 32066285 DOI: 10.1080/14779072.2020.1732210] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Introduction: Both heart failure with reduced ejection fraction (HFrEF) and atrial fibrillation (AF) independently cause significant morbidity and mortality. The two conditions commonly coexist and AF in the setting of HFrEF is associated with worse mortality, hospitalizations, and quality of life compared to HFrEF without AF. Despite the large burden of these conditions, there is no clear optimal management strategy for when they occur together.Areas covered: This review focuses on the pharmacological management of AF in HFrEF. Studies were identified through PubMed search of relevant keywords. The authors review key clinical trials that have influenced management strategies and guidelines. The authors focus on the classes of drugs used to treat AF for both rate and rhythm control strategies including beta-blockers, digoxin, amiodarone, and dofetilide. Additionally, the authors discuss select non-antiarrhythmic medications that affect AF in HFrEF. The authors highlight the strengths and weakness of the data supporting the use of these medications and suggest future directions.Expert opinion: The pharmacological treatment of AF in HFrEF will need further refinement alongside the emerging role of catheter ablation. Novel HF medications and antiarrhythmics offer new tools to prevent the development of AF, as well as for rate and rhythm control strategies.
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Affiliation(s)
- Alex Grubb
- Department of Medicine, Duke University Hospital, Durham, NC, USA
| | - Robert J Mentz
- Division of Cardiology, Department of Medicine, Duke University Hospital, Durham NC, USA.,Duke Clinical Research Institute, Durham NC, USA
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83
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Pokorney SD, Holmes DN, Shrader P, Thomas L, Fonarow GC, Mahaffey KW, Gersh BJ, Kowey PR, Naccarelli GV, Freeman JV, Singer DE, Washam JB, Peterson ED, Piccini JP, Reiffel JA. Patterns of amiodarone use and outcomes in clinical practice for atrial fibrillation. Am Heart J 2020; 220:145-154. [PMID: 31812756 DOI: 10.1016/j.ahj.2019.09.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 09/23/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Amiodarone is the most effective antiarrhythmic drug (AAD) for atrial fibrillation (AF), but it has a high incidence of adverse effects. METHODS Using the ORBIT AF registry, patients with AF on amiodarone at enrollment, prescribed amiodarone during follow-up, or never on amiodarone were analyzed for the proportion treated with a guideline-based indication for amiodarone, the variability in amiodarone use across sites, and the outcomes (mortality, hospitalization, and stroke) among patients treated with amiodarone. Hierarchical logistic regression modeling with site-specific random intercepts compared rates of amiodarone use across 170 sites. A logistic regression model for propensity to receive amiodarone created a propensity-matched cohort. Cox proportional hazards modeling, stratified by matched pairs evaluated the association between amiodarone and outcomes. RESULTS Among 6,987 AF patients, 867 (12%) were on amiodarone at baseline and 451 (6%) started on incident amiodarone during the 3-year follow-up. Use of amiodarone varied among sites from 3% in the lowest tertile to 21% in the highest (p<0.0001). Among those treated, 32% had documented contraindications to other AADs or had failed another AAD in the past. Mortality, cardiovascular hospitalization, and stroke were similar among matched patients on and not on amiodarone at baseline, while incident amiodarone use in matched patients was associated with higher all-cause mortality (adjusted HR 2.06, 95% CI 1.35-3.16). CONCLUSIONS Use of amiodarone among AF patients in community practice is highly variable. More than 2 out of 3 patients treated with amiodarone appeared to be eligible for a different AAD.
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Risk factors for recurrence of atrial fibrillation. Anatol J Cardiol 2020; 25:338-345. [PMID: 33960309 DOI: 10.14744/anatoljcardiol.2020.80914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE Atrial fibrillation (AF) is a progressive disease, associated with increased risk of mortality, stroke, heart failure, and worsens quality of life. There is a high incidence of AF recurrence despite the treatment. The aim of the study was to assess the time to recurrence of AF after sinus rhythm restoration with electrical or pharmacological cardioversion and to identify the risk factors. METHODS This study included 101 patients with AF (56% females) at a mean age of 68.02±7 years, after sinus rhythm restoration in a clinical observation of 1-year placebo-controlled treatment with spironolactone (1: 1). The patients were analyzed on the basis of AF recurrence, hospitalization, demographic parameters, comorbidities, embolic risk, and value of biomarker galectin-3 (Gal-3). RESULTS The average number of AF recurrences was1.62 per patient per year. The median time of occurrence of at least one new episode was 48 days, 95% confidence interval (CI) 14.24-81.76. Female patients experienced significantly more recurrences than male-53.3% vs. 28.6% hazard ration (HR) =1.76, 95% CI 1.02-3.03, p=0.036. The recurrences were more common with increased age, although not significantly. Patients with arterial hypertension had a threefold risk of recurrences than those without hypertension (p=0.025), independently of the treatment. CHA2DS2-VASc score was significantly associated with AF recurrent episodes. Patients with gout had a twofold increased risk, without statistical significance (p=0.15). There was no difference in the AF episodes according to treatment with spironolactone. The levels of Gal-3 did not affect the number of AF recurrences (p=0.9). CONCLUSION AF is associated with frequent recurrences after restoration of sinus rhythm in the majority of the patients. Most of them occurred within the first 3 months. Female sex, arterial hypertension, and CHA2DS2-VASc score were significant predictors of AF recurrence. Spironolactone did not reduce AF recurrences.
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85
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The role of amiodarone in contemporary management of complex cardiac arrhythmias. Pharmacol Res 2020; 151:104521. [PMID: 31756386 DOI: 10.1016/j.phrs.2019.104521] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 06/25/2019] [Accepted: 10/30/2019] [Indexed: 01/09/2023]
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86
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(Atrial fibrallation in a cardiological practice - focused on amiodarone). COR ET VASA 2019. [DOI: 10.33678/cor.2019.078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Ruzieh M, Moroi MK, Aboujamous NM, Ghahramani M, Naccarelli GV, Mandrola J, Foy AJ. Meta-Analysis Comparing the Relative Risk of Adverse Events for Amiodarone Versus Placebo. Am J Cardiol 2019; 124:1889-1893. [PMID: 31653351 DOI: 10.1016/j.amjcard.2019.09.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Revised: 09/05/2019] [Accepted: 09/05/2019] [Indexed: 11/25/2022]
Abstract
Amiodarone has been associated with adverse events that may restrict its use. We performed a meta-analysis of placebo-controlled trials to assess the relative risk of adverse events of amiodarone compared with placebo. In total, 43 randomized trials were included. A total of 11,395 patients were included (5,792 patients randomized to amiodarone and 5,603 patients randomized to placebo). The incident rate of adverse events per 10,000 person-years was higher in the amiodarone group compared with placebo for pulmonary (129 vs 74; relative risk (RR) 1.77, p = 0.002), thyroid (201 vs 42; RR 4.44, p <0.001), hepatic (54 vs 25; RR 2.27, p = 0.01), cardiac (771 vs 450; RR 1.94, p <0.001), neurological (140 vs 76; RR 1.93, p <0.001), and skin (81 vs 23; RR 1.99, p = 0.04) adverse events. Low-dose amiodarone was not associated with statistically significant increase in pulmonary adverse events but was still associated with thyroid and liver adverse events. In conclusion, the likelihood of experiencing adverse events related to amiodarone was higher than that of placebo. The overall rate of adverse events however, was low, and severe adverse events were rare.
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Kuck KH, Merkely B, Zahn R, Arentz T, Seidl K, Schlüter M, Tilz RR, Piorkowski C, Gellér L, Kleemann T, Hindricks G. Catheter Ablation Versus Best Medical Therapy in Patients With Persistent Atrial Fibrillation and Congestive Heart Failure. Circ Arrhythm Electrophysiol 2019; 12:e007731. [DOI: 10.1161/circep.119.007731] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Optimal treatment of patients with persistent atrial fibrillation (AF) and heart failure (HF) with reduced left ventricular ejection fraction (LVEF) and an indication for internal defibrillator therapy is controversial.
Methods:
Patients with persistent/longstanding persistent AF and LVEF ≤35% were randomly allocated to catheter ablation of AF or best medical therapy (BMT). The primary study end point was the absolute increase in LVEF from baseline at 1 year. Secondary end points included 6-minute walk test, quality-of-life, and NT-proBNP (N-terminal pro-brain natriuretic peptide). Pulmonary vein isolation was the primary ablation approach; BMT comprised rate or rhythm control. All patients were discharged after index hospitalization with a cardioverter-defibrillator or cardiac resynchronization therapy defibrillator implanted. The study was terminated early for futility.
Results:
Of 140 patients (65±8 years, 126 [90%] men) available for the end point analysis, 68 and 72 patients were assigned to ablation and BMT, respectively. At 1 year, LVEF had increased in ablation patients by 8.8% (95% CI, 5.8%–11.9%) and in BMT patients by 7.3% (4.3%–10.3%;
P
=0.36). Sinus rhythm was recorded on 12-lead electrocardiograms at 1 year in 61/83 ablation patients (73.5%) and 42/84 BMT patients (50%). Device-recorded AF burden at 1 year was 0% or maximally 5% of the time in 28/39 ablation patients (72%) and 16/36 BMT patients (44%). There was no difference in secondary end point outcome between ablation patients and BMT patients.
Conclusions:
The AMICA trial (Atrial Fibrillation Management in Congestive Heart Failure With Ablation) did not reveal any benefit of catheter ablation in patients with AF and advanced HF. This was mainly because of the fact that at 1 year, LVEF increased in ablation patients to a similar extent as in BMT patients. The effect of catheter ablation of AF in patients with HF may be affected by the extent of HF at baseline, with a rather limited ablation benefit in patients with seriously advanced HF.
Clinical Trial Registration:
URL:
https://www.clinicaltrials.gov
. Unique identifier: NCT00652522.
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Affiliation(s)
- Karl-Heinz Kuck
- Department of Cardiology, Asklepios Klinik St Georg, Hamburg, Germany (K.-H.K., R.R.T.)
| | - Béla Merkely
- Semmelweis Medical University, Budapest, Hungary (B.M., L.G.)
| | - Ralf Zahn
- Heart Center, Ludwigshafen, Germany (R.Z.)
| | - Thomas Arentz
- University Heart Center Freiburg-Bad Krozingen, Germany (T.A.)
| | | | | | - Roland Richard Tilz
- Department of Cardiology, Asklepios Klinik St Georg, Hamburg, Germany (K.-H.K., R.R.T.)
| | | | - László Gellér
- Semmelweis Medical University, Budapest, Hungary (B.M., L.G.)
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Valembois L, Audureau E, Takeda A, Jarzebowski W, Belmin J, Lafuente‐Lafuente C. Antiarrhythmics for maintaining sinus rhythm after cardioversion of atrial fibrillation. Cochrane Database Syst Rev 2019; 9:CD005049. [PMID: 31483500 PMCID: PMC6738133 DOI: 10.1002/14651858.cd005049.pub5] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Atrial fibrillation is the most frequent sustained arrhythmia. Atrial fibrillation often recurs after restoration of normal sinus rhythm. Antiarrhythmic drugs have been widely used to prevent recurrence. This is an update of a review previously published in 2006, 2012 and 2015. OBJECTIVES To determine the effects of long-term treatment with antiarrhythmic drugs on death, stroke, drug adverse effects and recurrence of atrial fibrillation in people who had recovered sinus rhythm after having atrial fibrillation. SEARCH METHODS We updated the searches of CENTRAL, MEDLINE and Embase in January 2019, and ClinicalTrials.gov and WHO ICTRP in February 2019. We checked the reference lists of retrieved articles, recent reviews and meta-analyses. SELECTION CRITERIA Two authors independently selected randomised controlled trials (RCTs) comparing any antiarrhythmic drug with a control (no treatment, placebo, drugs for rate control) or with another antiarrhythmic drug in adults who had atrial fibrillation and in whom sinus rhythm was restored, spontaneously or by any intervention. We excluded postoperative atrial fibrillation. DATA COLLECTION AND ANALYSIS Two authors independently assessed quality and extracted data. We pooled studies, if appropriate, using Mantel-Haenszel risk ratios (RR), with 95% confidence intervals (CI). All results were calculated at one year of follow-up or the nearest time point. MAIN RESULTS This update included one new study (100 participants) and excluded one previously included study because of double publication. Finally, we included 59 RCTs comprising 20,981 participants studying quinidine, disopyramide, propafenone, flecainide, metoprolol, amiodarone, dofetilide, dronedarone and sotalol. Overall, mean follow-up was 10.2 months.All-cause mortalityHigh-certainty evidence from five RCTs indicated that treatment with sotalol was associated with a higher all-cause mortality rate compared with placebo or no treatment (RR 2.23, 95% CI 1.03 to 4.81; participants = 1882). The number need to treat for an additional harmful outcome (NNTH) for sotalol was 102 participants treated for one year to have one additional death. Low-certainty evidence from six RCTs suggested that risk of mortality may be higher in people taking quinidine (RR 2.01, 95% CI 0.84 to 4.77; participants = 1646). Moderate-certainty evidence showed increased RR for mortality but with very wide CIs for metoprolol (RR 2.02, 95% CI 0.37 to 11.05, 2 RCTs, participants = 562) and amiodarone (RR 1.66, 95% CI 0.55 to 4.99, 2 RCTs, participants = 444), compared with placebo.We found little or no difference in mortality with dofetilide (RR 0.98, 95% CI 0.76 to 1.27; moderate-certainty evidence) or dronedarone (RR 0.86, 95% CI 0.68 to 1.09; high-certainty evidence) compared to placebo/no treatment. There were few data on mortality for disopyramide, flecainide and propafenone, making impossible a reliable estimation for those drugs.Withdrawals due to adverse eventsAll analysed drugs increased withdrawals due to adverse effects compared to placebo or no treatment (quinidine: RR 1.56, 95% CI 0.87 to 2.78; disopyramide: RR 3.68, 95% CI 0.95 to 14.24; propafenone: RR 1.62, 95% CI 1.07 to 2.46; flecainide: RR 15.41, 95% CI 0.91 to 260.19; metoprolol: RR 3.47, 95% CI 1.48 to 8.15; amiodarone: RR 6.70, 95% CI 1.91 to 23.45; dofetilide: RR 1.77, 95% CI 0.75 to 4.18; dronedarone: RR 1.58, 95% CI 1.34 to 1.85; sotalol: RR 1.95, 95% CI 1.23 to 3.11). Certainty of the evidence for this outcome was low for disopyramide, amiodarone, dofetilide and flecainide; moderate to high for the remaining drugs.ProarrhythmiaVirtually all studied antiarrhythmics showed increased proarrhythmic effects (counting both tachyarrhythmias and bradyarrhythmias attributable to treatment) (quinidine: RR 2.05, 95% CI 0.95 to 4.41; disopyramide: no data; flecainide: RR 4.80, 95% CI 1.30 to 17.77; metoprolol: RR 18.14, 95% CI 2.42 to 135.66; amiodarone: RR 2.22, 95% CI 0.71 to 6.96; dofetilide: RR 5.50, 95% CI 1.33 to 22.76; dronedarone: RR 1.95, 95% CI 0.77 to 4.98; sotalol: RR 3.55, 95% CI 2.16 to 5.83); with the exception of propafenone (RR 1.32, 95% CI 0.39 to 4.47) for which the certainty of evidence was very low and we were uncertain about the effect. Certainty of the evidence for this outcome for the other drugs was moderate to high.StrokeEleven studies reported stroke outcomes with quinidine, disopyramide, flecainide, amiodarone, dronedarone and sotalol. High-certainty evidence from two RCTs suggested that dronedarone may be associated with reduced risk of stroke (RR 0.66, 95% CI 0.47 to 0.95; participants = 5872). This result is attributed to one study dominating the meta-analysis and has yet to be reproduced in other studies. There was no apparent effect on stroke rates with the other antiarrhythmics.Recurrence of atrial fibrillationModerate- to high-certainty evidence, with the exception of disopyramide which was low-certainty evidence, showed that all analysed drugs, including metoprolol, reduced recurrence of atrial fibrillation (quinidine: RR 0.83, 95% CI 0.78 to 0.88; disopyramide: RR 0.77, 95% CI 0.59 to 1.01; propafenone: RR 0.67, 95% CI 0.61 to 0.74; flecainide: RR 0.65, 95% CI 0.55 to 0.77; metoprolol: RR 0.83 95% CI 0.68 to 1.02; amiodarone: RR 0.52, 95% CI 0.46 to 0.58; dofetilide: RR 0.72, 95% CI 0.61 to 0.85; dronedarone: RR 0.85, 95% CI 0.80 to 0.91; sotalol: RR 0.83, 95% CI 0.80 to 0.87). Despite this reduction, atrial fibrillation still recurred in 43% to 67% of people treated with antiarrhythmics. AUTHORS' CONCLUSIONS There is high-certainty evidence of increased mortality associated with sotalol treatment, and low-certainty evidence suggesting increased mortality with quinidine, when used for maintaining sinus rhythm in people with atrial fibrillation. We found few data on mortality in people taking disopyramide, flecainide and propafenone, so it was not possible to make a reliable estimation of the mortality risk for these drugs. However, we did find moderate-certainty evidence of marked increases in proarrhythmia and adverse effects with flecainide.Overall, there is evidence showing that antiarrhythmic drugs increase adverse events, increase proarrhythmic events and some antiarrhythmics may increase mortality. Conversely, although they reduce recurrences of atrial fibrillation, there is no evidence of any benefit on other clinical outcomes, compared with placebo or no treatment.
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Affiliation(s)
- Lucie Valembois
- Groupe Hospitalier Pitié‐Salpêtrière‐Charles Foix, AP‐HP, Université Pierre et Marie CurieService de Gériatrie à Orientation Cardiologique et Neurologique7 avenue de la RépubliqueIvry‐sur‐SeineFrance94200
| | - Etienne Audureau
- Hôpital Henri‐Mondor, APHP, Université Paris 12 UPECService de Santé Publique51 Avenue du Maréchal de Lattre de TassignyCréteilFrance94010
| | - Andrea Takeda
- University College LondonInstitute of Health Informatics ResearchLondonUK
| | | | - Joël Belmin
- Université Pierre et Marie Curie (Paris 6)La Triade ‐ Service Hospitalo‐Universitaire de GérontologieGroup Hospitalier Pitié‐Salpêtrière‐Charles Foix7, Avenue de la République, 94 Ivry‐sur‐SeineParisFrance
| | - Carmelo Lafuente‐Lafuente
- Groupe Hospitalier Pitié‐Salpêtrière‐Charles Foix, AP‐HP, Université Pierre et Marie CurieService de Gériatrie à Orientation Cardiologique et Neurologique7 avenue de la RépubliqueIvry‐sur‐SeineFrance94200
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Abstract
Atrial fibrillation (AF) is the most common arrhythmia and its management may be organized into risk stratification and/or treatment of heart failure, stroke prevention, and symptom control. At the core of symptom control, treatment is tailored to either allow AF continue with controlled heart rates, so-called rate control, versus restoring and maintaining sinus rhythm or rhythm control. Rate control strategies mainly use rate-modulating medications, whereas rhythm control treatment includes therapy aimed at restoring sinus rhythm, including pharmacologic and direct current cardioversion, as well as maintenance of sinus rhythm, including antiarrhythmic medications and ablation therapy.
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Affiliation(s)
- Vishal Dahya
- Cardiovascular Disease, Summa Health System, NEOMED University, Akron City Hospital, 95 Arch Street, Suite 300, Akron, OH 44304, USA
| | - Tyler L Taigen
- Section of Pacing and Electrophysiology, Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue/J2, Cleveland, OH 44195, USA.
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91
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Katsumata Y, Tamura Y, Kimura T, Kohsaka S, Sadahiro T, Nishiyama T, Aizawa Y, Azuma K, Fukuda K, Takatsuki S. A high BNP level predicts an improvement in exercise tolerance after a successful catheter ablation of persistent atrial fibrillation. J Cardiovasc Electrophysiol 2019; 30:2283-2290. [PMID: 31471993 DOI: 10.1111/jce.14149] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 07/17/2019] [Accepted: 07/23/2019] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Restoration of sinus rhythm (SR) by catheter ablation (CA) of atrial fibrillation (AF) improves exercise tolerance. However, it is still unclear what characteristics of patients are contributing to an improvement in exercise tolerance after CA of AF without heart failure. METHODS AND RESULTS This study consisted of 51 consecutive patients with persistent or long-standing persistent AF without heart failure who were restored to SR for over 6 months by a successful CA. Exercise tolerance was evaluated by cardiopulmonary exercise testing before and 3 and 6 months after CA. The clinical characteristics contributing to an improvement in exercise tolerance was elucidated. The peak oxygen uptake (VO2 )% significantly increased from 101.4 ± 20.3% to 110.9 ± 19.9% 3 months after the CA (P < .001). The improvement rate in the peak VO2 % exhibited a positive correlation to the baseline brain natriuretic peptide (BNP; ρ = 0.39, P < .01), but not to the age, AF duration, left ventricular ejection fraction, or left atrial size. The linear regression analysis revealed that the baseline BNP was an independent predictor of an improvement in the peak VO2 % (coefficients = 0.32; 95% confidence interval = 0.08, 0.54; P = .01). The peak VO2 % improved significantly in the patients whose baseline BNP level was greater than 100 pg/mL, compared to the others (P < .01). These favorable findings were also observed 6 months after the CA. CONCLUSION Elimination of persistent AF by CA was associated with an improvement in exercise tolerance. This was particularly true in patients with high BNP values at baseline.
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Affiliation(s)
| | - Yuichi Tamura
- Department of Cardiology, International University of Health and Welfare Mita Hospital, Tokyo, Japan
| | - Takehiro Kimura
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Taketaro Sadahiro
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Takahiko Nishiyama
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Yoshiyasu Aizawa
- Department of Cardiology, International University of Health and Welfare Mita Hospital, Tokyo, Japan
| | - Koichiro Azuma
- Institute for Integrated Sports Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Keiichi Fukuda
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Seiji Takatsuki
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
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92
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Srivatsa UN, Danielsen B, Amsterdam EA, Pezeshkian N, Yang Y, Nordsieck E, Fan D, Chiamvimonvat N, White RH. CAABL-AF (California Study of Ablation for Atrial Fibrillation): Mortality and Stroke, 2005 to 2013. Circ Arrhythm Electrophysiol 2019; 11:e005739. [PMID: 29884619 DOI: 10.1161/circep.117.005739] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Accepted: 03/27/2018] [Indexed: 01/25/2023]
Abstract
BACKGROUND Ablation for atrial fibrillation (AF) is superior to medical therapy for rhythm control. We compared stroke and mortality among patients undergoing ablation for AF to matched controls in a large multiethnic population. METHODS Using discharge and surgical records from California nonfederal hospitals, we identified patients who had ablation and principal diagnosis of AF with at least 1 prior hospitalization for AF. We excluded cases with valve disease, open maze, other arrhythmias, or implantable devices. Matched controls were selected based on years of AF diagnosis, age, sex, and being alive the same number of days from the initial AF encounter to the ablation date. Clinical outcomes, including mortality, ischemic stroke, or hemorrhagic stroke, were assessed using a weighted proportional hazard model, adjusting for demographics, prior admissions with AF before the ablation, calendar year, and presence of chronic comorbidities. RESULTS There were 4169 ablation cases and 4169 weighted-matched controls; 39% percent of the ablation group was >65 years, 72% men, 84% white; mean follow-up was up to 3.6±0.9 years. In adjusted models, ablation was associated with significantly lower mortality (per patient-years) 0.9% versus 1.9%, hazard ratio=0.59 (P<0.0001; confidence interval: 0.45-0.77); ischemic stroke (>30 days post-ablation ≤5 years), 0.37% versus 0.59%, hazard ratio=0.68 (P=0.04; confidence interval: 0.47-0.97); hemorrhagic stroke 0.11% versus 0.35%, hazard ratio=0.36 (P=0.001; confidence interval: 0.20-0.64) compared with controls. CONCLUSIONS In this large population-based study of hospitalized patients with nonvalvular AF, ablation was associated with lower mortality, ischemic stroke, and hemorrhagic stroke compared with controls.
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Affiliation(s)
- Uma N Srivatsa
- Division of Cardiovascular Medicine (U.N.S. E.A.A., N.P., Y.Y., E.N., D.F., N.C.),
| | | | - Ezra A Amsterdam
- Division of Cardiovascular Medicine (U.N.S. E.A.A., N.P., Y.Y., E.N., D.F., N.C.)
| | - Nayereh Pezeshkian
- Division of Cardiovascular Medicine (U.N.S. E.A.A., N.P., Y.Y., E.N., D.F., N.C.)
| | - Yingbo Yang
- Division of Cardiovascular Medicine (U.N.S. E.A.A., N.P., Y.Y., E.N., D.F., N.C.)
| | - Eric Nordsieck
- Division of Cardiovascular Medicine (U.N.S. E.A.A., N.P., Y.Y., E.N., D.F., N.C.)
| | - Dali Fan
- Division of Cardiovascular Medicine (U.N.S. E.A.A., N.P., Y.Y., E.N., D.F., N.C.)
| | | | - Richard H White
- Department of Internal Medicine (R.H.W.), University of California, Davis School of Medicine, Sacramento
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93
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Editorial commentary: Amiodarone-induced thyroid diseases: Additional unintended consequences. Trends Cardiovasc Med 2019; 29:296-297. [DOI: 10.1016/j.tcm.2018.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 10/08/2018] [Indexed: 11/21/2022]
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94
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Safety of rapid switching from amiodarone to dofetilide in atrial fibrillation patients with an implantable cardioverter–defibrillator. Heart Rhythm 2019; 16:990-995. [DOI: 10.1016/j.hrthm.2019.01.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Indexed: 11/20/2022]
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95
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Podzolkov VI, Tarzimanova AI. Antiarrhythmic therapy in the treatment of atrial fibrillation: yesterday, today, tomorrow. КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2019. [DOI: 10.15829/1728-8800-2019-3-81-87] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Atrial fibrillation (AF) is the most common heart rhythm disorder encountered in clinical practice. Each year, the number of patients with AF significantly increases. It is associated with an increase of life expectancy and frequency of cardiovascular pathologies. Treatment of AF remains one of the most difficult tasks of modern cardiology. Currently, only a few antiarrhythmic drugs are available for use in Russia. More and more new attempts are being made to create a universal antiarrhythmic drug with a high level of anti-relapsing efficacy and adverse effects. The accumulated information suggests that the tactics of management of patients with arrhythmias will be intended to improving the new surgical and interventional treatment methods with use of anticoagulants and antiarrhythmic drugs. The multidisciplinary team of specialists on AF treatment should include an expert (cardiologist) in antiarrhythmic drug therapy, an interventional electrophysiologist, and a cardiac surgeon — master the technology of interventional or surgical ablation. Effective interaction of specialists of various levels will improve the results of rhythm control and prevention of complications in patients with AF.
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96
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Um KJ, McIntyre WF, Healey JS, Mendoza PA, Koziarz A, Amit G, Chu VA, Whitlock RP, Belley-Côté EP. Pre- and post-treatment with amiodarone for elective electrical cardioversion of atrial fibrillation: a systematic review and meta-analysis. Europace 2019; 21:856-863. [PMID: 30875422 DOI: 10.1093/europace/euy310] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 12/03/2018] [Indexed: 09/07/2023] Open
Abstract
AIMS Clinicians frequently pre-treat patients with amiodarone to increase the efficacy of electrical cardioversion for atrial fibrillation (AF). Our objective was to determine the precise effects of amiodarone pre- and post-treatment on conversion efficacy and sinus rhythm maintenance. METHODS AND RESULTS We conducted a systematic review and meta-analysis of trials comparing pre- and post-treatment for electrical cardioversion with amiodarone vs. no therapy on (i) acute restoration and (ii) maintenance of sinus rhythm after 1 year. We searched MEDLINE and EMBASE from inception to July 2018 for randomized controlled trials. We evaluated the risk of bias for individual studies with the Cochrane tool and overall quality of evidence with the GRADE framework. We identified eight eligible studies (n = 1012). Five studies were deemed to have unclear or high risk of selection bias. We found the evidence to be of high quality based on GRADE. Treatment with amiodarone (200-800 mg daily for 1-6 weeks pre-cardioversion; 0-200 mg daily post-cardioversion) was associated with higher rates of acute restoration [relative risk (RR) 1.22, 95% confidence interval (CI) 1.07-1.39, P = 0.004, n = 1012, I2 = 65%] and maintenance of sinus rhythm over 13 months (RR 4.39, 95% CI 2.99-6.45, P < 0.001, n = 695, I2 = 0%). The effects of amiodarone for acute restoration were maintained when considering only studies at low risk of bias (RR 1.22, 95% CI 1.10-1.36, P < 0.001, n = 572, I2 = 0%). Adverse effects were typically non-serious, occurring in 3.4% (6/174) of subjects receiving amiodarone. CONCLUSION High-quality evidence demonstrated that treatment with amiodarone improved the restoration and maintenance of sinus rhythm after electrical cardioversion of AF. Short-term amiodarone was well-tolerated.
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Affiliation(s)
- Kevin J Um
- McMaster University, Hamilton, ON, Canada
| | - William F McIntyre
- McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, Hamilton, ON, Canada
| | - Jeff S Healey
- McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, Hamilton, ON, Canada
| | | | | | - Guy Amit
- McMaster University, Hamilton, ON, Canada
| | | | - Richard P Whitlock
- McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, Hamilton, ON, Canada
| | - Emilie P Belley-Côté
- McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, Hamilton, ON, Canada
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97
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Rabatin A, Snider MJ, Boyd JM, Houmsse M, Boyd JM. Safety of Twice Daily Sotalol in Patients with Renal Impairment: A Single Center, Retrospective Review. J Atr Fibrillation 2019; 11:2047. [PMID: 31139270 DOI: 10.4022/jafib.2047] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Revised: 08/19/2017] [Accepted: 09/14/2017] [Indexed: 11/10/2022]
Abstract
Background The class III antiarrhythmic sotalol is renally eliminated with a dose-related propensity to cause adverse drug reactions (ADR) potentially leading to life-threatening arrhythmias. Although product labeling recommends once daily dosing in patients with renal impairment, twice daily dosing is commonly utilized. This study evaluates the safety of this practice. Methods This retrospective, observational study examined renally impaired patients with atrial fibrillation or atrial flutter admitted for sotalol initiation from July 1, 2012 - December 31, 2014, then for up to 20 months after initiation. Primary endpoints included rates of ADR and therapy changes due to ADR. Secondary endpoints included therapy changes due to arrhythmia recurrence, admissions due to arrhythmia recurrence, and therapy changes for any cause. Results Analysis included 134 patients with an average creatinine clearance of 51 ml/min, followed over a median of 170 days. Length of stay averaged 3 days withADR occurring in 53.7% of patients, most commonly QT prolongation or bradycardia. Therapy change due to ADR occurred in 45.5% of patients (n=61). Therapy change due to arrhythmia recurrence occurred in 23.1% (n=31), admission due to arrhythmia recurrence occurred in 24.6% (n=33), and therapy change for any cause occurred in 74.6% (n=100). Conclusion Initiating sotalol twice daily in renally impaired patients results in ADR and therapy change rates consistent with rates seen in clinical practice for non-renally impaired patients, with minimal length of stay.This practice may be reasonable when initiated in the acute care setting with subsequent outpatient monitoring, however further study is needed.
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Affiliation(s)
- Abigail Rabatin
- The Ohio State University Wexner Medical Center 452 West 10th Ave Columbus, OH 43210
| | - Melissa J Snider
- The Ohio State University Wexner Medical Center 452 West 10th Ave Columbus, OH 43210
| | - J Michael Boyd
- The Ohio State University Wexner Medical Center 452 West 10th Ave Columbus, OH 43210
| | - Mahmoud Houmsse
- The Ohio State University Wexner Medical Center 452 West 10th Ave Columbus, OH 43210
| | - J Michael Boyd
- The Ohio State University Wexner Medical Center 452 West 10th Ave Columbus, OH 43210
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Alzahrani T, McCaffrey J, Mercader M, Solomon A. Rate Versus Rhythm Control in Patients with Normal to Mild Left Atrial Enlargement: Insights from the AFFIRM Trial. J Atr Fibrillation 2019; 11:2067. [PMID: 31139272 DOI: 10.4022/jafib.2067] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Revised: 08/19/2017] [Accepted: 09/14/2017] [Indexed: 12/19/2022]
Abstract
Background Atrial fibrillation is the most commonly encountered sustained arrhythmia and is associated with significant morbidity and mortality. Several trials have demonstrated that no mortality benefit exists when choosing a rhythm-control strategy over a rate-control strategy, with some trials suggesting an increase in mortality. Using the AFFIRM trial database we sought to determine the effect of rhythm control strategy in patients with normal or mild atrial enlargement. Methods AFFIRM Trial database was used to evaluate the effect of rhythm-control strategy compared to rate-control strategy in a subgroup of patients with normal to mild left atrial (LA) enlargement. The primary outcome measures of this study were all-cause mortality, cardiovascular mortality, non-cardiovascular mortality, and hospitalization/ED visit. Results We identified a subgroup of subjects from the AFFIRM trial with normal or mild LA enlargement (n=2022 of 4060 total subjects). Subjects in the rhythm-control group(n= 1022) had an increased risk of all-cause mortality by 34% (RR 1.34, 95% CI 1.08-1.67; P=0.007) and hospitalization/ED visits by 10% (RR 1.10, 95% CI 1.05-2.16; P=<0.001) compared to rate control group(n= 1000). Conclusion This study demonstrated that rhythm-control strategy increases the risk of mortality and hospitalization in a subgroup of patients with normal to mild atrial enlargement compared to rate-control strategy. Amiodarone use in this subgroup of patients likely drove these findings.
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Affiliation(s)
- Talal Alzahrani
- Division of Cardiology, Department of Medicine, George Washington University, Washington, DC
| | - James McCaffrey
- Division of Cardiology, Department of Medicine, George Washington University, Washington, DC
| | - Marco Mercader
- Division of Cardiology, Department of Medicine, George Washington University, Washington, DC
| | - Allen Solomon
- Division of Cardiology, Department of Medicine, George Washington University, Washington, DC
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Peyronnet R, Ravens U. Atria-selective antiarrhythmic drugs in need of alliance partners. Pharmacol Res 2019; 145:104262. [PMID: 31059791 DOI: 10.1016/j.phrs.2019.104262] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 04/30/2019] [Accepted: 05/03/2019] [Indexed: 12/15/2022]
Abstract
Atria-selective antiarrhythmic drugs in need of alliance partners. Guideline-based treatment of atrial fibrillation (AF) comprises prevention of thromboembolism and stroke, as well as antiarrhythmic therapy by drugs, electrical rhythm conversion, ablation and surgical procedures. Conventional antiarrhythmic drugs are burdened with unwanted side effects including a propensity of triggering life-threatening ventricular fibrillation. In order to solve this therapeutic dilemma, 'atria-selective' antiarrhythmic drugs have been developed for the treatment of supraventricular arrhythmias. These drugs are designed to aim at atrial targets, taking advantage of differences in atrial and ventricular ion channel expression and function. However it is not clear, whether such drugs are sufficiently antiarrhythmic or whether they are in need of an alliance partner for clinical efficacy. Atria-selective Na+ channel blockers display fast dissociation kinetics and high binding affinity to inactivated channels. Compounds targeting atria-selective K+ channels include blockers of ultra rapid delayed rectifier (Kv1.5) or acetylcholine-activated inward rectifier K+ channels (Kir3.x), inward rectifying K+ channels (Kir2.x), Ca2+-activated K+ channels of small conductance (SK), weakly rectifying two-pore domain K+ channels (K2P), and transient receptor potential channels (TRP). Despite good antiarrhythmic data from in-vitro and animal model experiments, clinical efficacy of atria-selective antiarrhythmic drugs remains to be demonstrated. In the present review we will briefly summarize the novel compounds and their proposed antiarrhythmic action. In addition, we will discuss the evidence for putative improvement of antiarrhythmic efficacy and potency by addressing multiple pathophysiologically relevant targets as possible alliance partners.
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Affiliation(s)
- Rémi Peyronnet
- Institute for Experimental Cardiovascular Medicine, University Heart Center Freiburg Bad Krozingen, Medical Center, University of Freiburg, Freiburg, Germany; Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ursula Ravens
- Institute for Experimental Cardiovascular Medicine, University Heart Center Freiburg Bad Krozingen, Medical Center, University of Freiburg, Freiburg, Germany; Institute of Physiology, Medical Faculty TU Dresden, Dresden, Germany.
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Abstract
Despite proven effectiveness in treating tachyarrhythmias, sotalol is proarrhythmic and can cause torsades de pointes. Given the emergence of studies that show no benefit from rhythm control strategies in managing atrial fibrillation, as well as the introduction of nonpharmacological approaches to treating arrhythmias, we felt it necessary to ascertain if there was any role for sotalol given its side effects. Review of the literature regarding sotalol use in the prevention and treatment of supraventricular and ventricular tachyarrhythmias seems to show that more effective and safer agents and nonpharmacological alternatives are currently available. However, sotalol still seems to be useful in preventing supraventricular tachyarrhythmias postcardiac surgery and in reverting hemodynamically stable sustained ventricular tachycardias in the setting of coronary artery disease. Its role in the prevention of tachyarrhythmias in the setting of arrhythmogenic right ventricular cardiomyopathy requires further investigation.
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