2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS

Digoxin versus placebo, no intervention, or other medical interventions for atrial fibrillation and atrial flutter: a protocol for a systematic review with meta-analysis and Trial Sequential Analysis

BACKGROUND

Atrial fibrillation is the most common arrhythmia of the heart with a prevalence of approximately 2% in the western world. Atrial flutter, another arrhythmia, occurs less often with an incidence of approximately 200,000 new patients per year in the USA. Patients with atrial fibrillation and atrial flutter have an increased risk of death and morbidities. In the management of atrial fibrillation and atrial flutter, it is often necessary to use medical interventions to lower the heart rate. Lowering the heart rate may theoretically prevent the development of heart failure and tachycardia-mediated cardiomyopathy. The evidence on the benefits and harms of digoxin compared with placebo or with other medical interventions is unclear. This protocol for a systematic review aims at identifying the beneficial and harmful effects of digoxin compared with placebo, no intervention, or with other medical interventions for atrial fibrillation and atrial flutter.

METHODS

This protocol for a systematic review was conducted following the recommendations of Cochrane and the eight-step assessment procedure suggested by Jakobsen and colleagues. We plan to include all relevant randomised clinical trials comparing digoxin with placebo, no intervention, or with other medical interventions. We plan to search the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, LILACS, Science Citation Index Expanded on Web of Science, and BIOSIS to identify relevant trials. Any eligible trial will be assessed and classified as either at high risk of bias or low risk of bias, and our primary conclusions will be based on trials with low risk of bias. We will perform our meta-analyses of the extracted data using Review Manager 5.3 and Trial Sequential Analysis ver. 0.9.5.5 beta. For both our primary and secondary outcomes, we will create a 'Summary of Findings' table based on GRADE assessments of the quality of the evidence.

DISCUSSION

The results of this systematic review have the potential to benefit millions of patients worldwide as well as healthcare economy.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016052935.

The Significance Of Troponin Elevation In Atrial Fibrillation

Cardiac troponin assays have provided a significant contribution for the early diagnosis of cardiovascular events. There is significant evidence about the association between the absolute value of elevated cardiac troponin levels with the prognosis of patients with chest pain. However, it is well-known that elevated cardiac troponin levels may occur in situations other than acute coronary syndromes, as it happens with atrial fibrillation. The significance and prognosis of this elevation are not entirely clear. We review the evidence about the meaning of such elevation in the setting of atrial fibrillation.

Renal failure caused by a partly calcified aortic aneurysm in a patient with dabigatran therapy: A case report

RATIONALE

Abdominal aortic aneurysms (AAAs) are mostly asymptomatic. If aortic aneurysms become symptomatic, complications include peripheral embolization, acute aortic occlusion, and aortic rupture. However, there are also unusual complications caused by aortic aneurysms.

PATIENT CONCERNS

An 87-old male with dabigatran therapy presented with newly developed melena and acute renal failure. Radiological imaging revealed an AAA with thrombotic and calcified deposits which affected the renal arteries.

DIAGNOSES

Gastrointestinal bleeding and hypercoagulation caused by renal failure which was triggered in turn due to an AAA.

INTERVENTIONS

Adapted antihypertensive therapy and initiation of simvastatin 40mg once daily as well as antiplatelet therapy with aspirin 50 mg once daily due to patient's refusal of any aneurysm intervention.

OUTCOME

Neither bleeding event nor aneurysm rupture occurred with the adapted antihypertensive therapy, simvastatin and aspirin.

LESSONS

Nonruptured AAAs can cause rare, unusual, and even life-threatening complications depending on their size and anatomical position.

Characteristics of the new AtriCure cryoFORM® cryoablation probe for the surgical treatment of cardiac arrhythmias

INTRODUCTION

Atrial fibrillation has a significant impact on patient mortality and morbidity. In particular, stroke is a frequent complication associated with atrial fibrillation. In recent years, various treatment options have been developed that are based on the elimination of atypical electrically active atrial areas. Areas covered: This manuscript presents a new cryoablation probe from AtriCure Inc. In addition to describing the characteristics of the probe, we also discuss atrial fibrillation and its surgical therapy options as well as the basics of cryosurgery. The cryoFORM® cryoablation probe is an ablation system developed for cardiothoracic surgeons that utilizes nitrous oxide (N₂O) to create continuous transmural lesions that block propagation of atrial activation. The main features of the probe are an excellent working capacity due to the use of N₂O, high flexibility, and, in combination with the cryoICE® Box V6, an active defrost mode for quick detachment. Expert commentary: The cryoFORM® ablation probe is a new device for the treatment of atrial fibrillation using N₂O as an energy source. The probe is made from stainless steel and has a corrugated surface, a design that provides a higher flexibility than the cryoICE probe.

Calcium-mediated cellular triggered activity in atrial fibrillation

Although atrial fibrillation (AF) is the most commonly encountered cardiac arrhythmia, the basic mechanisms underlying this disorder remain incompletely understood. During the past decade or so, it has become clear that alterations in intracellular Ca²⁺ handling may play a role in the pathogenesis of AF. Studies in small and large animal models, as well as atrial samples from patients with different forms of AF, have implicated ryanodine receptor type 2 (RyR2) dysfunction and enhanced spontaneous Ca²⁺ release events from the sarcoplasmic reticulum (SR) as a potential cause of proarrhythmic cellular ectopic (triggered) activity in AF. The molecular mechanisms leading to RyR2 dysfunction and SR Ca²⁺ leak depend on the clinical stage of AF or specific animal model studied. This review focuses on the mechanisms and role of calcium-mediated cellular triggered activity in AF, and addresses some of the current controversies in the field.

Use of rivaroxaban in patients with stroke

Rivaroxaban, an inhibitor of Factor Xa, is a direct oral anti-coagulant that has been found to be non-inferior to warfarin in preventing cerebral ischemia in patients with non-valvular atrial fibrillation and in the subgroup of patients with a history of the previous stroke or transient ischemic attack. Vascular neurologists in daily clinical practice may encounter patients taking rivaroxaban or patients who may benefit from its use. In this paper, we review the current clinical indications, contraindications, and clinical management guidelines for rivaroxaban while providing a special focus on neurological aspects and expert opinions on rivaroxaban therapy management in various situations that a neurologist may encounter when treating patients with an ischemic stroke (including those requiring intravenous or intra-arterial reperfusion therapy) and patients with an intracerebral hemorrhage. Since data from clinical trials and real-life data are missing in some clinical situations, strong recommendations are not always available. Nevertheless, practical guidelines should be adopted to maximize benefits from this oral anti-coagulant.

Emergency Surgery in a Critically Ill Patient with Major Drug-Induced Bleeding and Severe Ischaemic Heart Failure

Introduction

Anticoagulant overdose frequently occurs in elderly populations especially in remote areas where medical services are scarce. When emergency surgery is required, such patients offer major anaesthetic challenges.

Case presentation

We describe the case of an elderly patient admitted to a surgical ward with acute abdominal pain, on dual anti-platelet therapy and acenocoumarol for a recent acute myocardial infarction treated percutaneously with two drug-eluting stents. Laboratory tests showed severe anticoagulant overdose with uncoagulable INR. The decision was made to use of both light transmission aggregometry [LTA] for platelet function testing and thromboelastography to aid in the management of perioperative haemostasis in order to prevent both severe bleeding and stent thrombosis. Surgery revealed haemoperitoneum, volvulus of the ileum and a venous mesenteric infarction. Intraoperative blood loss was minimal and no blood products were administered. Postoperative course was uneventful without either thrombotic or haemorrhagic complications and the patient was discharged from the Postanaesthesia Care Unit on postoperative day two.

Conclusion

The use of aggregometry and thrombography helped in both evaluation and management of haemostasis of a high-risk patient by goal-directed administration of pro-and anti-coagulants.

Exercise-based cardiac rehabilitation for adults with atrial fibrillation

BACKGROUND

Exercise-based cardiac rehabilitation may benefit adults with atrial fibrillation or those who had been treated for atrial fibrillation. Atrial fibrillation is caused by multiple micro re-entry circuits within the atrial tissue, which result in chaotic rapid activity in the atria.

OBJECTIVES

To assess the benefits and harms of exercise-based rehabilitation programmes, alone or with another intervention, compared with no-exercise training controls in adults who currently have AF, or have been treated for AF.

SEARCH METHODS

We searched the following electronic databases; CENTRAL and the Database of Abstracts of Reviews of Effectiveness (DARE) in the Cochrane Library, MEDLINE Ovid, Embase Ovid, PsycINFO Ovid, Web of Science Core Collection Thomson Reuters, CINAHL EBSCO, LILACS Bireme, and three clinical trial registers on 14 July 2016. We also checked the bibliographies of relevant systematic reviews identified by the searches. We imposed no language restrictions.

SELECTION CRITERIA

We included randomised controlled trials (RCT) that investigated exercise-based interventions compared with any type of no-exercise control. We included trials that included adults aged 18 years or older with atrial fibrillation, or post-treatment for atrial fibrillation.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data. We assessed the risk of bias using the domains outlined in the Cochrane Handbook for Systematic Reviews of Interventions. We assessed clinical and statistical heterogeneity by visual inspection of the forest plots, and by using standard Chi² and I² statistics. We performed meta-analyses using fixed-effect and random-effects models; we used standardised mean differences where different scales were used for the same outcome. We assessed the risk of random errors with trial sequential analysis (TSA) and used the GRADE methodology to rate the quality of evidence, reporting it in the 'Summary of findings' table.

MAIN RESULTS

We included six RCTs with a total of 421 patients with various types of atrial fibrillation. All trials were conducted between 2006 and 2016, and had short follow-up (eight weeks to six months). Risks of bias ranged from high risk to low risk.The exercise-based programmes in four trials consisted of both aerobic exercise and resistance training, in one trial consisted of Qi-gong (slow and graceful movements), and in another trial, consisted of inspiratory muscle training.For mortality, very low-quality evidence from six trials suggested no clear difference in deaths between the exercise and no-exercise groups (relative risk (RR) 1.00, 95% confidence interval (CI) 0.06 to 15.78; participants = 421; I² = 0%; deaths = 2). Very low-quality evidence from five trials suggested no clear difference between groups for serious adverse events (RR 1.01, 95% CI 0.98 to 1.05; participants = 381; I² = 0%; events = 8). Low-quality evidence from two trials suggested no clear difference in health-related quality of life for the Short Form-36 (SF-36) physical component summary measure (mean difference (MD) 1.96, 95% CI -2.50 to 6.42; participants = 224; I² = 69%), or the SF-36 mental component summary measure (MD 1.99, 95% CI -0.48 to 4.46; participants = 224; I² = 0%). Exercise capacity was assessed by cumulated work, or maximal power (Watt), obtained by cycle ergometer, or by six minute walking test, or ergospirometry testing measuring VO2 peak. We found moderate-quality evidence from two studies that exercise-based rehabilitation increased exercise capacity, measured by VO2 peak, more than no exercise (MD 3.76, 95% CI 1.37 to 6.15; participants = 208; I² = 0%); and very low-quality evidence from four studies that exercise-based rehabilitation increased exercise capacity more than no exercise, measured by the six-minute walking test (MD 75.76, 95% CI 14.00 to 137.53; participants = 272; I² = 85%). When we combined the different assessment tools for exercise capacity, we found very low-quality evidence from six trials that exercise-based rehabilitation increased exercise capacity more than no exercise (standardised mean difference (SMD) 0.86, 95% CI 0.46 to 1.26; participants = 359; I² = 65%). Overall, the quality of the evidence for the outcomes ranged from moderate to very-low.

AUTHORS' CONCLUSIONS

Due to few randomised patients and outcomes, we could not evaluate the real impact of exercise-based cardiac rehabilitation on mortality or serious adverse events. The evidence showed no clinically relevant effect on health-related quality of life. Pooled data showed a positive effect on the surrogate outcome of physical exercise capacity, but due to the low number of patients and the moderate to very low-quality of the underpinning evidence, we could not be certain of the magnitude of the effect. Future high-quality randomised trials are needed to assess the benefits and harms of exercise-based cardiac rehabilitation for adults with atrial fibrillation on patient-relevant outcomes.

Chemical cardioversion of recent-onset atrial fibrillation in the emergency department using vernakalant hydrochloride achieves safe and rapid restoration of sinus rhythm and facilitates same day discharge

BACKGROUND

Vernakalant hydrochloride is a rapid-acting antiarrhythmic drug licensed in the EU since 2010 for the conversion of recent-onset atrial fibrillation with proven efficacy and safety when compared with placebo and amiodarone in randomized clinical trials.

AIMS

The aim of our study was to determine the feasibility of same day discharge (following 2 h monitoring) from the emergency department after successful cardioversion using vernakalant hydrochloride.

METHODS

Patients with recent-onset atrial fibrillation treated in the emergency department of a large Dublin academic teaching hospital. Patients received a maximum of two weight based 10 min infusions of vernakalant. Hypotensive events (>30% initial blood pressure), arrhythmias, conversion rates, and time to conversion were recorded.

RESULTS

Sinus rhythm was restored in 35 out of 42 patients (83%) in an average of 8.8 min (median 8 min), average CHA2DS2-VASc of 0.92, HAS-BLED of 0.21 and average symptoms duration of 12 h. There were no hypotensive or arrhythmogenic events. 41 out of 42 patients were discharged after 2 h of monitoring.

CONCLUSIONS

Vernakalant hydrochloride has provided a quick, safe, and practical means of achieving rapid restoration of sinus rhythm in our ED population with stable recent-onset AF who would otherwise not have undergone routine electrically cardioversion and same day discharge.

Atrial high-rate episodes and stroke prevention

While the benefit of oral anticoagulants (OACs) for stroke prevention in patients with atrial fibrillation (AF) is well established, it is not known whether oral anticoagulation is indicated in patients with atrial high-rate episodes (AHRE) recorded on a cardiac implantable electronic device, sometimes also called subclinical AF, and lasting for at least 6 min in the absence of clinically diagnosed AF. Clinical evidence has shown that short episodes of rapid atrial tachycarrhythmias are often detected in patients presenting with stroke and transient ischaemic attack. Patients with AHRE have a higher likelihood of suffering from subsequent strokes, but their stroke rate seems lower than in patients with diagnosed AF, and not all AHRE episodes correspond to AF. The prognostic and pathological significance of AHRE is not yet fully understood. Clinical trials of OAC therapy are being conducted to determine whether therapeutic intervention would be beneficial to patients experiencing AHRE in terms of reducing the risk of stroke.

Monitoring for AF: Identifying the Burden of Atrial Fibrillation and Assessing Post-Ablation

The management of atrial fibrillation (AF) is among the most challenging aspects of cardiology and uncertainties abound concerning stroke assessment and stroke risk reduction. Currently, AF is viewed as a dichotomous variable (fully present or absent) when it comes to stroke risk; there is no regard to the amount of AF either spontaneously or due to rhythm control strategies. For this reason, monitoring in patients with a known AF history, particularly after ablation, has focused on easily measured outcomes such as time to recurrence. However, emerging data suggest that thresholds exist between stroke risk and AF quantity as measured by either duration or burden. As a result, there is an increasing interest in long-term continuous monitoring following a rhythm control strategy to assess efficacy beyond typical symptom reduction. Insertable cardiac monitors (ICMs) with AF-sensing algorithms and remote data transmission capabilities can be used for this purpose, and wearable devices with similar functions are on the horizon. In addition to their diagnostic potential, these tools are also being used therapeutically with efforts to target anticoagulation therapy only in response to AF episodes.

High prevalence of modifiable stroke risk factors identified in a pharmacy-based screening programme

Background

Population-based screening for atrial fibrillation (AF) is a promising public health strategy to prevent stroke. However, none of the published reports have evaluated comprehensive screening for additional stroke risk factors such as hypertension and diabetes in a pharmacy setting.

Methods

The Program for the Identification of ‘Actionable’ Atrial Fibrillation in the Pharmacy Setting (PIAAF-Pharmacy) screened individuals aged ≥65 years, attending community pharmacies in Canada, who were not receiving oral anticoagulation (OAC). Participants were screened for AF using a hand-held ECG device, had blood pressure (BP) measured, and diabetes risk estimated using the Canadian Diabetes Risk Assessment Questionnaire (CANRISK) questionnaire. ‘Actionable’ AF was defined as unrecognised or undertreated AF. A 6-week follow-up visit with the family physician was suggested for participants with ‘actionable’ AF and a scheduled 3-month visit occurred at an AF clinic.

Results

During 6 months, 1145 participants were screened at 30 pharmacies. ‘Actionable’ AF was identified in 2.5% (95% CI 1.7 to 3.6; n=29); of these, 96% were newly diagnosed. Participants with ‘actionable AF’ had a mean age of 77.2±6.8 years, 58.6% were male and 93.1% had a CHA₂DS₂-VASc score ≥2. A BP>140/90 was found in 54.9% (616/1122) of participants and 44.4% (214/492) were found to be at high risk of diabetes. At 3 months, only 17% of participants were started on OAC, 50% had improved BP and 71% had confirmatory diabetes testing.

Conclusions

Integrated stroke screening identifies a high prevalence of individuals who could benefit from stroke prevention therapies but must be coupled with a defined care pathway.

Clinical characteristics of complex aortic plaque in patients with non-valvular atrial fibrillation

BACKGROUND

Although complex aortic plaque (CxAoP) is a component of the CHA₂DS₂-VASc score in patients with atrial fibrillation (AF), it is underestimated without detection by trans-esophageal echocardiogram (TEE). We have evaluated the incidence and significance of CxAoP among patients with non-valvular AF (NVAF).

METHODS

We included 981 patients with NVAF who underwent catheter ablation (59.1±11.1years old, 73.7% male, 70.2% paroxysmal AF). All of the patients underwent pre-procedural TEE evaluation. Left atrial (LA)-cardioembolic (CE) milieu was defined as a dense spontaneous echo-contrast or LA appendage flow velocity≤20cm/s.

RESULTS

CxAoP was present in 8.3% of patients, and independently associated with age (OR 1.07, 95% CI 1.03-1.10, p<0.001), male sex (OR 2.34, 95% CI 1.29-4.24, p=0.005), and CHA₂DS₂-VASc score≥2 (OR 3.33, 95%CI 1.42-7.77, p=0.005). The presence of LA-CE milieu overlapped with CxAoP in only 11% of patients. Patients with CxAoP had a higher prevalence of hypertension (p=0.004), smoking history (p=0.008), paroxysmal AF (PAF, p<0.001), and a smaller LA volume index (p<0.001) than those with LA-CE milieu. The prevalence of persistent AF among patients with a history of stroke was significantly lower in the presence of CxAoP than in those with LA-CE milieu (p=0.014). CHA₂DS₂-VASc score was underestimated in 11% of high-risk patients (CHA₂DS₂-VASc score≥2) due to undetected CxAoP.

CONCLUSIONS

CxAoP may contribute to the risk of stroke by a different mechanism than LA-CE milieu in patients with NVAF. Imaging assessment for CxAoP affects thromboembolic risk stratification and decision making for stroke prevention in patients with NVAF.

Role of hospitalists in the diagnosis of atrial fibrillation for the management of cryptogenic stroke patients

Cryptogenic strokes are responsible for significant morbidity and mortality. Identifying the underlying cause of cryptogenic stroke is imperative for appropriate short and long-term management of these patients. In particular, detecting atrial fibrillation in cryptogenic stroke patients may shed insight into the cause of the index stroke, but is also important to identify an important cause of secondary stroke. There is accumulating evidence indicating that monitoring for durations beyond the guideline recommended 30 day-period results in greater atrial fibrillation yield. This article reviews current guidelines and practices for the diagnosis of cryptogenic stroke, as well as outpatient cardiac monitoring options available, and focuses on the role that hospitalists have to play in the care of these patients.

Atrial Fibrillation and Heart Failure: How Should We Manage Our Patients?

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