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Riddle M, McCallum R, Ojha CP, Paul TK, Gupta V, Baran DA, Prakash BV, Misra A, Mares AC, Abedin M, Kedar A, Mulukutla V, Ibrahim A, Nagarajarao H. Advances in the management of atrial fibrillation with a special focus on non-pharmacological approaches to prevent thromboembolism: a review of current recommendations. J Investig Med 2020; 68:1317-1333. [PMID: 33203786 DOI: 10.1136/jim-2020-001500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/13/2020] [Indexed: 11/04/2022]
Abstract
Atrial fibrillation (AFIB) is the most common heart rhythm abnormality and is associated with significant morbidity and mortality. While the treatment of AFIB involves strategies of rate with or without rhythm control, it is also essential to strategize appropriate therapies to prevent thromboembolic complications arising from AFIB. Previously, anticoagulation was the main treatment option which exposed patients to higher than usual risk of bleeding. However, with the advent of new technology, novel therapeutic options aimed at surgical or percutaneous exclusion or occlusion of the left atrial appendage in preventing thromboembolic complications from AFIB have evolved. This review evaluates recent advances and therapeutic options in treating AFIB with a special focus on both surgical and percutaneous interventions which can reduce and/or eliminate thromboembolic complications of AFIB.
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Affiliation(s)
- Malini Riddle
- Paul L Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, Texas, USA
| | - Richard McCallum
- Internal Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, Texas, USA
| | - Chandra Prakash Ojha
- Internal Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, Texas, USA
| | - Timir Kumar Paul
- Internal Medicine, East Tennessee State University James H Quillen College of Medicine, Johnson City, Tennessee, USA
| | - Vineet Gupta
- Department of Internal Medicine, University of California San Diego, La Jolla, California, USA
| | - David Alan Baran
- Cardiovascular Diseases, Sentara Healthcare Inc, Norfolk, Virginia, USA
| | - Bharat Ved Prakash
- Department of Medicine, Texas Tech University Health Sciences Center El Paso, Transmountain Campus, El Paso, Texas, USA
| | - Amogh Misra
- Department of Biochemistry, The University of Texas at Austin, Austin, Texas, USA
| | - Adriana Camila Mares
- Internal Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, Texas, USA
| | - Moeen Abedin
- Division of Cardiology, University Medical Center of El Paso, El Paso, Texas, USA
| | - Archana Kedar
- Internal Medicine, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | | | - Ahmed Ibrahim
- Internal Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, Texas, USA
| | - Harsha Nagarajarao
- Internal Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, Texas, USA
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Packer M. Characterization, Pathogenesis, and Clinical Implications of Inflammation-Related Atrial Myopathy as an Important Cause of Atrial Fibrillation. J Am Heart Assoc 2020; 9:e015343. [PMID: 32242478 PMCID: PMC7428644 DOI: 10.1161/jaha.119.015343] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Historically, atrial fibrillation has been observed in clinical settings of prolonged hemodynamic stress, eg, hypertension and valvular heart disease. However, recently, the most prominent precedents to atrial fibrillation are metabolic diseases that are associated with adipose tissue inflammation (ie, obesity and diabetes mellitus) and systemic inflammatory disorders (ie, rheumatoid arthritis and psoriasis). These patients typically have little evidence of left ventricular hypertrophy or dilatation; instead, imaging reveals abnormalities of the structure or function of the atria, particularly the left atrium, indicative of an atrial myopathy. The left atrium is enlarged, fibrotic and noncompliant, potentially because the predisposing disorder leads to an expansion of epicardial adipose tissue, which transmits proinflammatory mediators to the underlying left atrium. The development of an atrial myopathy not only leads to atrial fibrillation, but also contributes to pulmonary venous hypertension and systemic thromboembolism. These mechanisms explain why disorders of systemic or adipose tissue inflammation are accompanied an increased risk of atrial fibrillation, abnormalities of left atrium geometry and an enhanced risk of stroke. The risk of stroke exceeds that predicted by conventional cardiovascular risk factors or thromboembolism risk scores used to guide the use of anticoagulation, but it is strongly linked to clinical evidence and biomarkers of systemic inflammation.
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Affiliation(s)
- Milton Packer
- Baylor Heart and Vascular Institute Baylor University Medical Center Dallas TX.,Imperial College London United Kingdom
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Abstract
Guidelines on the use of digoxin are inconsistent with evidence from randomised trials
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Tamargo J, Delpón E, Caballero R. The safety of digoxin as a pharmacological treatment of atrial fibrillation. Expert Opin Drug Saf 2006; 5:453-67. [PMID: 16610972 DOI: 10.1517/14740338.5.3.453] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Digoxin has traditionally been the drug of choice for ventricular rate control in patients with chronic atrial fibrillation (AF), with or without heart failure (HF) with systolic dysfunction. In patients with permanent AF, digoxin monotherapy is ineffective to control ventricular rate during exercise, but the combination of digoxin with a beta-blocker or a non-dihydropyridine calcium channel antagonist can control heart rate both at rest and during exercise. Only a few randomised, controlled studies have evaluated the adverse effects of digoxin in patients with AF in a systematic way and side effects requiring drug withdrawal have rarely been reported. When reported, the most frequent adverse effects were cardiac arrhythmias (ventricular arrhythmias, AV block of varying degrees and sinus pauses). This evidence suggested that, in contrast to other antiarrhythmic drugs, digoxin is a safe drug in patients with AF. However, this safety profile can be erroneous due to the short follow-up of the studies and patient selection. Because patients with HF have been excluded in most studies, the safety profile of digoxin in this population has not been directly addressed. Early recognition that an arrhythmia is related to digoxin intoxication as well as recognition of concomitant medications or medical conditions that may directly alter the pharmacokinetic profile of digoxin, or indirectly alter its cardiac effects by pharmacodynamic interactions remain essential for safe and effective use of digoxin in patients with AF.
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Affiliation(s)
- Juan Tamargo
- Department of Pharmacology, School of Medicine, Universidad Complutense, 28040 Madrid, Spain.
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Abstract
To control ventricular rate in patients with AF, physicians should seek to control heart rate at rest and with exertion. The goal has to be achieved while minimizing costs and adverse effects. For emergency use, i.v. diltiazem or esmolol are drugs useful because of their rapid onset of action. They have to be used with caution in patients with concomitant left ventricular failure symptoms, however. For most patients with AF, chronic control of the ventricular rate can be achieved with one drug. For the chronic control of ventricular rate in patients with AF and normal ventricular function, diltiazem, atenolol, are metoprolol are probably the drugs of choice. For patients with AF and structurally abnormal hearts, atenolol, metoprolol, or carvedilol are appropriate choices. Adequate ventricular rate control by pharmacological agents should be evaluated by either 24-hour Holter monitoring or a submaximal stress test to determine the resting and exercise ventricular rate. If the mean ventricular rate is not close to 80 beats per minute, or the heart rate on moderate exertion is not between 90 to 115 beats per minute, a second agent to control the rate should be added. Excessive reductions in ventricular rates that could limit exercise tolerance should be avoided.
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Affiliation(s)
- Leonardo J Tamariz
- Division of General Internal Medicine, Johns Hopkins University, Welch Center for Prevention, Epidemiology and Clinical Research, 2024 East Monument Street, Room 2-516, Baltimore, MD 21205, USA.
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Atwood JE, Myers J, Quaglietti S, Grumet J, Gianrossi R, Umman T. Effect of betaxolol on the hemodynamic, gas exchange, and cardiac output response to exercise in chronic atrial fibrillation. Chest 1999; 115:1175-80. [PMID: 10208225 DOI: 10.1378/chest.115.4.1175] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND beta-blockade controls the ventricular response to exercise in chronic atrial fibrillation (AF), but the effects of beta-blockers on exercise capacity in AF have been debated. METHODS Twelve men with AF (65+/-8 years) participated in a randomized, double-blind, placebo-controlled study of betaxolol (20 mg daily). Patients underwent maximal exercise testing with ventilatory gas exchange analysis, and a separate, submaximal test (50% of maximum) during which cardiac output was measured by a CO2 rebreathing technique. RESULTS After betaxolol therapy, heart rate was reduced both at rest (92+/-27 vs 62+/-12 beats/min; p < 0.001) and at peak exercise (173+/-22 vs 116+/-24 beats/min; p < 0.001). Maximal oxygen uptake (VO2) was reduced by 19% after betaxolol (21.8+/-5.3 with placebo vs 17.6+/-5.1 mL/kg/min with betaxolol; p < 0.05), with similar reductions observed for maximal exercise time, minute ventilation, and CO2 production. VO2 was reduced by a similar extent (19%) at the ventilatory threshold. Submaximal cardiac output was reduced by 15% during betaxolol therapy (12.9+/-2.3 vs 10.9+/-1.3 L/min; p < 0.05), and stroke volume was higher (88.0+/-21 vs 105.6+/-19 mL/beat; p < 0.05). CONCLUSION Betaxolol therapy in patients with AF effectively controlled the ventricular rate at rest and during exercise, but also caused considerable reductions in maximal VO2 and cardiac output during exercise. The observed increase in stroke volume could not adequately compensate for reduced heart rate to maintain VO2 during exercise.
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Affiliation(s)
- J E Atwood
- Cardiology Division, Palo Alto Veterans Affairs Health Care System and Stanford University, CA 94304, USA
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Piot O, Chauvel C, Lazarus A, Pellerin D, David D, Leneveut-Ledoux L, Guize L, Le Heuzey JY. Effects of a selective A1-adenosine receptor agonist on heart rate and heart rate variability during permanent atrial fibrillation. Pacing Clin Electrophysiol 1998; 21:2459-64. [PMID: 9825367 DOI: 10.1111/j.1540-8159.1998.tb01201.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Mean heart rate and irregularity of the rate, i.e., heart rate variability (HRV), are two aspects of heart rate during atrial fibrillation (AF). An important goal of AF therapy is to control mean heart rate during exercise; the determinants of HRV during AF remain poorly known although its prognostic value has been established. OBJECTIVES To investigate the effects of a stable, long-acting, selective A1-adenosine receptor agonist, SDZ WAG994, on heart rate during exercise and on HRV. METHODS In a multicenter, double-blind, randomized, placebo-controlled, parallel group study, patients with permanent AF performed a symptom-limited exercise test and underwent 24-hour ECG monitoring on day 1 during treatment with placebo, and on day 2 during treatment with either placebo or 2 mg SDZWAG994 orally. Changes in mean heart rate during exercise and changes in HRV indices between day 1 and day 2 were compared between the two groups. RESULTS Thirty-two patients (64 +/- 8 years; 81% male; 25% in NYHA Class II; 38% with no structural heart disease) were included in the study. During active treatments, heart rate remained unchanged at rest and increased significantly during exercise. A significant daytime increase in short-term HRV indices (DpNN50 = 4.5% P = 0.01; DrMSSD = 6% P = 0.03; DSDNN Index = 6% P = 0.02) occurred during active treatment. CONCLUSIONS Selective A1-adenosine receptor agonism with SDZ/WAG994 limits the increase in mean heart rate during exercise in patients with AF. In addition, this agonist selectively increases short-term HRV indices, suggesting that pNN50, rMSSD, and SDNN reflect vagal influences during AF.
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Affiliation(s)
- O Piot
- Service de Cardiologie, Hôpital Broussais, Paris, France
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Brignole M, Menozzi C. Control of rapid heart rate in patients with atrial fibrillation: drugs or ablation? Pacing Clin Electrophysiol 1996; 19:348-56. [PMID: 8657596 DOI: 10.1111/j.1540-8159.1996.tb03337.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- M Brignole
- Section of Arrhythmology, Ospedali Riuniti, Lavagna, Italy
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Abstract
Atrial fibrillation represents a common and challenging arrhythmia. A rational approach to management of the individual case depends on careful assessment of the temporal of the arrhythmia, any associated cardiovascular disease, and any particular features suggesting the advisability or risks of any particular treatment regimen. The nature of an arrhythmia and of individual patient factors change over time, requiring a flexible approach to long-term treatment that may be defined only after months or years. While new treatment options such as catheter ablation techniques and implantable atrial defibrillators are being tested, old therapies (e.g., low-dose amiodarone) are undergoing reappraisal. Increasing recognition of the dangers of antiarrhythmic therapy used to maintain sinus rhythm is focusing attention on nonpharmacologic methods. All patients with persistent atrial fibrillation merit serious consideration for direct current cardioversion before accepting that atrial fibrillation is permanent, and many patients may benefit from more than one attempt to restore and maintain sinus rhythm.
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Affiliation(s)
- S M Sopher
- Department of Cardiological Sciences, St. George's Hospital and Medical School, London, United Kingdom
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Koh KK, Song JH, Kwon KS, Park HB, Baik SH, Park YS, In HH, Moon TH, Park GS, Cho SK. Comparative study of efficacy and safety of low-dose diltiazem or betaxolol in combination with digoxin to control ventricular rate in chronic atrial fibrillation: randomized crossover study. Int J Cardiol 1995; 52:167-74. [PMID: 8749878 DOI: 10.1016/0167-5273(95)02480-k] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND The combination therapy of low-dose diltiazem or bexatolol with digoxin can be a useful adjunct for achieving heart rate control with minimal side effects. But there has not been a study including patients with impaired left ventricular function and evaluating whether the beneficial effects of medication will be maintained during a follow-up period. OBJECTIVES The purpose of this study was three-fold: (1) to compare the efficacy of digoxin with low-dose diltiazem and digoxin with low-dose betaxolol on randomized crossover study; (2) to evaluate whether the beneficial effects of medication will be maintained after 7 months; (3) to evaluate the safety of the combination therapy in patients with impaired left ventricular function. METHODS We did a prospective randomized crossover study in 35 patients with chronic atrial fibrillation (AF) including 15 patients with left ventricular dysfunction. After enrollment, each patient was evaluated for heart rate, blood pressure, rate-pressure products, maximal exercise tolerance at rest and during symptom-limited treadmill test before medication, at 4 weeks after medication of digoxin (0.125-0.5 mg daily) with diltiazem (90 mg twice daily), and at 4 weeks after digoxin with betaxolol (20 mg once daily). We performed 24-h ambulatory electrocardiogram (ECG) in 15 patients at the end of each phase of treatment. We repeated symptom-limited treadmill test like above method in 15 patients at 7 months of medication. RESULTS (1) Ventricular rates were significantly reduced in digoxin with low-dose betaxolol therapy at rest and during exercise (67 +/- 3, 135 +/- 5 (mean +/- S.E.M.) beats/min, respectively) in comparison to digoxin with low-dose diltiazem therapy (80 +/- 7, 154 +/- 5) (P < 0.05). (2) Rate-pressure products were significantly less in digoxin with low-dose betaxolol at rest and during exercise (85 +/- 4, 213 +/- 12 x 10(2) mmHg/min) than in digoxin with low-dose diltiazem therapy (105 +/- 6, 269 +/- 12) (P < 0.05). (3) Exercise capacity was significantly improved in digoxin with low-dose betaxolol (9.3 +/- 0.5 METS) or digoxin with low-dose diltiazem (9.7 +/- 0.5) in comparison to control state (8.3 +/- 0.5) (P < 0.05). (4) At 7 months evaluation, there was no significant difference between at 4 weeks and at 7 months. (5) Results on 24-h ambulatory ECG showed the same findings as on treadmill test. (6) Although side effects occurred more frequently in digoxin with low-dose betaxolol therapy, they were minimal and no patient had to withdraw medication. Worsening of left ventricular dysfunction was not observed. CONCLUSION Our study suggested that (1) combination therapy of low-dose betaxolol with digoxin was more superior to low-dose diltiazem with digoxin in controlling ventricular rate and reducing rate-pressure products; (2) the effects controlling ventricular rate, reducing rate-pressure products and improving exercise capacity have been well maintained even after 7 months of medication with each combination therapy.
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Affiliation(s)
- K K Koh
- Department of Internal Medicine, Inha University Hospital, Kyunggi-do, Korea
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Koh KK, Kwon KS, Park HB, Baik SH, Park SJ, Lee KH, Kim EJ, Kim SH, Cho SK, Kim SS. Efficacy and safety of digoxin alone and in combination with low-dose diltiazem or betaxolol to control ventricular rate in chronic atrial fibrillation. Am J Cardiol 1995; 75:88-90. [PMID: 7801876 DOI: 10.1016/s0002-9149(99)80538-4] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- K K Koh
- Department of Internal Medicine and Epidemiology, Inha University Hospital, Soojung-ku Sungnam-si, Kyunggi-do, Korea
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