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Muanda FT, Weir MA, Ahmadi F, McArthur E, Sontrop JM, Abdullah SS, Urquhart BL, Sadeghi H, Kim RB, Garg AX. Thirty-day risk of digoxin toxicity among older adults co-prescribed trimethoprim-sulfamethoxazole versus amoxicillin: A population-based cohort study. Pharmacotherapy 2024; 44:558-569. [PMID: 38922947 DOI: 10.1002/phar.2948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 05/13/2024] [Accepted: 05/22/2024] [Indexed: 06/28/2024]
Abstract
IMPORTANCE Trimethoprim-sulfamethoxazole (TMP-SMX) may increase digoxin concentration, a medication with a narrow therapeutic index. Small changes in digoxin concentration could predispose individuals to the risk of toxicity. OBJECTIVE To characterize the risk of digoxin toxicity in older adults taking digoxin following co-prescription of TMP-SMX compared with co-prescription of amoxicillin. DESIGN, SETTINGS, AND PARTICIPANTS Retrospective population-based cohort study in Ontario, Canada (2002-2020) using linked health care data. Participants comprised 47,961 older adults taking digoxin (58% women; median age 80 years [interquartile range 74-86]) who were newly treated with TMP-SMX (n = 10,273) compared with those newly treated with amoxicillin (n = 37,688). EXPOSURE Co-prescription of TMP-SMX versus amoxicillin in older adults concurrently taking digoxin. MAIN OUTCOME AND MEASURE The primary outcome was a hospital encounter (i.e., hospital admission or emergency department visit) with digoxin toxicity within 30 days of the antibiotic prescription. Inverse probability of treatment weighting on the propensity score was used to balance comparison groups on indicators of baseline health. Weighted risk ratios (RR) were obtained using modified Poisson regression and weighted risk differences (RD) using binomial regression. The number needed to harm (NNH) was calculated as 1/RD. RESULTS A hospital encounter with digoxin toxicity occurred in 49/10,273 (0.48%) patients treated with TMP-SMX versus 32/37,688 (0.08%) in those treated with amoxicillin (weighted RR, 5.71 [95% confidence interval (CI), 3.19 to 10.24]; weighted RD, 0.39% [95% CI, 0.25% to 0.53%]; NNH 256 [95% CI, 233 to 400]). CONCLUSION AND RELEVANCE In older adults taking digoxin, the 30-day risk of a hospital encounter with digoxin toxicity was nearly 6 times higher in those co-prescribed TMP-SMX versus amoxicillin, although the absolute risk difference was low (0.4%). Physicians should prescribe an alternative antibiotic when clinically appropriate. If TMP-SMX must be co-prescribed with digoxin (if the benefit is believed to outweigh the risk), digoxin should be dose-reduced on an individual basis.
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Affiliation(s)
- Flory T Muanda
- ICES Western, London, Ontario, Canada
- Department of Physiology and Pharmacology, Western University, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Matthew A Weir
- ICES Western, London, Ontario, Canada
- Department of Physiology and Pharmacology, Western University, London, Ontario, Canada
- Division of Nephrology, Department of Medicine, Western University, London, Ontario, Canada
| | - Fatemeh Ahmadi
- ICES Western, London, Ontario, Canada
- Department of Physiology and Pharmacology, Western University, London, Ontario, Canada
| | - Eric McArthur
- ICES Western, London, Ontario, Canada
- Lawson Health Research Institute, London Health Sciences Centre, London, Ontario, Canada
| | - Jessica M Sontrop
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Sheikh S Abdullah
- ICES Western, London, Ontario, Canada
- Lawson Health Research Institute, London Health Sciences Centre, London, Ontario, Canada
| | - Brad L Urquhart
- Department of Physiology and Pharmacology, Western University, London, Ontario, Canada
| | - Hasti Sadeghi
- Department of Biology, Western University, London, Ontario, Canada
| | - Richard B Kim
- Division of Clinical Pharmacology, Department of Medicine, Western University, London, Ontario, Canada
| | - Amit X Garg
- ICES Western, London, Ontario, Canada
- Department of Physiology and Pharmacology, Western University, London, Ontario, Canada
- Division of Nephrology, Department of Medicine, Western University, London, Ontario, Canada
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Ono K, Iwasaki YK, Akao M, Ikeda T, Ishii K, Inden Y, Kusano K, Kobayashi Y, Koretsune Y, Sasano T, Sumitomo N, Takahashi N, Niwano S, Hagiwara N, Hisatome I, Furukawa T, Honjo H, Maruyama T, Murakawa Y, Yasaka M, Watanabe E, Aiba T, Amino M, Itoh H, Ogawa H, Okumura Y, Aoki-Kamiya C, Kishihara J, Kodani E, Komatsu T, Sakamoto Y, Satomi K, Shiga T, Shinohara T, Suzuki A, Suzuki S, Sekiguchi Y, Nagase S, Hayami N, Harada M, Fujino T, Makiyama T, Maruyama M, Miake J, Muraji S, Murata H, Morita N, Yokoshiki H, Yoshioka K, Yodogawa K, Inoue H, Okumura K, Kimura T, Tsutsui H, Shimizu W. JCS/JHRS 2020 Guideline on Pharmacotherapy of Cardiac Arrhythmias. Circ J 2022; 86:1790-1924. [DOI: 10.1253/circj.cj-20-1212] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
| | - Yu-ki Iwasaki
- Department of Cardiovascular Medicine, Nippon Medical School
| | - Masaharu Akao
- Department of Cardiovascular Medicine, National Hospital Organization Kyoto Medical Center
| | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Graduate School of Medicine
| | - Kuniaki Ishii
- Department of Pharmacology, Yamagata University Faculty of Medicine
| | - Yasuya Inden
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Kengo Kusano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Yoshinori Kobayashi
- Division of Cardiology, Department of Medicine, Tokai University Hachioji Hospital
| | | | - Tetsuo Sasano
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University
| | - Naokata Sumitomo
- Department of Pediatric Cardiology, Saitama Medical University International Medical Center
| | - Naohiko Takahashi
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University
| | - Shinichi Niwano
- Department of Cardiovascular Medicine, Kitasato University School of Medicine
| | | | | | - Tetsushi Furukawa
- Department of Bio-information Pharmacology, Medical Research Institute, Tokyo Medical and Dental University
| | - Haruo Honjo
- Research Institute of Environmental Medicine, Nagoya University
| | - Toru Maruyama
- Department of Hematology, Oncology and Cardiovascular Medicine, Kyushu University Hospital
| | - Yuji Murakawa
- The 4th Department of Internal Medicine, Teikyo University School of Medicine, Mizonokuchi Hospital
| | - Masahiro Yasaka
- Department of Cerebrovascular Medicine and Neurology, Clinical Research Institute, National Hospital Organization Kyushu Medical Center
| | - Eiichi Watanabe
- Department of Cardiology, Fujita Health University School of Medicine
| | - Takeshi Aiba
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Mari Amino
- Department of Cardiovascular Medicine, Tokai University School of Medicine
| | - Hideki Itoh
- Division of Patient Safety, Hiroshima University Hospital
| | - Hisashi Ogawa
- Department of Cardiology, National Hospital Organisation Kyoto Medical Center
| | - Yasuo Okumura
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
| | - Chizuko Aoki-Kamiya
- Department of Obstetrics and Gynecology, National Cerebral and Cardiovascular Center
| | - Jun Kishihara
- Department of Cardiovascular Medicine, Kitasato University School of Medicine
| | - Eitaro Kodani
- Department of Cardiovascular Medicine, Nippon Medical School Tama Nagayama Hospital
| | - Takashi Komatsu
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University School of Medicine
| | | | | | - Tsuyoshi Shiga
- Department of Clinical Pharmacology and Therapeutics, The Jikei University School of Medicine
| | - Tetsuji Shinohara
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University
| | - Atsushi Suzuki
- Department of Cardiology, Tokyo Women's Medical University
| | - Shinya Suzuki
- Department of Cardiovascular Medicine, The Cardiovascular Institute
| | - Yukio Sekiguchi
- Department of Cardiology, National Hospital Organization Kasumigaura Medical Center
| | - Satoshi Nagase
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Noriyuki Hayami
- Department of Fourth Internal Medicine, Teikyo University Mizonokuchi Hospital
| | | | - Tadashi Fujino
- Department of Cardiovascular Medicine, Toho University, Faculty of Medicine
| | - Takeru Makiyama
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Mitsunori Maruyama
- Department of Cardiovascular Medicine, Nippon Medical School Musashi Kosugi Hospital
| | - Junichiro Miake
- Department of Pharmacology, Tottori University Faculty of Medicine
| | - Shota Muraji
- Department of Pediatric Cardiology, Saitama Medical University International Medical Center
| | | | - Norishige Morita
- Division of Cardiology, Department of Medicine, Tokai University Hachioji Hospital
| | - Hisashi Yokoshiki
- Department of Cardiovascular Medicine, Sapporo City General Hospital
| | - Koichiro Yoshioka
- Division of Cardiology, Department of Internal Medicine, Tokai University School of Medicine
| | - Kenji Yodogawa
- Department of Cardiovascular Medicine, Nippon Medical School
| | | | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School
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Wang X, Luo Y, Xu D, Zhao K. Effect of Digoxin Therapy on Mortality in Patients With Atrial Fibrillation: An Updated Meta-Analysis. Front Cardiovasc Med 2021; 8:731135. [PMID: 34660731 PMCID: PMC8517124 DOI: 10.3389/fcvm.2021.731135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Accepted: 09/06/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Whether digoxin is associated with increased mortality in atrial fibrillation (AF) remains controversial. We aimed to assess the risk of mortality and clinical effects of digoxin use in patients with AF. Methods: PubMed, Embase, and the Cochrane library were systematically searched to identify eligible studies comparing all-cause mortality of patients with AF taking digoxin with those not taking digoxin, and the length of follow-up was at least 6 months. Hazard ratios (HRs) with 95% confidence intervals (CIs) were extracted and pooled. Results: A total of 29 studies with 621,478 patients were included. Digoxin use was associated with an increased risk of all-cause mortality in all patients with AF (HR 1.17, 95% CI 1.13–1.22, P < 0.001), especially in patients without HF (HR 1.28, 95% CI 1.11–1.47, P < 0.001). There was no significant association between digoxin and mortality in patients with AF and HF (HR 1.06, 95% CI 0.99–1.14, P = 0.110). In all patients with AF, regardless of concomitant HF, digoxin use was associated with an increased risk of sudden cardiac death (SCD) (HR 1.40, 95% CI 1.23–1.60, P < 0.001) and cardiovascular (CV) mortality (HR 1.27, 95% CI 1.08–1.50, P < 0.001), and digoxin use had no significant association with all-cause hospitalization (HR 1.13, 95% CI 0.92–1.39, P = 0.230). Conclusion: We conclude that digoxin use is associated with an increased risk of all-cause mortality, CV mortality, and SCD, and it does not reduce readmission for AF, regardless of concomitant HF. Digoxin may have a neutral effect on all-cause mortality in patients with AF with concomitant HF. Systematic Review Registration:https://www.crd.york.ac.ukPROSPERO.
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Affiliation(s)
- Xiaoxu Wang
- Department of Cardiovascular Diseases, The First Branch, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yi Luo
- Department of Cardiovascular Diseases, The First Branch, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Dan Xu
- Department of Cardiovascular Diseases, The First Branch, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Kun Zhao
- Department of Sports Medicine, Zhejiang University School of Medicine, Hangzhou, China
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Martin N, Manoharan K, Davies C, Lumbers RT. Beta-blockers and inhibitors of the renin-angiotensin aldosterone system for chronic heart failure with preserved ejection fraction. Cochrane Database Syst Rev 2021; 5:CD012721. [PMID: 34022072 PMCID: PMC8140651 DOI: 10.1002/14651858.cd012721.pub3] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Beta-blockers and inhibitors of the renin-angiotensin-aldosterone system improve survival and reduce morbidity in people with heart failure with reduced left ventricular ejection fraction (LVEF); a review of the evidence is required to determine whether these treatments are beneficial for people with heart failure with preserved ejection fraction (HFpEF). OBJECTIVES To assess the effects of beta-blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, angiotensin receptor neprilysin inhibitors, and mineralocorticoid receptor antagonists in people with HFpEF. SEARCH METHODS We updated searches of CENTRAL, MEDLINE, Embase, and one clinical trial register on 14 May 2020 to identify eligible studies, with no language or date restrictions. We checked references from trial reports and review articles for additional studies. SELECTION CRITERIA: We included randomised controlled trials with a parallel group design, enrolling adults with HFpEF, defined by LVEF greater than 40%. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS We included 41 randomised controlled trials (231 reports), totalling 23,492 participants across all comparisons. The risk of bias was frequently unclear and only five studies had a low risk of bias in all domains. Beta-blockers (BBs) We included 10 studies (3087 participants) investigating BBs. Five studies used a placebo comparator and in five the comparator was usual care. The mean age of participants ranged from 30 years to 81 years. A possible reduction in cardiovascular mortality was observed (risk ratio (RR) 0.78, 95% confidence interval (CI) 0.62 to 0.99; number needed to treat for an additional benefit (NNTB) 25; 1046 participants; three studies), however, the certainty of evidence was low. There may be little to no effect on all-cause mortality (RR 0.82, 95% CI 0.67 to 1.00; 1105 participants; four studies; low-certainty evidence). The effects on heart failure hospitalisation, hyperkalaemia, and quality of life remain uncertain. Mineralocorticoid receptor antagonists (MRAs) We included 13 studies (4459 participants) investigating MRA. Eight studies used a placebo comparator and in five the comparator was usual care. The mean age of participants ranged from 54.5 to 80 years. Pooled analysis indicated that MRA treatment probably reduces heart failure hospitalisation (RR 0.82, 95% CI 0.69 to 0.98; NNTB = 41; 3714 participants; three studies; moderate-certainty evidence). However, MRA treatment probably has little or no effect on all-cause mortality (RR 0.91, 95% CI 0.78 to 1.06; 4207 participants; five studies; moderate-certainty evidence) and cardiovascular mortality (RR 0.90, 95% CI 0.74 to 1.11; 4070 participants; three studies; moderate-certainty evidence). MRA treatment may have little or no effect on quality of life measures (mean difference (MD) 0.84, 95% CI -2.30 to 3.98; 511 participants; three studies; low-certainty evidence). MRA treatment was associated with a higher risk of hyperkalaemia (RR 2.11, 95% CI 1.77 to 2.51; number needed to treat for an additional harmful outcome (NNTH) = 11; 4291 participants; six studies; high-certainty evidence). Angiotensin-converting enzyme inhibitors (ACEIs) We included eight studies (2061 participants) investigating ACEIs. Three studies used a placebo comparator and in five the comparator was usual care. The mean age of participants ranged from 70 to 82 years. Pooled analyses with moderate-certainty evidence suggest that ACEI treatment likely has little or no effect on cardiovascular mortality (RR 0.93, 95% CI 0.61 to 1.42; 945 participants; two studies), all-cause mortality (RR 1.04, 95% CI 0.75 to 1.45; 1187 participants; five studies) and heart failure hospitalisation (RR 0.86, 95% CI 0.64 to 1.15; 1019 participants; three studies), and may result in little or no effect on the quality of life (MD -0.09, 95% CI -3.66 to 3.48; 154 participants; two studies; low-certainty evidence). The effects on hyperkalaemia remain uncertain. Angiotensin receptor blockers (ARBs) Eight studies (8755 participants) investigating ARBs were included. Five studies used a placebo comparator and in three the comparator was usual care. The mean age of participants ranged from 61 to 75 years. Pooled analyses with high certainty of evidence suggest that ARB treatment has little or no effect on cardiovascular mortality (RR 1.02, 95% 0.90 to 1.14; 7254 participants; three studies), all-cause mortality (RR 1.01, 95% CI 0.92 to 1.11; 7964 participants; four studies), heart failure hospitalisation (RR 0.92, 95% CI 0.83 to 1.02; 7254 participants; three studies), and quality of life (MD 0.41, 95% CI -0.86 to 1.67; 3117 participants; three studies). ARB was associated with a higher risk of hyperkalaemia (RR 1.88, 95% CI 1.07 to 3.33; 7148 participants; two studies; high-certainty evidence). Angiotensin receptor neprilysin inhibitors (ARNIs) Three studies (7702 participants) investigating ARNIs were included. Two studies used ARBs as the comparator and one used standardised medical therapy, based on participants' established treatments at enrolment. The mean age of participants ranged from 71 to 73 years. Results suggest that ARNIs may have little or no effect on cardiovascular mortality (RR 0.96, 95% CI 0.79 to 1.15; 4796 participants; one study; moderate-certainty evidence), all-cause mortality (RR 0.97, 95% CI 0.84 to 1.11; 7663 participants; three studies; high-certainty evidence), or quality of life (high-certainty evidence). However, ARNI treatment may result in a slight reduction in heart failure hospitalisation, compared to usual care (RR 0.89, 95% CI 0.80 to 1.00; 7362 participants; two studies; moderate-certainty evidence). ARNI treatment was associated with a reduced risk of hyperkalaemia compared with valsartan (RR 0.88, 95% CI 0.77 to 1.01; 5054 participants; two studies; moderate-certainty evidence). AUTHORS' CONCLUSIONS There is evidence that MRA and ARNI treatment in HFpEF probably reduces heart failure hospitalisation but probably has little or no effect on cardiovascular mortality and quality of life. BB treatment may reduce the risk of cardiovascular mortality, however, further trials are needed. The current evidence for BBs, ACEIs, and ARBs is limited and does not support their use in HFpEF in the absence of an alternative indication. Although MRAs and ARNIs are probably effective at reducing the risk of heart failure hospitalisation, the treatment effect sizes are modest. There is a need for improved approaches to patient stratification to identify the subgroup of patients who are most likely to benefit from MRAs and ARNIs, as well as for an improved understanding of disease biology, and for new therapeutic approaches.
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Affiliation(s)
- Nicole Martin
- Institute of Health Informatics Research, University College London, London, UK
| | | | - Ceri Davies
- Department of Cardiology, Barts Heart Centre, St Bartholomew's Hospital, London, UK
| | - R Thomas Lumbers
- Institute of Health Informatics, University College London, London, UK
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5
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Baker WL, Sobieraj DM, DiDomenico RJ. Influence of digoxin on mortality in patients with atrial fibrillation: Overview of systematic reviews. Pharmacotherapy 2021; 41:394-404. [PMID: 33544894 DOI: 10.1002/phar.2510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/18/2021] [Accepted: 01/24/2021] [Indexed: 11/08/2022]
Abstract
Once a routine part of atrial fibrillation (AF) management, digoxin use has declined. Likely hastening this decline are findings from several studies and systematic reviews identifying a potential association between digoxin use and all-cause mortality in AF populations. However, inconsistency exists within some of these studies potentially leading to confusion among clinicians. To critically evaluate the current literature to contextualize the associations between digoxin and mortality risk in patients with AF by performing an overview of systematic reviews. We searched MEDLINE, Cochrane Central Database of Systematic Reviews, and SCOPUS from their earliest date through October 12, 2020, to identify systematic reviews (SRs) that included studies enrolling patients with AF or atrial flutter and evaluated the association between digoxin use and all-cause mortality. We used the AMSTAR 2 tool to assess the risk of bias for each included SR. Results from reviews are qualitatively synthesized. Our search identified 10 SRs that met our inclusion criteria. Of the 41 unique AF studies included in these SRs, 41% were cohort studies, 29% were post hoc analyses of randomized controlled trials (RCTs), 15% were RCTs, and 15% were registry studies. Based on our AMSTAR 2 assessment, the overall confidence in the results of the 10 reviews was rated as "moderate" in three SRs, "low" in three SRs, and "critically low" in the rest. Except for one review, each included SR shows that digoxin use in AF is associated with a 15 to 38% higher risk of all-cause mortality. This association may be greater when AF-only populations are considered compared with a mix of AF and heart failure populations. Serum digoxin concentration (SDC) data were infrequently considered, but available data suggested a greater association between increasing SDC and all-cause mortality. This overview of reviews found general consistency regarding the association between digoxin use and higher all-cause mortality in AF populations. However, heterogeneity exists among and between SRs and an unmet need exists for additional study in a RCT setting with close monitoring and reporting of SDC to better inform clinical practice.
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Affiliation(s)
- William L Baker
- Department of Pharmacy Practice, University of Connecticut School of Pharmacy, University of Connecticut, Storrs, Connecticut, USA
| | - Diana M Sobieraj
- Department of Pharmacy Practice, University of Connecticut School of Pharmacy, University of Connecticut, Storrs, Connecticut, USA
| | - Robert J DiDomenico
- Department of Pharmacy Practice, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois, USA
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6
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Fu JL, Yu Q, Li MD, Hu CM, Shi G. Deleterious cardiovascular effect of exosome in digitalis-treated decompensated congestive heart failure. J Biochem Mol Toxicol 2020; 34:e22462. [PMID: 32045083 DOI: 10.1002/jbt.22462] [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: 09/14/2019] [Revised: 11/16/2019] [Accepted: 01/21/2020] [Indexed: 12/16/2022]
Abstract
Heart failure (HF) is a medical condition inability of the heart to pump sufficient blood to meet the metabolic demand of the body to take place. The number of hospitalized patients with cardiovascular diseases is estimated to be more than 1 million each year, of which 80% to 90% of patients ultimately progress to decompensated HF. Digitalis glycosides exert modest inotropic actions when administered to patients with decompensated HF. Although its efficacy in patients with HF and atrial fibrillation is clear, its value in patients with HF and sinus rhythm has often been questioned. A series of recent studies have cast serious doubt on the benefit of digoxin when added to contemporary HF treatment. We are hypothesizing the role and mechanism of exosome and its biological constituents responsible for worsening the disease state and mortality in decompensated HF patients on digitalis.
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Affiliation(s)
- Jin-Ling Fu
- Department of Ophthalmology, The Second Hospital of Jilin University, Changchun, Jilin, China
| | - Qiong Yu
- Department of Hematology and Oncology, The Second Hospital of Jilin University, Changchun, Jilin, China
| | - Meng-Di Li
- Department of Hematology and Oncology, The Second Hospital of Jilin University, Changchun, Jilin, China
| | - Chun-Mei Hu
- Department of Hematology and Oncology, The Second Hospital of Jilin University, Changchun, Jilin, China
| | - Guang Shi
- Department of Hematology and Oncology, The Second Hospital of Jilin University, Changchun, Jilin, China
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7
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Tsutsui H, Isobe M, Ito H, Ito H, Okumura K, Ono M, Kitakaze M, Kinugawa K, Kihara Y, Goto Y, Komuro I, Saiki Y, Saito Y, Sakata Y, Sato N, Sawa Y, Shiose A, Shimizu W, Shimokawa H, Seino Y, Node K, Higo T, Hirayama A, Makaya M, Masuyama T, Murohara T, Momomura SI, Yano M, Yamazaki K, Yamamoto K, Yoshikawa T, Yoshimura M, Akiyama M, Anzai T, Ishihara S, Inomata T, Imamura T, Iwasaki YK, Ohtani T, Onishi K, Kasai T, Kato M, Kawai M, Kinugasa Y, Kinugawa S, Kuratani T, Kobayashi S, Sakata Y, Tanaka A, Toda K, Noda T, Nochioka K, Hatano M, Hidaka T, Fujino T, Makita S, Yamaguchi O, Ikeda U, Kimura T, Kohsaka S, Kosuge M, Yamagishi M, Yamashina A. JCS 2017/JHFS 2017 Guideline on Diagnosis and Treatment of Acute and Chronic Heart Failure ― Digest Version ―. Circ J 2019; 83:2084-2184. [DOI: 10.1253/circj.cj-19-0342] [Citation(s) in RCA: 276] [Impact Index Per Article: 55.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences
| | | | - Hiroshi Ito
- Department of Cardiovascular and Respiratory Medicine, Akita University Graduate School of Medicine
| | - Hiroshi Ito
- Department of Cardiovascular Medicine, Division of Biophysiological Sciences, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center
| | - Minoru Ono
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo
| | - Masafumi Kitakaze
- Department of Clinical Medicine and Development, National Cerebral and Cardiovascular Center
| | | | - Yasuki Kihara
- Department of Cardiovascular Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University
| | | | - Issei Komuro
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo
| | - Yoshikatsu Saiki
- Department of Cardiovascular Surgery, Tohoku University Graduate School of Medicine
| | - Yoshihiko Saito
- Department of Cardiovascular Medicine, Nara Medical University
| | - Yasushi Sakata
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
| | - Naoki Sato
- Department of Cardiovascular Medicine, Kawaguchi Cardiovascular and Respiratory Hospital
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Akira Shiose
- Department of Cardiovascular Surgery, Kyushu University Graduate School of Medical Sciences
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School
| | - Hiroaki Shimokawa
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
| | | | - Koichi Node
- Department of Cardiovascular Medicine, Saga University
| | - Taiki Higo
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences
| | - Atsushi Hirayama
- The Division of Cardiology, Department of Medicine, Nihon University Graduate School of Medicine
| | | | - Tohru Masuyama
- Cardiovascular Division, Department of Internal Medicine, Hyogo College of Medicine
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | | | - Masafumi Yano
- Department of Medicine and Clinical Science, Yamaguchi University Graduate School of Medicine
| | - Kenji Yamazaki
- Department of Cardiology Surgery, Tokyo Women’s Medical University
| | - Kazuhiro Yamamoto
- Department of Molecular Medicine and Therapeutics, Faculty of Medicine, Tottori University
| | | | - Michihiro Yoshimura
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine
| | - Masatoshi Akiyama
- Department of Cardiovascular Surgery, Tohoku University Graduate School of Medicine
| | - Toshihisa Anzai
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine
| | - Shiro Ishihara
- Department of Cardiology, Nippon Medical School Musashi-Kosugi Hospital
| | - Takayuki Inomata
- Department of Cardiovascular Medicine, Kitasato University Kitasato Institute Hospital
| | | | - Yu-ki Iwasaki
- Department of Cardiovascular Medicine, Nippon Medical School
| | - Tomohito Ohtani
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
| | | | - Takatoshi Kasai
- Cardiovascular Respiratory Sleep Medicine, Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine
| | - Mahoto Kato
- Department of Cardiovascular Medicine, Nihon University Graduate School of Medicine
| | - Makoto Kawai
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine
| | | | - Shintaro Kinugawa
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine
| | - Toru Kuratani
- Department of Minimally Invasive Cardiovascular Medicine, Osaka University Graduate School of Medicine
| | - Shigeki Kobayashi
- Department of Medicine and Clinical Science, Yamaguchi University Graduate School of Medicine
| | - Yasuhiko Sakata
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
| | | | - Koichi Toda
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Takashi Noda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Kotaro Nochioka
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
| | - Masaru Hatano
- Department of Cardiovascular Medicine, The University of Tokyo Hospital
| | | | - Takeo Fujino
- Department of Advanced Cardiopulmonary Failure, Kyushu University Graduate School of Medical Sciences
| | - Shigeru Makita
- Department of Cardiac Rehabilitation, Saitama Medical University International Medical Center
| | - Osamu Yamaguchi
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
| | | | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine and Faculty of Medicine, Kyoto University
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine
| | - Masami Kosuge
- Division of Cardiology, Yokohama City University Medical Center
| | - Masakazu Yamagishi
- Department of Cardiovascular and Internal Medicine, Kanazawa University Graduate School of Medicine
| | - Akira Yamashina
- Medical Education Promotion Center, Tokyo Medical University
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Xu T, Huang Y, Zhou H, Bai Y, Huang X, Hu Y, Xu D, Zhang Y, Zhang J. β-blockers and risk of all-cause mortality in patients with chronic heart failure and atrial fibrillation-a meta-analysis. BMC Cardiovasc Disord 2019; 19:135. [PMID: 31159740 PMCID: PMC6547467 DOI: 10.1186/s12872-019-1079-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 04/15/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Effects of β-blockers on outcomes in patients with chronic heart failure (CHF) and atrial fibrillation (AF) is still in controversy. METHODS Searching was conducted by using keywords "atrial fibrillation", and "heart failure" in PubMed, MEDLINE and Embase databases before November 30, 2017. Prospective studies [i.e. randomized control trials (RCTs), post-hoc analysis of RCTs, prospective cohort studies and registry studies] that studied the effect of β-blockers and all-cause mortality in patients with CHF and AF were included. The analysis was stratified by study design. RESULTS We identified 12 studies, including 6 post-hoc analysis of RCTs and 6 observational studies (including prospective registry studies and prospective cohort studies), which enrolled 38,133 patients with CHF and AF. Overall, β-blockers treatment was associated with significant decrease in all-cause mortality [Risk Ratio (RR) =0.73; 95% Confidence Interval (CI) 0.65-0.82, P < 0.001]. When stratified by study design, β-blockers treatment was associated with 34% reduction in patients with CHF and AF in observational study (RR = 0.66; 95% CI 0.58-0.76, P < 0. 001), but not in post-hoc analysis of RCT (RR = 0.87; 95% CI 0.74-1.02, P = 0.09). CONCLUSIONS β-blockers treatment was associated with significantly decrease the risk of all-cause mortality in patients with AF-CHF and it was only seen in observational study group, but not in subgroup analysis of RCT group. Further large RCTs are required to verify the effect of β-blockers treatment on patients with CHF and AF. The main limitation of this study is the lack of individual data on patients in each study.
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Affiliation(s)
- Tianyu Xu
- State Key Laboratory of Cardiovascular Disease, Heart Failure Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Beijing, 100037, China
| | - Yuli Huang
- Department of Cardiology, Shunde Hospital, Southern Medical University, F Penglai Road, Daliang Town, Shunde District, Foshan, 528300, China.,State Key Laboratory of Organ Failure Research, Department of Cardiology, Nanfang Hospital, Southern Medical University, 1838 North Guangzhou Avenue, Guangzhou, 510515, China
| | - Haobin Zhou
- State Key Laboratory of Organ Failure Research, Department of Cardiology, Nanfang Hospital, Southern Medical University, 1838 North Guangzhou Avenue, Guangzhou, 510515, China
| | - Yujia Bai
- State Key Laboratory of Organ Failure Research, Department of Cardiology, Nanfang Hospital, Southern Medical University, 1838 North Guangzhou Avenue, Guangzhou, 510515, China
| | - Xingfu Huang
- State Key Laboratory of Organ Failure Research, Department of Cardiology, Nanfang Hospital, Southern Medical University, 1838 North Guangzhou Avenue, Guangzhou, 510515, China
| | - Yunzhao Hu
- Department of Cardiology, Shunde Hospital, Southern Medical University, F Penglai Road, Daliang Town, Shunde District, Foshan, 528300, China
| | - Dingli Xu
- State Key Laboratory of Organ Failure Research, Department of Cardiology, Nanfang Hospital, Southern Medical University, 1838 North Guangzhou Avenue, Guangzhou, 510515, China
| | - Yuhui Zhang
- State Key Laboratory of Cardiovascular Disease, Heart Failure Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Beijing, 100037, China.
| | - Jian Zhang
- State Key Laboratory of Cardiovascular Disease, Heart Failure Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Beijing, 100037, China.
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Gopinathannair R, Cornwell WK, Dukes JW, Ellis CR, Hickey KT, Joglar JA, Pagani FD, Roukoz H, Slaughter MS, Patton KK. Device Therapy and Arrhythmia Management in Left Ventricular Assist Device Recipients: A Scientific Statement From the American Heart Association. Circulation 2019; 139:e967-e989. [DOI: 10.1161/cir.0000000000000673] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Left ventricular assist devices (LVADs) are an increasingly used strategy for the management of patients with advanced heart failure with reduced ejection fraction. Although these devices effectively improve survival, atrial and ventricular arrhythmias are common, predispose these patients to additional risk, and complicate patient management. However, there is no consensus on best practices for the medical management of these arrhythmias or on the optimal timing for procedural interventions in patients with refractory arrhythmias. Although the vast majority of these patients have preexisting cardiovascular implantable electronic devices or cardiac resynchronization therapy, given the natural history of heart failure, it is common practice to maintain cardiovascular implantable electronic device detection and therapies after LVAD implantation. Available data, however, are conflicting on the efficacy of and optimal device programming after LVAD implantation. Therefore, the primary objective of this scientific statement is to review the available evidence and to provide guidance on the management of atrial and ventricular arrhythmias in this unique patient population, as well as procedural interventions and cardiovascular implantable electronic device and cardiac resynchronization therapy programming strategies, on the basis of a comprehensive literature review by electrophysiologists, heart failure cardiologists, cardiac surgeons, and cardiovascular nurse specialists with expertise in managing these patients. The structure and design of commercially available LVADs are briefly reviewed, as well as clinical indications for device implantation. The relevant physiological effects of long-term exposure to continuous-flow circulatory support are highlighted, as well as the mechanisms and clinical significance of arrhythmias in the setting of LVAD support.
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Rush CJ, Campbell RT, Jhund PS, Petrie MC, McMurray JJV. Association is not causation: treatment effects cannot be estimated from observational data in heart failure. Eur Heart J 2018; 39:3417-3438. [PMID: 30085087 PMCID: PMC6166137 DOI: 10.1093/eurheartj/ehy407] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 04/01/2018] [Accepted: 06/27/2018] [Indexed: 12/21/2022] Open
Abstract
Aims Treatment 'effects' are often inferred from non-randomized and observational studies. These studies have inherent biases and limitations, which may make therapeutic inferences based on their results unreliable. We compared the conflicting findings of these studies to those of prospective randomized controlled trials (RCTs) in relation to pharmacological treatments for heart failure (HF). Methods and results We searched Medline and Embase to identify studies of the association between non-randomized drug therapy and all-cause mortality in patients with HF until 31 December 2017. The treatments of interest were: angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, beta-blockers, mineralocorticoid receptor antagonists (MRAs), statins, and digoxin. We compared the findings of these observational studies with those of relevant RCTs. We identified 92 publications, reporting 94 non-randomized studies, describing 158 estimates of the 'effect' of the six treatments of interest on all-cause mortality, i.e. some studies examined more than one treatment and/or HF phenotype. These six treatments had been tested in 25 RCTs. For example, two pivotal RCTs showed that MRAs reduced mortality in patients with HF with reduced ejection fraction. However, only one of 12 non-randomized studies found that MRAs were of benefit, with 10 finding a neutral effect, and one a harmful effect. Conclusion This comprehensive comparison of studies of non-randomized data with the findings of RCTs in HF shows that it is not possible to make reliable therapeutic inferences from observational associations. While trials undoubtedly leave gaps in evidence and enrol selected participants, they clearly remain the best guide to the treatment of patients.
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Affiliation(s)
- Christopher J Rush
- British Heart Foundation Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow, UK
| | - Ross T Campbell
- British Heart Foundation Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow, UK
| | - Pardeep S Jhund
- British Heart Foundation Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow, UK
| | - Mark C Petrie
- British Heart Foundation Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow, UK
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow, UK
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Martin N, Manoharan K, Thomas J, Davies C, Lumbers RT. Beta-blockers and inhibitors of the renin-angiotensin aldosterone system for chronic heart failure with preserved ejection fraction. Cochrane Database Syst Rev 2018; 6:CD012721. [PMID: 29952095 PMCID: PMC6513293 DOI: 10.1002/14651858.cd012721.pub2] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Beta-blockers and inhibitors of the renin-angiotensin aldosterone system improve survival and reduce morbidity in people with heart failure with reduced left ventricular ejection fraction. There is uncertainty whether these treatments are beneficial for people with heart failure with preserved ejection fraction and a comprehensive review of the evidence is required. OBJECTIVES To assess the effects of beta-blockers, angiotensin converting enzyme inhibitors, angiotensin receptor blockers, angiotensin receptor neprilysin inhibitors, and mineralocorticoid receptor antagonists in people with heart failure with preserved ejection fraction. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase and two clinical trial registries on 25 July 2017 to identify eligible studies. Reference lists from primary studies and review articles were checked for additional studies. There were no language or date restrictions. SELECTION CRITERIA We included randomised controlled trials with a parallel group design enrolling adult participants with heart failure with preserved ejection fraction, defined by a left ventricular ejection fraction of greater than 40 percent. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies for inclusion and extracted data. The outcomes assessed included cardiovascular mortality, heart failure hospitalisation, hyperkalaemia, all-cause mortality and quality of life. Risk ratios (RR) and, where possible, hazard ratios (HR) were calculated for dichotomous outcomes. For continuous data, mean difference (MD) or standardised mean difference (SMD) were calculated. We contacted trialists where neccessary to obtain missing data. MAIN RESULTS 37 randomised controlled trials (207 reports) were included across all comparisons with a total of 18,311 participants.Ten studies (3087 participants) investigating beta-blockers (BB) were included. A pooled analysis indicated a reduction in cardiovascular mortality (15% of participants in the intervention arm versus 19% in the control arm; RR 0.78; 95% confidence interval (CI) 0.62 to 0.99; number needed to treat to benefit (NNTB) 25; 1046 participants; 3 studies). However, the quality of evidence was low and no effect on cardiovascular mortality was observed when the analysis was limited to studies with a low risk of bias (RR 0.81; 95% CI 0.50 to 1.29; 643 participants; 1 study). There was no effect on all-cause mortality, heart failure hospitalisation or quality of life measures, however there is uncertainty about these effects given the limited evidence available.12 studies (4408 participants) investigating mineralocorticoid receptor antagonists (MRA) were included with the quality of evidence assessed as moderate. MRA treatment reduced heart failure hospitalisation (11% of participants in the intervention arm versus 14% in the control arm; RR 0.82; 95% CI 0.69 to 0.98; NNTB 41; 3714 participants; 3 studies; moderate-quality evidence) however, little or no effect on all-cause and cardiovascular mortality and quality of life measures was observed. MRA treatment was associated with a greater risk of hyperkalaemia (16% of participants in the intervention group versus 8% in the control group; RR 2.11; 95% CI 1.77 to 2.51; 4291 participants; 6 studies; high-quality evidence).Eight studies (2061 participants) investigating angiotensin converting enzyme inhibitors (ACEI) were included with the overall quality of evidence assessed as moderate. The evidence suggested that ACEI treatment likely has little or no effect on cardiovascular mortality, all-cause mortality, heart failure hospitalisation, or quality of life. Data for the effect of ACEI on hyperkalaemia were only available from one of the included studies.Eight studies (8755 participants) investigating angiotensin receptor blockers (ARB) were included with the overall quality of evidence assessed as high. The evidence suggested that treatment with ARB has little or no effect on cardiovascular mortality, all-cause mortality, heart failure hospitalisation, or quality of life. ARB was associated with an increased risk of hyperkalaemia (0.9% of participants in the intervention group versus 0.5% in the control group; RR 1.88; 95% CI 1.07 to 3.33; 7148 participants; 2 studies; high-quality evidence).We identified a single ongoing placebo-controlled study investigating the effect of angiotensin receptor neprilysin inhibitors (ARNI) in people with heart failure with preserved ejection fraction. AUTHORS' CONCLUSIONS There is evidence that MRA treatment reduces heart failure hospitalisation in heart failure with preserverd ejection fraction, however the effects on mortality related outcomes and quality of life remain unclear. The available evidence for beta-blockers, ACEI, ARB and ARNI is limited and it remains uncertain whether these treatments have a role in the treatment of HFpEF in the absence of an alternative indication for their use. This comprehensive review highlights a persistent gap in the evidence that is currently being addressed through several large ongoing clinical trials.
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Affiliation(s)
- Nicole Martin
- University College LondonFarr Institute of Health Informatics Research222 Euston RoadLondonUKNW1 2DA
| | - Karthick Manoharan
- John Radcliffe HospitalEmergency Department3 Sherwood AvenueLondonMiddlesexUKUb6 0pg
| | - James Thomas
- University College LondonEPPI‐Centre, Social Science Research Unit, UCL Institute of EducationLondonUK
| | - Ceri Davies
- Barts Heart Centre, St Bartholomew's HospitalDepartment of CardiologyWest SmithfieldLondonUKEC1A 7BE
| | - R Thomas Lumbers
- University College LondonInstitute of Health InformaticsLondonUK
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12
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Sethi NJ, Nielsen EE, Safi S, Feinberg J, Gluud C, Jakobsen JC. Digoxin for atrial fibrillation and atrial flutter: A systematic review with meta-analysis and trial sequential analysis of randomised clinical trials. PLoS One 2018. [PMID: 29518134 PMCID: PMC5843263 DOI: 10.1371/journal.pone.0193924] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background During recent years, systematic reviews of observational studies have compared digoxin to no digoxin in patients with atrial fibrillation or atrial flutter, and the results of these reviews suggested that digoxin seems to increase the risk of all-cause mortality regardless of concomitant heart failure. Our objective was to assess the benefits and harms of digoxin for atrial fibrillation and atrial flutter based on randomized clinical trials. Methods We searched CENTRAL, MEDLINE, Embase, LILACS, SCI-Expanded, BIOSIS for eligible trials comparing digoxin versus placebo, no intervention, or other medical interventions in patients with atrial fibrillation or atrial flutter in October 2016. Our primary outcomes were all-cause mortality, serious adverse events, and quality of life. Our secondary outcomes were heart failure, stroke, heart rate control, and conversion to sinus rhythm. We performed both random-effects and fixed-effect meta-analyses and chose the more conservative result as our primary result. We used Trial Sequential Analysis (TSA) to control for random errors. We used GRADE to assess the quality of the body of evidence. Results 28 trials (n = 2223 participants) were included. All were at high risk of bias and reported only short-term follow-up. When digoxin was compared with all control interventions in one analysis, we found no evidence of a difference on all-cause mortality (risk ratio (RR), 0.82; TSA-adjusted confidence interval (CI), 0.02 to 31.2; I2 = 0%); serious adverse events (RR, 1.65; TSA-adjusted CI, 0.24 to 11.5; I2 = 0%); quality of life; heart failure (RR, 1.05; TSA-adjusted CI, 0.00 to 1141.8; I2 = 51%); and stroke (RR, 2.27; TSA-adjusted CI, 0.00 to 7887.3; I2 = 17%). Our analyses on acute heart rate control (within 6 hours of treatment onset) showed firm evidence of digoxin being superior compared with placebo (mean difference (MD), -12.0 beats per minute (bpm); TSA-adjusted CI, -17.2 to -6.76; I2 = 0%) and inferior compared with beta blockers (MD, 20.7 bpm; TSA-adjusted CI, 14.2 to 27.2; I2 = 0%). Meta-analyses on acute heart rate control showed that digoxin was inferior compared with both calcium antagonists (MD, 21.0 bpm; TSA-adjusted CI, -30.3 to 72.3) and with amiodarone (MD, 14.7 bpm; TSA-adjusted CI, -0.58 to 30.0; I2 = 42%), but in both comparisons TSAs showed that we lacked information. Meta-analysis on acute conversion to sinus rhythm showed that digoxin compared with amiodarone reduced the probability of converting atrial fibrillation to sinus rhythm, but TSA showed that we lacked information (RR, 0.54; TSA-adjusted CI, 0.13 to 2.21; I2 = 0%). Conclusions The clinical effects of digoxin on all-cause mortality, serious adverse events, quality of life, heart failure, and stroke are unclear based on current evidence. Digoxin seems to be superior compared with placebo in reducing the heart rate, but inferior compared with beta blockers. The long-term effect of digoxin is unclear, as no trials reported long-term follow-up. More trials at low risk of bias and low risk of random errors assessing the clinical effects of digoxin are needed. Systematic review registration PROSPERO CRD42016052935
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Affiliation(s)
- Naqash J. Sethi
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- * E-mail:
| | - Emil E. Nielsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Sanam Safi
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Joshua Feinberg
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- The Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Janus C. Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- The Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Cardiology, Holbæk Hospital, Holbæk, Denmark
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13
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Kadado AJ, Akar JG, Hummel JP. Arrhythmias after left ventricular assist device implantation: Incidence and management. Trends Cardiovasc Med 2018; 28:41-50. [DOI: 10.1016/j.tcm.2017.07.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 07/04/2017] [Accepted: 07/04/2017] [Indexed: 10/19/2022]
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14
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Kim YD, Cha MJ, Kim J, Lee DH, Lee HS, Nam CM, Nam HS, Heo JH. Ischaemic cardiovascular mortality in patients with non-valvular atrial fibrillation according to CHADS2 score. Thromb Haemost 2017; 105:712-20. [DOI: 10.1160/th10-11-0692] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2010] [Accepted: 12/31/2010] [Indexed: 11/05/2022]
Abstract
SummaryThe CHADS2 score predicts the risk of ischaemic stroke in patients with non-valvular atrial fibrillation (NVAF). Most components of the CHADS2 score are also risk factors of atherosclerosis, and clustering of these risk factors is associated with increased risk of cardiovascular disease, including ischaemic heart disease. The aim of this study was to investigate whether the CHADS2 score and CHA2DS2-VASc score are predictive of fatal ischaemic heart disease as well as fatal ischaemic stroke. Among 5,268 stroke patients admitted between August 1994 and December 2008, 770 stroke patients with NVAF were enroled in this study. The relationship between CHADS2 score or CHA2DS2-VASc score and the fatal ischaemic events was examined using a Cox regression model. During the follow-up period of 1156.0 ± 1205.0 days (median 729.5, in-terquartile range 179.0 – 1751.0), 321 patients died (41.7%). The CHADS2 score or CHA2DS2-VASc score was positively correlated with fatal ischaemic heart disease as well as with fatal ischaemic stroke. After adjustment for all potential confounders, the occurrence of fatal ischaemic heart disease was independently associated with CHADS2 score or CHA2DS2-VASc score, and previous history of ischaemic heart disease. The CHADS2 and CHA2DS2-VASc scores provide valuable information for identifying high-risk individuals for fatal ischaemic heart and brain diseases among stroke patients with NVAF.
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15
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Predictors of digoxin use and risk of mortality in ED patients with atrial fibrillation. Am J Emerg Med 2017; 35:1589-1594. [DOI: 10.1016/j.ajem.2017.04.070] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 04/26/2017] [Accepted: 04/26/2017] [Indexed: 11/23/2022] Open
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Urbaniak AM, Strøm BO, Krontveit R, Svanqvist KH. Prescription Patterns of Non-Vitamin K Oral Anticoagulants Across Indications and Factors Associated with Their Increased Prescribing in Atrial Fibrillation Between 2012–2015: A Study from the Norwegian Prescription Database. Drugs Aging 2017; 34:635-645. [DOI: 10.1007/s40266-017-0476-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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17
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Wan H, Wu S, Wang J, Yang Y, Zhu J, Shao X, Huang B, Zhang H. Body mass index and the risk of all-cause mortality among patients with nonvalvular atrial fibrillation: a multicenter prospective observational study in China. Eur J Clin Nutr 2016; 71:494-499. [PMID: 27782115 DOI: 10.1038/ejcn.2016.183] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Revised: 07/25/2016] [Accepted: 08/09/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND/OBJECTIVES High body mass index (BMI) is associated with increased incident atrial fibrillation (AF) and mortality rate. In patients presenting with nonvalvular AF (NVAF), the prognostic relevance of BMI remains unclear. SUBJECTS/METHODS In this prospective observational study, a total of 1759 patients with NVAF (69.9±12.9 years old, 47.9% male) were divided into three clinical settings according to estimated stroke risks (CHADS2 score ⩽1 (low), =2 (moderate) and ⩾3 (high)). The primary outcome was all-cause mortality, and the secondary outcomes included thromboembolism and major bleeding. Cox-proportional hazard models were used to estimate the association between BMI levels and clinical outcomes. RESULTS During a mean follow-up of 1 year representing 1974 patient-years at risk, 256 patients died, 142 suffered from thromboembolism and 17 developed major bleeding. Multivariate adjusted Cox analysis indicated that a BMI of 24.0-27.9 kg/m2 was independently associated with improved survival among all patients (hazard ratio (HR) 0.689, 95% confidence interval (CI) 0.512-0.928; P=0.018) and patients at high stroke risk (HR 0.622, 95% CI 0.410-0.943; P=0.024), but not among those at low or moderate stroke risks. No associations were observed between BMI levels and the incidence of thromboembolic events in various clinical settings. CONCLUSIONS A paradoxical BMI-all-cause mortality risk association was observed in Chinese patients with NVAF, and this association was pronounced among patients at high stroke risk rather than in those at low stroke risk.
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Affiliation(s)
- H Wan
- Emergence and Intensive Care Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Department of Cardiology, First Affiliated Hospital, Jinan University, Guangzhou, China
| | - S Wu
- Emergence and Intensive Care Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - J Wang
- Emergence and Intensive Care Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Y Yang
- Emergence and Intensive Care Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - J Zhu
- Emergence and Intensive Care Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - X Shao
- Emergence and Intensive Care Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - B Huang
- Emergence and Intensive Care Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - H Zhang
- Emergence and Intensive Care Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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18
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Digoxin: The good and the bad. Trends Cardiovasc Med 2016; 26:585-95. [DOI: 10.1016/j.tcm.2016.03.011] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Revised: 03/14/2016] [Accepted: 03/28/2016] [Indexed: 02/06/2023]
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Addition of beta-blockers to digoxin is associated with improved 1- and 10-year survival of patients hospitalized due to decompensated heart failure. Int J Cardiol 2016; 221:198-204. [DOI: 10.1016/j.ijcard.2016.06.202] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Revised: 05/12/2016] [Accepted: 06/25/2016] [Indexed: 11/17/2022]
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Sessa M, Mascolo A, Andersen MP, Rosano G, Rossi F, Capuano A, Torp-Pedersen C. Effect of Chronic Kidney Diseases on Mortality among Digoxin Users Treated for Non-Valvular Atrial Fibrillation: A Nationwide Register-Based Retrospective Cohort Study. PLoS One 2016; 11:e0160337. [PMID: 27467520 PMCID: PMC4965154 DOI: 10.1371/journal.pone.0160337] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 07/18/2016] [Indexed: 12/20/2022] Open
Abstract
PURPOSE This study investigated the impact of chronic kidney disease on all-causes and cardiovascular mortality in patients with atrial fibrillation treated with digoxin. METHODS All patients with non-valvular atrial fibrillation and/or atrial flutter as hospitalization diagnosis from January 1, 1997 to December 31, 2012 were identified in Danish nationwide administrative registries. Cox proportional hazard model was used to compare the adjusted risk of all-causes and cardiovascular mortality among patients with and without chronic kidney disease and among patients with different chronic kidney disease stages within 180 days and 2 years from the first digoxin prescription. RESULTS We identified 37,981 patients receiving digoxin; 1884 patients had the diagnosis of chronic kidney disease. Cox regression analysis showed no statistically significant differences in all-causes (Hazard Ratio, HR 0.89; 95% confident interval, CI 0.78-1.03) and cardiovascular mortality (HR 0.88; 95%CI 0.74-1.05) among patients with and without chronic kidney disease within 180 days of follow-up period. No statistically significant differences was found using a 2 years follow-up period neither for all causes mortality (HR 0.90; 95%CI 0.79-1.03), nor for cardiovascular mortality (HR 0.87; 95%CI 0.74-1.02). No statistically significant differences was found comparing patients with and without estimated Glomerular Filtration Rate <30ml/min/1.73m2 and patients with different stages of chronic kidney disease, for all-causes and cardiovascular mortality within 180 days and 2 years from the first digoxin prescription. CONCLUSIONS This study suggest no direct effect of chronic kidney disease and chronic kidney disease stages on all-causes and cardiovascular mortality within both 180 days and 2 years from the first digoxin prescription in patients treatment-naïve with digoxin for non-valvular atrial fibrillation.
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Affiliation(s)
- Maurizio Sessa
- Department of Experimental Medicine, Section of Pharmacology L. Donatelli, Second University of Naples, Naples, Italy
- * E-mail:
| | - Annamaria Mascolo
- Department of Experimental Medicine, Section of Pharmacology L. Donatelli, Second University of Naples, Naples, Italy
| | | | - Giuseppe Rosano
- IRCCS San Raffaele Pisana, Rome, Italy
- Cardiovascular and Cell Sciences Research Institute, St. George's University of London, London, United Kingdom
| | - Francesco Rossi
- Department of Experimental Medicine, Section of Pharmacology L. Donatelli, Second University of Naples, Naples, Italy
| | - Annalisa Capuano
- Department of Experimental Medicine, Section of Pharmacology L. Donatelli, Second University of Naples, Naples, Italy
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Digoxin Is Associated With Increased All-cause Mortality in Patients With Atrial Fibrillation Regardless of Concomitant Heart Failure: A Meta-analysis. J Cardiovasc Pharmacol 2016; 66:270-5. [PMID: 26348825 DOI: 10.1097/fjc.0000000000000274] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
For decades, digoxin has been widely used to control ventricular rate in atrial fibrillation (AF). However, it remains controversial as to whether digoxin is associated with increased mortality in AF. In this study, we searched relevant studies that were published before December 1, 2014, in PubMed, EMBASE, and the Cochrane central databases. We systematically reviewed the references and performed a meta-analysis of 8 carefully selected studies with 302,738 patients who were included for the final analysis. It was shown that digoxin use was associated with increased risk of all-cause mortality in AF overall [hazard ratio (HR) = 1.375, 95% confidence intervals (CI), 1.201-1.574, P = 0.0001]. Subgroup analysis further revealed that digoxin was associated with increased all-cause mortality in patients with AF, which was complicated by heart failure (HF) (HR = 1.201, CI, 1.074- 1.344, P = 0.001), and in those subjects without HF (HR = 1.172, CI, 1.148-1.198, P = 0.0001). Sensitivity analyses found results to be robust. Our findings indicated that digoxin use was associated with significantly increased all-cause mortality in patients with AF regardless of concomitant HF. We suggest that digoxin should not be preferentially used over other rate control medications in AF.
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Abstract
BACKGROUND Digoxin is the oldest known treatment for heart failure (HF) and has been demonstrated to reduce admissions for worsening heart failure in a large randomized trial recruiting patients in sinus rhythm with heart failure and ejection fraction <45%. This study forms the basis for current international guidelines recommending that digoxin should be considered in patients with symptomatic HF despite optimal doses of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, β-blockers, and mineralocorticoid receptor antagonists in addition to device therapy, if indicated. However, digoxin predates mortality reducing HF therapies, and this article reviews the historical and recent data. METHODS Multiple PubMed searches were performed including, but not limited to, the search terms "digoxin," "heart failure," "efficacy," "treatment," "side-effects," "morbidity," "mortality," and "arrythmia." Articles were excluded if not relevant, not in English or without abstract. Reference lists of relevant articles were manually searched for further references. Due to the large number of articles retrieved, a selection was reviewed based on the authors' best judgement. RESULTS Three randomized controlled trials and three large contemporary observational reports of digoxin therapy in heart failure and sinus rhythm were retrieved. Other studies were noted that included patients with heart failure and atrial fibrillation, which were also reviewed. CONCLUSION Definitive randomized evidence of digoxin efficacy as add-on therapy in HF is lacking because most landmark trials of modern HF disease modifying agents postdate the randomized studies of digoxin. Furthermore, questions remain regarding the optimum dose of digoxin and there are signals that digoxin may be harmful in some patients with HF. All contemporary data for digoxin in HF are derived from observational studies and the findings are conflicting. Despite two centuries of experience using cardiac glycosides to treat HF, fundamental questions regarding the efficacy and safety of digoxin in HF remain unanswered.
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Affiliation(s)
- Parminder S Chaggar
- North West Heart Centre, University Hospital of South Manchester, Manchester, UK
| | - Steven M Shaw
- North West Heart Centre, University Hospital of South Manchester, Manchester, UK
| | - Simon G Williams
- North West Heart Centre, University Hospital of South Manchester, Manchester, UK
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23
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Fauchier L, Laborie G, Clementy N, Babuty D. Beta-blockers or Digoxin for Atrial Fibrillation and Heart Failure? Card Fail Rev 2016; 2:35-39. [PMID: 28785450 DOI: 10.15420/cfr.2015:28:2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
In patients with atrial fibrillation (AF) and heart failure (HF) with or without systolic dysfunction, either rhythm control or rate control is an acceptable primary therapeutic option. If a rate control strategy is chosen, treatment with a beta-blocker is almost always required to achieve rate control. Adequate ventricular rate control is usually a resting rate of less than 100 beats per minute, but lower resting rates may be appropriate. Non-dihydropyridine calcium channel blockers are often contraindicated when AF is associated with HF with systolic dysfunction. There have been recent debates on a possible reduced efficacy of beta-blockers as well as safety issues with digoxin when treating HF patients with AF. The benefit of beta-blockers on survival may be lower in patients with HF with reduced ejection fraction when AF is present. Digoxin does not improve survival but may help to obtain satisfactory rate control in combination with a beta-blocker. Digoxin may be useful in the presence of hypotension or an absolute contraindication to beta-blocker treatment.
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Affiliation(s)
- Laurent Fauchier
- Department of Cardiology, Trousseau University Hospital and Faculty of Medicine,University François Rabelais, Tours, France
| | - Guillaume Laborie
- Department of Cardiology, Trousseau University Hospital and Faculty of Medicine,University François Rabelais, Tours, France
| | - Nicolas Clementy
- Department of Cardiology, Trousseau University Hospital and Faculty of Medicine,University François Rabelais, Tours, France
| | - Dominique Babuty
- Department of Cardiology, Trousseau University Hospital and Faculty of Medicine,University François Rabelais, Tours, France
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Chamaria S, Desai AM, Reddy PC, Olshansky B, Dominic P. Digoxin Use to Control Ventricular Rate in Patients with Atrial Fibrillation and Heart Failure Is Not Associated with Increased Mortality. Cardiol Res Pract 2015; 2015:314041. [PMID: 26788401 PMCID: PMC4691628 DOI: 10.1155/2015/314041] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Accepted: 11/24/2015] [Indexed: 12/25/2022] Open
Abstract
Introduction. Digoxin is used to control ventricular rate in atrial fibrillation (AF). There is conflicting evidence regarding safety of digoxin. We aimed to evaluate the risk of mortality with digoxin use in patients with AF using meta-analyses. Methods. PubMed was searched for studies comparing outcomes of patients with AF taking digoxin versus no digoxin, with or without heart failure (HF). Studies were excluded if they reported only a point estimate of mortality, duplicated patient populations, and/or did not report adjusted hazard ratios (HR). The primary endpoint was all-cause mortality. Adjusted HRs were combined using generic inverse variance and log hazard ratios. A multivariate metaregression model was used to explore heterogeneity in studies. Results. Twelve studies with 321,944 patients were included in the meta-analysis. In all AF patients, irrespective of heart failure status, digoxin is associated with increased all-cause mortality (HR [1.23], 95% confidence interval [CI] 1.16-1.31). However, digoxin is not associated with increased mortality in patients with AF and HF (HR [1.08], 95% CI 0.99-1.18). In AF patients without HF digoxin is associated with increased all-cause mortality (HR [1.38], 95% CI 1.12-1.71). Conclusion. In patients with AF and HF, digoxin use is not associated with an increased risk of all-cause mortality when used for rate control.
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Affiliation(s)
- Surbhi Chamaria
- Division of Cardiology and Center for Cardiovascular Diseases and Science, LSU Health Science Center, Shreveport, LA 71103, USA
| | - Anand M. Desai
- Division of Cardiology and Center for Cardiovascular Diseases and Science, LSU Health Science Center, Shreveport, LA 71103, USA
| | - Pratap C. Reddy
- Division of Cardiology and Center for Cardiovascular Diseases and Science, LSU Health Science Center, Shreveport, LA 71103, USA
| | - Brian Olshansky
- Division of Cardiovascular Medicine, University of Iowa, Iowa City, IA 52242, USA
| | - Paari Dominic
- Division of Cardiology and Center for Cardiovascular Diseases and Science, LSU Health Science Center, Shreveport, LA 71103, USA
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25
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Chen Y, Cai X, Huang W, Wu Y, Huang Y, Hu Y. Increased All-Cause Mortality Associated With Digoxin Therapy in Patients With Atrial Fibrillation: An Updated Meta-Analysis. Medicine (Baltimore) 2015; 94:e2409. [PMID: 26717399 PMCID: PMC5291640 DOI: 10.1097/md.0000000000002409] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Digoxin is still commonly used in atrial fibrillation (AF) patients with and without heart failure (HF) for heart rate control. Studies concerning the detrimental effects of digoxin therapy in AF patients are inconsistent. This updated meta-analysis examined the association of digoxin therapy with all-cause mortality in AF patients, stratified by heart function status. We included observational studies with multivariate-adjusted data on digoxin and all-cause mortality in the analysis. The relative risks (RRs) of all-cause mortality were calculated and reported with 95% confidence intervals (95% CIs). Seventeen studies comprising 408,660 patients were included. Overall, in AF patients, digoxin treatment was associated with a significant increase in all-cause mortality after multivariate-adjustment (RR = 1.22; 95% CI 1.15-1.30). When stratified by heart function status, digoxin treatment was associated with a 14% increase in all-cause mortality in AF patients with HF (RR = 1.14, 95% CI 1.04-1.24), and a 36% increase in those without HF (RR = 1.36, 95% CI 1.18-1.56). The increased risk of all-cause mortality was significantly higher in AF patients without HF compared with those with HF (P for interaction = 0.04). This meta-analysis demonstrates that digoxin therapy was associated with a significant increase in all-cause mortality in AF patients, especially in those without HF. Given other available options, digoxin should be avoided as a first-line agent for heart rate control in AF patients.
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Affiliation(s)
- Ying Chen
- From the Department of Cardiology (YC, WH, YW, YH, YH); The Second Out-patient Department, the First People's Hospital of Shunde (YC); and Clinical Medicine Research Institute, the First People's Hospital of Shunde, Foshan, P.R. China (XC, YH, YH)
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26
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Ziff OJ, Lane DA, Samra M, Griffith M, Kirchhof P, Lip GYH, Steeds RP, Townend J, Kotecha D. Safety and efficacy of digoxin: systematic review and meta-analysis of observational and controlled trial data. BMJ 2015; 351:h4451. [PMID: 26321114 PMCID: PMC4553205 DOI: 10.1136/bmj.h4451] [Citation(s) in RCA: 210] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To clarify the impact of digoxin on death and clinical outcomes across all observational and randomised controlled trials, accounting for study designs and methods. DATA SOURCES AND STUDY SELECTION Comprehensive literature search of Medline, Embase, the Cochrane Library, reference lists, and ongoing studies according to a prospectively registered design ( PROSPERO CRD42014010783), including all studies published from 1960 to July 2014 that examined treatment with digoxin compared with control (placebo or no treatment). DATA EXTRACTION AND SYNTHESIS Unadjusted and adjusted data pooled according to study design, analysis method, and risk of bias. MAIN OUTCOME MEASURES Primary outcome (all cause mortality) and secondary outcomes (including admission to hospital) were meta-analysed with random effects modelling. RESULTS 52 studies were systematically reviewed, comprising 621,845 patients. Digoxin users were 2.4 years older than control (weighted difference 95% confidence interval 1.3 to 3.6), with lower ejection fraction (33% v 42%), more diabetes, and greater use of diuretics and anti-arrhythmic drugs. Meta-analysis included 75 study analyses, with a combined total of 4,006,210 patient years of follow-up. Compared with control, the pooled risk ratio for death with digoxin was 1.76 in unadjusted analyses (1.57 to 1.97), 1.61 in adjusted analyses (1.31 to 1.97), 1.18 in propensity matched studies (1.09 to 1.26), and 0.99 in randomised controlled trials (0.93 to 1.05). Meta-regression confirmed that baseline differences between treatment groups had a significant impact on mortality associated with digoxin, including markers of heart failure severity such as use of diuretics (P=0.004). Studies with better methods and lower risk of bias were more likely to report a neutral association of digoxin with mortality (P<0.001). Across all study types, digoxin led to a small but significant reduction in all cause hospital admission (risk ratio 0.92, 0.89 to 0.95; P<0.001; n=29,525). CONCLUSIONS Digoxin is associated with a neutral effect on mortality in randomised trials and a lower rate of admissions to hospital across all study types. Regardless of statistical analysis, prescription biases limit the value of observational data.
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Affiliation(s)
- Oliver J Ziff
- University of Birmingham Centre for Cardiovascular Sciences, Birmingham, UK Royal Free London NHS Foundation Trust, London, UK
| | - Deirdre A Lane
- University of Birmingham Centre for Cardiovascular Sciences, Birmingham, UK Sandwell and West Birmingham NHS Trust, City Hospital, Birmingham, UK
| | - Monica Samra
- Royal Free London NHS Foundation Trust, London, UK
| | | | - Paulus Kirchhof
- University of Birmingham Centre for Cardiovascular Sciences, Birmingham, UK Sandwell and West Birmingham NHS Trust, City Hospital, Birmingham, UK
| | - Gregory Y H Lip
- University of Birmingham Centre for Cardiovascular Sciences, Birmingham, UK Sandwell and West Birmingham NHS Trust, City Hospital, Birmingham, UK
| | | | - Jonathan Townend
- University of Birmingham Centre for Cardiovascular Sciences, Birmingham, UK University Hospitals Birmingham NHS Trust, Birmingham, UK
| | - Dipak Kotecha
- University of Birmingham Centre for Cardiovascular Sciences, Birmingham, UK Sandwell and West Birmingham NHS Trust, City Hospital, Birmingham, UK University Hospitals Birmingham NHS Trust, Birmingham, UK Monash Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Australia
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27
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Wan H, Yang Y, Zhu J, Shao X, Wang J, Huang B, Zhang H. The prognostic effects of ventricular heart rate among patients with permanent atrial fibrillation with and without coronary artery disease: a multicenter prospective observational study. Medicine (Baltimore) 2015; 94:e920. [PMID: 26039126 PMCID: PMC4616350 DOI: 10.1097/md.0000000000000920] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Heart rate control is important among patients with either atrial fibrillation (AF) or coronary artery disease (CAD). However, the relationship between the ventricular heart rate and adverse outcomes among patients with AF and CAD remains unclear. This study aimed to assess the prognostic effects of ventricular heart rate in patients with permanent AF (permAF) and CAD. We performed a multicenter, prospective, observational study of patients with AF in China. Patients≥18 years old with permAF were included and divided into a CAD group and a non-CAD group. All patients underwent 1 year of follow-up. The primary outcome was total mortality. Cox proportional hazard models were used to evaluate the relationship between risk factors and the survival rate in the study population.A total of 852 patients (69.1±12.7 years old, 43.3% male, 44.7% with CAD) were included in the analysis. Patients with CAD were older, were more likely to be male and exhibited higher prevalences of hypertension, diabetes mellitus, LV dysfunction, chronic obstructive pulmonary disease (COPD) and stroke compared with patients without CAD. During the follow-up period, a higher total mortality rate was noted in the CAD group than in the non-CAD group (21.5% vs 15.5%, P = 0.023). In the patients without CAD, the lowest quartile (≤76 beats/min) exhibited the best 1-year survival rate; however, in the patients with CAD, the highest quartile (>110 beats/min) exhibited the worst survival rate. Multivariate adjusted Cox analysis indicated that age (HR 1.039, 95% CI 1.025-1.055, P < 0.001) and heart rate (P = 0.004) were each independently associated with total mortality. Patients with CAD have more risk factors, and comorbidities and higher mortality rates than patients without CAD. In the patients with permAF without CAD, a ventricular rate of ≤76 beats/minute was associated with the best survival rate; however, among the patients with CAD, no increased mortality was observed unless the heart rate was >110 beats/min.
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Affiliation(s)
- Huaibin Wan
- From the Emergency and Intensive Care Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
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Vamos M, Erath JW, Hohnloser SH. Digoxin-associated mortality: a systematic review and meta-analysis of the literature. Eur Heart J 2015; 36:1831-8. [PMID: 25939649 DOI: 10.1093/eurheartj/ehv143] [Citation(s) in RCA: 175] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Accepted: 04/08/2015] [Indexed: 12/21/2022] Open
Abstract
There are conflicting data regarding the effect of digoxin use on mortality in patients with atrial fibrillation (AF) or with congestive heart failure (CHF). The aim of this meta-analysis was to provide detailed analysis of the currently available study reports. We performed a MEDLINE and a COCHRANE search (1993-2014) of the English literature dealing with the effects of digoxin on all-cause-mortality in subjects with AF or CHF. Only full-sized articles published in peer-reviewed journals were considered for this meta-analysis. A total of 19 reports were identified. Nine reports dealt with AF patients, seven with patients suffering from CHF, and three with both clinical conditions. Based on the analysis of adjusted mortality results of all 19 studies comprising 326 426 patients, digoxin use was associated with an increased relative risk of all-cause mortality [Hazard ratio (HR) 1.21, 95% confidence interval (CI), 1.07 to 1.38, P < 0.01]. Compared with subjects not receiving glycosides, digoxin was associated with a 29% increased mortality risk (HR 1.29; 95% CI, 1.21 to 1.39) in the subgroup of publications comprising 235 047 AF patients. Among 91.379 heart failure patients, digoxin-associated mortality risk increased by 14% (HR 1.14, 95% CI, 1.06 to 1.22). The present systematic review and meta-analysis of all available data sources suggest that digoxin use is associated with an increased mortality risk, particularly among patients suffering from AF.
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Affiliation(s)
- Mate Vamos
- Department of Cardiology, Division of Clinical Electrophysiology, J.W. Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Julia W Erath
- Department of Cardiology, Division of Clinical Electrophysiology, J.W. Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Stefan H Hohnloser
- Department of Cardiology, Division of Clinical Electrophysiology, J.W. Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
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29
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Abstract
Pharmacological treatment of atrial fibrillation in the context of heart failure poses numerous challenges. Management decisions are limited by contraindications to several drugs and the paucity of robust clinical trials that provide evidence-based guidance. This review proposes a structured action plan for managing atrial fibrillation coexisting with heart failure that considers published clinical guidelines and integrates recent data derived from substudies of randomized trials, including the atrial fibrillation and congestive heart failure (AF-CHF) trial. Areas of uncertainty, such as target heart rates in atrial fibrillation and upstream therapies, are also discussed.
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30
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Bavishi C, Khan AR, Ather S. Digoxin in patients with atrial fibrillation and heart failure: A meta-analysis. Int J Cardiol 2015; 188:99-101. [PMID: 25900519 DOI: 10.1016/j.ijcard.2015.04.031] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Accepted: 04/03/2015] [Indexed: 12/25/2022]
Affiliation(s)
- Chirag Bavishi
- Mount Sinai St. Luke's & Roosevelt Hospitals, New York, NY, USA.
| | | | - Sameer Ather
- University of Alabama at Birmingham, Birmingham, AL, USA
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31
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Ouyang AJ, Lv YN, Zhong HL, Wen JH, Wei XH, Peng HW, Zhou J, Liu LL. Meta-analysis of digoxin use and risk of mortality in patients with atrial fibrillation. Am J Cardiol 2015; 115:901-6. [PMID: 25660972 DOI: 10.1016/j.amjcard.2015.01.013] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Revised: 01/03/2015] [Accepted: 01/03/2015] [Indexed: 01/22/2023]
Abstract
There is an ongoing debate on the safety of digoxin use in patients with atrial fibrillation (AF). To address this issue, the investigators assembled a synthesis of the available evidence on the relation between digoxin and all-cause mortality in patients with AF. PubMed and the Embase database were systematically searched to identify all eligible studies examining the association between digoxin use and the mortality risk in AF. Overall hazard ratios and 95% confidence intervals were calculated using the random-effects model. Eleven observational studies were identified that met the inclusion criteria, 5 of which additionally used propensity score matching for statistical adjustment. In total, 318,191 patients were followed up for a mean of 2.8 years. Overall, digoxin use was associated with a 21% increased risk for mortality (hazard ratio 1.21, 95% confidence interval 1.12 to 1.30). Sensitivity analyses found the results to be robust. In the propensity score-matched AF patients, digoxin use was associated with a 17% greater risk for mortality (hazard ratio 1.17, 95% confidence interval 1.13 to 1.22). When the AF cohort was grouped into patients with and without heart failure, the use of digoxin was associated with an increase in mortality in patients with and those without heart failure, and no significant heterogeneity was seen between the groups (p >0.10). In conclusion, the results suggest that digoxin use was associated with a greater risk for mortality in patients with AF, regardless of concomitant heart failure. A well-powered randomized trial is necessary to reveal the true effect of digoxin.
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Affiliation(s)
- Ai-Jun Ouyang
- Department of Pharmacy, The First Affiliated Hospital of Nanchang University, Nanchang, China.
| | - Yan-Ni Lv
- Department of Pharmacy, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Hai-Li Zhong
- Department of Pharmacy, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Jin-Hua Wen
- Department of Pharmacy, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Xiao-Hua Wei
- Department of Pharmacy, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Hong-Wei Peng
- Department of Pharmacy, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Jian Zhou
- Department of Pharmacy, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Li-Li Liu
- Department of Pharmacy, The First Affiliated Hospital of Nanchang University, Nanchang, China
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Taillandier S, Brunet Bernard A, Lallemand B, Simeon E, Pericart L, Clementy N, Babuty D, Fauchier L. Prognosis in patients hospitalized with permanent and nonpermanent atrial fibrillation in heart failure. Am J Cardiol 2014; 113:1189-95. [PMID: 24507167 DOI: 10.1016/j.amjcard.2013.12.024] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Revised: 12/16/2013] [Accepted: 12/16/2013] [Indexed: 10/25/2022]
Abstract
Atrial fibrillation (AF) and heart failure (HF) frequently coexist and are associated with an increased mortality. This study evaluated the prognosis of permanent and nonpermanent AF in patients with both AF and HF. All AF patients seen in our institution were identified and followed up. We included 1,906 patients suffering from AF and HF: 839 patients (44%) had preserved left ventricular ejection fraction (LVEF) and 1,067 patients (56%) had decreased LVEF; 1,056 patients (55%) had nonpermanent AF and 850 patients (45%) had permanent AF. During a median follow-up of 1.9 years (interquartile range 0.3 to 5.0), 377 patients died, 462 were readmitted for HF, and 200 had stroke or thromboembolic events. In patients with decreased LVEF, the rate of death was similar in patients with permanent or nonpermanent AF. In patients with preserved LVEF, permanent AF was associated with a higher risk of death and a higher risk of HF hospitalization. Stroke risk did not differ with permanent AF whatever the LVEF. NYHA functional class was an independent predictor of death (risk ratio [RR]=1.33, 95% confidence interval [CI] 1.12 to 1.59, p=0.001), as was permanent AF (RR=1.79, 95%CI 1.32 to 2.42, p=0.0002). Permanent AF (RR=1.52, 95% CI 1.20 to 1.93, p=0.0006) was also an independent predictor of readmission for HF. In conclusion, in patients with AF and HF, the risk of admission for HF and risk of death were higher when AF was permanent, particularly in patients with preserved LVEF. Stroke risk did not differ according to the pattern of AF, whatever the LVEF.
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33
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Banerjee A, Taillandier S, Olesen JB, Lane DA, Lallemand B, Lip GY, Fauchier L. Ejection fraction and outcomes in patients with atrial fibrillation and heart failure: the Loire Valley Atrial Fibrillation Project. Eur J Heart Fail 2014; 14:295-301. [PMID: 22294759 DOI: 10.1093/eurjhf/hfs005] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Affiliation(s)
- Amitava Banerjee
- University of Birmingham Centre for Cardiovascular Sciences; City Hospital; Birmingham B18 7QH UK
| | - Sophie Taillandier
- Service de Cardiologie, Pôle Coeur Thorax Vasculaire, Centre Hospitalier, Universitaire Trousseau et Faculté de Médecine; Université François Rabelais; Tours France
| | - Jonas Bjerring Olesen
- University of Birmingham Centre for Cardiovascular Sciences; City Hospital; Birmingham B18 7QH UK
- Department of Cardiology; Copenhagen University Hospital Gentofte; Hellerup 2900 Denmark
| | - Deirdre A. Lane
- University of Birmingham Centre for Cardiovascular Sciences; City Hospital; Birmingham B18 7QH UK
| | - Benedicte Lallemand
- Service de Cardiologie, Pôle Coeur Thorax Vasculaire, Centre Hospitalier, Universitaire Trousseau et Faculté de Médecine; Université François Rabelais; Tours France
| | - Gregory Y.H. Lip
- University of Birmingham Centre for Cardiovascular Sciences; City Hospital; Birmingham B18 7QH UK
| | - Laurent Fauchier
- Service de Cardiologie, Pôle Coeur Thorax Vasculaire, Centre Hospitalier, Universitaire Trousseau et Faculté de Médecine; Université François Rabelais; Tours France
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Clua-Espuny JL, Panisello-Tafalla A, Lopez-Pablo C, Lechuga-Duran I, Bosch-Princep R, Lucas-Noll J, Gonzalez-Henares A, Queralt-Tomas L, Ripolles-Vicente R, Calduch-Noll C, Gonzalez-Rojas N, Gallofre-Lopez M. Atrial Fibrillation and Cardiovascular Comorbidities, Survival and Mortality: A Real-Life Observational Study. Cardiol Res 2014; 5:12-22. [PMID: 28392870 PMCID: PMC5358274 DOI: 10.14740/cr324e] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2014] [Indexed: 11/22/2022] Open
Abstract
Background Atrial fibrillation (AF) is the most common cardiac tachyarrhythmia encountered in clinical practice affecting up to 10% of the population over 60 years old and its prevalence rises with age. The main goals were to characterize the AF patient population after the initial diagnosis of AF and to determine overall survival. Methods It is a real-life observational study of 269 subjects with an AF diagnosis over 60 years old randomly selected. The collected variables were: sociodemographic, cardiovascular complications/comorbidities (CVCs) included in the CHA2DS2-VASc and HAS_BLED scores, drug assigned as clinical treatment, mean range INR and CVCs and death dates (all-cause mortality). The survival curve and the risk of death were assessed using Kaplan-Meier survival curve and comparisons with log-rank. Results The average following time was 6.2 ± 3.7 years (0.2-20.4). Eleven point five percent died. Sixty-five point four percent had some CVCs. There were no differences in the overall incidence of CVCs by gender. The survival probability was 0.86 ± DE 0.03 among men and 0.90 ± DE 0.04 among women without differences. Thirty-six point eight percent (95% CI: 30.8 - 42.7) were diagnosed vascular complications before AF diagnosis, being ischemic cardiopathy (24.2%) and ischemic stroke (23.2%) the most frequent. The mortality is higher (P < 0.036) among those who suffered ≥ 3 vascular complications and significantly lower among those treated with statins (P = 0.032). After AF diagnosis, the most frequent was the cardiac heart failure (46.7%), significantly higher among women (P = 0.037). The mortality is significantly lower in those treated with OAC (P = 0.003). Conclusions AF is associated with ischemic heart disease, ischemic stroke and congestive heart failure, but the average mortality age is not different from the global population in Spain and Catalonia.
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Affiliation(s)
- Jose Luis Clua-Espuny
- Institut Catala de la Salut (ICS), Gerencia Territorial Terres de l'Ebre, Tortosa, Spain
| | - Anna Panisello-Tafalla
- Institut Catala de la Salut (ICS), Gerencia Territorial Terres de l'Ebre, Tortosa, Spain; These authors contributed equally to this article
| | - Carlos Lopez-Pablo
- Department of Research, ICS Terres de l'Ebre, IDIAP Jordi Gol-IISPV, Tortosa, Spain
| | - Inigo Lechuga-Duran
- Institut Catala de la Salut (ICS), Gerencia Territorial Terres de l'Ebre, Tortosa, Spain
| | - Ramon Bosch-Princep
- Department of Research, ICS Terres de l'Ebre, IDIAP Jordi Gol-IISPV, Tortosa, Spain
| | - Jorgina Lucas-Noll
- Institut Catala de la Salut (ICS), Gerencia Territorial Terres de l'Ebre, Tortosa, Spain; These authors contributed equally to this article
| | - Antonia Gonzalez-Henares
- Institut Catala de la Salut (ICS), Gerencia Territorial Terres de l'Ebre, Tortosa, Spain; These authors contributed equally to this article
| | - Lluisa Queralt-Tomas
- Institut Catala de la Salut (ICS), Gerencia Territorial Terres de l'Ebre, Tortosa, Spain; These authors contributed equally to this article
| | - Rosa Ripolles-Vicente
- Institut Catala de la Salut (ICS), Gerencia Territorial Terres de l'Ebre, Tortosa, Spain; These authors contributed equally to this article
| | - Cristina Calduch-Noll
- Institut Catala de la Salut (ICS), Gerencia Territorial Terres de l'Ebre, Tortosa, Spain; These authors contributed equally to this article
| | - Nuria Gonzalez-Rojas
- Health Economics Department, Boehringer-Ingelheim, Sant Cugat del Valles, Barcelona, Spain
| | - Miguel Gallofre-Lopez
- Cerebral Vascular Disease' Management Plan in Catalonia, Health Department Generalitat de Catalunya, Barcelona, Spain
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Maan A, Mansour M, N Ruskin J, Heist EK. Current Evidence and Recommendations for Rate Control in Atrial Fibrillation. Arrhythm Electrophysiol Rev 2013; 2:30-5. [PMID: 26835037 PMCID: PMC4711525 DOI: 10.15420/aer.2013.2.1.30] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Accepted: 04/15/2013] [Indexed: 01/29/2023] Open
Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia encountered in clinical practice, which is associated with substantial risk of stroke and thromboembolism. As an arrhythmia that is particularly common in the elderly, it is an important contributor towards morbidity and mortality. Ventricular rate control has been a preferred and therapeutically convenient treatment strategy for the management of AF. Recent research in the field of rhythm control has led to the advent of newer antiarrhythmic drugs and catheter ablation techniques as newer therapeutic options. Currently available antiarrhythmic drugs still remain limited by their suboptimal efficacy and significant adverse effects. Catheter ablation as a newer modality to achieve sinus rhythm (SR) continues to evolve, but data on long-term outcomes on its efficacy and mortality outcomes are not yet available. Despite these current developments, rate control continues to be the front-line treatment strategy, especially in older and minimally symptomatic patients who might not tolerate the antiarrhythmic drug treatment. This review article discusses the current evidence and recommendations for ventricular rate control in the management of AF. We also highlight the considerations for rhythm control strategy in the management of patients of AF.
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Affiliation(s)
| | | | | | - E Kevin Heist
- Assistant Professor of Medicine, Harvard Medical School and Massachusetts General Hospital, Boston, US
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Kotecha D, Manzano L, Altman DG, Krum H, Erdem G, Williams N, Flather MD. Individual patient data meta-analysis of beta-blockers in heart failure: rationale and design. Syst Rev 2013; 2:7. [PMID: 23327629 PMCID: PMC3564787 DOI: 10.1186/2046-4053-2-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2012] [Accepted: 12/03/2012] [Indexed: 12/16/2022] Open
Abstract
UNLABELLED The Beta-Blockers in Heart Failure Collaborative Group (BB-HF) was formed to obtain and analyze individual patient data from the major randomized controlled trials of beta-blockers in heart failure. Even though beta-blockers are an established treatment for heart failure, uptake is still sub-optimal. Further, the balance of efficacy and safety remains uncertain for common groups including older persons, women, those with impaired renal function and diabetes. Our aim is to provide clinicians with a thorough and definitive evidence-based assessment of these agents. We have identified 11 large randomized trials of beta-blockers versus placebo in heart failure and plan to meta-analyze the data on an individual patient level. In total, these trials have enrolled 18,630 patients. Uniquely, the BB-HF group has secured access to the individual data for all of these trials, with the participation of key investigators and pharmaceutical companies.Our principal objectives include deriving an overall estimate of efficacy for all-cause mortality and cardiovascular hospitalization. Importantly, we propose a statistically-robust sub-group assessment according to age, gender, diabetes and other key factors; analyses which are only achievable using an individual patient data meta-analysis. Further, we aim to provide an assessment of economic benefit and develop a risk model for the prognosis of patients with chronic heart failure.This paper outlines inclusion criteria, search strategies, outcome measures and planned statistical analyses. CLINICAL TRIAL REGISTRATION INFORMATION http://clinicaltrials.gov/ct2/show/NCT00832442.
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Affiliation(s)
- Dipak Kotecha
- Clinical Trials and Evaluation Unit, Royal Brompton Hospital, Sydney Street, London, SW3 6NP, UK.
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The 2012 Canadian Cardiovascular Society heart failure management guidelines update: focus on acute and chronic heart failure. Can J Cardiol 2012. [PMID: 23201056 DOI: 10.1016/j.cjca.2012.10.007] [Citation(s) in RCA: 156] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The 2012 Canadian Cardiovascular Society Heart Failure (HF) Guidelines Update provides management recommendations for acute and chronic HF. In 2006, the Canadian Cardiovascular Society HF Guidelines committee first published an overview of HF management. Since then, significant additions to and changes in many of these recommendations have become apparent. With this in mind and in response to stakeholder feedback, the Guidelines Committee in 2012 has updated the overview of both acute and chronic heart failure diagnosis and management. The 2012 Update also includes recommendations, values and preferences, and practical tips to assist the medical practitioner manage their patients with HF.
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Whitbeck MG, Charnigo RJ, Khairy P, Ziada K, Bailey AL, Zegarra MM, Shah J, Morales G, Macaulay T, Sorrell VL, Campbell CL, Gurley J, Anaya P, Nasr H, Bai R, Di Biase L, Booth DC, Jondeau G, Natale A, Roy D, Smyth S, Moliterno DJ, Elayi CS. Increased mortality among patients taking digoxin--analysis from the AFFIRM study. Eur Heart J 2012. [PMID: 23186806 DOI: 10.1093/eurheartj/ehs348] [Citation(s) in RCA: 192] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
AIMS Digoxin is frequently used for rate control of atrial fibrillation (AF). It has, however, been associated with increased mortality. It remains unclear whether digoxin itself is responsible for the increased mortality (toxic drug effect) or whether it is prescribed to sicker patients with inherently higher mortality due to comorbidities. The goal of our study was to determine the relationship between digoxin and mortality in patients with AF. METHODS AND RESULTS The association between digoxin and mortality was assessed in patients enrolled in the AF Follow-Up Investigation of Rhythm Management (AFFIRM) trial using multivariate Cox proportional hazards models. Analyses were conducted in all patients and in subsets according to the presence or absence of heart failure (HF), as defined by a history of HF and/or an ejection fraction <40%. Digoxin was associated with an increase in all-cause mortality [estimated hazard ratio (EHR) 1.41, 95% confidence interval (CI) 1.19-1.67, P < 0.001], cardiovascular mortality (EHR 1.35, 95% CI 1.06-1.71, P = 0.016), and arrhythmic mortality (EHR 1.61, 95% CI 1.12-2.30, P = 0.009). The all-cause mortality was increased with digoxin in patients without or with HF (EHR 1.37, 95% CI 1.05-1.79, P = 0.019 and EHR 1.41, 95% CI 1.09-1.84, P = 0.010, respectively). There was no significant digoxin-gender interaction for all-cause (P = 0.70) or cardiovascular (P = 0.95) mortality. CONCLUSION Digoxin was associated with a significant increase in all-cause mortality in patients with AF after correcting for clinical characteristics and comorbidities, regardless of gender or of the presence or absence of HF. These findings call into question the widespread use of digoxin in patients with AF.
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Affiliation(s)
- Matthew G Whitbeck
- Division of Cardiovascular Medicine, Gill Heart Institute University of Kentucky, 900 South Limestone Street, Lexington, KY 40536-0200, USA
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Sarkar S, Koehler J, Crossley GH, Tang WW, Abraham WT, Warman EN, Whellan DJ. Burden of atrial fibrillation and poor rate control detected by continuous monitoring and the risk for heart failure hospitalization. Am Heart J 2012; 164:616-24. [PMID: 23067922 DOI: 10.1016/j.ahj.2012.06.020] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2012] [Accepted: 06/22/2012] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Atrial fibrillation (AF) on electrocardiogram has been identified as a risk factor for hospitalizations in patients with heart failure (HF). We investigated whether continuous AF monitoring can identify when patients with HF are at risk for hospitalization. METHODS In this retrospective analysis of data from 4 studies enrolling patients with HF with cardiac resynchronization therapy defibrillator devices with ≥90 days of follow-up (n = 1561), patients were identified as having AF if they had ≥1 day of >5 minutes of AF and >1 hour of total AF during entire follow-up. In patients with AF, device recorded AF burden (AFb) and ventricular rate during AF (VRAF) over the last 30 days was classified on a monthly basis into 3 evaluation groups: (1) ≥1 day of high burden of paroxysmal AF (≥6 hours) or persistent AF (all 30 days with AFb >23 hours) with poor rate control (VRAF >90 beats/min), (2) ≥1 day of high burden of paroxysmal AF with good rate control (VRAF ≤ 90 beats/min), and (3) no days with high burden of AF (AFb <6 hours) or persistent AF with good rate control. Each group was compared with monthly evaluations in patients without AF using an Anderson-Gill model for occurrence of HF hospitalizations in the next 30 days. RESULTS Patients with AF (n = 519, 33%) have a greater risk (hazard ratio [HR] 2.0, P < .001) for impending HF hospitalizations during entire follow-up compared with patients with no AF. One day of high burden of paroxysmal AF with good rate control in the last 30 days increases risk for HF hospitalization in the next 30 days (HR 3.4, P < .001). The risk increases further (HR 5.9, P < .001) with 1 day of poor rate control during persistent AF or high burden paroxysmal AF in last 30 days. CONCLUSION Evaluation of AFb and rate control information on a monthly basis can identify patients at risk for HF hospitalization in the next 30 days.
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Abstract
Among geriatric patients, atrial fibrillation is the most common cardiac arrhythmia. In patients over 80 years of age, the prevalence rises to approximately 10%. Atrial fibrillation is associated with serious health implications, including a 2-fold increase in mortality risk and a 5-fold increase in stroke risk. In contrast to these facts, the current guidelines on the management of atrial fibrillation of the European Society of Cardiology (ESC) contain only a short paragraph on these patients. Many relevant clinical aspects go without any comment. Thus, the purpose of our paper is to discuss those special needs of geriatric patients and their physicians which are not mentioned in the guidelines of the ESC. In our review, we discuss rhythm versus rate control, oral anticoagulation, outcome, prevention, falls, adherence, polypharmacy, dementia, nursing home patients, frailty, and geriatric assessment in consideration of geriatric patients. An extended search of the literature on Pubmed served as the basis for this review. Individual aspects of each geriatric patient should be considered when managing these complex patients; however, the complexity of each case must not lead to an individualized therapy that is not in accordance with current guidelines and the literature. A large number of papers which help us to answer most of the clinical questions regarding the management of trial fibrillation in geriatric patients have already been published.
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Caldeira D, David C, Sampaio C. Rate vs rhythm control in patients with atrial fibrillation and heart failure: a systematic review and meta-analysis of randomised controlled trials. Eur J Intern Med 2011; 22:448-55. [PMID: 21925051 DOI: 10.1016/j.ejim.2011.05.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2011] [Revised: 04/27/2011] [Accepted: 05/02/2011] [Indexed: 12/14/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) is a common arrhythmia that can promote or worsen heart failure (HF). Our purpose was to compare the effects of rate and rhythm control in patients with atrial fibrillation and heart failure. METHODS We developed a systematic search in August 2010 through CENTRAL and MEDLINE databases to identify randomised controlled trials (RCTs) comparing rate control with rhythm control in patients with both AF and HF. We analysed mortality, hospitalisations, stroke/thromboembolic events, quality of life, and drugs adverse events. Relative risks (RR) and 95% confidence intervals (95% CI) were calculated for mortality and hospitalisations. The remaining outcomes were analysed qualitatively. RESULTS Four RCTs with a total of 2486 patients with atrial fibrillation and heart failure were identified. Mortality and stroke/thromboembolic events were not significantly different in rate and rhythm control arms [RR 1.03; 95% CI: 0.90-1.17] and [RR 1.09; 95% CI: 0.61-1.96], respectively. Hospitalisations were less frequent with rate control than with rhythm control [RR 0.92; 95% CI: 0.86-0.98; p=0.008], in 3 studies involving 2425 patients. Number needed to treat to prevent one hospitalisation was 19 patients. CONCLUSIONS In patients with AF and HF, rate control compared with rhythm control showed inferior risk of hospitalisation.
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Affiliation(s)
- Daniel Caldeira
- Clinical Pharmacology and Therapeutics Laboratory, Faculty of Medicine, Lisbon, Portugal
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Quirós-López R, Noureddine-López M, Villena-Ruiz M, García-Alegría J. Indicaciones de la digoxina para el tratamiento de la fibrilación auricular. Rev Clin Esp 2011; 211:492-3. [DOI: 10.1016/j.rce.2011.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2011] [Accepted: 02/08/2011] [Indexed: 11/16/2022]
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Elayi CS, Whitbeck MG, Charnigo R, Shah J, Macaulay TE, Morales G, Gurley JC, Kakavand B, Thal S, Ching CK, Khaykin Y, Verma A, Barrett C, Bai R, Di Biase L, Patwardhan A, Moliterno DJ, Natale A. Is there an association between external cardioversions and long-term mortality and morbidity? Insights from the Atrial Fibrillation Follow-up Investigation of Rhythm Management study. Circ Arrhythm Electrophysiol 2011; 4:465-9. [PMID: 21511994 DOI: 10.1161/circep.110.960591] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Cardiac electric therapies effectively terminate tachyarrhythmias. Recent data suggest a possible increase in long-term mortality associated with implantable cardioverter-defibrillator shocks. Little is known about the association between external cardioversion episodes (ECVe) and long-term mortality. We sought to assess the safety of repeated ECVe with regard to cardiovascular mortality and morbidity. METHODS AND RESULTS We analyzed the data of the 4060 patients from the AFFIRM (Atrial Fibrillation Follow-up Investigation of Rhythm Management) trial. In particular, associations of ECVe with all-cause mortality, cardiovascular mortality, and hospitalizations after ECVe were studied. Over an average follow-up of 3.5 years, 660 (16.3%) patients died, 331 (8.2%) from cardiovascular causes. A total of 207 (5.1%) and 1697 (41.8%) patients had low ejection fraction and nonparoxysmal atrial fibrillation, respectively; 2460 patients received no ECVe, whereas 1600 experienced ≥ 1 ECVe. Death occurred in 412 (16.7%), 196 (16.5%), 39 (13.5%), and 13 (10.4%) of patients with 0, 1, 2, and ≥ 3 ECVe, respectively. There was no significant association between ECVe and mortality within any of the 4 subgroups defined by ejection fraction and atrial fibrillation type, although myocardial infarction, coronary artery bypass graft, and digoxin were significantly associated with death (estimated hazard ratios, 1.65, 1.59, and 1.62, respectively; P < 0.0001). ECVe were associated with increased cardiac hospitalization reported at the next follow-up visit (39.3% versus 5.8%; estimated odds ratio, 1.39; P < 0.0001). CONCLUSIONS In the AFFIRM study, there was no significant association between ECVe and long-term mortality, even though ECVe were associated with increased hospitalizations from cardiac causes. Digoxin, myocardial infarction, and coronary artery bypass graft were significantly associated with mortality.
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Camm AJ, Kirchhof P, Lip GYH, Schotten U, Savelieva I, Ernst S, Van Gelder IC, Al-Attar N, Hindricks G, Prendergast B, Heidbuchel H, Alfieri O, Angelini A, Atar D, Colonna P, De Caterina R, De Sutter J, Goette A, Gorenek B, Heldal M, Hohloser SH, Kolh P, Le Heuzey JY, Ponikowski P, Rutten FH. Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). Europace 2011; 12:1360-420. [PMID: 20876603 DOI: 10.1093/europace/euq350] [Citation(s) in RCA: 1016] [Impact Index Per Article: 78.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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Camm AJ, Kirchhof P, Lip GYH, Schotten U, Savelieva I, Ernst S, Van Gelder IC, Al-Attar N, Hindricks G, Prendergast B, Heidbuchel H, Alfieri O, Angelini A, Atar D, Colonna P, De Caterina R, De Sutter J, Goette A, Gorenek B, Heldal M, Hohloser SH, Kolh P, Le Heuzey JY, Ponikowski P, Rutten FH. Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). Eur Heart J 2010; 31:2369-429. [PMID: 20802247 DOI: 10.1093/eurheartj/ehq278] [Citation(s) in RCA: 3273] [Impact Index Per Article: 233.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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Atrial fibrillation in heart failure: a comprehensive review. Am J Med 2010; 123:198-204. [PMID: 20193823 DOI: 10.1016/j.amjmed.2009.06.033] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2009] [Revised: 06/02/2009] [Accepted: 06/09/2009] [Indexed: 12/15/2022]
Abstract
Chronic heart failure and atrial fibrillation are 2 major disorders that are closely linked. Their coexistence is associated with adverse prognosis. Both share several common predisposing conditions, but their interaction involves complex ultrastructural, electrophysiologic, and neurohormonal processes that go beyond mere sharing of mutual risk factors. Rate control approach remains the standard therapy for atrial fibrillation in heart failure because current strategies at rhythm control have so far failed to positively impact mortality and morbidity. This is largely because of the shortcomings of current pharmacologic anti-arrhythmic agents. Surgical and catheter-based therapies are promising, but long-term data are lacking. The role of non-anti-arrhythmic therapeutic agents also is being explored. Further progress toward improved understanding the complex relationship between atrial fibrillation and heart failure should improve management strategies.
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Abstract
Atrial fibrillation (AF) and heart failure (HF) are common and interrelated conditions, each promoting the other, and both associated with increased mortality. HF leads to structural and electrical atrial remodeling, thus creating the basis for the development and perpetuation of AF; and AF may lead to hemodynamic deterioration and the development of tachycardia-mediated cardiomyopathy. Stroke prevention by antithrombotic therapy is crucial in patients with AF and HF. Of the 2 principal therapeutic strategies to treat AF, rate control and rhythm control, neither has been shown to be superior to the other in terms of survival, despite better survival in patients with sinus rhythm compared with those in AF. Antiarrhythmic drug toxicity and poor efficacy are concerns. Catheter ablation of AF can establish sinus rhythm without the risks of antiarrhythmic drug therapy, but has important procedural risks, and data from randomized trials showing a survival benefit of this treatment strategy are still lacking. In intractable cases, ablation of the atrioventricular junction and placement of a permanent pacemaker is a treatment alternative; and biventricular pacing may prevent or reduce the negative consequences of chronic right ventricular pacing.
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Nieuwlaat R, Eurlings LW, Crijns HJ. Reply. J Am Coll Cardiol 2010. [DOI: 10.1016/j.jacc.2009.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Mortality in Patients With Atrial Fibrillation and Heart Failure. J Am Coll Cardiol 2010; 55:168; author reply 168-9. [DOI: 10.1016/j.jacc.2009.06.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2009] [Accepted: 06/09/2009] [Indexed: 11/21/2022]
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