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Lu N, MacGillivray J, Andrade JG, Krahn AD, Hawkins NM, Laksman Z, Deyell MW, Chakrabarti S, Yeung-Lai-Wah JA, Bennett MT. Effectiveness of a simple medication adjustment protocol for optimizing peri-cardioversion rate control: A derivation and validation cohort study. Heart Rhythm O2 2021; 2:46-52. [PMID: 34113904 PMCID: PMC8183961 DOI: 10.1016/j.hroo.2021.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background Rate control medications are foundational in the management of persistent atrial fibrillation (AF). There are no guidelines for adjusting these medications prior to elective direct-current cardioversion (DCCV). Objective To derive and validate a preprocedural medication adjustment protocol that maintains peri-DCCV rate control and minimizes risk of postconversion bradycardia, pauses, need for pacing, and cardiopulmonary resuscitation (CPR). Methods Consecutive patients with persistent AF awaiting elective DCCV across 2 hospitals were screened for inclusion into derivation, validation, and control cohorts. In the derivation cohort, each patient taking an atrioventricular (AV) nodal blocker had medications adjusted based on heart rate (HR) 2 days before DCCV, and the magnitude of dose adjustment was compared with peri-DCCV HR. The adjustment protocol that achieved the highest percentage of optimal peri-DCCV rate control was tested prospectively in the validation cohort and compared to a standard-of-care control group. Results The optimal protocol from the derivation cohort (n = 71), based on the 2-day pre-DCCV HR, was to (1) CONTINUE AV nodal blocker for HR ≥ 100 beats per minute (bpm), (2) reduce dose by ONE increment when 80–99 bpm, (3) reduce dose by TWO increments when 60–79 bpm, and (4) HOLD when <60 bpm. In the prospective validation cohort (n = 106), this protocol improved peri-DCCV rate control (82% vs 62%, P < .001) compared to current standard of care (n = 107). There were no conversion pauses ≥5 seconds, need for pacing, or CPR post-DCCV. Conclusion This simple preprocedural medication adjustment protocol provides an effective strategy of optimizing peri-DCCV rate control in patients with AF.
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Affiliation(s)
- Nelson Lu
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Jenny MacGillivray
- Lower Mainland Pharmacy Services, Vancouver General Hospital, Vancouver, Canada
| | - Jason G Andrade
- Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Andrew D Krahn
- Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Nathaniel M Hawkins
- Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Zachary Laksman
- Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Marc W Deyell
- Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Shanta Chakrabarti
- Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, Canada
| | - John A Yeung-Lai-Wah
- Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Matthew T Bennett
- Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, Canada
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Geurink K, Holmes D, Ezekowitz MD, Pieper K, Fonarow G, Kowey PR, Reiffel JA, Singer DE, Freeman J, Gersh BJ, Mahaffey KW, Hylek EM, Naccarelli G, Piccini JP, Peterson ED, Pokorney SD. Patterns of oral anticoagulation use with cardioversion in clinical practice. Heart 2020; 107:642-649. [PMID: 32591363 DOI: 10.1136/heartjnl-2019-316315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Revised: 05/05/2020] [Accepted: 05/07/2020] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Cardioversion is common among patients with atrial fibrillation (AF). We hypothesised that novel oral anticoagulants (NOAC) used in clinical practice resulted in similar rates of stroke compared with vitamin K antagonists (VKA) for cardioversion. METHODS Using the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation II, patients with AF who had a cardioversion, follow-up data and an AF diagnosis within 6 months of enrolment were identified retrospectively. Clinical outcomes were compared for patients receiving a NOAC or VKA for 1 year following cardioversion. RESULTS Among 13 004 patients with AF, 2260 (17%) underwent cardioversion. 1613 met the inclusion criteria for this analysis. At the time of cardioversion, 283 (17.5%) were receiving a VKA and 1330 (82.5%) a NOAC. A transoesophageal echocardiogram (TOE) was performed in 403 (25%) cardioversions. The incidence of stroke/transient ischaemic attack (TIA) at 30 days was the same for patients having (3.04 per 100 patient-years) or not having (3.04 per 100 patient-years) a TOE (p=0.99). There were no differences in the incidence of death (HR 1.19, 95% CI 0.62 to 2.28, p=0.61), cardiovascular hospitalisation (HR 1.02, 95% CI 0.76 to 1.35, p=0.91), stroke/TIA (HR 1.18, 95% CI 0.30 to 4.74, p=0.81) or bleeding-related hospitalisation (HR 1.29, 95% CI 0.66 to 2.52, p=0.45) at 1 year for patients treated with either a NOAC or VKA. CONCLUSIONS Cardioversion was a low-risk procedure for patients treated with NOAC, and there were statistically similar rates of stroke/TIA 30 days after cardioversion as for patients treated with VKA. There were no statically significant differences in death, stroke/TIA or major bleeding at 1 year among patients treated with NOAC compared with VKA after cardioversion.
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Affiliation(s)
- Kyle Geurink
- Duke University Health System, Durham, North Carolina, USA
| | | | | | - Karen Pieper
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | | | - Peter R Kowey
- Cardiovascular Medicine, Lankenau Institute for Medical Research, Wynnewood, Pennsylvania, USA
| | - James A Reiffel
- Cardiovascular Medicine, College of Physicians and Surgeons-Columbia University, New York, New York, USA
| | | | - James Freeman
- Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | | | - Kenneth W Mahaffey
- Department of Medicine, Stanford Hospital and Clinics, Stanford, California, USA
| | - Elaine M Hylek
- Cardiovascular Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Gerald Naccarelli
- Penn State Hershey Heart and Vascular Institute, Hershey, Pennsylvania, USA
| | - Jonathan P Piccini
- Duke Clinical Research Institute, Durham, North Carolina, USA.,Duke University School of Medicine, Durham, North Carolina, USA
| | - Eric D Peterson
- Duke Clinical Research Institute, Durham, North Carolina, USA.,Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Sean D Pokorney
- Duke Clinical Research Institute, Durham, North Carolina, USA.,Duke University School of Medicine, Durham, North Carolina, USA
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3
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Loungani RS, Rehorn MR, Geurink KR, Coniglio AC, Black-Maier E, Pokorney SD, Khouri MG. Outcomes following cardioversion for patients with cardiac amyloidosis and atrial fibrillation or atrial flutter. Am Heart J 2020; 222:26-29. [PMID: 32004797 DOI: 10.1016/j.ahj.2020.01.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 01/02/2020] [Indexed: 12/20/2022]
Abstract
Atrial arrhythmias commonly occur in patients with cardiac amyloidosis (CA), but there is limited data on safety or efficacy of cardioversion (DCCV) for management of these rhythms in CA. We identified 25 patients with CA (20 with transthyretin (TTR) and 5 with light-chain (AL) amyloidosis) at Duke University who underwent DCCV for atrial arrhythmias and documented procedural success, complications, and long-term morbidity and mortality. While DCCV successfully restored sinus rhythm in 96% of patients, 36% of patients experienced immediate procedural complications (primarily bradycardia and hypotension), 80% had recurrence of atrial arrhythmias at 1 year, and 52% died at 3 years, highlighting short-term safety concerns, long-term inefficacy, and poor prognosis associated with symptomatic atrial arrhythmias requiring DCCV in CA.
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Affiliation(s)
- Rahul S Loungani
- Division of Cardiovascular Disease, Duke University Medical Center, Durham, NC
| | - Michael R Rehorn
- Division of Cardiovascular Disease, Duke University Medical Center, Durham, NC
| | - Kyle R Geurink
- Division of Cardiovascular Disease, Duke University Medical Center, Durham, NC
| | - Amanda C Coniglio
- Division of Cardiovascular Disease, Duke University Medical Center, Durham, NC
| | - Eric Black-Maier
- Division of Cardiovascular Disease, Duke University Medical Center, Durham, NC
| | - Sean D Pokorney
- Division of Cardiovascular Disease, Duke University Medical Center, Durham, NC; Electrophysiology Section, Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Michel G Khouri
- Division of Cardiovascular Disease, Duke University Medical Center, Durham, NC.
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4
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Morello ML, Khoury PR, Knilans TK, Veldtman G, Spar DS, Anderson JB, Czosek RJ. Risks and outcomes of direct current cardioversion in children and young adults with congenital heart disease. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2018; 41:472-479. [DOI: 10.1111/pace.13315] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 01/28/2018] [Accepted: 02/11/2018] [Indexed: 01/08/2023]
Affiliation(s)
- Melissa L. Morello
- Department of Pediatrics, Division of Pediatric Cardiology; The Heart Institute at Cincinnati Children's Hospital Medical Center; Cincinnati OH USA
| | - Philip R. Khoury
- Department of Pediatrics, Division of Pediatric Cardiology; The Heart Institute at Cincinnati Children's Hospital Medical Center; Cincinnati OH USA
| | - Timothy K. Knilans
- Department of Pediatrics, Division of Pediatric Cardiology; The Heart Institute at Cincinnati Children's Hospital Medical Center; Cincinnati OH USA
| | - Gruschen Veldtman
- Department of Pediatrics, Division of Pediatric Cardiology; The Heart Institute at Cincinnati Children's Hospital Medical Center; Cincinnati OH USA
| | - David S. Spar
- Department of Pediatrics, Division of Pediatric Cardiology; The Heart Institute at Cincinnati Children's Hospital Medical Center; Cincinnati OH USA
| | - Jeffery B. Anderson
- Department of Pediatrics, Division of Pediatric Cardiology; The Heart Institute at Cincinnati Children's Hospital Medical Center; Cincinnati OH USA
| | - Richard J. Czosek
- Department of Pediatrics, Division of Pediatric Cardiology; The Heart Institute at Cincinnati Children's Hospital Medical Center; Cincinnati OH USA
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Kotecha D, Piccini JP. Atrial fibrillation in heart failure: what should we do? Eur Heart J 2015; 36:3250-7. [PMID: 26419625 PMCID: PMC4670966 DOI: 10.1093/eurheartj/ehv513] [Citation(s) in RCA: 116] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 08/25/2015] [Accepted: 09/07/2015] [Indexed: 01/06/2023] Open
Abstract
Heart failure (HF) and atrial fibrillation (AF) are two conditions that are likely to dominate the next 50 years of cardiovascular (CV) care. Both are increasingly prevalent and associated with high morbidity, mortality, and healthcare cost. They are closely inter-related with similar risk factors and shared pathophysiology. Patients with concomitant HF and AF suffer from even worse symptoms and poorer prognosis, yet evidence-based evaluation and management of this group of patients is lacking. In this review, we evaluate the common mechanisms for the development of AF in HF patients and vice versa, focusing on the evidence for potential treatment strategies. Recent data have suggested that these patients may respond differently than those with HF or AF alone. These results highlight the clear clinical need to identify and treat according to best evidence, in order to prevent adverse outcomes and reduce the huge burden that HF and AF are expected to have on global healthcare systems in the future. We propose an easy-to-use clinical mnemonic to aid the initial management of newly discovered concomitant HF and AF, the CAN-TREAT HFrEF + AF algorithm (Cardioversion if compromised; Anticoagulation unless contraindication; Normalize fluid balance; Target initial heart rate <110 b.p.m.; Renin-angiotensin-aldosterone modification; Early consideration of rhythm control; Advanced HF therapies; Treatment of other CV disease).
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Affiliation(s)
- Dipak Kotecha
- Institute of Cardiovascular Science, University of Birmingham, Birmingham, UK Monash Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Australia
| | - Jonathan P Piccini
- Duke Center for Atrial Fibrillation, Clinical Cardiac Electrophysiology, Duke University Medical Center, Durham, USA
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