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Rosas Diaz AN, Troy AL, Kaplinskiy V, Pritchard A, Vani R, Ko D, Orkaby AR. Assessment and Management of Atrial Fibrillation in Older Adults with Frailty. Geriatrics (Basel) 2024; 9:50. [PMID: 38667517 PMCID: PMC11050611 DOI: 10.3390/geriatrics9020050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 03/28/2024] [Accepted: 04/06/2024] [Indexed: 04/28/2024] Open
Abstract
Atrial fibrillation (AF) is a major driver of morbidity and mortality among older adults with frailty. Moreover, frailty is highly prevalent in older adults with AF. Understanding and addressing the needs of frail older adults with AF is imperative to guide clinicians caring for older adults. In this review, we summarize current evidence to support the assessment and management of older adults with AF and frailty, incorporating numerous recent landmark trials and studies in the context of the 2023 US AF guideline.
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Affiliation(s)
| | - Aaron L. Troy
- Beth Israel Deaconess Medical Center, Boston, MA 02215, USA (A.L.T.)
| | | | - Abiah Pritchard
- Beth Israel Deaconess Medical Center, Boston, MA 02215, USA (A.L.T.)
| | - Rati Vani
- Beth Israel Deaconess Medical Center, Boston, MA 02215, USA (A.L.T.)
| | - Darae Ko
- Section of Cardiovascular Medicine, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA 02118, USA
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, 1200 Center Street, Boston, MA 02131, USA
| | - Ariela R. Orkaby
- New England GRECC (Geriatric Research, Education and Clinical Center), VA Boston Healthcare System, Boston, MA 02130, USA
- Division of Aging, Brigham & Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
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2
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Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2024; 149:e1-e156. [PMID: 38033089 PMCID: PMC11095842 DOI: 10.1161/cir.0000000000001193] [Citation(s) in RCA: 231] [Impact Index Per Article: 231.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
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Affiliation(s)
| | | | | | | | | | | | - Anita Deswal
- ACC/AHA Joint Committee on Clinical Practice Guidelines liaison
| | | | | | | | | | - Paul L Hess
- ACC/AHA Joint Committee on Performance Measures liaison
| | | | | | | | | | - Kazuhiko Kido
- American College of Clinical Pharmacy representative
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3
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Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2024; 83:109-279. [PMID: 38043043 PMCID: PMC11104284 DOI: 10.1016/j.jacc.2023.08.017] [Citation(s) in RCA: 66] [Impact Index Per Article: 66.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Patients With Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
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4
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Zhang C, Wang XY, Lou L, Zhang X, Chen LL, Chen YX, Yang J. Pacemaker and Atrioventricular Junction Ablation in Patients With Atrial Fibrillation—A Systematic Review of Systematic Review and Meta-Analysis. Front Cardiovasc Med 2022; 8:587297. [PMID: 35127840 PMCID: PMC8810654 DOI: 10.3389/fcvm.2021.587297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 12/20/2021] [Indexed: 11/25/2022] Open
Abstract
Background Cardiac resynchronization therapy (CRT) could be considered for heart failure (HF) patients with atrial fibrillation (AF) unless a potent ventricular capture strategy is conducted. However, the benefit of a pacemaker (PM; as part of CRT) in patients with AF and whether atrioventricular junction (or nodal) ablation (AVAB) can improve the prognosis of these patients compared with those treated medically to support ventricular capture are unclear. Methods and Results Systematic reviews and meta-analyses investigating the roles of PMs and AVAB in patients with AF were obtained in a search of the PubMed, Embase, and Medline databases and then analyzed with respect to the following outcomes: mortality, left ventricular ejection fraction, and clinical findings including the New York Heart Association class, 6-min walk distance (6MWD), quality of life as assessed in a specific questionnaire, and response to CRT. The quality of the included reviews was assessed using the Assessing the Methodological Quality of Systematic Reviews 2 tool, which includes 16 items. This study was finally based on 13 systematic reviews or meta-analyses. The results showed that patients with AF have higher all-cause mortality rates compared with patients with sinus rhythm and that AVAB can reduce all-cause mortality in patients with AF. Although the functional improvement was better in sinus rhythm than in patients with AF, in the latter, AVAB increased the 6MWD and reduced the CRT nonresponse rate in patients with AF. Conclusion Atrial fibrillation is associated with a higher all-cause mortality rate in patients with CRT implantation. AVAB, by increasing the 6MWD and survival, can improve the prognosis of these patients.
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5
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Ablate and pace: The ultimate treatment for atrial fibrillation? Rev Port Cardiol 2022; 41:27-29. [DOI: 10.1016/j.repc.2021.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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6
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Brignole M, Pentimalli F, Palmisano P, Landolina M, Quartieri F, Occhetta E, Calò L, Mascia G, Mont L, Vernooy K, van Dijk V, Allaart C, Fauchier L, Gasparini M, Parati G, Soranna D, Rienstra M, Van Gelder IC. AV junction ablation and cardiac resynchronization for patients with permanent atrial fibrillation and narrow QRS: the APAF-CRT mortality trial. Eur Heart J 2021; 42:4731-4739. [PMID: 34453840 DOI: 10.1093/eurheartj/ehab569] [Citation(s) in RCA: 110] [Impact Index Per Article: 36.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 07/21/2021] [Accepted: 08/04/2021] [Indexed: 11/13/2022] Open
Abstract
AIMS In patients with atrial fibrillation (AF) and heart failure (HF), strict and regular rate control with atrioventricular junction ablation and biventricular pacemaker (Ablation + CRT) has been shown to be superior to pharmacological rate control in reducing HF hospitalizations. However, whether it also improves survival is unknown. METHODS AND RESULTS In this international, open-label, blinded outcome trial, we randomly assigned patients with severely symptomatic permanent AF >6 months, narrow QRS (≤110 ms) and at least one HF hospitalization in the previous year to Ablation + CRT or to pharmacological rate control. We hypothesized that Ablation + CRT is superior in reducing the primary endpoint of all-cause mortality. A total of 133 patients were randomized. The mean age was 73 ± 10 years, and 62 (47%) were females. The trial was stopped for efficacy at interim analysis after a median of 29 months of follow-up per patient. The primary endpoint occurred in 7 patients (11%) in the Ablation + CRT arm and in 20 patients (29%) in the Drug arm [hazard ratio (HR) 0.26, 95% confidence interval (CI) 0.10-0.65; P = 0.004]. The estimated death rates at 2 years were 5% and 21%, respectively; at 4 years, 14% and 41%. The benefit of Ablation + CRT of all-cause mortality was similar in patients with ejection fraction (EF) ≤35% and in those with >35%. The secondary endpoint combining all-cause mortality or HF hospitalization was significantly lower in the Ablation + CRT arm [18 (29%) vs. 36 (51%); HR 0.40, 95% CI 0.22-0.73; P = 0.002]. CONCLUSIONS Ablation + CRT was superior to pharmacological therapy in reducing mortality in patients with permanent AF and narrow QRS who were hospitalized for HF, irrespective of their baseline EF. STUDY REGISTRATION ClinicalTrials.gov Identifier: NCT02137187.
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Affiliation(s)
- Michele Brignole
- Department of Cardiology, Ospedali del Tigullio, Lavagna, Italy.,Department of Cardiology, IRCCS Istituto Auxologico Italiano, Ospedale San Luca, Piazzale Brescia 20, 20149 Milan, Italy
| | | | | | | | - Fabio Quartieri
- Department of Cardiology, Ospedale S. Maria Nuova, Reggio Emilia, Italy
| | - Eraldo Occhetta
- Department of Cardiology, Ospedale Maggiore della Carità, Novara, Italy
| | - Leonardo Calò
- Department of Cardiology, Policlinico Casilino, Roma, Italy
| | - Giuseppe Mascia
- Department of Cardiology, Ospedale San Giovanni di Dio, Firenze, Italy
| | - Lluis Mont
- Department of Cardiology, Hospital Clinic, Barcelona, Spain
| | - Kevin Vernooy
- Department of Cardiology, University Medical Center, Maastricht, The Netherlands
| | - Vincent van Dijk
- Department of Cardiology, University Medical Center, Nieuwegein, The Netherlands
| | - Cor Allaart
- Department of Cardiology, University Medical Center, Amsterdam, The Netherlands
| | - Laurent Fauchier
- Department of Cardiology, Centre Hospitalier Universitaire Trousseau, Université François Rabelais, Tours, France
| | | | - Gianfranco Parati
- Department of Cardiology, IRCCS Istituto Auxologico Italiano, Ospedale San Luca, Piazzale Brescia 20, 20149 Milan, Italy.,Department of Cardiology, University of Milano Bicocca, Milan, Italy
| | - Davide Soranna
- Department of Cardiology, IRCCS Istituto Auxologico Italiano, Biostatistic Unit, Milan, Italy
| | - Michiel Rienstra
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Isabelle C Van Gelder
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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7
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Carmo P. Pace and ablate: The ultimate treatment for atrial fibrillation? REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2021. [DOI: 10.1016/j.repce.2021.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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8
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Carmo P. Pace and ablate: The ultimate treatment for atrial fibrillation? Rev Port Cardiol 2020; 40:105-107. [PMID: 33384185 DOI: 10.1016/j.repc.2020.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Pedro Carmo
- Hospital de Santa Cruz, CHLO, Carnaxide, Portugal.
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9
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Brignole M, Pokushalov E, Pentimalli F, Palmisano P, Chieffo E, Occhetta E, Quartieri F, Calò L, Ungar A, Mont L, Menozzi C, Alboni P, Bertero G, Klersy C, Noventa F, Brignole M, Oddone D, Donateo O, Maggi R, Croci F, Solano A, Pentimalli F, Palmisano P, Landolina M, Chieffo E, Taravelli E, Occhetta E, Quartieri F, Bottoni N, Iori M, Calò L, Sgueglia M, Pieragnoli, Giorni A, Nesti M, Giannini I, Ungar A, Padeletti L, Pokushalov E, Romanov A, Peregudov I, Vidorreda S, Nunez R, Mont L, Corbucci G, Valsecchi S, Lovecchio M. A randomized controlled trial of atrioventricular junction ablation and cardiac resynchronization therapy in patients with permanent atrial fibrillation and narrow QRS. Eur Heart J 2018; 39:3999-4008. [DOI: 10.1093/eurheartj/ehy555] [Citation(s) in RCA: 89] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Accepted: 08/16/2018] [Indexed: 12/29/2022] Open
Affiliation(s)
- Michele Brignole
- Department of Cardiology, Ospedali del Tigullio, Via don Bobbio, Lavagna, Italy
| | - Evgeny Pokushalov
- Department of Cardiology, Novosibirsk Research Institute, Novosibirsk, Russia
| | | | | | - Enrico Chieffo
- Department of Cardiology, Ospedale Maggiore, Crema, Italy
| | - Eraldo Occhetta
- Department of Cardiology, Ospedale Maggiore della Carità, Novara, Italy
| | - Fabio Quartieri
- Department of Cardiology, Ospedale S. Maria Nuova, Reggio Emilia, Italy
| | - Leonardo Calò
- Department of Cardiology, Policlinico Casilino, Roma, Italy
| | - Andrea Ungar
- Department of Cardiology, Ospedale Careggi, Firenze, Italy
| | - Lluis Mont
- Department of Cardiology, Hospital Clinic, Barcelona, Spain
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10
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Wang RX, Lee HC, Li JP, Hodge DO, Cha YM, Friedman PA, Munger TM, Srivathsan K, Pavri BB, Shen WK. Sudden death and its risk factors after atrioventricular junction ablation and pacemaker implantation in patients with atrial fibrillation. Clin Cardiol 2016; 40:18-25. [PMID: 27748530 DOI: 10.1002/clc.22600] [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] [Received: 06/18/2016] [Revised: 08/25/2016] [Accepted: 08/31/2016] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Although sudden death (SD) is a rare complication after atrioventricular junction (AVJ) ablation and permanent pacemaker implantation, the risk factors leading to this SD remain unknown. The purpose of this study was to investigate SD and its risk factors after ablate-and-pace strategy for rate control in atrial fibrillation (AF) patients during long-term follow-up. HYPOTHESIS METHODS: From January 2005 to December 2009, we enrolled into this study 517 AF patients with AVJ ablation and right ventricular pacemaker implantation. Patients were divided into 2 groups, SD and non-SD. Cox proportional hazards models were used to assess potential risk factors for overall mortality and SD. RESULTS During a mean follow-up of 25.8 ± 18.6 months (range, 3 days to 63.8 months), 53 patients died (15 with SD). Cox proportional hazards models showed that the presence of congestive heart failure, New York Heart Association functional class, chronic renal failure, and nonsustained ventricular tachycardia were risk factors that predicted overall mortality. For SD, the presence of dilated cardiomyopathy and mitral stenosis were associated risk factors. SD was exclusively seen in patients who had narrow QRS complex or right bundle branch block prior to AVJ ablation and pacemaker implantation; SD was not seen in any patient with preexisting complete left bundle branch block. CONCLUSIONS Dilated cardiomyopathy, mitral stenosis, and baseline QRS morphology should be examined as potential risk factors for SD after AVJ ablation and pacemaker implantation.
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Affiliation(s)
- Ru-Xing Wang
- Department of Cardiology, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi 214023, PR China
| | - Hon-Chi Lee
- Division of Cardiovascular Diseases, Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Jia-Ping Li
- Department of Cardiology, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi 214023, PR China
| | - David O Hodge
- Division of Cardiovascular Diseases, Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Yong-Mei Cha
- Division of Cardiovascular Diseases, Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Paul A Friedman
- Division of Cardiovascular Diseases, Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Thomas M Munger
- Division of Cardiovascular Diseases, Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | | | - Behzad B Pavri
- Division of Cardiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Win-Kuang Shen
- Division of Cardiovascular Diseases, Mayo Clinic, Scottsdale, Arizona
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11
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Rich MW, Chyun DA, Skolnick AH, Alexander KP, Forman DE, Kitzman DW, Maurer MS, McClurken JB, Resnick BM, Shen WK, Tirschwell DL. Knowledge Gaps in Cardiovascular Care of Older Adults: A Scientific Statement from the American Heart Association, American College of Cardiology, and American Geriatrics Society: Executive Summary. J Am Geriatr Soc 2016; 64:2185-2192. [PMID: 27673575 DOI: 10.1111/jgs.14576] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The incidence and prevalence of most cardiovascular disorders increase with age, and cardiovascular disease (CVD) is the leading cause of death and major disability in adults aged 75 and older. Despite the effect of CVD on quality of life, morbidity, and mortality in older adults, individuals aged 75 and older have been markedly underrepresented in most major cardiovascular trials, and virtually all trials have excluded older adults with complex comorbidities, significant physical or cognitive disabilities, frailty, or residence in nursing homes and assisted living facilities. As a result, current guidelines are unable to provide evidence-based recommendations for diagnosis and treatment of older adults typical of those encountered in routine clinical practice. The objectives of this scientific statement are to summarize current guideline recommendations as they apply to older adults, identify critical gaps in knowledge that preclude informed evidence-based decision-making, and recommend future research to close existing knowledge gaps. To achieve these objectives, a detailed review was conducted of current American College of Cardiology/American Heart Association (ACC/AHA) and American Stroke Association (ASA) guidelines to identify content and recommendations that explicitly targeted older adults. A pervasive lack of evidence to guide clinical decision-making in older adults with CVD was found, as well as a paucity of data on the effect of diagnostic and therapeutic interventions on outcomes that are particularly important to older adults, such as quality of life, physical function, and maintenance of independence. Accordingly, there is a critical need for a multitude of large population-based studies and clinical trials that include a broad spectrum of older adults representative of those seen in clinical practice and that incorporate relevant outcomes important to older adults in the study design. The results of these studies will provide the foundation for future evidence-based guidelines applicable to older adults and enhance person-centered care of older individuals with CVD in the United States and around the world.
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Affiliation(s)
- Michael W Rich
- School of Medicine, Washington University, St. Louis, Missouri
| | | | - Adam H Skolnick
- Leon H. Charney Division of Cardiology, NYU Langone Medical Center, New York, New York
| | - Karen P Alexander
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Daniel E Forman
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.,Department of Veterans Affairs, Geriatric, Research, Education, and Clinical Center, Pittsburgh, Pennsylvania
| | - Dalane W Kitzman
- School of Medicine, Wake Forest University, Winston-Salem, North Carolina
| | | | - James B McClurken
- RA Reif Heart Institute, Doylestown Hospital, Doylestown, Pennsylvania.,Temple University, Philadelphia, Pennsylvania
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12
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Garcia B, Clementy N, Benhenda N, Pierre B, Babuty D, Olshansky B, Fauchier L. Mortality After Atrioventricular Nodal Radiofrequency Catheter Ablation With Permanent Ventricular Pacing in Atrial Fibrillation. Circ Arrhythm Electrophysiol 2016; 9:CIRCEP.116.003993. [DOI: 10.1161/circep.116.003993] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 05/27/2016] [Indexed: 11/16/2022]
Abstract
Background—
Atrioventricular nodal radiofrequency ablation (AVNA) with permanent ventricular pacing can be used to control rate in patients with atrial fibrillation (AF). However, long-term outcomes after AVNA are uncertain, especially in light of irreversible pacemaker dependence.
Methods and Results—
We examined 9122 consecutive patients with AF. The outcomes in 453 patients with AVNA (26% of whom underwent an implantable cardiac defibrillator implant and 37% underwent cardiac resynchronization therapy implant) were compared with AF patients without AVNA after propensity score 1:1 matching. During follow-up in the propensity-matched cohort (2.41±3.23 years, median 1.23, quartiles 0.33–3.12), 100 patients died (yearly rate of death 6.6%). Mode of death was available in 86% of patients, which was cardiovascular in 67% of the patients (related to heart failure in 38%, sudden death in 5%, and other cardiovascular reason in 24%) and noncardiovascular in 33%. AVNA in patients with AF was associated with a lower risk of mortality (odds ratio 0.47, 95% confidence interval, 0.29–0.77;
P
=0.003), a lower risk of cardiovascular mortality (odds ratio =0.41, 95% confidence interval 0.23–0.73;
P
=0.003), and nonsignificant lower risk of stroke and thromboembolic events (odds ratio =0.61, 95% confidence interval 0.36–1.06;
P
=0.08).
Conclusions—
In sick AF patients with multiple comorbidities, AVNA with permanent ventricular pacing for rate control seems safe during follow-up and may be associated with lower mortality.
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Affiliation(s)
- Bruno Garcia
- From the Service de Cardiologie, Pôle Cœur Thorax Vasculaire, Centre Hospitalier Universitaire Trousseau et Faculté de Médecine, Université François Rabelais, Tours, France (B.G., N.C., N.B., B.P., D.B., L.F.); and Division of Cardiology, Cardiac Electrophysiology, Mercy Hospital-North Iowa, Mason City, IA (B.O.)
| | - Nicolas Clementy
- From the Service de Cardiologie, Pôle Cœur Thorax Vasculaire, Centre Hospitalier Universitaire Trousseau et Faculté de Médecine, Université François Rabelais, Tours, France (B.G., N.C., N.B., B.P., D.B., L.F.); and Division of Cardiology, Cardiac Electrophysiology, Mercy Hospital-North Iowa, Mason City, IA (B.O.)
| | - Nazih Benhenda
- From the Service de Cardiologie, Pôle Cœur Thorax Vasculaire, Centre Hospitalier Universitaire Trousseau et Faculté de Médecine, Université François Rabelais, Tours, France (B.G., N.C., N.B., B.P., D.B., L.F.); and Division of Cardiology, Cardiac Electrophysiology, Mercy Hospital-North Iowa, Mason City, IA (B.O.)
| | - Bertrand Pierre
- From the Service de Cardiologie, Pôle Cœur Thorax Vasculaire, Centre Hospitalier Universitaire Trousseau et Faculté de Médecine, Université François Rabelais, Tours, France (B.G., N.C., N.B., B.P., D.B., L.F.); and Division of Cardiology, Cardiac Electrophysiology, Mercy Hospital-North Iowa, Mason City, IA (B.O.)
| | - Dominique Babuty
- From the Service de Cardiologie, Pôle Cœur Thorax Vasculaire, Centre Hospitalier Universitaire Trousseau et Faculté de Médecine, Université François Rabelais, Tours, France (B.G., N.C., N.B., B.P., D.B., L.F.); and Division of Cardiology, Cardiac Electrophysiology, Mercy Hospital-North Iowa, Mason City, IA (B.O.)
| | - Brian Olshansky
- From the Service de Cardiologie, Pôle Cœur Thorax Vasculaire, Centre Hospitalier Universitaire Trousseau et Faculté de Médecine, Université François Rabelais, Tours, France (B.G., N.C., N.B., B.P., D.B., L.F.); and Division of Cardiology, Cardiac Electrophysiology, Mercy Hospital-North Iowa, Mason City, IA (B.O.)
| | - Laurent Fauchier
- From the Service de Cardiologie, Pôle Cœur Thorax Vasculaire, Centre Hospitalier Universitaire Trousseau et Faculté de Médecine, Université François Rabelais, Tours, France (B.G., N.C., N.B., B.P., D.B., L.F.); and Division of Cardiology, Cardiac Electrophysiology, Mercy Hospital-North Iowa, Mason City, IA (B.O.)
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13
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Rich MW, Chyun DA, Skolnick AH, Alexander KP, Forman DE, Kitzman DW, Maurer MS, McClurken JB, Resnick BM, Shen WK, Tirschwell DL. Knowledge Gaps in Cardiovascular Care of the Older Adult Population: A Scientific Statement From the American Heart Association, American College of Cardiology, and American Geriatrics Society. J Am Coll Cardiol 2016; 67:2419-2440. [PMID: 27079335 PMCID: PMC7733163 DOI: 10.1016/j.jacc.2016.03.004] [Citation(s) in RCA: 117] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The incidence and prevalence of most cardiovascular disorders increase with age, and cardiovascular disease is the leading cause of death and major disability in adults ≥75 years of age; however, despite the large impact of cardiovascular disease on quality of life, morbidity, and mortality in older adults, patients aged ≥75 years have been markedly underrepresented in most major cardiovascular trials, and virtually all trials have excluded older patients with complex comorbidities, significant physical or cognitive disabilities, frailty, or residence in a nursing home or assisted living facility. As a result, current guidelines are unable to provide evidence-based recommendations for diagnosis and treatment of older patients typical of those encountered in routine clinical practice. The objectives of this scientific statement are to summarize current guideline recommendations as they apply to older adults, identify critical gaps in knowledge that preclude informed evidence-based decision making, and recommend future research to close existing knowledge gaps. To achieve these objectives, we conducted a detailed review of current American College of Cardiology/American Heart Association and American Stroke Association guidelines to identify content and recommendations that explicitly targeted older patients. We found that there is a pervasive lack of evidence to guide clinical decision making in older patients with cardiovascular disease, as well as a paucity of data on the impact of diagnostic and therapeutic interventions on key outcomes that are particularly important to older patients, such as quality of life, physical function, and maintenance of independence. Accordingly, there is a critical need for a multitude of large population-based studies and clinical trials that include a broad spectrum of older patients representative of those seen in clinical practice and that incorporate relevant outcomes important to older patients in the study design. The results of these studies will provide the foundation for future evidence-based guidelines applicable to older patients, thereby enhancing patient-centered evidence-based care of older people with cardiovascular disease in the United States and around the world.
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Rich MW, Chyun DA, Skolnick AH, Alexander KP, Forman DE, Kitzman DW, Maurer MS, McClurken JB, Resnick BM, Shen WK, Tirschwell DL. Knowledge Gaps in Cardiovascular Care of the Older Adult Population. Circulation 2016; 133:2103-22. [DOI: 10.1161/cir.0000000000000380] [Citation(s) in RCA: 111] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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15
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Zamani P, Verdino RJ. Management of Atrial Fibrillation. J Intensive Care Med 2014; 30:484-98. [PMID: 24828991 DOI: 10.1177/0885066614534603] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2013] [Accepted: 03/03/2014] [Indexed: 12/19/2022]
Abstract
Atrial fibrillation remains the most prevalent cardiac arrhythmia, and its incidence is increasing as the population ages. Common conditions associated with an increased incidence include advanced age, hypertension, heart failure, and valvular heart disease. Patients with atrial fibrillation may complain of palpitations, fatigue, and decreased exercise tolerance or may be completely asymptomatic. Options for treating patients who experience atrial fibrillation include rate-controlling drugs such as digoxin, β-blockers, and calcium channel blockers or a rhythm-controlling strategy with agents such as sodium channel blockers and potassium channel blockers. Atrial fibrillation increases the risk of stroke due to atrial thrombus formation and embolization. Anticoagulation with the vitamin K antagonist, warfarin, remains the most widely prescribed treatment option to decrease stroke risk. Several other antithrombotic agents have recently become available and offer excellent alternatives to warfarin. Catheter ablation can be undertaken as a nonpharmacologic rhythm control option with varying degrees of success depending on duration of atrial fibrillation and follow-up time from the procedure. This review article further describes the management options for patients presenting with atrial fibrillation.
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Affiliation(s)
- Payman Zamani
- Division of Cardiovascular Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Ralph J Verdino
- Division of Cardiovascular Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
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Abstract
Atrial fibrillation is the most common arrhythmia affecting patients today. Disease prevalence is increasing at an alarming rate worldwide, and is associated with often catastrophic and costly consequences, including heart failure, syncope, dementia, and stroke. Therapies including anticoagulants, anti-arrhythmic medications, devices, and non-pharmacologic procedures in the last 30 years have improved patients' functionality with the disease. Nonetheless, it remains imperative that further research into AF epidemiology, genetics, detection, and treatments continues to push forward rapidly as the worldwide population ages dramatically over the next 20 years.
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Affiliation(s)
- Thomas M. Munger
- Heart Rhythm Services, Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN 55905, USA;
| | - Li-Qun Wu
- Department of Cardiology, Rui Jin Hospital, Shanghai Jiao Tong University of Medicine, Shanghai 200025, China;
| | - Win K. Shen
- Division of Cardiovascular Diseases, Mayo Clinic, Phoenix, AZ 85054, USA.
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Abstract
In patients with atrial fibrillation (AF) undergoing cardiac resynchronization therapy (CRT) for heart failure, continuous monitoring of the percentage of biventricular BiV% pacing has shown that the greatest improvement and reduction in mortality occur with a BiV pacing greater than 98%. Continuous monitoring of BiV pacing has improved the CRT management of patients with AF. Continuous monitoring has generated important new questions about anticoagulant therapy, which require randomized trials. Anticoagulant therapy should probably be considered in patients who have a high risk of thromboembolism according to standard scoring systems.
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Affiliation(s)
- Bengt Herweg
- Department of Cardiovascular Disease, University of South Florida Morsani College of Medicine, South Tampa Campus (5th Floor), Two Tampa General Circle, Tampa, FL 33606, USA.
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Wang RX, Lee HC, Hodge DO, Cha YM, Friedman PA, Rea RF, Munger TM, Jahangir A, Srivathsan K, Shen WK. Effect of pacing method on risk of sudden death after atrioventricular node ablation and pacemaker implantation in patients with atrial fibrillation. Heart Rhythm 2013; 10:696-701. [PMID: 23333719 DOI: 10.1016/j.hrthm.2013.01.021] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2012] [Indexed: 01/09/2023]
Abstract
BACKGROUND Sudden death may occur after radiofrequency catheter ablation of the atrioventricular node (AVN) and permanent pacemaker implantation. It is unclear whether a faster initial heart rate with gradual rate reduction decreases the risk of sudden death. OBJECTIVE To evaluate the effects of initial pacing at a faster rate after AVN ablation, with a gradual rate decrease over 3 months, on the rate of sudden death in patients with atrial fibrillation. METHODS We compared the rate of likely or possible procedure-related sudden death in 2 groups of patients who had AVN ablation and pacemaker implantation. The study cohort was treated between January 2005 and December 2009, and pacemakers were programmed to a lower rate of 90 beats/min after the procedure, with a monthly decrement of 10 beats/min until 60 beats/min was reached. The control group was treated between July 1990 and December 1998 when pacemakers were programmed to a lower rate of 60 beats/min immediately after ablation. RESULTS The study cohort included 520 patients (mean age 73.6 ± 10.3 years), and the control cohort comprised 334 patients (mean age 68.1 ± 1.1 years). Sudden death deemed likely or possibly related to ablation and pacemaker implantation occurred in 1 patient in the study cohort (0.2%) and in 7 patients (2.1%) in the control group (P = .007). CONCLUSIONS Sudden death was significantly decreased in the study cohort compared to controls. The faster lower pacing rate immediately after AVN ablation with a gradual decrease is a plausible mechanism for the improved clinical outcome.
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Affiliation(s)
- Ru-Xing Wang
- Department of Cardiology, Wuxi People's Hospital, Nanjing Medical University, Wuxi, China
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Barold SS, Herweg B. Cardiac resynchronization and atrial fibrillation: what's new? PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2012; 35:1281-9. [PMID: 22564027 DOI: 10.1111/j.1540-8159.2012.03416.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- S Serge Barold
- Florida Heart Rhythm Institute, and Tampa General Hospital, Tampa, Florida, USA.
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Chatterjee NA, Upadhyay GA, Ellenbogen KA, Hayes DL, Singh JP. Atrioventricular nodal ablation in atrial fibrillation: a meta-analysis of biventricular vs. right ventricular pacing mode. Eur J Heart Fail 2012; 14:661-7. [PMID: 22436544 DOI: 10.1093/eurjhf/hfs036] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
AIMS For patients with refractory atrial fibrillation (AF) undergoing atrioventricular nodal ablation (AVNA), initial single-chamber right ventricular (RV)-only pacing is standard. Given the deleterious effects of chronic RV-only pacing, the impact of an initial biventricular (BiV) pacing strategy post-ablation is of interest. METHODS AND RESULTS We conducted a meta-analysis to determine the effect of BiV vs. RV-only pacing in patients undergoing AVNA for refractory atrial fibrillation. A search of multiple electronic databases identified 921 reports, which included four randomized controlled trials (n = 534). Mean New York Heart Association (NYHA) class was 2.3 and mean left ventricular ejection fraction (LVEF) was 44%. When compared with RV-only pacing, BiV pacing was not associated with reduced mortality [risk ratio 0.85, 95% confidence interval (CI) 0.40-1.82, P = 0.68]. In three studies comprised of patients with left ventricular systolic dysfunction (mean EF 41 ± 3%), BiV pacing demonstrated a non-significant reduction in cardiac mortality (risk ratio 0.59, 95% CI 0.25-1.39; P = 0.23). Compared with RV-only pacing, BiV pacing was associated with significant improvement in symptoms [Minnesota Living with Heart Failure Questionnaire (MLWHFQ) 2.72 points fewer, 95% CI 1.45-3.99] and increased LVEF (+2.6%, 95% CI 1.69-3.44), but no significant change in 6 min walk distance (6MWD) (5.02 ms more, 95% CI -1.56 to 11.59; P = 0.13). CONCLUSIONS In patients with refractory AF undergoing AVNA, BiV pacing was not associated with significantly improved survival when compared with RV-only pacing. A modest, but significant improvement in structural and functional response to BiV pacing was observed.
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Affiliation(s)
- Neal A Chatterjee
- Department of Medicine and the Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, MA 02411, USA
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Chatterjee NA, Upadhyay GA, Ellenbogen KA, McAlister FA, Choudhry NK, Singh JP. Atrioventricular Nodal Ablation in Atrial Fibrillation. Circ Arrhythm Electrophysiol 2012; 5:68-76. [DOI: 10.1161/circep.111.967810] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Neal A. Chatterjee
- From the Department of Medicine and the Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, MA (N.A.C., G.A.U., J.P.S.); the Division of Cardiology, Virginia Commonwealth University School of Medicine, Richmond, VA (K.A.E.); the Division of Internal Medicine, University of Alberta Hospital, Edmonton, Canada (F.A.M.); and the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (N.K.C.)
| | - Gaurav A. Upadhyay
- From the Department of Medicine and the Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, MA (N.A.C., G.A.U., J.P.S.); the Division of Cardiology, Virginia Commonwealth University School of Medicine, Richmond, VA (K.A.E.); the Division of Internal Medicine, University of Alberta Hospital, Edmonton, Canada (F.A.M.); and the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (N.K.C.)
| | - Kenneth A. Ellenbogen
- From the Department of Medicine and the Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, MA (N.A.C., G.A.U., J.P.S.); the Division of Cardiology, Virginia Commonwealth University School of Medicine, Richmond, VA (K.A.E.); the Division of Internal Medicine, University of Alberta Hospital, Edmonton, Canada (F.A.M.); and the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (N.K.C.)
| | - Finlay A. McAlister
- From the Department of Medicine and the Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, MA (N.A.C., G.A.U., J.P.S.); the Division of Cardiology, Virginia Commonwealth University School of Medicine, Richmond, VA (K.A.E.); the Division of Internal Medicine, University of Alberta Hospital, Edmonton, Canada (F.A.M.); and the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (N.K.C.)
| | - Niteesh K. Choudhry
- From the Department of Medicine and the Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, MA (N.A.C., G.A.U., J.P.S.); the Division of Cardiology, Virginia Commonwealth University School of Medicine, Richmond, VA (K.A.E.); the Division of Internal Medicine, University of Alberta Hospital, Edmonton, Canada (F.A.M.); and the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (N.K.C.)
| | - Jagmeet P. Singh
- From the Department of Medicine and the Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, MA (N.A.C., G.A.U., J.P.S.); the Division of Cardiology, Virginia Commonwealth University School of Medicine, Richmond, VA (K.A.E.); the Division of Internal Medicine, University of Alberta Hospital, Edmonton, Canada (F.A.M.); and the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (N.K.C.)
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Right Ventricular Pacing, Mechanical Dyssynchrony, and Heart Failure. J Cardiovasc Transl Res 2011; 5:219-31. [DOI: 10.1007/s12265-011-9341-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2011] [Accepted: 12/11/2011] [Indexed: 11/25/2022]
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23
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Davy JM, Tri Cung T, Cransac F, Massin F, Tapiero A, Roubille F, Pasquié JL. La fibrillation atriale permanente. ARCHIVES OF CARDIOVASCULAR DISEASES SUPPLEMENTS 2011. [DOI: 10.1016/s1878-6480(11)70393-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Eleid MF, Shen WK. Role of atrioventricular nodal ablation and pacemaker therapy in elderly patients with recurrent atrial fibrillation. Interv Cardiol 2011. [DOI: 10.2217/ica.11.71] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Brignole M, Botto G, Mont L, Iacopino S, De Marchi G, Oddone D, Luzi M, Tolosana JM, Navazio A, Menozzi C. Cardiac resynchronization therapy in patients undergoing atrioventricular junction ablation for permanent atrial fibrillation: a randomized trial. Eur Heart J 2011; 32:2420-9. [PMID: 21606084 DOI: 10.1093/eurheartj/ehr162] [Citation(s) in RCA: 240] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
AIMS On the basis of the current knowledge, cardiac resynchronization therapy (CRT) cannot be recommended as a first-line treatment for patients with severely symptomatic permanent atrial fibrillation undergoing atrioventricular (AV) junction ablation. We examined whether CRT was superior to conventional right ventricular (RV) pacing in reducing heart failure (HF) events. METHODS AND RESULTS In this prospective, multi-centre study, we randomly assigned 186 patients, in whom AV junction ablation and CRT device implantation had been successfully performed, to receive optimized echo-guided CRT (97 patients) or RV apical pacing (89 patients). The data were analysed according to the intention-to-treat principle. During a median follow-up of 20 months (interquartile range 11-24), the primary composite endpoint of death from HF, hospitalization due to HF, or worsening HF occurred in 11 (11%) patients in the CRT group and 23 (26%) patients in the RV group [CRT vs. RV group: sub-hazard ratio (SHR) 0.37 ( 95% CI 0.18-0.73), P = 0.005]. In the CRT group, compared with the RV group, fewer patients had worsening HF [SHR 0.27 (95% CI 0.12-0.58), P = 0.001] and hospitalizations for HF [SHR 0.20 (95% CI 0.06-0.72), P = 0.013]. Total mortality was similar in both groups [hazard ratio (HR) 1.57 (95% CI 0.58-4.27), P = 0.372]. The beneficial effects of CRT were consistent in patients who had ejection fraction ≤35%, New York Heart Association Class ≥III and QRS width ≥120 and in those who did not. At multi-variable Cox regression, only CRT mode remained an independent predictor of absence of clinical failure during the follow-up [HR = 0.23 (95% CI 0.08-0.66), P = 0.007]. CONCLUSIONS In patients undergoing 'Ablate and Pace' therapy for severely symptomatic permanent atrial fibrillation, CRT is superior to RV apical pacing in reducing the clinical manifestations of HF. (ClinicalTrials.gov number: NCT00111527).
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Affiliation(s)
- Michele Brignole
- Arrhythmologic Centre, Department of Cardiology, Ospedali del Tigullio, 16033 Lavagna, Italy.
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van Bommel RJ, Borleffs CJW, Ypenburg C, Marsan NA, Delgado V, Bertini M, van der Wall EE, Schalij MJ, Bax JJ. Morbidity and mortality in heart failure patients treated with cardiac resynchronization therapy: influence of pre-implantation characteristics on long-term outcome. Eur Heart J 2010; 31:2783-90. [PMID: 20693544 DOI: 10.1093/eurheartj/ehq252] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
AIMS Cardiac resynchronization therapy (CRT) improves cardiac function, heart failure symptoms, and prognosis in selected patients. Many baseline characteristics associated with heart failure may influence prognosis after CRT. The objective of this study was to evaluate the effect of several baseline characteristics in relation to long-term prognosis in heart failure patients treated with CRT. METHODS AND RESULTS A total of 716 consecutive heart failure patients treated with CRT were included in an observational registry. All available data, including clinical and echocardiographic measurements, were analysed in relation to two endpoints: all-cause mortality and a combined endpoint of all-cause mortality or major cardiovascular event. Outcome data were collected by chart review, device interrogation, and telephone contact. Mean follow-up was 25 ± 19 months. During follow-up, 141 patients (20%) died (primary endpoint). Most of these patients (61%) died due to worsening heart failure. A total of 214 patients (30%) reached the secondary endpoint. Larger left ventricular end-systolic volume, less distance covered in the 6 min walking test, poor renal function, more severe heart failure, male gender, presence of atrial fibrillation, no posterolateral left ventricular (LV) lead, and no LV dyssynchrony were associated with poor prognosis after CRT. CONCLUSION In this large single-centre registry, several baseline clinical and echocardiographic characteristics were associated with prognosis after CRT. Worsening heart failure was the main cause of death in heart failure patients treated with CRT.
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Affiliation(s)
- Rutger J van Bommel
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands
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Bottoni N, Tritto M, Ricci R, Accogli M, Di Biase M, Iacopino S, Iori M, Themistoclakis S, Sitta N, Spadacini G, De Ponti R, Brignole M. Adherence to guidelines for atrial fibrillation management of patients referred to cardiology departments: Studio Italiano multicentrico sul Trattamento della Fibrillazione Atriale (SITAF). Europace 2010; 12:1070-7. [DOI: 10.1093/europace/euq158] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Abstract
Atrial fibrillation (AF) and congestive heart failure are common conditions and each predisposes to the development of the other. Basic research using animal models of the two conditions continues to yield insights that may improve therapies. The role of medical therapies aimed at the underlying structural changes in AF continues to be a subject of ongoing studies. Cardiac resynchronization therapy is effective in appropriately selected patients with both sinus rhythm and AF. Catheter ablation is emerging as a potential alternative to antiarrhythmic drug therapy, but large randomized trials will be needed to assess its role.
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Abstract
The therapeutic strategy of heart rate control for atrial fibrillation (AF) is undergoing a renaissance since several recent randomized trials demonstrated clear advantages over the rhythm control for many patients. Heart rate control for AF is hampered, however, by a dearth of information relating target heart rates to physiological measures or clinical outcomes. In this review, the rather sparse rationale behind the data elements for heart rate control - resting heart rate, activity heart rate, and regularity of the heart rate, is outlined. Beat-to-beat stroke volume is probably a key variable for calibrating heart rate targets. Presently it seems reasonable to propose targets for resting and activity heart rates but not for regularity. It also seems plausible but remains unproven that there should be a range (upper and lower) of heart rate targets rather than a simple upper limit. Nevertheless, it remains to be demonstrated through randomized clinical trials how to apply various heart rate control targets in patients with AF and whether complexity offers any advantage over simplicity.
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Leclercq C, Mabo P. Cardiac resynchronization therapy and atrial fibrillation. Do we have a final answer? Eur Heart J 2008; 29:1597-9. [DOI: 10.1093/eurheartj/ehn237] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Abstract
PURPOSE OF REVIEW The aim of this review is to provide a perspective on rate control in atrial fibrillation, in the era after the large randomized trials comparing rate and rhythm control. This review emphasizes the indications for rate control, the optimal heart rate and the different treatment modalities. RECENT FINDINGS Large studies have shown that rate control is not inferior to rhythm control with regard to cardiovascular morbidity and mortality. Rate control may now be instituted earlier during the course of the disease, even as first-choice therapy in some patients, particularly those with hypertension and underlying heart diseases, and those who are not (severely) symptomatic. The goals of rate-control therapy are to reduce symptoms, improve quality of life, minimize the development of heart failure, and prevent thromboembolic complications. An important negative aspect of rate-control therapy is the side effects of drugs. The optimal heart rate during atrial fibrillation has not yet been carefully investigated. Several approaches to control rate during atrial fibrillation are available, including pharmacological rate control and atrioventricular nodal ablation with pacemaker implantation. SUMMARY Understanding the indications for rate control, treatment goals and options will gain the largest benefit for the individual patient with atrial fibrillation.
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Tan ES, Rienstra M, Wiesfeld ACP, Schoonderwoerd BA, Hobbel HHF, Van Gelder IC. Long-term outcome of the atrioventricular node ablation and pacemaker implantation for symptomatic refractory atrial fibrillation. Europace 2008; 10:412-8. [PMID: 18272509 DOI: 10.1093/europace/eun020] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Eng S Tan
- Department of Cardiology, Thoraxcenter, University Medical Center Groningen, University of Groningen, PO Box 30.001, 9700 RB Groningen, The Netherlands
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Current World Literature. Curr Opin Cardiol 2008; 23:72-8. [DOI: 10.1097/hco.0b013e3282f40209] [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: 11/26/2022]
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