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Yakabe D, Ohtani K, Araki M, Inoue S, Nakamura T. Long-term outcomes after catheter ablation for idiopathic atypical atrial flutter. Heart Rhythm 2024:S1547-5271(24)02378-6. [PMID: 38615868 DOI: 10.1016/j.hrthm.2024.04.051] [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: 01/17/2024] [Revised: 03/22/2024] [Accepted: 04/08/2024] [Indexed: 04/16/2024]
Abstract
BACKGROUND Idiopathic atypical (non-cavotricuspid isthmus-dependent) atrial flutter (IAAFL) may be seen in patients without structural heart disease and without previous cardiac surgery or ablation. OBJECTIVE This study sought to determine the patient characteristics, electrophysiologic and electroanatomic properties, and clinical outcomes after ablation in patients with IAAFL. METHODS We retrospectively compared IAAFL patients with cavotricuspid isthmus-dependent AFL (C-AFL) patients undergoing catheter ablation. The primary outcome was a composite of death from cardiovascular causes, ischemic stroke, and hospitalization for worsening of heart failure. RESULTS Of 180 patients who underwent catheter ablation for AFL, 89 were included in this study (22 IAAFL and 67 C-AFL). Electrophysiologic study showed significantly longer intra-atrial conduction time and lower atrial voltage during sinus rhythm in the IAAFL group compared with the C-AFL group. The atrial scar was observed in all 22 IAAFL patients, with the most common sites being the posterior or lateral wall of the right atrium in 10 (45.5%) and the anterior wall of the left atrium in 8 (36.4%). During 3.5 ± 2.8 years of follow-up, the composite primary end point occurred significantly more frequently in the IAAFL group (hazard ratio [HR], 3.45; 95% confidence interval [CI], 1.20-9.89; P = .015). In multivariable analysis, brain natriuretic peptide levels (HR, 1.01; 95% CI, 1.00-1.01, per 1 pg/mL; P = .01) and IAAFL (HR, 4.14; 95% CI, 1.21-14.07; P = .02) were independently associated with the primary outcome. CONCLUSION IAAFL in patients had distinct electrophysiologic features suggestive of atrial cardiomyopathy. These patients are at risk for development of cardiovascular adverse events after ablation.
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Affiliation(s)
- Daisuke Yakabe
- Department of Cardiovascular Medicine, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Kisho Ohtani
- Department of Cardiovascular Medicine, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan.
| | - Masahiro Araki
- Department of Cardiovascular Medicine, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Shujiro Inoue
- Department of Cardiovascular Medicine, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Toshihiro Nakamura
- Department of Cardiovascular Medicine, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
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2
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Jilek C, Gleirscher L, Strzelczyk E, Sepela D, Tiemann K, Lewalter T. [Isthmus-dependent right atrial flutter : Clinical course after isthmus ablation]. Herzschrittmacherther Elektrophysiol 2023; 34:291-297. [PMID: 37847416 DOI: 10.1007/s00399-023-00966-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 09/25/2023] [Indexed: 10/18/2023]
Abstract
Ablation of the cavotricuspid isthmus (CTI) to create bidirectional isthmus blockade is the most effective way to achieve rhythm control in typical atrial flutter. Compared with drug therapy, ablation reduces cardiovascular mortality, all-cause mortality, stroke risk, and the risk of cardiac decompensation. Concomitant arrhythmia of atrial flutter is atrial fibrillation (AF); therefore the duration of oral anticoagulation should be adapted according to the risk of stroke and bleeding. A combined procedure of CTI ablation and pulmonary vein isolation (PVI) in patients with typical atrial flutter but without evidence of AF should be evaluated individually especially in patients aged > 54 years depending on (cardiac) comorbidities. The comprehensive diagnostic view should keep in mind not only arrhythmias but also possibly underlying coronary artery disease.
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Affiliation(s)
- Clemens Jilek
- Peter-Osypka Herzzentrum München, Internistisches Klinikum München Süd, Am Isarkanal 36, 81379, München, Deutschland.
| | - Lukas Gleirscher
- Peter-Osypka Herzzentrum München, Internistisches Klinikum München Süd, Am Isarkanal 36, 81379, München, Deutschland
| | - Elmar Strzelczyk
- Peter-Osypka Herzzentrum München, Internistisches Klinikum München Süd, Am Isarkanal 36, 81379, München, Deutschland
| | - Dominik Sepela
- Peter-Osypka Herzzentrum München, Internistisches Klinikum München Süd, Am Isarkanal 36, 81379, München, Deutschland
| | - Klaus Tiemann
- Peter-Osypka Herzzentrum München, Internistisches Klinikum München Süd, Am Isarkanal 36, 81379, München, Deutschland
| | - Thorsten Lewalter
- Peter-Osypka Herzzentrum München, Internistisches Klinikum München Süd, Am Isarkanal 36, 81379, München, Deutschland
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3
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An SJ, Davis D, Peiffer S, Gallaher J, Tignanelli CJ, Charles A. Arrhythmias in Critically Ill Surgical and Non-surgical Patients: A National Propensity-Matched Study. World J Surg 2023; 47:2668-2675. [PMID: 37524957 DOI: 10.1007/s00268-023-07129-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2023] [Indexed: 08/02/2023]
Abstract
BACKGROUND Arrhythmias are common in critically ill patients, though the impact of arrhythmias on surgical patients is not well delineated. We aimed to characterize mortality following arrhythmias in critically ill patients. METHODS We performed a propensity-matched retrospective analysis of intensive care unit (ICU) patients from 2007 to 2017 in the Cerner Acute Physiology and Chronic Health Evaluation database. We compared outcomes between patients with and without arrhythmias and those with and without surgical indications for ICU admission. We also modeled predictors of arrhythmias in surgical patients. RESULTS 467,951 patients were included; 97,958 (20.9%) were surgical patients. Arrhythmias occurred in 1.4% of the study cohorts. Predictors of arrhythmias in surgical patients included a history of cardiovascular disease (odds ratio [OR] 1.35, 95% confidence interval [CI95] 1.11-1.63), respiratory failure (OR 1.48, CI95 1.12-1.96), pneumonia (OR 3.17, CI95 1.98-5.10), higher bicarbonate level (OR 1.03, CI95 1.01-1.05), lower albumin level (OR 0.79, CI95 0.68-0.91), and vasopressor requirement (OR 27.2, CI95 22.0-33.7). After propensity matching, surgical patients with arrhythmias had a 42% mortality risk reduction compared to non-surgical patients (risk ratio [RR] 0.58, CI 95 0.43-0.79). Predicted probabilities of mortality for surgical patients were lower at all ages. CONCLUSIONS Surgical patients with arrhythmias are at lower risk of mortality than non-surgical patients. In this propensity-matched analysis, predictors of arrhythmias in critically ill surgical patients included a history of cardiovascular disease, respiratory complications, increased bicarbonate levels, decreased albumin levels, and vasopressor requirement. These findings highlight the differential effect of arrhythmias on different cohorts of critically ill populations.
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Affiliation(s)
- Selena J An
- Department of Surgery, University of North Carolina at Chapel Hill, 4001 Burnett Womack Building, CB 7050, Chapel Hill, NC, 27599, USA
| | - Dylane Davis
- School of Medicine, University of North Carolina at Chapel Hill, 1001 Bondurant Hall, CB 9535, Chapel Hill, NC, 27599, USA
| | - Sarah Peiffer
- Baylor College of Medicine, 1 Moursund St, Houston, TX, 77030, USA
| | - Jared Gallaher
- Department of Surgery, University of North Carolina at Chapel Hill, 4001 Burnett Womack Building, CB 7050, Chapel Hill, NC, 27599, USA
| | - Christopher J Tignanelli
- Department of Surgery, University of Minnesota, 11-132 Phillips-Wangensteen Bldg., 516 Delaware Street SE, Minneapolis, MN, 55455, USA
| | - Anthony Charles
- Department of Surgery, University of North Carolina at Chapel Hill, 4001 Burnett Womack Building, CB 7050, Chapel Hill, NC, 27599, USA.
- Department of Surgery, UNC School of Medicine, 4008 Burnett Womack Building, CB 7228, Chapel Hill, USA.
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4
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Tondo C. The endless fascination of right atrial flutter: Can we predict its occurrence? J Cardiovasc Electrophysiol 2023; 34:1384-1385. [PMID: 37272696 DOI: 10.1111/jce.15958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 05/21/2023] [Indexed: 06/06/2023]
Affiliation(s)
- Claudio Tondo
- Department of Electrophysiology & Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
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Ryckman N, Crinion D, Enriquez A, Bakker D, Chacko S, Abdollah H, Baranchuk A, Simpson C, Redfearn DP. Right atrial collision time (RACT): A novel marker of propensity for typical atrial flutter. J Cardiovasc Electrophysiol 2023; 34:1377-1383. [PMID: 37222182 DOI: 10.1111/jce.15935] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 03/28/2023] [Accepted: 05/04/2023] [Indexed: 05/25/2023]
Abstract
INTRODUCTION The risk of typical atrial flutter (AFL) is increased proportionately to right atrial (RA) size or right atrial scarring that results in reduced conduction velocity. These characteristics result in propagation of a flutter wave by ensuring the macro re-entrant wave front does not meet its refractory tail. The time taken to traverse the circuit would take account of both of these characteristics and may provide a novel marker of propensity to develop AFL. Our goal was to investigate right atrial collision time (RACT) as a marker of existing typical AFL. METHODS This single-centre, prospective study recruited consecutive typical AFL ablation patients that were in sinus rhythm. Controls were consecutive electrophysiology study patients >18 years of age. While pacing the coronary sinus (CS) ostium at 600 ms, a local activation time map was created to locate the latest collision point on the anterolateral right atrial wall. This RACT is a measure of conduction velocity and distance from CS to a collision point on the lateral right atrial wall. RESULTS Ninety-eight patients were included in the analysis, 41 with atrial flutter and 57 controls. Patients with atrial flutter were older, 64.7 ± 9.7 versus 52.4 ± 16.8 years (<.001), and more often male (34/41 vs. 31/57 [.003]). The AFL group mean RACT (132.6 ± 17.3 ms) was significantly longer than that of controls (99.1 ± 11.6 ms) (p < .001). A RACT cut-off of 115.5 ms had a sensitivity and specificity of 92.7% and 93.0%, respectively for diagnosis of atrial flutter. A ROC curve indicated an AUC of 0.96 (95% CI: 0.93-1.0, p < .01). CONCLUSION RACT is a novel and promising marker of propensity for typical AFL. This data will inform larger prospective studies.
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Affiliation(s)
- Nick Ryckman
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, Canada
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
- Kingston Health Sciences Centre, Queen's University, Kingston, Ontario, Canada
| | - Derek Crinion
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
- Kingston Health Sciences Centre, Queen's University, Kingston, Ontario, Canada
| | - Andres Enriquez
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
- Kingston Health Sciences Centre, Queen's University, Kingston, Ontario, Canada
| | - David Bakker
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
- Kingston Health Sciences Centre, Queen's University, Kingston, Ontario, Canada
| | - Sanoj Chacko
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
- Kingston Health Sciences Centre, Queen's University, Kingston, Ontario, Canada
| | - Hoshiar Abdollah
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
- Kingston Health Sciences Centre, Queen's University, Kingston, Ontario, Canada
| | - Adrian Baranchuk
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
- Kingston Health Sciences Centre, Queen's University, Kingston, Ontario, Canada
| | - Christopher Simpson
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
- Kingston Health Sciences Centre, Queen's University, Kingston, Ontario, Canada
| | - Damian P Redfearn
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
- Kingston Health Sciences Centre, Queen's University, Kingston, Ontario, Canada
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6
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Kim KM, Kim SY, Schulman KL, Kim MH. Incremental healthcare cost burden in patients with atrial flutter only. Front Cardiovasc Med 2023; 10:1094316. [PMID: 36937931 PMCID: PMC10014458 DOI: 10.3389/fcvm.2023.1094316] [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: 11/09/2022] [Accepted: 01/30/2023] [Indexed: 03/05/2023] Open
Abstract
Background Limited information is available on the costs related to atrial flutter only. This study provides a comprehensive estimate of the cost in patients with atrial flutter only versus matched patients without any atrial arrhythmia. Methods Patients over 20 years of age with a minimum of one inpatient or two outpatient diagnosis codes for atrial flutter in 2005 and a minimum of 12 months of continuous enrollment pre- and post-index were identified using the MarketScan Commercial and Medicare databases. Atrial flutter patients were propensity matched to patients without atrial arrhythmias. Total costs for each patient for 12 months post-index were calculated. National cost was estimated using the projected prevalence of atrial flutter for 2010. Results A total of 1,042 patients with atrial flutter only were successfully matched with comparison patients. For atrial flutter patients compared to matched controls without atrial arrhythmias, total mean annual cost per patient was 81% higher ($23,008 vs. $12,717) and mean annual inpatient expenditure was 214% higher ($8,518 vs. $2,713). When applied to national atrial flutter prevalence data, total incremental cost burden was estimated to be $687.9 million per year more than patients without atrial arrhythmias, primarily due to cardiovascular specific expenditure ($377 million, 55% of total) with 58% ($218.5 million) of the increased inpatient expenditure due to cardiovascular specific admissions and $159 million (23%) for atrial flutter specific care. Sex-related differences were also present in atrial flutter only patients. Conclusion Although atrial flutter-only patients are less prevalent than atrial fibrillation patients, the national incremental cost burden in atrial flutter is substantial on a per-patient level.
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Affiliation(s)
- Kathryn M. Kim
- Chicago Medical School, Rosalind Franklin University, North Chicago, IL, United States
| | - Steven Y. Kim
- School of Medicine, Des Moines University, Des Moines, IA, United States
| | | | - Michael H. Kim
- CHI Health, School of Medicine, Creighton University, Omaha, NE, United States
- *Correspondence: Michael H. Kim,
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Braunstein ED, Chugh SS, Makkar RR, Ehdaie A, Shehata M, Wang X. Catheter ablation of typical and atypical atrial flutters in a patient with transcatheter tricuspid valve replacement. HeartRhythm Case Rep 2022; 9:105-108. [PMID: 36860750 PMCID: PMC9968896 DOI: 10.1016/j.hrcr.2022.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- Eric D. Braunstein
- Address reprint requests and correspondence: Dr Eric D. Braunstein, Cedars-Sinai Smidt Heart Institute, 127 S. San Vicente Blvd, Suite A3600, Los Angeles, CA 90048.
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8
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Muacevic A, Adler JR, Smith AJ. Rare Paradoxical Response of Tachyarrhythmia to Adenosine Complicated by Novel ECG Artifact. Cureus 2022; 14:e31827. [PMID: 36579198 PMCID: PMC9787696 DOI: 10.7759/cureus.31827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2022] [Indexed: 11/24/2022] Open
Abstract
Adenosine is widely used for the diagnosis and treatment of supraventricular tachyarrhythmia. We report a rare case of adenosine use associated with the development of 1:1 atrial flutter with aberrancy. The diagnosis was further complicated by a newly described ECG artifact associated with Wireless Acquisition Module (WAMTM) ECG acquisition mimicking rhythm irregularity.
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Domazetoski V, Gligoric G, Marinkovic M, Shvilkin A, Krsic J, Kocarev L, Ivanovic MD. The influence of atrial flutter in automated detection of atrial arrhythmias - are we ready to go into clinical practice?". COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2022; 221:106901. [PMID: 35636359 DOI: 10.1016/j.cmpb.2022.106901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 05/13/2022] [Accepted: 05/19/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To investigate the impact of atrial flutter (Afl) in the atrial arrhythmias classification task. We additionally advocate the use of a subject-based split for future studies in the field in order to avoid within-subject correlation which may lead to over-optimistic inferences. Finally, we demonstrate the effectiveness of the classifiers outside of the initially studied circumstances, by performing an inter-dataset model evaluation of the classifiers in data from different sources. METHODS ECG signals of two private and three public (two MIT-BIH and Chapman ecgdb) databases were preprocessed and divided into 10s segments which were then subject to feature extraction. The created datasets were divided into a training and test set in two ways, based on a random split and a patient split. Classification was performed using the XGBoost classifier, as well as two benchmark classification models using both data splits. The trained models were then used to make predictions on the test data of the remaining datasets. RESULTS The XGBoost model yielded the best performance across all datasets compared to the remaining benchmark models, however variability in model performance was seen across datasets, with accuracy ranging from 70.6% to 89.4%, sensitivity ranging from 61.4% to 76.8%, and specificity ranging from 87.3% to 95.5%. When comparing the results between the patient and the random split, no significant difference was seen in the two private datasets and the Chapman dataset, where the number of samples per patient is low. Nonetheless, in the MIT-BIH dataset, where the average number of samples per patient is approximately 1300, a noticeable disparity was identified. The accuracy, sensitivity, and specificity of the random split in this dataset of 93.6%, 86.4%, and 95.9% respectively, were decreased to 88%, 61.4%, and 89.8% in the patient split, with the largest drop being in Afl sensitivity, from 71% to 5.4%. The inter-dataset scores were also significantly lower than their intra-dataset counterparts across all datasets. CONCLUSIONS CAD systems have great potential in the assistance of physicians in reliable, precise and efficient detection of arrhythmias. However, although compelling research has been done in the field, yielding models with excellent performances on their datasets, we show that these results may be over-optimistic. In our study, we give insight into the difficulty of detection of Afl on several datasets and show the need for a higher representation of Afl in public datasets. Furthermore, we show the necessity of a more structured evaluation of model performance through the use of a patient-based split and inter-dataset testing scheme to avoid the problem of within-subject correlation which may lead to misleadingly high scores. Finally, we stress the need for the creation and use of datasets with a higher number of patients and a more balanced representation of classes if we are to progress in this mission.
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Affiliation(s)
- Viktor Domazetoski
- Research Center for Computer Science and Information Technologies, Macedonian Academy of Sciences and Arts, Skopje, Macedonia.
| | - Goran Gligoric
- Vinca Institute of Nuclear Sciences - National Institute of the Republic of Serbia, University of Belgrade, Belgrade, Serbia
| | - Milan Marinkovic
- Cardiology clinic, Clinical center of Serbia, School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Alexei Shvilkin
- Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, USA
| | - Jelena Krsic
- Vinca Institute of Nuclear Sciences - National Institute of the Republic of Serbia, University of Belgrade, Belgrade, Serbia
| | - Ljupco Kocarev
- Research Center for Computer Science and Information Technologies, Macedonian Academy of Sciences and Arts, Skopje, Macedonia; Faculty of Computer Science and Engineering, Ss. Cyril and Methodius University, Skopje, Macedonia
| | - Marija D Ivanovic
- Vinca Institute of Nuclear Sciences - National Institute of the Republic of Serbia, University of Belgrade, Belgrade, Serbia
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Thyagaturu HS, Bolton A, Thangjui S, Shah K, Shrestha B, Voruganti D, Katz D. Differences in Stroke or Systemic Thromboembolism Readmission Risk After Hospitalization for Atrial Fibrillation and Atrial Flutter. Cureus 2022; 14:e23844. [PMID: 35530853 PMCID: PMC9070688 DOI: 10.7759/cureus.23844] [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] [Accepted: 04/05/2022] [Indexed: 11/05/2022] Open
Abstract
Background Although atrial fibrillation (AF) and atrial flutter (AFL) are different arrhythmias, they are assumed to confer the same risk of stroke and systemic thromboembolism (STE) despite a lack of available evidence. In this study, we investigated the difference in the risk of stroke or STE after AF and AFL hospitalizations. Methodology The National Readmission Database (NRD) 2018 was used to identify AF and AFL patients using appropriate International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes and were followed until the end of the calendar year to identify stroke or STE readmissions. Survival estimates were calculated, and a Cox proportional hazards model was used to calculate the adjusted hazards ratio (aHR) and compare the risk of stroke or STE readmissions between AF and AFL groups. Results A total of 215,810 AF and 15,292 AFL patients were identified. AFL patients were more likely to be younger (66 vs. 70 years), male (68% vs. 47%), and had higher prevalence of obesity (25% vs. 22%), obstructive sleep apnea (14% vs. 12%), diabetes mellitus (31% vs. 26%), and alcohol use (6.9% vs. 5.5%) (all p < 0.01). After adjusting for potential patient and hospital-level characteristics, there was a statistically significant decrease in one-year stroke or STE readmission risk in AFL patients compared to AF patients (aHR 0.79 (0.66-0.95); p = 0.01). Conclusions AFL patients are commonly younger males with a higher burden of medical comorbidity. There is a decrease in the one-year risk of stroke or STE events in AFL patients compared to AF. The predictors of stroke and STE are similar in both AFL and AF groups. Further studies with longer follow-up and anticoagulation data are needed to verify the results.
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Yugo D, Chen YY, Lin YJ, Chien KL, Chang SL, Lo LW, Hu YF, Chao TF, Chung FP, Liao JN, Chang TY, Lin CY, Tuan TC, Kuo L, Wu CI, Liu CM, Liu SH, Li CH, Hsieh YC, Chen SA. Long-term mortality and cardiovascular outcomes in patients with atrial flutter after catheter ablation. Europace 2021; 24:970-978. [PMID: 34939091 DOI: 10.1093/europace/euab308] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 12/01/2021] [Indexed: 11/14/2022] Open
Abstract
AIMS For patients with typical and atypical atrial flutter (AFL) but without history of atrial fibrillation (AF), the long-term cardiovascular (CV) outcomes after catheter ablation for AFL remain unclear. We compared the long-term all-cause mortality and CV outcomes in patients with AFL receiving catheter ablation compared with the results with medical therapy. METHODS AND RESULTS Atrial flutter patients receiving catheter ablation for typical AFL were identified using the Health Insurance Database, and constituted the 'AFL ablation group'. Patients with typical and atypical AFL but without ablation (AFL without ablation group) were propensity matched to the AFL ablation group. Patients with prior AF diagnosis were excluded. Primary outcomes included all-cause and CV mortality, heart failure (HF) hospitalization, and stroke. The multivariable cox hazards regression model was used to evaluate the hazard ratio (HR) for study outcomes. A total of 3784 AFL patients (1892 patients in each group) was studied. Their mean follow-up durations were 7.85 ± 2.57 years (AFL without ablation group) and 8.31 ± 4.53 years (AFL ablation group). Atrial flutter with ablation patients had lower risks of all-cause mortality (HR: 0.68, P < 0.001), CV deaths (HR: 0.78, P = 0.001), HF hospitalization (HR: 0.84, P = 0.01), and stroke (HR: 0.80, P = 0.01). CONCLUSIONS Catheter ablation for AFL in patients without prior AF was associated with lower risks of all-cause mortality and CV events compared with AFL patients without ablation during long-term follow-ups.
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Affiliation(s)
- Dony Yugo
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwa.,Cardiovascular Department, Faculty of Medicine, University of Indonesia, Jakarta, Indonesia
| | - Yun-Yu Chen
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwa.,Institute of Epidemiology and Preventive Medicine College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Yenn-Jiang Lin
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwa.,Faculty of Medicine and Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei and Hsinchu, Taiwan
| | - Kuo-Liong Chien
- Institute of Epidemiology and Preventive Medicine College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Shih-Lin Chang
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwa.,Faculty of Medicine and Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei and Hsinchu, Taiwan
| | - Li-Wei Lo
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwa.,Faculty of Medicine and Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei and Hsinchu, Taiwan
| | - Yu-Feng Hu
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwa.,Faculty of Medicine and Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei and Hsinchu, Taiwan
| | - Tze-Fan Chao
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwa.,Faculty of Medicine and Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei and Hsinchu, Taiwan
| | - Fa-Po Chung
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwa.,Faculty of Medicine and Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei and Hsinchu, Taiwan
| | - Jo-Nan Liao
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwa.,Faculty of Medicine and Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei and Hsinchu, Taiwan
| | - Ting-Yung Chang
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwa.,Faculty of Medicine and Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei and Hsinchu, Taiwan
| | - Chin-Yu Lin
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwa.,Faculty of Medicine and Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei and Hsinchu, Taiwan
| | - Ta-Chuan Tuan
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwa
| | - Ling Kuo
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwa
| | - Cheng-I Wu
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwa.,Faculty of Medicine and Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei and Hsinchu, Taiwan
| | - Chih-Min Liu
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwa.,Faculty of Medicine and Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei and Hsinchu, Taiwan
| | - Shin-Huei Liu
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwa
| | - Cheng-Hung Li
- Faculty of Medicine and Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei and Hsinchu, Taiwan.,Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Yu-Cheng Hsieh
- Faculty of Medicine and Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei and Hsinchu, Taiwan.,Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Shih-Ann Chen
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwa.,Faculty of Medicine and Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei and Hsinchu, Taiwan.,Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
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Patoulias DI, Boulmpou A, Teperikidis E, Katsimardou A, Siskos F, Doumas M, Papadopoulos CE, Vassilikos V. Cardiovascular efficacy and safety of dipeptidyl peptidase-4 inhibitors: A meta-analysis of cardiovascular outcome trials. World J Cardiol 2021; 13:585-592. [PMID: 34754403 PMCID: PMC8554356 DOI: 10.4330/wjc.v13.i10.585] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 07/08/2021] [Accepted: 09/10/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Dipeptidyl peptidase-4 (DPP-4) inhibitors are a generally safe and well tolerated antidiabetic drug class with proven efficacy in type 2 diabetes mellitus (T2DM). Recently, a series of large, randomized controlled trials (RCTs) addressing cardiovascular outcomes with DPP-4 inhibitors have been published.
AIM To pool data from the aforementioned trials concerning the impact of DPP-4 inhibitors on surrogate cardiovascular efficacy outcomes and on major cardiac arrhythmias.
METHODS We searched PubMed and grey literature sources for all published RCTs assessing cardiovascular outcomes with DPP-4 inhibitors compared to placebo until October 2020. We extracted data concerning the following “hard” efficacy outcomes: fatal and non-fatal myocardial infarction, fatal and non-fatal stroke, hospitalization for heart failure, hospitalization for unstable angina, hospitalization for coronary revascularization and cardiovascular death. We also extracted data regarding the risk for major cardiac arrhythmias, such as atrial fibrillation, atrial flutter, ventricular fibrillation and ventricular tachycardia.
RESULTS We pooled data from 6 trials in a total of 52520 patients with T2DM assigned either to DPP-4 inhibitor or placebo. DPP-4 inhibitors compared to placebo led to a non-significant increase in the risk for fatal and non-fatal myocardial infarction [risk ratio (RR) = 1.02, 95%CI: 0.94-1.11, I2 = 0%], hospitalization for heart failure (RR = 1.09, 95%CI: 0.92-1.29, I2 = 65%) and cardiovascular death (RR = 1.02, 95%CI: 0.93-1.11, I2 = 0%). DPP-4 inhibitors resulted in a non-significant decrease in the risk for fatal and non-fatal stroke (RR = 0.96, 95%CI: 0.85-1.08, I2 = 0%) and coronary revascularization (RR = 0.99, 95%CI: 0.90-1.09, I2 = 0%), Finally, DPP-4 inhibitors demonstrated a neutral effect on the risk for hospitalization due to unstable angina (RR = 1.00, 95%CI: 0.85-1.18, I2 = 0%). As far as cardiac arrhythmias are concerned, DPP-4 inhibitors did not significantly affect the risk for atrial fibrillation (RR = 0.95, 95%CI: 0.78-1.17, I2 = 0%), while they were associated with a significant increase in the risk for atrial flutter, equal to 52% (RR = 1.52, 95%CI: 1.03-2.24, I2 = 0%). DPP-4 inhibitors did not have a significant impact on the risk for any of the rest assessed cardiac arrhythmias.
CONCLUSION DPP-4 inhibitors do not seem to confer any significant cardiovascular benefit for patients with T2DM, while they do not seem to be associated with a significant risk for any major cardiac arrhythmias, except for atrial flutter. Therefore, this drug class should not be the treatment of choice for patients with established cardiovascular disease or multiple risk factors, except for those cases when newer antidiabetics (glucagon-like peptide-1 receptor agonists and sodium-glucose co-transporter-2 inhibitors) are not tolerated, contraindicated or not affordable for the patient.
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Affiliation(s)
- Dimitrios Ioannis Patoulias
- Second Propedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, Hippokration General Hospital, Thessaloniki 54642, Greece
| | - Aristi Boulmpou
- Third Department of Cardiology, Aristotle University of Thessaloniki, Hippokration General Hospital, Thessaloniki 54642, Greece
| | - Eleftherios Teperikidis
- Third Department of Cardiology, Aristotle University of Thessaloniki, Hippokration General Hospital, Thessaloniki 54642, Greece
| | - Alexandra Katsimardou
- Second Propedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, Hippokration General Hospital, Thessaloniki 54642, Greece
| | - Fotios Siskos
- Second Propedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, Hippokration General Hospital, Thessaloniki 54642, Greece
| | - Michael Doumas
- Second Propedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, Hippokration General Hospital, Thessaloniki 54642, Greece
| | - Christodoulos E Papadopoulos
- Third Department of Cardiology, Aristotle University of Thessaloniki, Hippokration General Hospital, Thessaloniki 54642, Greece
| | - Vassilios Vassilikos
- Third Department of Cardiology, Aristotle University of Thessaloniki, Hippokration General Hospital, Thessaloniki 54642, Greece
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Diamant MJ, Andrade JG, Virani SA, Jhund PS, Petrie MC, Hawkins NM. Heart failure and atrial flutter: a systematic review of current knowledge and practices. ESC Heart Fail 2021; 8:4484-4496. [PMID: 34505352 PMCID: PMC8712920 DOI: 10.1002/ehf2.13526] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 06/04/2021] [Accepted: 07/05/2021] [Indexed: 01/14/2023] Open
Abstract
While the interplay between heart failure (HF) and atrial fibrillation (AF) has been extensively studied, little is known regarding HF and atrial flutter (AFL), which may be managed differently. We reviewed the incidence, prevalence, and predictors of HF in AFL and vice versa, and the outcomes of treatment of AFL in HF. A systematic literature review of PubMed/Medline and EMBASE yielded 65 studies for inclusion and qualitative synthesis. No study described the incidence or prevalence of AFL in unselected patients with HF. Most cohorts enrolled patients with AF/AFL as interchangeable diagnoses, or highly selected patients with tachycardia‐induced cardiomyopathy. The prevalence of HF in AFL ranged from 6% to 56%. However, the phenotype of HF was never defined by left ventricular ejection fraction (LVEF). No studies reported the predictors, phenotype, and prognostic implications of AFL in HF. There was significant variation in treatments studied, including the proportion that underwent ablation. When systolic dysfunction was tachycardia‐mediated, catheter ablation demonstrated LVEF normalization in up to 88%, as well as reduced cardiovascular mortality. In summary, AFL and HF often coexist but are understudied, with no randomized trial data to inform care. Further research is warranted to define the epidemiology and establish optimal management.
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Affiliation(s)
- Michael J Diamant
- Division of Cardiology, Royal Columbian Hospital, New Westminster, British Columbia, Canada.,Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jason G Andrade
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sean A Virani
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Pardeep S Jhund
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Mark C Petrie
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Nathaniel M Hawkins
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
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14
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Post AD, Buchan S, John M, Safavi-Naeini P, Cosgriff-Hernández E, Razavi M. Reconstituting electrical conduction in soft tissue: the path to replace the ablationist. Europace 2021; 23:1892-1902. [PMID: 34477862 DOI: 10.1093/europace/euab187] [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: 03/23/2021] [Accepted: 07/08/2021] [Indexed: 11/13/2022] Open
Abstract
Cardiac arrhythmias are a leading cause of morbidity and mortality in the developed world. A common mechanism underlying many of these arrhythmias is re-entry, which may occur when native conduction pathways are disrupted, often by myocardial infarction. Presently, re-entrant arrhythmias are most commonly treated with antiarrhythmic drugs and myocardial ablation, although both treatment methods are associated with adverse side effects and limited efficacy. In recent years, significant advancements in the field of biomaterials science have spurred increased interest in the development of novel therapies that enable restoration of native conduction in damaged or diseased myocardium. In this review, we assess the current landscape of materials-based approaches to eliminating re-entrant arrhythmias. These approaches potentially pave the way for the eventual replacement of myocardial ablation as a preferred therapy for such pathologies.
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Affiliation(s)
- Allison D Post
- Electrophysiology Clinical Research and Innovations, Texas Heart Institute, 6770 Bertner Avenue, Houston, TX 77030, USA
| | - Skylar Buchan
- Electrophysiology Clinical Research and Innovations, Texas Heart Institute, 6770 Bertner Avenue, Houston, TX 77030, USA
| | - Mathews John
- Electrophysiology Clinical Research and Innovations, Texas Heart Institute, 6770 Bertner Avenue, Houston, TX 77030, USA
| | - Payam Safavi-Naeini
- Electrophysiology Clinical Research and Innovations, Texas Heart Institute, 6770 Bertner Avenue, Houston, TX 77030, USA
| | | | - Mehdi Razavi
- Electrophysiology Clinical Research and Innovations, Texas Heart Institute, 6770 Bertner Avenue, Houston, TX 77030, USA.,Department of Cardiology, Baylor College of Medicine, Houston, TX, USA
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15
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Faust O, Kareem M, Ali A, Ciaccio EJ, Acharya UR. Automated Arrhythmia Detection Based on RR Intervals. Diagnostics (Basel) 2021; 11:diagnostics11081446. [PMID: 34441380 PMCID: PMC8391893 DOI: 10.3390/diagnostics11081446] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 07/29/2021] [Accepted: 08/03/2021] [Indexed: 11/16/2022] Open
Abstract
Abnormal heart rhythms, also known as arrhythmias, can be life-threatening. AFIB and AFL are examples of arrhythmia that affect a growing number of patients. This paper describes a method that can support clinicians during arrhythmia diagnosis. We propose a deep learning algorithm to discriminate AFIB, AFL, and NSR RR interval signals. The algorithm was designed with data from 4051 subjects. With 10-fold cross-validation, the algorithm achieved the following results: ACC = 99.98%, SEN = 100.00%, and SPE = 99.94%. These results are significant because they show that it is possible to automate arrhythmia detection in RR interval signals. Such a detection method makes economic sense because RR interval signals are cost-effective to measure, communicate, and process. Having such a cost-effective solution might lead to widespread long-term monitoring, which can help detecting arrhythmia earlier. Detection can lead to treatment, which improves outcomes for patients.
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Affiliation(s)
- Oliver Faust
- Department of Engineering and Mathematics, Sheffield Hallam University, Sheffield S1 1WB, UK;
- Correspondence:
| | - Murtadha Kareem
- Department of Engineering and Mathematics, Sheffield Hallam University, Sheffield S1 1WB, UK;
| | - Ali Ali
- Sheffield Teaching Hospitals NIHR Biomedical Research Centre, Sheffield S10 2JF, UK;
| | - Edward J. Ciaccio
- Department of Medicine—Cardiology, Columbia University, New York, NY 10027, USA;
| | - U. Rajendra Acharya
- School of Engineering, Ngee Ann Polytechnic, Singapore 599489, Singapore;
- Department of Bioinformatics and Medical Engineering, Asia University, Taichung 41354, Taiwan
- School of Science and Technology, Singapore University of Social Sciences, Clementi 599494, Singapore
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16
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Takahira H, Kajiyama T, Kondo Y, Nakano M, Nakano M, Ito R, Kitagawa M, Sugawara M, Chiba T, Kobayashi Y. Pathophysiological background and prognosis of common atrial flutter in non-elderly patients: Comparison to Atrial Fibrillation. J Cardiol 2021; 78:362-367. [PMID: 34140202 DOI: 10.1016/j.jjcc.2021.05.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 04/25/2021] [Accepted: 05/07/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND It is unclear whether there is any difference in the background and prognosis between non-elderly patients who undergo catheter ablation of atrial fibrillation (AF) and common atrial flutter (CAFL). PURPOSE To investigate the difference between the patient background of both CAFL and AF in the non-elderly. METHODS In 526 consecutive patients who underwent catheter ablation of clinical paroxysmal/persistent CAFL or AF in our hospital, we enrolled only patients under 60 years old. Cases harboring both AFL and AF were excluded. We analyzed the patient characteristics, echocardiographic findings, electrocardiographic (ECG) abnormalities during sinus rhythm, and clinical course after ablation. RESULTS In total, 196 patients (Cohort 1: 142 males, 156 AF cases) were analyzed. AFL patients were younger than AF patients (47.4 ± 10.6 vs. 50.2 ± 6.4years, p = 0.031) and organic heart disease (OHD) was significantly more common in AFL patients than AF patients (42.5% vs. 11.5%, p<0.001). In 161 patients excluding OHD (Cohort 2), ECG abnormalities were more frequent in AFL than in AF patients (78.3% vs. 39.1%, p = 0.001). There were no significant differences in all-cause death, onset of heart failure, and cerebral strokes. On the other hand, the number of cases that required a pacemaker was significantly higher in the CAFL group than AF group (0.0% vs. 26.1%, p-value <0.001). These results suggested that CAFL may reflect occurrence of any atrial myocardial damage, even if it does not lead to heart failure. CONCLUSIONS Our present study suggested that CAFL may be associated with a broader atrial myocardial disorder in non-elderly patients.
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Affiliation(s)
- Haruhiro Takahira
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Takatsugu Kajiyama
- Department of Advanced Cardiorhythm Therapeutics, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan.
| | - Yusuke Kondo
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Masahiro Nakano
- Department of Advanced Cardiorhythm Therapeutics, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan
| | - Miyo Nakano
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Ryo Ito
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Mari Kitagawa
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Masafumi Sugawara
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Toshinori Chiba
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
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Abstract
The World Heart Federation (WHF) commenced a Roadmap initiative in 2015 to reduce the global burden of cardiovascular disease and resultant burgeoning of healthcare costs. Roadmaps provide a blueprint for implementation of priority solutions for the principal cardiovascular diseases leading to death and disability. Atrial fibrillation (AF) is one of these conditions and is an increasing problem due to ageing of the world’s population and an increase in cardiovascular risk factors that predispose to AF. The goal of the AF roadmap was to provide guidance on priority interventions that are feasible in multiple countries, and to identify roadblocks and potential strategies to overcome them. Since publication of the AF Roadmap in 2017, there have been many technological advances including devices and artificial intelligence for identification and prediction of unknown AF, better methods to achieve rhythm control, and widespread uptake of smartphones and apps that could facilitate new approaches to healthcare delivery and increasing community AF awareness. In addition, the World Health Organisation added the non-vitamin K antagonist oral anticoagulants (NOACs) to the Essential Medicines List, making it possible to increase advocacy for their widespread adoption as therapy to prevent stroke. These advances motivated the WHF to commission a 2020 AF Roadmap update. Three years after the original Roadmap publication, the identified barriers and solutions were judged still relevant, and progress has been slow. This 2020 Roadmap update reviews the significant changes since 2017 and identifies priority areas for achieving the goals of reducing death and disability related to AF, particularly targeted at low-middle income countries. These include advocacy to increase appreciation of the scope of the problem; plugging gaps in guideline management and prevention through physician education, increasing patient health literacy, and novel ways to increase access to integrated healthcare including mHealth and digital transformations; and greater emphasis on achieving practical solutions to national and regional entrenched barriers. Despite the advances reviewed in this update, the task will not be easy, but the health rewards of implementing solutions that are both innovative and practical will be great.
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18
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Feinberg JB, Olsen MH, Brandes A, Raymond L, Nielsen WB, Nielsen EE, Stensgaard-Hansen F, Dixen U, Pedersen OD, Gang UJO, Gluud C, Jakobsen JC. Lenient rate control versus strict rate control for atrial fibrillation: a protocol for the Danish Atrial Fibrillation (DanAF) randomised clinical trial. BMJ Open 2021; 11:e044744. [PMID: 33789853 PMCID: PMC8016086 DOI: 10.1136/bmjopen-2020-044744] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION Atrial fibrillation is the most common heart arrhythmia with a prevalence of approximately 2% in the western world. Atrial fibrillation is associated with an increased risk of death and morbidity. In many patients, a rate control strategy is recommended. The optimal heart rate target is disputed despite the results of the the RAte Control Efficacy in permanent atrial fibrillation: a comparison between lenient vs strict rate control II (RACE II) trial.Our primary objective will be to investigate the effect of lenient rate control strategy (<110 beats per minute (bpm) at rest) compared with strict rate control strategy (<80 bpm at rest) on quality of life in patients with persistent or permanent atrial fibrillation. METHODS AND ANALYSIS We plan a two-group, superiority randomised clinical trial. 350 outpatients with persistent or permanent atrial fibrillation will be recruited from four hospitals, across three regions in Denmark. Participants will be randomised 1:1 to a lenient medical rate control strategy (<110 bpm at rest) or a strict medical rate control strategy (<80 bpm at rest). The recruitment phase is planned to be 2 years with 3 years of follow-up. Recruitment is expected to start in January 2021. The primary outcome will be quality of life using the Short Form-36 (SF-36) questionnaire (physical component score). Secondary outcomes will be days alive outside hospital, symptom control using the Atrial Fibrillation Effect on Quality of Life, quality of life using the SF-36 questionnaire (mental component score) and serious adverse events. The primary assessment time point for all outcomes will be 1 year after randomisation. ETHICS AND DISSEMINATION Ethics approval was obtained through the ethics committee in Region Zealand. The design and findings will be published in peer-reviewed journals as well as be made available on ClinicalTrials.gov. TRIAL REGISTRATION NUMBER NCT04542785.
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Affiliation(s)
- Joshua Buron Feinberg
- Department of Internal Medicine - Cardiology Section, Holbaek Hospital, Holbaek, Region Zealand, Denmark
- Department of Regional Health Research, University of Southern Denmark Faculty of Health Sciences, Odense, Denmark
| | - Michael Hecht Olsen
- Department of Internal Medicine - Cardiology Section, Holbaek Hospital, Holbaek, Region Zealand, Denmark
- Department of Regional Health Research, University of Southern Denmark Faculty of Health Sciences, Odense, Denmark
| | - Axel Brandes
- Department of Cardiology, Odense University Hospital, Odense C, Denmark
| | - Llan Raymond
- Department of Internal Medicine - Cardiology Section, Holbaek Hospital, Holbaek, Region Zealand, Denmark
| | - Walter Bjørn Nielsen
- Department of Internal Medicine - Cardiology Section, Holbaek Hospital, Holbaek, Region Zealand, Denmark
| | - Emil Eik Nielsen
- Department of Internal Medicine - Cardiology Section, Holbaek Hospital, Holbaek, Region Zealand, Denmark
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Capital Region of Denmark, Copenhagen, Denmark
| | - Frank Stensgaard-Hansen
- Department of Internal Medicine - Cardiology Section, Holbaek Hospital, Holbaek, Region Zealand, Denmark
| | - Ulrik Dixen
- Department of Cardiology, Hvidovre University Hospital, Hvidovre, Denmark
| | - Ole Dyg Pedersen
- Department of cardiology, Zealand University Hospital Roskilde, Roskilde, Region Zealand, Denmark
| | - Uffe Jakob Ortved Gang
- Department of cardiology, Zealand University Hospital Roskilde, Roskilde, Region Zealand, Denmark
| | - Christian Gluud
- Department of Regional Health Research, University of Southern Denmark Faculty of Health Sciences, Odense, Denmark
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Capital Region of Denmark, Copenhagen, Denmark
| | - Janus Christian Jakobsen
- Department of Regional Health Research, University of Southern Denmark Faculty of Health Sciences, Odense, Denmark
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Capital Region of Denmark, Copenhagen, Denmark
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Ebner B, Grant J, Vincent L, Maning J, Olorunfemi O, Olarte N, Colombo R, Lambrakos L, Mendoza I. Comparison of in-hospital outcomes of patients undergoing catheter ablation for typical versus atypical atrial flutter. J Interv Card Electrophysiol 2021; 63:295-302. [PMID: 33770337 DOI: 10.1007/s10840-021-00982-4] [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: 01/17/2021] [Accepted: 03/15/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Catheter ablation (CA) is indicated as definitive therapy for patients with either typical or atypical atrial flutter (TAFlutter and AAFlutter, respectively) which is unresponsive to medical therapy. There is a paucity of data regarding in-hospital outcomes of patients undergoing CA. METHODS Retrospective study using the NIS to identify patients ≥18 years who underwent CA between 2015 and 2017. Individuals were identified using ICD-10-CM/PCS for TAFlutter, AAFlutter, and CA. RESULTS A total of 17,390 patients underwent CA for Aflutter (33% AAFlutter and 67% TAFlutter). The TAFlutter group was younger (mean 65.9 years vs. 67.2 years), with less females (30% vs. 43%, p ≤ 0.001 for both) compared to the AAFlutter group. The TAFlutter group had a higher rate of diabetes, tobacco use, obesity, and chronic obstructive pulmonary disease (p ≤ 0.001 for all). The AAFlutter cohort had increased prior strokes and atrial fibrillation (p ≤ 0.001 for both). The mean CHA2DS2-VASc score was found to be 2.3 in AAFlutter compared to 2.1 in TAFlutter (p ≤ 0.001). There were significantly higher proportions of thromboembolic events, transfusions, and longer length of stay in the TAFlutter group (p ≤ 0.001 for all) with the AAFlutter group having significantly higher rates of cardioversion, implantation of cardiac devices, and increased hospital charges (p ≤ 0.001 for all); no significant difference was found in mortality after controlling for comorbidities. CONCLUSIONS We found higher complication rates in CA for patients with TAFlutter, but no difference in in-hospital all-cause mortality. Variation in CA depending upon the mechanism of AFlutter may underlie these differences, and warrant further study.
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Affiliation(s)
- Bertrand Ebner
- Department of Internal Medicine, University of Miami Hospital Miller School of Medicine/Jackson Memorial Hospital, 1611 NW 12th Avenue, Miami, FL, 33136, USA.
| | - Jelani Grant
- Department of Internal Medicine, University of Miami Hospital Miller School of Medicine/Jackson Memorial Hospital, 1611 NW 12th Avenue, Miami, FL, 33136, USA
| | - Louis Vincent
- Department of Internal Medicine, University of Miami Hospital Miller School of Medicine/Jackson Memorial Hospital, 1611 NW 12th Avenue, Miami, FL, 33136, USA
| | - Jennifer Maning
- Department of Internal Medicine, University of Miami Hospital Miller School of Medicine/Jackson Memorial Hospital, 1611 NW 12th Avenue, Miami, FL, 33136, USA
| | - Odunayo Olorunfemi
- Cardiovascular Division, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Neal Olarte
- Cardiovascular Division, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Rosario Colombo
- Cardiovascular Division, Jackson Memorial Hospital, Miami, FL, USA
| | - Litsa Lambrakos
- Cardiovascular Division, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Ivan Mendoza
- Cardiovascular Division, Jackson Memorial Hospital, Miami, FL, USA
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Iden L, Richardt G, Weinert R, Groschke S, Toelg R, Borlich M. Typical atrial flutter but not fibrillation predicts coronary artery disease in formerly healthy patients. Europace 2021; 23:1227-1236. [PMID: 33611584 DOI: 10.1093/europace/euab002] [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: 02/28/2020] [Accepted: 01/06/2021] [Indexed: 11/14/2022] Open
Abstract
AIMS Long-term mortality after ablation of typical atrial flutter has been found to be increased two-fold in comparison to atrial fibrillation ablations through a period of 5 years with unclear mechanism. METHODS AND RESULTS We analysed 189 consecutive patients who underwent ablation for typical atrial flutter (AFL), in which the incidence of AF was the first manifestation of cardiac disease. According to the clinical standards of our centre, the routine recommendation was to evaluate for coronary artery disease (CAD) by invasive angiogram or computed tomography scan. We compared the AFL patients to 141 patients with paroxysmal atrial fibrillation (AFIB) without known structural heart disease who underwent ablation in the same period and who had routine coronary angiograms performed. Out of 189 patients who presented with AFL, coronary status was available in 152 patients (80.4%). Both groups were balanced for mean age (64.9 years in AFL vs. 63.2 years in AFIB; P = 0.15), body mass index (BMI; 28.8 vs. 28.5 kg/m2; P = 0.15), CHA2DS2-VASc-Score (2.20 vs. 2.04; P = 0.35), smoking status (22.2% smokers vs. 28.4%; P = 0.23), and renal function (GFR >60 mL/min in 96.7% of all patients vs. 95.7%; P = 0.76). There were significantly lower values for left ventricular ejection fraction (52.5% vs. 59.7%; P < 0.001), female sex (17.0% vs. 47.5%; P < 0.001), hyperlipidaemia (37.9% vs. 58.9%; P < 0.001), and family history of cardiovascular disease (CVD) (15.0 vs. 31.9%; P = 0.001) in the AFL vs. AFIB cohorts. Coronary artery disease with stenoses >50% was found in 26.3% of all patients with available coronary status in AFL and in 7.0% in AFIB (P < 0.001). Coronary artery disease with stenoses >75% in 16.4% in AFL whereas only in 1.4% in AFIB (P < 0.001). Multivessel disease was detected in 10.5% in AFL and 0.7% in AFIB (P < 0.001). After correction for age, left ventricular ejection fraction, BMI, CHA2DS2-VASc-Score and its individual components, smoking status, hyperlipidaemia, and family history of CVD, there was a more than five-fold increase in the likelihood of CAD with stenosis >50% in AFL as compared to AFIB [odds ratio (OR 5.26)]. A multivariate analysis was performed in the AFL group. Patients with clinically relevant stenoses (>75%) were older (70.6 years vs. 63.8 years; P = 0.001), had a higher number of risk factors (3.08 vs. 2.24; P ≤ 0.0016) and a higher CHA2DS2-VASc-Score (3.20 vs. 2.00; P < 0.0001). With logistic regression, significant CAD could be predicted by higher values for CHA2DS2-VASc-Score with an exponential rise to a pretest-probability of 42.1% at a value of 4 points. CONCLUSION These data suggest that typical atrial flutter constitutes a manifestation of previously asymptomatic CAD. Due to the inclusion criteria, CAD has to be considered silent and chronic in most of the patients. Therefore, the presence of typical atrial flutter in formerly healthy patients should raise suspicion of otherwise silent CAD and initiate further investigations and risk stratification with particular emphasis on the individual CHA2DS2-VASc-Scores.
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Affiliation(s)
- Leon Iden
- Department of Cardiology, Heart Center, Segeberger Kliniken (Academic Teaching Hospital of the Universities of Kiel, Lübeck and Hamburg), Am Kurpark 1, Bad Segeberg, Schleswig-Holstein, 23795, Germany
| | - Gert Richardt
- Department of Cardiology, Heart Center, Segeberger Kliniken (Academic Teaching Hospital of the Universities of Kiel, Lübeck and Hamburg), Am Kurpark 1, Bad Segeberg, Schleswig-Holstein, 23795, Germany
| | - Rolf Weinert
- Department of Cardiology, Heart Center, Segeberger Kliniken (Academic Teaching Hospital of the Universities of Kiel, Lübeck and Hamburg), Am Kurpark 1, Bad Segeberg, Schleswig-Holstein, 23795, Germany
| | - Susann Groschke
- Department of Cardiology, Heart Center, Segeberger Kliniken (Academic Teaching Hospital of the Universities of Kiel, Lübeck and Hamburg), Am Kurpark 1, Bad Segeberg, Schleswig-Holstein, 23795, Germany
| | - Ralph Toelg
- Department of Cardiology, Heart Center, Segeberger Kliniken (Academic Teaching Hospital of the Universities of Kiel, Lübeck and Hamburg), Am Kurpark 1, Bad Segeberg, Schleswig-Holstein, 23795, Germany
| | - Martin Borlich
- Department of Cardiology, Heart Center, Segeberger Kliniken (Academic Teaching Hospital of the Universities of Kiel, Lübeck and Hamburg), Am Kurpark 1, Bad Segeberg, Schleswig-Holstein, 23795, Germany
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21
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Lionnet A, Cueff C, de Gaalon S, Manigold T, Sévin M, Testard N, Guillon B. Cause cardiache di embolia cerebrale. Neurologia 2020. [DOI: 10.1016/s1634-7072(20)44011-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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22
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Nigussie B, Abaleka FI, Suhail M, Yimer E, Rotatori F. Diagnosis and Management of 1:1 Atrial Flutter in the Setting of Aortic Valve Endocarditis and Embolic Stroke. Cureus 2020; 12:e8739. [PMID: 32596092 PMCID: PMC7308918 DOI: 10.7759/cureus.8739] [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] [Indexed: 11/16/2022] Open
Abstract
Atrial flutter is a rapid, regular atrial tachyarrhythmia that occurs most commonly in patients with underlying structural heart disease. Spontaneous 1:1 conduction of atrial flutter is indeed rare, but its diagnosis and management is of critical importance. We describe a case of a 65-year-old man with hypertension, preserved ejection fraction heart failure, end-stage renal disease, Parkinson’s disease, and Alzheimer’s dementia, in whom atrial flutter was associated with 1:1 atrioventricular conduction. Our patient was hemodynamically unstable with aortic valve endocarditis and recent septic embolic stroke. This case report emphasizes the importance of recognition and management to avoid hemodynamic compromise.
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Baman JR, Kaplan RM, Diaz CL, Peigh G, Bavishi AA, Trivedi A, Wasserlauf J, Chicos AB, Arora R, Kim S, Lin A, Verma N, Knight BP, Passman RS. Characterization of atrial flutter after pulmonary vein isolation by cryoballoon ablation. J Interv Card Electrophysiol 2020; 57:233-240. [PMID: 31102114 PMCID: PMC7025862 DOI: 10.1007/s10840-019-00560-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 05/06/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE Pulmonary vein isolation (PVI) by cryoballoon ablation (CBA) has emerged as a commonly used technique for the treatment of atrial fibrillation. We sought to explore the incidence, risk factors for, and characterization of post-CBA-PVI atrial flutter. METHODS We analyzed a prospective registry of patients who underwent CBA-PVI at a single institution. We included patients with more than 3 months of follow-up data and excluded those with a history of cavotricuspid isthmus (CTI) ablation. Locations of post-CBA-PVI atrial flutters were determined by analysis of intracardiac electrograms and electroanatomic maps. RESULTS There were 556 patients included in the analysis. The mean age was 61.0 ± 10.6 years, 67.4% were male, the number of failed anti-arrhythmic medication trials was 1.2 ± 0.8, and the duration of atrial fibrillation pre-CBA was 54.3 ± 69.1 months. The 28-mm second-generation cryoballoon was used almost exclusively. Over a median follow-up time of 22.7 ± 17.9 months, 25 (4.5%) patients developed post-CBA-PVI atrial flutter after the 3-month blanking period. Of those 25 patients, 15 (60%) underwent subsequent ablation to eliminate the atrial flutter circuit, with 60% being CTI-dependent and the remainder left-sided (p value not significant). Risk factors for the development of atrial flutter included NYHA class ≥ 2 (OR 5.02, p < 0.001), presence of baseline bundle branch block (OR 4.33, p = 0.006), and left ventricular ejection fraction < 50% (OR 3.36, p = 0.007). CONCLUSIONS The rate of post-CBA-PVI atrial flutter is low after the blanking period even with medium-term follow-up. The origin of atrial flutter is equally divided between the right and left atria.
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Affiliation(s)
- Jayson R Baman
- Division of Cardiology, Department of Medicine, and the Bluhm Cardiovascular Institute, Northwestern Memorial Hospital, Northwestern University, 676 N St Claire Street; Suite 600, Chicago, IL, 60611, USA
| | - Rachel M Kaplan
- Division of Cardiology, Department of Medicine, and the Bluhm Cardiovascular Institute, Northwestern Memorial Hospital, Northwestern University, 676 N St Claire Street; Suite 600, Chicago, IL, 60611, USA
| | - Celso L Diaz
- Division of Cardiology, Department of Medicine, and the Bluhm Cardiovascular Institute, Northwestern Memorial Hospital, Northwestern University, 676 N St Claire Street; Suite 600, Chicago, IL, 60611, USA
| | - Graham Peigh
- Division of Cardiology, Department of Medicine, and the Bluhm Cardiovascular Institute, Northwestern Memorial Hospital, Northwestern University, 676 N St Claire Street; Suite 600, Chicago, IL, 60611, USA
| | - Aakash A Bavishi
- Division of Cardiology, Department of Medicine, and the Bluhm Cardiovascular Institute, Northwestern Memorial Hospital, Northwestern University, 676 N St Claire Street; Suite 600, Chicago, IL, 60611, USA
| | - Amar Trivedi
- Division of Cardiology, Department of Medicine, and the Bluhm Cardiovascular Institute, Northwestern Memorial Hospital, Northwestern University, 676 N St Claire Street; Suite 600, Chicago, IL, 60611, USA
| | - Jeremiah Wasserlauf
- Division of Cardiology, Department of Medicine, and the Bluhm Cardiovascular Institute, Northwestern Memorial Hospital, Northwestern University, 676 N St Claire Street; Suite 600, Chicago, IL, 60611, USA
| | - Alexandru B Chicos
- Division of Cardiology, Department of Medicine, and the Bluhm Cardiovascular Institute, Northwestern Memorial Hospital, Northwestern University, 676 N St Claire Street; Suite 600, Chicago, IL, 60611, USA
| | | | - Susan Kim
- Division of Cardiology, Department of Medicine, and the Bluhm Cardiovascular Institute, Northwestern Memorial Hospital, Northwestern University, 676 N St Claire Street; Suite 600, Chicago, IL, 60611, USA
| | - Albert Lin
- Division of Cardiology, Department of Medicine, and the Bluhm Cardiovascular Institute, Northwestern Memorial Hospital, Northwestern University, 676 N St Claire Street; Suite 600, Chicago, IL, 60611, USA
| | - Nishant Verma
- Division of Cardiology, Department of Medicine, and the Bluhm Cardiovascular Institute, Northwestern Memorial Hospital, Northwestern University, 676 N St Claire Street; Suite 600, Chicago, IL, 60611, USA
| | - Bradley P Knight
- Division of Cardiology, Department of Medicine, and the Bluhm Cardiovascular Institute, Northwestern Memorial Hospital, Northwestern University, 676 N St Claire Street; Suite 600, Chicago, IL, 60611, USA
| | - Rod S Passman
- Division of Cardiology, Department of Medicine, and the Bluhm Cardiovascular Institute, Northwestern Memorial Hospital, Northwestern University, 676 N St Claire Street; Suite 600, Chicago, IL, 60611, USA.
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Potapova KV, Nosov VP, Koroleva LY, Amineva NV. [Atrial Flutter: up-to-date Problem Evaluation with Clinical Positions]. ACTA ACUST UNITED AC 2020; 60:70-80. [PMID: 32245357 DOI: 10.18087/cardio.2020.1.n693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 10/29/2019] [Indexed: 11/18/2022]
Abstract
The review provides current ideas about the etiology and prevalence of atrial flutter (AF), mechanism and substrate of arrhythmogenesis, and principles of clinical and electrophysiological classification of this arrhythmia. Methods for conservative and surgical treatments of AF, including their comparative aspect, are described in detail. The review presented recent data on efficacy and potential risks of different approaches to reversing the arrhythmia. The authors indicated a need for early diagnosis and strict control of the sinus rhythm in AF, which would help a successful intervention not only to completely cure the existing arrhythmia but also to prevent other heart rhythm disorders, primarily atrial fibrillation.
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Affiliation(s)
| | - V P Nosov
- Privolzhsky Research Medical University
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25
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Ueberham L, König S, Hohenstein S, Mueller-Roething R, Wiedemann M, Schade A, Seyfarth M, Sause A, Neuser H, Staudt A, Zacharzowsky U, Reithmann C, Shin DI, Andrie R, Wetzel U, Tebbenjohanns J, Wunderlich C, Kuhlen R, Hindricks G, Bollmann A. Sex differences of resource utilisation and outcomes in patients with atrial arrhythmias and heart failure. Heart 2019; 106:527-533. [DOI: 10.1136/heartjnl-2019-315566] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 11/16/2019] [Accepted: 11/25/2019] [Indexed: 12/14/2022] Open
Abstract
ObjectiveAtrial fibrillation or atrial flutter (AF) and heart failure (HF) often go hand in hand and, in combination, lead to an increased risk of death compared with patients with just one of both entities. Sex-specific differences in patients with AF and HF are under-reported. Therefore, the aim of this study was to investigate sex-specific catheter ablation (CA) use and acute in-hospital outcomes in patients with AF and concomitant HF in a retrospective cohort study.MethodsUsing International Statistical Classification of Diseases and Related Health Problems and Operations and Procedures codes, administrative data of 75 hospitals from 2010 to 2018 were analysed to identify cases with AF and HF. Sex differences were compared for baseline characteristics, right and left atrial CA use, procedure-related adverse outcomes and in-hospital mortality.ResultsOf 54 645 analysed cases with AF and HF, 46.2% were women. Women were significantly older (75.4±9.5 vs 68.7±11.1 years, p<0.001), had different comorbidities (more frequently: cerebrovascular disease (2.4% vs 1.8%, p<0.001), dementia (5.3% vs 2.2%, p<0.001), rheumatic disease (2.1% vs 0.8%, p<0.001), diabetes with chronic complications (9.7% vs 9.1%, p=0.033), hemiplegia or paraplegia (1.7% vs 1.2%, p<0.001) and chronic kidney disease (43.7% vs 33.5%, p<0.001); less frequently: myocardial infarction (5.4% vs 10.5%, p<0.001), peripheral vascular disease (6.9% vs 11.3%, p<0.001), mild liver disease (2.0% vs 2.3%, p=0.003) or any malignancy (1.0% vs 1.3%, p<0.001), underwent less often CA (12.0% vs 20.7%, p<0.001), had longer hospitalisations (6.6±5.8 vs 5.2±5.2 days, p<0.001) and higher in-hospital mortality (1.6% vs 0.9%, p<0.001). However, in the multivariable generalised linear mixed model for in-hospital mortality, sex did not remain an independent predictor (OR 0.96, 95% CI 0.82 to 1.12, p=0.579) when adjusted for age and comorbidities. Vascular access complications requiring interventions (4.8% vs 4.2%, p=0.001) and cardiac tamponade (0.3% vs 0.1%, p<0.001) occurred more frequently in women, whereas stroke (0.6% vs 0.5%, p=0.179) and death (0.3% vs 0.1%, p=0.101) showed no sex difference in patients undergoing CA.ConclusionsThere are sex differences in patients with AF and HF with respect to demographics, resource utilisation and in-hospital outcomes. This needs to be considered when treating women with AF and HF, especially for a sufficient patient informed decision making in clinical practice.
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Benjamin EJ, Muntner P, Alonso A, Bittencourt MS, Callaway CW, Carson AP, Chamberlain AM, Chang AR, Cheng S, Das SR, Delling FN, Djousse L, Elkind MSV, Ferguson JF, Fornage M, Jordan LC, Khan SS, Kissela BM, Knutson KL, Kwan TW, Lackland DT, Lewis TT, Lichtman JH, Longenecker CT, Loop MS, Lutsey PL, Martin SS, Matsushita K, Moran AE, Mussolino ME, O'Flaherty M, Pandey A, Perak AM, Rosamond WD, Roth GA, Sampson UKA, Satou GM, Schroeder EB, Shah SH, Spartano NL, Stokes A, Tirschwell DL, Tsao CW, Turakhia MP, VanWagner LB, Wilkins JT, Wong SS, Virani SS. Heart Disease and Stroke Statistics-2019 Update: A Report From the American Heart Association. Circulation 2019; 139:e56-e528. [PMID: 30700139 DOI: 10.1161/cir.0000000000000659] [Citation(s) in RCA: 5236] [Impact Index Per Article: 1047.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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27
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Fujita H, Cimr D. Computer Aided detection for fibrillations and flutters using deep convolutional neural network. Inf Sci (N Y) 2019. [DOI: 10.1016/j.ins.2019.02.065] [Citation(s) in RCA: 100] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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28
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Ma W, Zhu D, Zhang W. Ring versus band: All roads lead to Rome. J Thorac Cardiovasc Surg 2019; 157:e251-e252. [PMID: 30685176 DOI: 10.1016/j.jtcvs.2018.12.037] [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: 12/12/2018] [Accepted: 12/14/2018] [Indexed: 10/27/2022]
Affiliation(s)
- Wenrui Ma
- Department of Cardiovascular Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China; Department of Cardiac Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Dan Zhu
- Department of Cardiovascular Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Wei Zhang
- Department of Cardiovascular Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
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Bertomeu-González V, Castillo-Castillo J. Atrial flutter, time to acknowledge its own identity. Int J Clin Pract 2018; 72:e13266. [PMID: 30288925 DOI: 10.1111/ijcp.13266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Vicente Bertomeu-González
- Hospital Universitario de San Juan, Alicante, Spain
- Universidad Miguel Hernández, Elche, Spain
- CIBER Cardiovascular CB16/11/00420, Alicante, Spain
| | - Jesus Castillo-Castillo
- Hospital Universitario de San Juan, Alicante, Spain
- Universidad Miguel Hernández, Elche, Spain
- CIBER Cardiovascular CB16/11/00420, Alicante, Spain
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30
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Miyoshi T, Sakaguchi H, Shiraishi I, Yoshimatsu J, Ikeda T. Fetal paroxysmal atrial fibrillation during transplacental therapy for supraventricular tachycardia. HeartRhythm Case Rep 2018; 5:22-24. [PMID: 30693200 PMCID: PMC6342607 DOI: 10.1016/j.hrcr.2018.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Takekazu Miyoshi
- Department of Perinatology and Gynecology, National Cerebral and Cardiovascular Center, Suita, Japan.,Department of Obstetrics and Gynecology, Mie University, Tsu, Japan
| | - Heima Sakaguchi
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Isao Shiraishi
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Jun Yoshimatsu
- Department of Perinatology and Gynecology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Tomoaki Ikeda
- Department of Obstetrics and Gynecology, Mie University, Tsu, Japan
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Lin YS, Chen YL, Chen TH, Lin MS, Liu CH, Yang TY, Chung CM, Chen MC. Comparison of Clinical Outcomes Among Patients With Atrial Fibrillation or Atrial Flutter Stratified by CHA2DS2-VASc Score. JAMA Netw Open 2018; 1:e180941. [PMID: 30646091 PMCID: PMC6324304 DOI: 10.1001/jamanetworkopen.2018.0941] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 05/02/2018] [Indexed: 12/31/2022] Open
Abstract
Importance Current guidelines support treating atrial fibrillation (AF) and atrial flutter (AFL) as equivalent risk factors for ischemic stroke stratified by CHA2DS2-VASc scores, recommending anticoagulation therapy for patients with a CHA2DS2-VASc score of 2 or higher, but some studies found differences in clinical outcomes. Objective To investigate differences in clinical outcomes among AF, AFL, and matched control cohorts. Design, Setting, and Participants This nationwide cohort study analyzed data from the Taiwan National Health Insurance Research Database from January 1, 2001, through December 31, 2012. Follow-up and data analysis ended December 31, 2012. A total of 219 416 age- and sex-matched individuals participated in the study. Clinical outcomes were compared after stratification by CHA2DS2-VASc score (possible score range, 0-9; higher scores indicate greater risk of ischemic stroke). Main Outcomes and Measures Ischemic stroke, heart failure hospitalization, and all-cause mortality among the AF, AFL, and matched control cohorts were analyzed using Cox proportional hazards regression. Results This study comprised 188 811 patients in the AF cohort (mean [SD] age, 73.8 [13.4] years; 104 703 [55.5%] male), 6121 patients in the AFL cohort (mean [SD] age, 67.7 [15.8] years; 3735 [61.0%] male), and 24 484 patients in the matched control cohort (mean [SD] age, 67.3 [15.6] years; 14 940 [61.0%] male). The patients with AF were older, were more predominantly female, and had higher CHA2DS2-VASc scores than the patients with AFL and the control participants. After stratification by CHA2DS2-VASc score, the incidence densities (IDs; events per 100 person-years) of ischemic stroke (AF cohort: ID, 3.08; 95% CI, 3.03-3.13; AFL cohort: ID, 1.45; 95% CI, 1.28-1.62; controls: ID, 0.97; 95% CI, 0.92-1.03), heart failure hospitalization (AF cohort: ID, 3.39; 95% CI, 3.34-3.44; AFL cohort: ID, 1.57; 95% CI, 1.39-1.74; controls: ID, 0.32; 95% CI, 0.29-0.35), and all-cause mortality (AF cohort: ID, 17.8; 95% CI, 17.7-17.9; AFL cohort: ID, 13.9; 95% CI, 13.4-14.4; controls: ID, 4.2; 95% CI, 4.1-4.4) were significantly higher in the AF cohort than in the matched control cohort. For the AFL cohort vs the matched control cohort, the incidences of heart failure hospitalization and all-cause mortality were significantly higher across all levels, but the incidence of ischemic stroke was only significantly higher at CHA2DS2-VASc scores of 5 to 9. For the AF cohort vs the AFL cohort, the incidences of ischemic stroke and heart failure hospitalization were significantly higher at a CHA2DS2-VASc score of 1 or higher, but the incidence of all-cause mortality was significantly higher only at CHA2DS2-VASc scores of 1 to 3. Conclusions and Relevance This study found different clinical outcomes between patients with AFL and AF and those without AF and AFL. The current recommended level of the CHA2DS2-VASc score in preventing ischemic stroke in patients with AFL should be reevaluated.
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Affiliation(s)
- Yu-Sheng Lin
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
- Chang Gung University College of Medicine, Taoyuan, Taiwan
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yung-Lung Chen
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taiwan
| | - Tien-Hsing Chen
- Division of Cardiology, Department of Medicine, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Ming-Shyan Lin
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Chi-Hung Liu
- Stroke Center and Department of Neurology, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Teng-Yao Yang
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Chang-Ming Chung
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Mien-Cheng Chen
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taiwan
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Gula LJ, Redfearn DP, Jenkyn KB, Allen B, Skanes AC, Leong-Sit P, Shariff SZ. Elevated Incidence of Atrial Fibrillation and Stroke in Patients With Atrial Flutter—A Population-Based Study. Can J Cardiol 2018; 34:774-783. [DOI: 10.1016/j.cjca.2018.01.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 01/03/2018] [Accepted: 01/03/2018] [Indexed: 10/18/2022] Open
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Al-Kawaz M, Omran SS, Parikh NS, Elkind MS, Soliman EZ, Kamel H. Comparative Risks of Ischemic Stroke in Atrial Flutter versus Atrial Fibrillation. J Stroke Cerebrovasc Dis 2018; 27:839-844. [DOI: 10.1016/j.jstrokecerebrovasdis.2017.10.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 10/20/2017] [Indexed: 10/18/2022] Open
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Benjamin EJ, Virani SS, Callaway CW, Chamberlain AM, Chang AR, Cheng S, Chiuve SE, Cushman M, Delling FN, Deo R, de Ferranti SD, Ferguson JF, Fornage M, Gillespie C, Isasi CR, Jiménez MC, Jordan LC, Judd SE, Lackland D, Lichtman JH, Lisabeth L, Liu S, Longenecker CT, Lutsey PL, Mackey JS, Matchar DB, Matsushita K, Mussolino ME, Nasir K, O'Flaherty M, Palaniappan LP, Pandey A, Pandey DK, Reeves MJ, Ritchey MD, Rodriguez CJ, Roth GA, Rosamond WD, Sampson UKA, Satou GM, Shah SH, Spartano NL, Tirschwell DL, Tsao CW, Voeks JH, Willey JZ, Wilkins JT, Wu JH, Alger HM, Wong SS, Muntner P. Heart Disease and Stroke Statistics-2018 Update: A Report From the American Heart Association. Circulation 2018; 137:e67-e492. [PMID: 29386200 DOI: 10.1161/cir.0000000000000558] [Citation(s) in RCA: 4467] [Impact Index Per Article: 744.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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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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Diagnostic decision support systems for atrial fibrillation based on a novel electrocardiogram approach. J Electrocardiol 2018; 51:252-259. [DOI: 10.1016/j.jelectrocard.2017.10.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Indexed: 11/19/2022]
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Ehdaie A, Cingolani E, Shehata M, Wang X, Curtis AB, Chugh SS. Sex Differences in Cardiac Arrhythmias. Circ Arrhythm Electrophysiol 2018; 11:e005680. [DOI: 10.1161/circep.117.005680] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Accepted: 02/05/2018] [Indexed: 12/19/2022]
Affiliation(s)
- Ashkan Ehdaie
- From the The Smidt Heart Institute, Cedars-Sinai, Los Angeles, CA (A.E. E.C., M.S. X.W., S.S.C.); and Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, NY (A.B.C.)
| | - Eugenio Cingolani
- From the The Smidt Heart Institute, Cedars-Sinai, Los Angeles, CA (A.E. E.C., M.S. X.W., S.S.C.); and Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, NY (A.B.C.)
| | - Michael Shehata
- From the The Smidt Heart Institute, Cedars-Sinai, Los Angeles, CA (A.E. E.C., M.S. X.W., S.S.C.); and Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, NY (A.B.C.)
| | - Xunzhang Wang
- From the The Smidt Heart Institute, Cedars-Sinai, Los Angeles, CA (A.E. E.C., M.S. X.W., S.S.C.); and Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, NY (A.B.C.)
| | - Anne B. Curtis
- From the The Smidt Heart Institute, Cedars-Sinai, Los Angeles, CA (A.E. E.C., M.S. X.W., S.S.C.); and Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, NY (A.B.C.)
| | - Sumeet S. Chugh
- From the The Smidt Heart Institute, Cedars-Sinai, Los Angeles, CA (A.E. E.C., M.S. X.W., S.S.C.); and Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, NY (A.B.C.)
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38
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Abstract
BACKGROUND Patients with atrial fibrillation not being adequately treated with oral anticoagulant (OAC) therapy, with therapy underutilization or premature termination, have been commonly reported. However, studies on the utilization pattern of OAC therapy for patients with atrial flutter (AFL) are few. The aim of this study was to investigate the utilization of OAC therapy, and its influencing factors for patients with AFL in South Korea, as well as the types and percentages of anticoagulants used. METHODS We analyzed Aged Population Sample data compiled by the Health Insurance Review & Assessment Service from 2011 to 2015. We identified patients with AFL having the KCD-6 code I48.1. Patients at high risk of stroke with a congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke (or transient ischemic attack), vascular disease, sex score of ≥2 and at low risk of bleeding with an anticoagulation and risk factors in atrial fibrillation score of ≤4 were included in the study. Oral anticoagulant therapy underutilization was estimated in these patients using anticoagulant underutilization (ACU) scales. Demographic and clinical factors associated with OAC therapy underutilization were investigated using a logistic regression model. RESULTS The mean ACU value was calculated as 67.4% between 2011 and 2015. Positive risk factors for ACU were identified as follows: female sex, aspirin utilization, and limited anticoagulant options. Negative risk factors included comorbidities, such as congestive heart failure and valvular heart disease, and a history of stroke or transient ischemic attack. CONCLUSIONS Our study demonstrates that two-third of patients with AFL in South Korea failed to obtain adequate stroke prevention treatment, even in the era of direct OAC availability. This tendency was more profound in women or those on aspirin therapy.
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Affiliation(s)
- Sanghun Lee
- 1 College of Pharmacy, Pusan National University, Geumjeong-gu, Busan, Republic of Korea
| | - Nam Kyung Je
- 1 College of Pharmacy, Pusan National University, Geumjeong-gu, Busan, Republic of Korea
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39
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Waligóra M, Tyrka A, Miszalski-Jamka T, Urbańczyk-Zawadzka M, Podolec P, Kopeć G. Right atrium enlargement predicts clinically significant supraventricular arrhythmia in patients with pulmonary arterial hypertension. Heart Lung 2018; 47:237-242. [PMID: 29454666 DOI: 10.1016/j.hrtlng.2018.01.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Accepted: 01/08/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND Right atrial (RA) enlargement is a common finding in patients with pulmonary arterial hypertension (PAH) and an important predictor of mortality, however its relation to the risk of atrial arrhythmias has not been assessed. OBJECTIVES To assess whether RA enlargement is associated with supraventricular arrhythmias (SVA) and whether it predicts new clinically significant SVA (csSVA). METHODS Patients with PAH were recruited between January 2010 and December 2014 and followed until January 2017. csSVA was diagnosed if it resulted in hospitalization. To assess predictors of new csSVA, only patients without a history of SVA at baseline were analyzed. RESULTS Among 97 patients, any SVA was observed in 45 (46.4%) and included permanent atrial fibrillation(AF, n = 8), paroxysmal AF (n = 10), permanent atrial flutter (AFl, n = 1), paroxysmal AFl (n = 2) or other types of supraventricular tachycardia (n = 24). Patients with SVA as compared to patients without SVA were characterized by older age, lower distance in a 6-minute test, higher NT-proBNP, higher RA area index (RAai), left atrial area index, mean right atrial pressure (mRAP) and were more commonly treated with β-blocker. Eighty five patients who were in sinus rhythm at baseline assessment and had no history of significant SVA were observed for 37 ± 19.9 months. During that time csSVA occurred in 15.3%. In univariate models, the occurrence of csSVA were predicted by age, right ventricular ejection fraction, right ventricular end diastolic index, RAai and mRAP, but in multivariate model only RAai remained significant predictor for csSVA (HR of 1.23, 95%CI: 1.11-1.36, p < 0.001). The optimal threshold for RA enlargement as discriminator of csSVA was 21.7 cm2/m2. CONCLUSIONS In PAH patients RA enlargement is associated with increased prevalence of SVA. RAai is an independent predictor of hospitalization due to csSVA.
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Affiliation(s)
- Marcin Waligóra
- Department of Cardiac and Vascular Diseases, Faculty of Medicine, Jagiellonian University Medical College, John Paul II Hospital in Krakow, Pradnicka 80, Kraków, Poland
| | - Anna Tyrka
- Department of Cardiac and Vascular Diseases, Faculty of Medicine, Jagiellonian University Medical College, John Paul II Hospital in Krakow, Pradnicka 80, Kraków, Poland
| | - Tomasz Miszalski-Jamka
- Department of Radiology and Diagnostic Imaging, John Paul II Hospital in Krakow, Pradnicka 80, Kraków, Poland
| | | | - Piotr Podolec
- Department of Cardiac and Vascular Diseases, Faculty of Medicine, Jagiellonian University Medical College, John Paul II Hospital in Krakow, Pradnicka 80, Kraków, Poland
| | - Grzegorz Kopeć
- Department of Cardiac and Vascular Diseases, Faculty of Medicine, Jagiellonian University Medical College, John Paul II Hospital in Krakow, Pradnicka 80, Kraków, Poland.
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40
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Sethi NJ, Feinberg J, Nielsen EE, Safi S, Gluud C, Jakobsen JC. The effects of rhythm control strategies versus rate control strategies for atrial fibrillation and atrial flutter: A systematic review with meta-analysis and Trial Sequential Analysis. PLoS One 2017; 12:e0186856. [PMID: 29073191 PMCID: PMC5658096 DOI: 10.1371/journal.pone.0186856] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 10/09/2017] [Indexed: 01/16/2023] Open
Abstract
Background Atrial fibrillation and atrial flutter may be managed by either a rhythm control strategy or a rate control strategy but the evidence on the clinical effects of these two intervention strategies is unclear. Our objective was to assess the beneficial and harmful effects of rhythm control strategies versus rate control strategies for atrial fibrillation and atrial flutter. Methods We searched CENTRAL, MEDLINE, Embase, LILACS, Web of Science, BIOSIS, Google Scholar, clinicaltrials.gov, TRIP, EU-CTR, Chi-CTR, and ICTRP for eligible trials comparing any rhythm control strategy with any rate control strategy in patients with atrial fibrillation or atrial flutter published before November 2016. Our primary outcomes were all-cause mortality, serious adverse events, and quality of life. Our secondary outcomes were stroke and ejection fraction. We performed both random-effects and fixed-effect meta-analysis and chose the most conservative result as our primary result. We used Trial Sequential Analysis (TSA) to control for random errors. Statistical heterogeneity was assessed by visual inspection of forest plots and by calculating inconsistency (I2) for traditional meta-analyses and diversity (D2) for TSA. Sensitivity analyses and subgroup analyses were conducted to explore the reasons for substantial statistical heterogeneity. We assessed the risk of publication bias in meta-analyses consisting of 10 trials or more with tests for funnel plot asymmetry. We used GRADE to assess the quality of the body of evidence. Results 25 randomized clinical trials (n = 9354 participants) were included, all of which were at high risk of bias. Meta-analysis showed that rhythm control strategies versus rate control strategies significantly increased the risk of a serious adverse event (risk ratio (RR), 1.10; 95% confidence interval (CI), 1.02 to 1.18; P = 0.02; I2 = 12% (95% CI 0.00 to 0.32); 21 trials), but TSA did not confirm this result (TSA-adjusted CI 0.99 to 1.22). The increased risk of a serious adverse event did not seem to be caused by any single component of the composite outcome. Meta-analysis showed that rhythm control strategies versus rate control strategies were associated with better SF-36 physical component score (mean difference (MD), 6.93 points; 95% CI, 2.25 to 11.61; P = 0.004; I2 = 95% (95% CI 0.94 to 0.96); 8 trials) and ejection fraction (MD, 4.20%; 95% CI, 0.54 to 7.87; P = 0.02; I2 = 79% (95% CI 0.69 to 0.85); 7 trials), but TSA did not confirm these results. Both meta-analysis and TSA showed no significant differences on all-cause mortality, SF-36 mental component score, Minnesota Living with Heart Failure Questionnaire, and stroke. Conclusions Rhythm control strategies compared with rate control strategies seem to significantly increase the risk of a serious adverse event in patients with atrial fibrillation. Based on current evidence, it seems that most patients with atrial fibrillation should be treated with a rate control strategy unless there are specific reasons (e.g., patients with unbearable symptoms due to atrial fibrillation or patients who are hemodynamically unstable due to atrial fibrillation) justifying a rhythm control strategy. More randomized trials at low risk of bias and low risk of random errors are needed. Trial registration PROSPERO CRD42016051433
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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:
| | - Joshua Feinberg
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - 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
| | - 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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41
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Urgent catheter ablation in Octogenarians with Serious Tachyarrhythmias. Nihon Ronen Igakkai Zasshi 2017; 54:314-321. [PMID: 28855454 DOI: 10.3143/geriatrics.54.314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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42
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Soliman EZ. Race and atrial flutter: a needed update to understand the atrial fibrillation race paradox. Future Cardiol 2017; 13:423-427. [PMID: 28832187 DOI: 10.2217/fca-2017-0049] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
- Elsayed Z Soliman
- The Epidemiological Cardiology Research Center (EPICARE), Department of Epidemiology & Prevention, & Department of Medicine, Section on Cardiology, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA
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43
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Lin YS, Chen TH, Chi CC, Lin MS, Tung TH, Liu CH, Chen YL, Chen MC. Different Implications of Heart Failure, Ischemic Stroke, and Mortality Between Nonvalvular Atrial Fibrillation and Atrial Flutter-a View From a National Cohort Study. J Am Heart Assoc 2017; 6:e006406. [PMID: 28733435 PMCID: PMC5586326 DOI: 10.1161/jaha.117.006406] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 06/02/2017] [Indexed: 12/04/2022]
Abstract
BACKGROUND Atrial flutter (AFL) has been identified to be equivalent to atrial fibrillation (AF) in terms of preventing ischemic stroke, although differences exist in atrial rate, substrate, and electrophysiological mechanisms. This study aimed to investigate differences in clinical outcomes between nonvalvular AF and AFL. METHODS AND RESULTS AF and AFL patients without any prescribed anticoagulation were enrolled from a 13-year national cohort database. Under series exclusion criteria, ischemic stroke, heart failure hospitalization, and all-cause mortality were compared between the groups in real-world conditions and after propensity score matching. We identified 175 420 patients in the AF cohort and 6239 patients in the AFL cohort, and the prevalence of most comorbidities and frequency of medications were significantly higher in the AF group than the AFL group. In the real-world setting the AF patients had higher incidence rates of ischemic stroke, heart failure hospitalization, and all-cause mortality than the AFL patients (all P<0.001). After propensity score matching, the incidence rate of ischemic stroke in the AF cohort was 1.63-fold higher than in the AFL cohort (P<0.001), the incidence rate of heart failure hospitalization in the AF cohort was 1.70-fold higher than in the AFL cohort (P<0.001), and the incidence rate of all-cause mortality in the AF cohort was 1.08-fold higher than in the AFL cohort (P=0.002). CONCLUSIONS There were differences between AF and AFL in comorbidities and prognosis with regard to ischemic stroke, heart failure hospitalization, and all-cause mortality.
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Affiliation(s)
- Yu-Sheng Lin
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Tien-Hsing Chen
- Division of Cardiology, Department of Medicine, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Ching-Chi Chi
- Department of Dermatology, Chang Gung Memorial Hospital, Linkou, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ming-Shyan Lin
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Yunlin, Taiwan
| | - Tao-Hsin Tung
- Faculty of Public Health, College of Medicine, Fu-Jen Catholic University, Taipei, Taiwan
- Department of Medical Research and Education, Cheng Hsin General Hospital, Taipei, Taiwan
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Chi-Hung Liu
- Stroke Center and Department of Neurology, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Yung-Lung Chen
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Mien-Cheng Chen
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
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44
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He W, Chu Y. Atrial fibrillation as a prognostic indicator of myocardial infarction and cardiovascular death: a systematic review and meta-analysis. Sci Rep 2017; 7:3360. [PMID: 28611377 PMCID: PMC5469813 DOI: 10.1038/s41598-017-03653-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 05/03/2017] [Indexed: 01/20/2023] Open
Abstract
This study aimed to investigate whether atrial fibrillation (AF) predicts myocardial infarction (MI) or cardiovascular (CV) death. AF is a well-established risk factor for thrombotic stroke and all-cause mortality. PubMed, EmBase, and Cochrane Central were searched for articles comparing the incidence rates of MI, CV death, or CV events between AF and non-AF patients. Relative risk ratio (RR) was used as effect estimate. Crude and adjusted RRs were calculated. Data were pooled using a random-effects model. The meta-analysis included 27 studies. In the unadjusted analysis, AF patients had a nonsignificant trend toward a higher risk of MI compared with non-AF patients; however, a significant association was found. The crude data analysis showed that AF was associated with increased risk of CV death (P < 0.05) and CV events (P < 0.05). These associations remained significant after pooling data from adjusted models (CV death: RR = 1.95, 95% CI 1.51–2.51, P < 0.05; CV events: RR = 2.10, 95% CI 1.50–2.95, P < 0.05). These results showed that AF is an independent risk factor for MI, CV death, and CV events.
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Affiliation(s)
- Wenqi He
- Emergency department, Henan province People's Hospital, Zhengzhou, Henan Province, 450003, China
| | - Yingjie Chu
- Emergency department, Henan province People's Hospital, Zhengzhou, Henan Province, 450003, China.
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45
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Sethi NJ, Safi S, Feinberg J, Nielsen EE, Gluud C, Jakobsen JC. Digoxin versus placebo, no intervention, or other medical interventions for atrial fibrillation and atrial flutter: a protocol for a systematic review with meta-analysis and Trial Sequential Analysis. Syst Rev 2017; 6:71. [PMID: 28381269 PMCID: PMC5382469 DOI: 10.1186/s13643-017-0470-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 03/28/2017] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Atrial fibrillation is the most common arrhythmia of the heart with a prevalence of approximately 2% in the western world. Atrial flutter, another arrhythmia, occurs less often with an incidence of approximately 200,000 new patients per year in the USA. Patients with atrial fibrillation and atrial flutter have an increased risk of death and morbidities. In the management of atrial fibrillation and atrial flutter, it is often necessary to use medical interventions to lower the heart rate. Lowering the heart rate may theoretically prevent the development of heart failure and tachycardia-mediated cardiomyopathy. The evidence on the benefits and harms of digoxin compared with placebo or with other medical interventions is unclear. This protocol for a systematic review aims at identifying the beneficial and harmful effects of digoxin compared with placebo, no intervention, or with other medical interventions for atrial fibrillation and atrial flutter. METHODS This protocol for a systematic review was conducted following the recommendations of Cochrane and the eight-step assessment procedure suggested by Jakobsen and colleagues. We plan to include all relevant randomised clinical trials comparing digoxin with placebo, no intervention, or with other medical interventions. We plan to search the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, LILACS, Science Citation Index Expanded on Web of Science, and BIOSIS to identify relevant trials. Any eligible trial will be assessed and classified as either at high risk of bias or low risk of bias, and our primary conclusions will be based on trials with low risk of bias. We will perform our meta-analyses of the extracted data using Review Manager 5.3 and Trial Sequential Analysis ver. 0.9.5.5 beta. For both our primary and secondary outcomes, we will create a 'Summary of Findings' table based on GRADE assessments of the quality of the evidence. DISCUSSION The results of this systematic review have the potential to benefit millions of patients worldwide as well as healthcare economy. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42016052935.
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Affiliation(s)
- Naqash J Sethi
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
| | - Sanam Safi
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Joshua Feinberg
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Emil E Nielsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,The Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Janus C Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,The Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Cardiology, Holbæk Hospital, Holbæk, Denmark
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46
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Benjamin EJ, Blaha MJ, Chiuve SE, Cushman M, Das SR, Deo R, de Ferranti SD, Floyd J, Fornage M, Gillespie C, Isasi CR, Jiménez MC, Jordan LC, Judd SE, Lackland D, Lichtman JH, Lisabeth L, Liu S, Longenecker CT, Mackey RH, Matsushita K, Mozaffarian D, Mussolino ME, Nasir K, Neumar RW, Palaniappan L, Pandey DK, Thiagarajan RR, Reeves MJ, Ritchey M, Rodriguez CJ, Roth GA, Rosamond WD, Sasson C, Towfighi A, Tsao CW, Turner MB, Virani SS, Voeks JH, Willey JZ, Wilkins JT, Wu JH, Alger HM, Wong SS, Muntner P. Heart Disease and Stroke Statistics-2017 Update: A Report From the American Heart Association. Circulation 2017; 135:e146-e603. [PMID: 28122885 PMCID: PMC5408160 DOI: 10.1161/cir.0000000000000485] [Citation(s) in RCA: 6032] [Impact Index Per Article: 861.7] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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47
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Sethi NJ, Safi S, Nielsen EE, Feinberg J, Gluud C, Jakobsen JC. The effects of rhythm control strategies versus rate control strategies for atrial fibrillation and atrial flutter: a protocol for a systematic review with meta-analysis and Trial Sequential Analysis. Syst Rev 2017; 6:47. [PMID: 28264715 PMCID: PMC5340010 DOI: 10.1186/s13643-017-0449-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Accepted: 02/28/2017] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Atrial fibrillation is the most common arrhythmia of the heart with a prevalence of approximately 2% in the western world. Atrial flutter, another arrhythmia, occurs less often with an incidence of approximately 200,000 new patients per year in the USA. Patients with atrial fibrillation and atrial flutter have an increased risk of death and morbidities. The management of atrial fibrillation and atrial flutter is often based on interventions aiming at either a rhythm control strategy or a rate control strategy. The evidence on the comparable effects of these strategies is unclear. This protocol for a systematic review aims at identifying the best overall treatment strategy for atrial fibrillation and atrial flutter. METHODS This protocol for a systematic review was performed following the recommendations of the Cochrane Collaboration and the eight-step assessment procedure suggested by Jakobsen and colleagues. We plan to include all relevant randomised clinical trials assessing the effects of any rhythm control strategy versus any rate control strategy. We plan to search the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, LILACS, Science Citation Index Expanded on Web of Science, and BIOSIS to identify relevant trials. Any eligible trial will be assessed and classified as either high risk of bias or low risk of bias, and our conclusions will be based on trials with low risk of bias. The analyses of the extracted data will be performed using Review Manager 5 and Trial Sequential Analysis. For both our primary and secondary outcomes, we will create a 'Summary of Findings' table and use GRADE assessment to assess the quality of the evidence. DISCUSSION The results of this systematic review have the potential to benefit thousands of patients worldwide as well as healthcare systems and healthcare economy. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42016051433.
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Affiliation(s)
- Naqash J Sethi
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
| | - Sanam Safi
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Emil E Nielsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Joshua Feinberg
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,The Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Janus C Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,The Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Cardiology, Holbæk Hospital, Holbæk, Denmark
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48
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Relationship between smoking and adverse outcomes in patients with atrial fibrillation: A meta-analysis and systematic review. Int J Cardiol 2016; 222:289-294. [PMID: 27500755 DOI: 10.1016/j.ijcard.2016.07.220] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Accepted: 07/28/2016] [Indexed: 01/10/2023]
Abstract
BACKGROUND Several studies have investigated the impact of smoking on the prognosis of atrial fibrillation (AF), but the results remain controversial. We therefore aimed to estimate the association between smoking and adverse outcomes in patients with AF. METHODS We systematically searched the Cochrane Library, PubMed, and Elsevier databases through May 2016 for studies regarding the association between smoking and adverse outcomes in AF patients. Risk ratios [RRs] and 95% confidence intervals [CIs] were abstracted and then pooled using a random-effects model. RESULTS A total of 8 cohort studies with 87,373 participants were included in this meta-analysis. Among patients with AF, smoking was associated with increased risks of all-cause death (RR=1.82, 95% CI: 1.33-2.49, P=0.0002) and cardiovascular death (RR=1.54, 95% CI: 1.31-1.81, P<0.00001) but not stroke/thromboembolism (RR=1.19, 95% CI 0.97-1.46; P=0.10). In addition, smoking was associated with an increased risk of major bleeding (RR=1.93, 95% CI 1.08-3.47, P=0.03), even after adjustment for the antithrombotic treatment. CONCLUSIONS The published literature demonstrates that smoking is not associated with the risk of stroke/thromboembolism but increases the risks of all-cause death and cardiovascular death in AF patients, as well as the risk of major bleeding in AF patients using anticoagulants.
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49
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Shaikh AY, Wang N, Yin X, Larson MG, Vasan RS, Hamburg NM, Magnani JW, Ellinor PT, Lubitz SA, Mitchell GF, Benjamin EJ, McManus DD. Relations of Arterial Stiffness and Brachial Flow-Mediated Dilation With New-Onset Atrial Fibrillation: The Framingham Heart Study. Hypertension 2016; 68:590-6. [PMID: 27456517 DOI: 10.1161/hypertensionaha.116.07650] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 07/03/2016] [Indexed: 01/22/2023]
Abstract
The relations of measures of arterial stiffness, pulsatile hemodynamic load, and endothelial dysfunction to atrial fibrillation (AF) remain poorly understood. To better understand the pathophysiology of AF, we examined associations between noninvasive measures of vascular function and new-onset AF. The study sample included participants aged ≥45 years from the Framingham Heart Study offspring and third-generation cohorts. Using Cox proportional hazards regression models, we examined relations between incident AF and tonometry measures of arterial stiffness (carotid-femoral pulse wave velocity), wave reflection (augmentation index), pressure pulsatility (central pulse pressure), endothelial function (flow-mediated dilation), resting brachial arterial diameter, and hyperemic flow. AF developed in 407/5797 participants in the tonometry sample and 270/3921 participants in the endothelial function sample during follow-up (median 7.1 years, maximum 10 years). Higher augmentation index (hazard ratio, 1.16; 95% confidence interval, 1.02-1.32; P=0.02), baseline brachial artery diameter (hazard ratio, 1.20; 95% confidence interval, 1.01-1.43; P=0.04), and lower flow-mediated dilation (hazard ratio, 0.79; 95% confidence interval, 0.63-0.99; P=0.04) were associated with increased risk of incident AF. Central pulse pressure, when adjusted for age, sex, and hypertension (hazard ratio, 1.14; 95% confidence interval, 1.02-1.28; P=0.02) was associated with incident AF. Higher pulsatile load assessed by central pulse pressure and greater apparent wave reflection measured by augmentation index were associated with increased risk of incident AF. Vascular endothelial dysfunction may precede development of AF. These measures may be additional risk factors or markers of subclinical cardiovascular disease associated with increased risk of incident AF.
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Affiliation(s)
- Amir Y Shaikh
- From the Department of Medicine, University of Massachusetts Medical School, Worcester (A.Y.S.); Data Coordinating Center (N.W.), Department of Biostatistics (X.Y., M.G.L.), Department of Epidemiology (R.S.V.), and Department of Epidemiology (E.J.B.), Boston University School of Public Health, MA; National Heart Lung and Blood Institute's and Boston University's Framingham Heart Study, MA (X.Y., M.G.L., R.S.V., E.J.B.); Section of Cardiovascular Medicine, Preventive Medicine and Epidemiology, Department of Medicine (R.S.V.) and Cardiology Division, Department of Medicine (N.M.H., J.W.M.), Boston University School of Medicine, MA; Cardiology Division, Department of Medicine, Massachusetts General Hospital and Harvard Medical School (P.T.E., S.A.L.); The Broad Institute of Harvard and MIT, Cambridge, MA (P.T.E., S.A.L.); Cardiovascular Engineering, Inc, Norwood, MA (G.F.M.); Evans Memorial Medicine Department, Cardiology Section, and Preventive Medicine Section, School of Medicine, Boston University, MA (E.J.B.); and Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester (D.D.M.).
| | - Na Wang
- From the Department of Medicine, University of Massachusetts Medical School, Worcester (A.Y.S.); Data Coordinating Center (N.W.), Department of Biostatistics (X.Y., M.G.L.), Department of Epidemiology (R.S.V.), and Department of Epidemiology (E.J.B.), Boston University School of Public Health, MA; National Heart Lung and Blood Institute's and Boston University's Framingham Heart Study, MA (X.Y., M.G.L., R.S.V., E.J.B.); Section of Cardiovascular Medicine, Preventive Medicine and Epidemiology, Department of Medicine (R.S.V.) and Cardiology Division, Department of Medicine (N.M.H., J.W.M.), Boston University School of Medicine, MA; Cardiology Division, Department of Medicine, Massachusetts General Hospital and Harvard Medical School (P.T.E., S.A.L.); The Broad Institute of Harvard and MIT, Cambridge, MA (P.T.E., S.A.L.); Cardiovascular Engineering, Inc, Norwood, MA (G.F.M.); Evans Memorial Medicine Department, Cardiology Section, and Preventive Medicine Section, School of Medicine, Boston University, MA (E.J.B.); and Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester (D.D.M.)
| | - Xiaoyan Yin
- From the Department of Medicine, University of Massachusetts Medical School, Worcester (A.Y.S.); Data Coordinating Center (N.W.), Department of Biostatistics (X.Y., M.G.L.), Department of Epidemiology (R.S.V.), and Department of Epidemiology (E.J.B.), Boston University School of Public Health, MA; National Heart Lung and Blood Institute's and Boston University's Framingham Heart Study, MA (X.Y., M.G.L., R.S.V., E.J.B.); Section of Cardiovascular Medicine, Preventive Medicine and Epidemiology, Department of Medicine (R.S.V.) and Cardiology Division, Department of Medicine (N.M.H., J.W.M.), Boston University School of Medicine, MA; Cardiology Division, Department of Medicine, Massachusetts General Hospital and Harvard Medical School (P.T.E., S.A.L.); The Broad Institute of Harvard and MIT, Cambridge, MA (P.T.E., S.A.L.); Cardiovascular Engineering, Inc, Norwood, MA (G.F.M.); Evans Memorial Medicine Department, Cardiology Section, and Preventive Medicine Section, School of Medicine, Boston University, MA (E.J.B.); and Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester (D.D.M.)
| | - Martin G Larson
- From the Department of Medicine, University of Massachusetts Medical School, Worcester (A.Y.S.); Data Coordinating Center (N.W.), Department of Biostatistics (X.Y., M.G.L.), Department of Epidemiology (R.S.V.), and Department of Epidemiology (E.J.B.), Boston University School of Public Health, MA; National Heart Lung and Blood Institute's and Boston University's Framingham Heart Study, MA (X.Y., M.G.L., R.S.V., E.J.B.); Section of Cardiovascular Medicine, Preventive Medicine and Epidemiology, Department of Medicine (R.S.V.) and Cardiology Division, Department of Medicine (N.M.H., J.W.M.), Boston University School of Medicine, MA; Cardiology Division, Department of Medicine, Massachusetts General Hospital and Harvard Medical School (P.T.E., S.A.L.); The Broad Institute of Harvard and MIT, Cambridge, MA (P.T.E., S.A.L.); Cardiovascular Engineering, Inc, Norwood, MA (G.F.M.); Evans Memorial Medicine Department, Cardiology Section, and Preventive Medicine Section, School of Medicine, Boston University, MA (E.J.B.); and Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester (D.D.M.)
| | - Ramachandran S Vasan
- From the Department of Medicine, University of Massachusetts Medical School, Worcester (A.Y.S.); Data Coordinating Center (N.W.), Department of Biostatistics (X.Y., M.G.L.), Department of Epidemiology (R.S.V.), and Department of Epidemiology (E.J.B.), Boston University School of Public Health, MA; National Heart Lung and Blood Institute's and Boston University's Framingham Heart Study, MA (X.Y., M.G.L., R.S.V., E.J.B.); Section of Cardiovascular Medicine, Preventive Medicine and Epidemiology, Department of Medicine (R.S.V.) and Cardiology Division, Department of Medicine (N.M.H., J.W.M.), Boston University School of Medicine, MA; Cardiology Division, Department of Medicine, Massachusetts General Hospital and Harvard Medical School (P.T.E., S.A.L.); The Broad Institute of Harvard and MIT, Cambridge, MA (P.T.E., S.A.L.); Cardiovascular Engineering, Inc, Norwood, MA (G.F.M.); Evans Memorial Medicine Department, Cardiology Section, and Preventive Medicine Section, School of Medicine, Boston University, MA (E.J.B.); and Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester (D.D.M.)
| | - Naomi M Hamburg
- From the Department of Medicine, University of Massachusetts Medical School, Worcester (A.Y.S.); Data Coordinating Center (N.W.), Department of Biostatistics (X.Y., M.G.L.), Department of Epidemiology (R.S.V.), and Department of Epidemiology (E.J.B.), Boston University School of Public Health, MA; National Heart Lung and Blood Institute's and Boston University's Framingham Heart Study, MA (X.Y., M.G.L., R.S.V., E.J.B.); Section of Cardiovascular Medicine, Preventive Medicine and Epidemiology, Department of Medicine (R.S.V.) and Cardiology Division, Department of Medicine (N.M.H., J.W.M.), Boston University School of Medicine, MA; Cardiology Division, Department of Medicine, Massachusetts General Hospital and Harvard Medical School (P.T.E., S.A.L.); The Broad Institute of Harvard and MIT, Cambridge, MA (P.T.E., S.A.L.); Cardiovascular Engineering, Inc, Norwood, MA (G.F.M.); Evans Memorial Medicine Department, Cardiology Section, and Preventive Medicine Section, School of Medicine, Boston University, MA (E.J.B.); and Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester (D.D.M.)
| | - Jared W Magnani
- From the Department of Medicine, University of Massachusetts Medical School, Worcester (A.Y.S.); Data Coordinating Center (N.W.), Department of Biostatistics (X.Y., M.G.L.), Department of Epidemiology (R.S.V.), and Department of Epidemiology (E.J.B.), Boston University School of Public Health, MA; National Heart Lung and Blood Institute's and Boston University's Framingham Heart Study, MA (X.Y., M.G.L., R.S.V., E.J.B.); Section of Cardiovascular Medicine, Preventive Medicine and Epidemiology, Department of Medicine (R.S.V.) and Cardiology Division, Department of Medicine (N.M.H., J.W.M.), Boston University School of Medicine, MA; Cardiology Division, Department of Medicine, Massachusetts General Hospital and Harvard Medical School (P.T.E., S.A.L.); The Broad Institute of Harvard and MIT, Cambridge, MA (P.T.E., S.A.L.); Cardiovascular Engineering, Inc, Norwood, MA (G.F.M.); Evans Memorial Medicine Department, Cardiology Section, and Preventive Medicine Section, School of Medicine, Boston University, MA (E.J.B.); and Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester (D.D.M.)
| | - Patrick T Ellinor
- From the Department of Medicine, University of Massachusetts Medical School, Worcester (A.Y.S.); Data Coordinating Center (N.W.), Department of Biostatistics (X.Y., M.G.L.), Department of Epidemiology (R.S.V.), and Department of Epidemiology (E.J.B.), Boston University School of Public Health, MA; National Heart Lung and Blood Institute's and Boston University's Framingham Heart Study, MA (X.Y., M.G.L., R.S.V., E.J.B.); Section of Cardiovascular Medicine, Preventive Medicine and Epidemiology, Department of Medicine (R.S.V.) and Cardiology Division, Department of Medicine (N.M.H., J.W.M.), Boston University School of Medicine, MA; Cardiology Division, Department of Medicine, Massachusetts General Hospital and Harvard Medical School (P.T.E., S.A.L.); The Broad Institute of Harvard and MIT, Cambridge, MA (P.T.E., S.A.L.); Cardiovascular Engineering, Inc, Norwood, MA (G.F.M.); Evans Memorial Medicine Department, Cardiology Section, and Preventive Medicine Section, School of Medicine, Boston University, MA (E.J.B.); and Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester (D.D.M.)
| | - Steven A Lubitz
- From the Department of Medicine, University of Massachusetts Medical School, Worcester (A.Y.S.); Data Coordinating Center (N.W.), Department of Biostatistics (X.Y., M.G.L.), Department of Epidemiology (R.S.V.), and Department of Epidemiology (E.J.B.), Boston University School of Public Health, MA; National Heart Lung and Blood Institute's and Boston University's Framingham Heart Study, MA (X.Y., M.G.L., R.S.V., E.J.B.); Section of Cardiovascular Medicine, Preventive Medicine and Epidemiology, Department of Medicine (R.S.V.) and Cardiology Division, Department of Medicine (N.M.H., J.W.M.), Boston University School of Medicine, MA; Cardiology Division, Department of Medicine, Massachusetts General Hospital and Harvard Medical School (P.T.E., S.A.L.); The Broad Institute of Harvard and MIT, Cambridge, MA (P.T.E., S.A.L.); Cardiovascular Engineering, Inc, Norwood, MA (G.F.M.); Evans Memorial Medicine Department, Cardiology Section, and Preventive Medicine Section, School of Medicine, Boston University, MA (E.J.B.); and Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester (D.D.M.)
| | - Gary F Mitchell
- From the Department of Medicine, University of Massachusetts Medical School, Worcester (A.Y.S.); Data Coordinating Center (N.W.), Department of Biostatistics (X.Y., M.G.L.), Department of Epidemiology (R.S.V.), and Department of Epidemiology (E.J.B.), Boston University School of Public Health, MA; National Heart Lung and Blood Institute's and Boston University's Framingham Heart Study, MA (X.Y., M.G.L., R.S.V., E.J.B.); Section of Cardiovascular Medicine, Preventive Medicine and Epidemiology, Department of Medicine (R.S.V.) and Cardiology Division, Department of Medicine (N.M.H., J.W.M.), Boston University School of Medicine, MA; Cardiology Division, Department of Medicine, Massachusetts General Hospital and Harvard Medical School (P.T.E., S.A.L.); The Broad Institute of Harvard and MIT, Cambridge, MA (P.T.E., S.A.L.); Cardiovascular Engineering, Inc, Norwood, MA (G.F.M.); Evans Memorial Medicine Department, Cardiology Section, and Preventive Medicine Section, School of Medicine, Boston University, MA (E.J.B.); and Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester (D.D.M.)
| | - Emelia J Benjamin
- From the Department of Medicine, University of Massachusetts Medical School, Worcester (A.Y.S.); Data Coordinating Center (N.W.), Department of Biostatistics (X.Y., M.G.L.), Department of Epidemiology (R.S.V.), and Department of Epidemiology (E.J.B.), Boston University School of Public Health, MA; National Heart Lung and Blood Institute's and Boston University's Framingham Heart Study, MA (X.Y., M.G.L., R.S.V., E.J.B.); Section of Cardiovascular Medicine, Preventive Medicine and Epidemiology, Department of Medicine (R.S.V.) and Cardiology Division, Department of Medicine (N.M.H., J.W.M.), Boston University School of Medicine, MA; Cardiology Division, Department of Medicine, Massachusetts General Hospital and Harvard Medical School (P.T.E., S.A.L.); The Broad Institute of Harvard and MIT, Cambridge, MA (P.T.E., S.A.L.); Cardiovascular Engineering, Inc, Norwood, MA (G.F.M.); Evans Memorial Medicine Department, Cardiology Section, and Preventive Medicine Section, School of Medicine, Boston University, MA (E.J.B.); and Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester (D.D.M.)
| | - David D McManus
- From the Department of Medicine, University of Massachusetts Medical School, Worcester (A.Y.S.); Data Coordinating Center (N.W.), Department of Biostatistics (X.Y., M.G.L.), Department of Epidemiology (R.S.V.), and Department of Epidemiology (E.J.B.), Boston University School of Public Health, MA; National Heart Lung and Blood Institute's and Boston University's Framingham Heart Study, MA (X.Y., M.G.L., R.S.V., E.J.B.); Section of Cardiovascular Medicine, Preventive Medicine and Epidemiology, Department of Medicine (R.S.V.) and Cardiology Division, Department of Medicine (N.M.H., J.W.M.), Boston University School of Medicine, MA; Cardiology Division, Department of Medicine, Massachusetts General Hospital and Harvard Medical School (P.T.E., S.A.L.); The Broad Institute of Harvard and MIT, Cambridge, MA (P.T.E., S.A.L.); Cardiovascular Engineering, Inc, Norwood, MA (G.F.M.); Evans Memorial Medicine Department, Cardiology Section, and Preventive Medicine Section, School of Medicine, Boston University, MA (E.J.B.); and Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester (D.D.M.)
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Takahashi K, Hayashi M, Iwasaki YK, Miyauchi Y, Yodogawa K, Tsuboi I, Hayashi H, Oka E, Hagiwara K, Fujimoto YH, Shimizu W. Urgent Catheter Ablation in Octogenarians with Serious Tachyarrhythmias. J NIPPON MED SCH 2016; 83:62-70. [PMID: 27180791 DOI: 10.1272/jnms.83.62] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Urgent catheter ablation is often required for various tachyarrhythmias; however, its efficacy and safety in elderly patients have not been fully elucidated. METHODS This study included consecutive octogenarians who underwent urgent radiofrequency catheter ablation (RFCA) for various serious tachyarrhythmias (urgent group, n=28) that were life-threatening, hemodynamically deleterious, or provoking ischemia, and consecutive octogenarians who underwent elective RFCA (control group, n=36). The rate of a successful RFCA, complications, later arrhythmia recurrences, and mortality were compared between the groups. RESULTS There was no significant difference in the breakdown of the targeted arrhythmias between the groups, and common-type atrial flutter was most often targeted in both the urgent group (57%) and the elective group (56%). Compared with the control group patients, the patients of the urgent group were older (84±3 vs. 82±2 years P=0.001), with a higher frequency of baseline heart disease (68% vs. 17%, P<0.001) and lower left ventricular ejection fraction (45%±15% vs. 68%±10%, P<0.001). The rates of acute success (100% vs. 100%, P=1.00) and later arrhythmia recurrences (4% vs. 14%, P=0.22) were comparable between the groups. Two patients in the urgent group and 2 in the elective group had procedure-related nonlethal complications (7% vs. 6%, P=1.00): groin hematoma in 2, pressure ulcer in 1, and CO2 narcosis in 1. There were no in-hospital deaths, and mortality during follow-up did not differ between the urgent and elective groups (6.0% vs. 3.9% per year, log-rank P=0.38). CONCLUSION Even in octogenarian patients, urgent catheter ablation for serious tachyarrhythmias can be safely performed with a high success rate and acceptable prognosis.
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Affiliation(s)
- Kenta Takahashi
- Department of Cardiovascular Medicine, Nippon Medical School
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