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Shah AS, Ongtengco A, Qiao V, Chen Y, Diaz A, Hill M, Bhan A, Tofovic DS, Darbar D. Association Between Family History and Early-Onset Atrial Flutter Across Racial and Ethnic Groups. J Am Heart Assoc 2024; 13:e032320. [PMID: 38726902 PMCID: PMC11179838 DOI: 10.1161/jaha.123.032320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 04/17/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND Genetic and familial contributions to early-onset atrial fibrillation are described primarily in individuals of European ancestry. However, the role of racial and familial contributions in the pathogenesis of early-onset atrial flutter (EOAFL) is unclear. METHODS AND RESULTS In this cross-sectional study, participants were enrolled prospectively from 2015 to 2021 in multiple academic centers with a diagnosis of atrial flutter (AFL) confirmed by ECG. EOAFL was defined as a diagnosis of AFL before age 66 years with no concomitant or previous diagnosis of atrial tachyarrhythmias. Family history was adjudicated through baseline questionnaires and direct family interviews about the diagnosis of atrial tachyarrhythmias, stroke, and cardiomyopathy. The primary exposure was a positive family history in first-degree relatives, and the primary outcome was the odds of EOAFL versus late-onset AFL. A total of 909 patients were enrolled. Participants with a positive family history of atrial tachyarrhythmias were younger, less likely to be of Black race, and more likely to have EOAFL. The adjusted odds ratio (OR) for EOAFL in those with a positive family history was 1.8 (95% CI, 1.1-3.0). There was an increased odds of EOAFL in those of Black race (OR, 2.1 [95% CI, 1.4-3.2]), alcohol use (OR, 1.6 [95% CI, 1.0-2.6]), and obstructive sleep apnea (OR, 1.9 [95% CI, 1.0-3.4]). Use of cardioselective β blockers or calcium channel blockers before the diagnosis of AFL were associated with a lower odds of EOAFL (OR, 0.5 [95% CI, 0.2-0.9]). CONCLUSIONS These findings suggest a potentially hereditary predisposition to EOAFL across race and ethnicity, warranting further study of the genetic contributions to AFL.
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Affiliation(s)
- Anish S. Shah
- Division of Cardiology, Department of MedicineUniversity of Illinois ChicagoChicagoIL
- Jesse Brown Veterans Administration Medical CenterChicagoIL
| | - Ana Ongtengco
- Division of Cardiology, Department of MedicineUniversity of Illinois ChicagoChicagoIL
| | - Victor Qiao
- Division of Academic Internal Medicine, Department of MedicineUniversity of Illinois ChicagoChicagoIL
| | - Yining Chen
- Division of Cardiology, Department of MedicineUniversity of Illinois ChicagoChicagoIL
| | - Annette Diaz
- College of Liberal Arts and Sciences, University of Illinois ChicagoChicagoIL
| | - Michael Hill
- Division of Cardiology, Department of MedicineUniversity of Illinois ChicagoChicagoIL
- Jesse Brown Veterans Administration Medical CenterChicagoIL
| | | | - David S. Tofovic
- Division of Cardiology, Department of MedicineUniversity of Illinois ChicagoChicagoIL
- College of Liberal Arts and Sciences, University of Illinois ChicagoChicagoIL
- Center for Cardiovascular ResearchUniversity of Illinois ChicagoChicagoIL
| | - Dawood Darbar
- Division of Cardiology, Department of MedicineUniversity of Illinois ChicagoChicagoIL
- College of Liberal Arts and Sciences, University of Illinois ChicagoChicagoIL
- Center for Cardiovascular ResearchUniversity of Illinois ChicagoChicagoIL
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2
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Li Y, Chen L, Shao Y, Zhang M, Zhi L, Lu Y. The effect of apolipoprotein E gene polymorphism and Lp(a) levels on coronary artery disease with atrial fibrillation. J Int Med Res 2022; 50:3000605221109387. [PMID: 35850541 PMCID: PMC9310063 DOI: 10.1177/03000605221109387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 06/06/2022] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To explore the influence of apolipoprotein E (APOE) genotypes and blood lipid metabolism on coronary artery disease (CAD) with atrial fibrillation (AF). METHODS Patients with suspected CAD were consecutively enrolled and divided into groups with or without CAD and/or AF. Blood lipid levels and APOE genotypes were determined and analysed for associations with CAD and AF. RESULTS A total of 2048 patients were included (400 patients without CAD or AF [controls], 126 patients without CAD but with AF, 1294 patients with CAD without AF, and 228 patients with CAD and AF). Age and lipoprotein (a) (Lp[a]) levels were significantly higher in patients with CAD and AF versus those with CAD without AF. Among patients with CAD, the E3/E3 genotype and ε3 allele frequencies were significantly lower in patients with AF than in those without AF, and the E4/E4 genotype and ε4 allele frequencies were significantly increased. Multivariate logistic regression revealed that increased Lp(a) levels and age were independent risk factors for AF in patients with CAD. CONCLUSION Among patients with CAD, those with AF had increased age, ε4 frequencies and Lp(a) levels. Age and Lp(a) levels may be independent risk factors for AF in patients with CAD.
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Affiliation(s)
- Yong Li
- Department of Cardiology, Liangzhu Hospital, Yuhang District,
Hangzhou, Zhejiang, China
| | - Lei Chen
- Department of Cardiology, the Affiliated Hospital of Xuzhou
Medical University, Xuzhou, Jiangsu, China
| | - Yameng Shao
- Department of Cardiology, the Affiliated Hospital of Xuzhou
Medical University, Xuzhou, Jiangsu, China
| | - Min Zhang
- Department of Cardiology, the Affiliated Hospital of Xuzhou
Medical University, Xuzhou, Jiangsu, China
| | - Li Zhi
- Department of Cardiology, the Affiliated Hospital of Xuzhou
Medical University, Xuzhou, Jiangsu, China
| | - Yuan Lu
- Department of Cardiology, the Affiliated Hospital of Xuzhou
Medical University, Xuzhou, Jiangsu, China
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3
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Parkash R, Wells G, Rouleau J, Talajic M, Essebag V, Skanes A, Wilton SB, Verma A, Healey JS, Tang AS. A randomized ablation-based atrial fibrillation rhythm control versus rate control trial in patients with heart failure and high burden atrial fibrillation: The RAFT-AF trial rationale and design. Am Heart J 2021; 234:90-100. [PMID: 33472052 DOI: 10.1016/j.ahj.2021.01.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 01/15/2021] [Indexed: 10/22/2022]
Abstract
Heart failure (HF) and atrial fibrillation (AF) are 2 cardiac conditions that are increasing in prevalence and incidence. The 2 conditions frequently coexist, and are associated with increased morbidity and mortality. Catheter ablation of AF has been successfully performed in patients with HF, with an improvement in HF and AF, when compared to amiodarone, but further data is required to compare this to rate control. OBJECTIVES: The primary objective is to determine whether AF treated by catheter ablation, with or without antiarrhythmic drugs reduces all-cause mortality and hospitalizations for HF as compared with rate control in patients with HF and a high burden AF. METHODS: This is a multi-center prospective randomized open blinded endpoint (PROBE) study. Patients with NYHA class II-III HF (HF with reduced ejection fraction (<35%) or HF with preserved ejection fraction), and high burden AF are included in the trial. Patients are randomized to either rate control or catheter ablation-based AF rhythm control in a 1:1 ratio. Patients in the rate control group receive optimal HF therapy and rate control measures to achieve a resting hazard ratio (HR) < 80 bpm and 6-minute walk HR < 110 bpm. Patients randomized to catheter ablation-based AF rhythm control group receive optimal HF therapy and one or more aggressive catheter ablation, which include PV antral ablation and LA substrate ablation with or without adjunctive antiarrhythmic drug. The primary outcome is a composite of all-cause mortality and hospitalization for heart failure defined as an admission to a health care facility. The sample size is 600. Enrolment has been completed.
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Affiliation(s)
- Ratika Parkash
- Queen Elizabeth II Health Sciences Center, Halifax, Nova Scotia, Canada.
| | - George Wells
- University of Ottawa Cardiovascular Research Methods Center, Ottawa, ON, Canada
| | | | | | - Vidal Essebag
- McGill University Health Centre, Montreal, QC, Canada
| | - Allan Skanes
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Steve B Wilton
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | | | - Jeff S Healey
- Population Health Research Institute, Hamilton, ON, Canada
| | - Anthony Sl Tang
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
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4
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Rajão KMAB, Ribeiro ALP, Passos VMA, Benseñor IJM, Vidigal PG, Camacho CP, Diniz MDFHS. Subclinical Thyroid Dysfunction was not Associated with Cardiac Arrhythmias in a Cross-Sectional Analysis of the ELSA-Brasil Study. Arq Bras Cardiol 2019; 112:758-766. [PMID: 30843933 PMCID: PMC6636382 DOI: 10.5935/abc.20190037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Accepted: 10/17/2018] [Indexed: 11/20/2022] Open
Abstract
Background The association of subclinical thyroid dysfunction (STD) with cardiac
arrhythmias remains controversial, particularly in the non-elderly
population. Objective To investigate whether STD was associated with cardiac arrhythmias in a
cohort of middle-aged and older adults. Methods Baseline data of the Longitudinal Study of Adult Health, ELSA-Brasil (35-74
years) were collected from 2008 to 2010. After exclusion of clinical
hypothyroidism and hyperthyroidism, participants were categorized as
euthyroidism (TSH = 0.4-4.0 µU/mL), subclinical
hypothyroidism (TSH > 4.0 µU/mL; FT4 = 0.8-1.9
ng/dL), and subclinical hyperthyroidism (TSH < 0.4
µU/mL; FT4 = 0.8-1.9 ng/dL). The prevalence
rates of tachycardia (HR > 100) and bradycardia (HR < 60), atrial
fibrillation/flutter, conduction disorders, extrasystoles, low QRS voltage,
prolonged QT intervals, and persistent supraventricular rhythms were
compared between groups after adjusting for age, sex, comorbidities,
lifestyle, body mass index and medications. Results The HR data of 13,341 participants (52% female; median age, 51 years) and the
electrocardiogram readings of 11,795 were analyzed; 698 participants (5.23%)
were classified as subclinical hypothyroidism, 193 (1.45%) as subclinical
hyperthyroidism, and 12,450 (93.32%) as euthyroidism. The prevalence of
rhythm and conduction disorders was similar, as were HR medians, even in the
subgroups with TSH < 0.01 UI/mL or > 10.0 UI/mL or in older adults.
Conduction disorders were less prevalent in older adults with subclinical
hypothyroidism (adjusted OR = 0.44; 95% CI 0.24 to 0.80). Conclusion In this large, multicenter and cross-sectional study, STD was not associated
with cardiac arrhythmias, but a longitudinal assessment is necessary.
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Affiliation(s)
- Kamilla Maria Araújo Brandão Rajão
- Serviço de Endocrinologia e Metabologia do Hospital das Clínicas da Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG - Brazil
| | - Antônio Luiz Pinho Ribeiro
- Departamento de Clínica Médica da Faculdade de Medicina da Universidade Federal de Minas Gerais (FM-UFMG), Belo Horizonte, MG - Brazil.,Serviço de Cardiologia e Cirurgia Cardiovascular - Hospital das Clínicas da Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG - Brazil
| | - Valéria Maria Azeredo Passos
- Departamento de Clínica Médica da Faculdade de Medicina da Universidade Federal de Minas Gerais (FM-UFMG), Belo Horizonte, MG - Brazil
| | | | - Pedro Guatimosim Vidigal
- Departamento de Propedêutica da Faculdade de Medicina da Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG - Brazil
| | | | - Maria de Fátima Haueisen Sander Diniz
- Serviço de Endocrinologia e Metabologia do Hospital das Clínicas da Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG - Brazil.,Departamento de Clínica Médica da Faculdade de Medicina da Universidade Federal de Minas Gerais (FM-UFMG), Belo Horizonte, MG - Brazil
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5
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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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6
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Mechanisms, Clinical Significance, and Prevention of Cognitive Impairment in Patients With Atrial Fibrillation. Can J Cardiol 2017; 33:1556-1564. [DOI: 10.1016/j.cjca.2017.09.024] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 09/21/2017] [Accepted: 09/24/2017] [Indexed: 11/18/2022] Open
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McBeth PB, Weinberg JA, Sarani B, Yeung LYY, May AK. A surgeon's guide to anticoagulant and antiplatelet medications part one: warfarin and new direct oral anticoagulant medications. Trauma Surg Acute Care Open 2016; 1:e000020. [PMID: 29767647 PMCID: PMC5891717 DOI: 10.1136/tsaco-2016-000020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2016] [Indexed: 12/26/2022] Open
Abstract
An increasing number of potent antiplatelet and anticoagulant medications are being used for the long-term management of cardiac, cerebrovascular, and peripheral vascular conditions. Management of these medications in the perioperative and peri-injury settings can be challenging for surgeons, mandating an understanding of these agents and the risks and benefits of various management strategies. In this two-part review, agents commonly encounter by surgeons in the perioperative and peri-injury settings are discussed and management strategies for patients on long-term antiplatelet and anticoagulant therapy reviewed. In part I, we review warfarin and the new direct oral anticoagulants. In part II, we review antiplatelet agents and assessment of platelet function and the perioperative management of long-term anticoagulant and antiplatelet therapy.
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Affiliation(s)
- Paul B McBeth
- Departments of Surgery and Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jordan A Weinberg
- Department of Surgery, Dignity Health/St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Babak Sarani
- Center for Trauma and Critical Care, George Washington University, Washington DC, USA
| | | | - Addison K May
- Division of Trauma and Surgical Critical Care, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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8
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9
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Stroke Risk in Patients with Implanted Cardiac Devices. Card Electrophysiol Clin 2014; 6:133-9. [PMID: 27063828 DOI: 10.1016/j.ccep.2013.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Atrial fibrillation (AF) is associated with embolic stroke. AF can be asymptomatic and the first detection of AF may be from the stored electrograms of cardiac implantable electronic devices. These devices can digitally record and store intracardiac electrograms that satisfy criteria for AF. Current guidelines do not address management of device-detected AF and, in particular, whether these episodes should prompt the initiation of anticoagulation/antiplatelet therapy. This article reviews the data regarding management of device-detected AF.
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11
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Khaykin Y, Shamiss Y. Cost considerations in the management of atrial fibrillation - impact of dronedarone. CLINICOECONOMICS AND OUTCOMES RESEARCH 2012; 4:67-78. [PMID: 22427725 PMCID: PMC3304332 DOI: 10.2147/ceor.s16675] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia. It is associated with significant morbidity and mortality. At the societal level, AF carries an enormous cost. Strategies aimed at reducing AF morbidity and mortality and containing the associated fiscal burden are of paramount importance. This review will discuss AF treatment strategies and economics, focusing on the impact of dronedarone, a novel antiarrhythmic agent.
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Affiliation(s)
- Yaariv Khaykin
- Heart Rhythm Program, Southlake Regional Health Center, Newmarket, Ontario, Canada
- Faculty of Medicine, University of Toronto, Ontario, Canada
| | - Yana Shamiss
- Heart Rhythm Program, Southlake Regional Health Center, Newmarket, Ontario, Canada
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12
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Macle L, Khairy P, Verma A, Weerasooriya R, Willems S, Arentz T, Novak P, Veenhuyzen G, Scavée C, Skanes A, Puererfellner H, Jaïs P, Khaykin Y, Rivard L, Guerra PG, Dubuc M, Thibault B, Talajic M, Roy D, Nattel S. Adenosine Following Pulmonary Vein Isolation to Target Dormant Conduction Elimination (ADVICE): Methods and Rationale. Can J Cardiol 2012; 28:184-90. [DOI: 10.1016/j.cjca.2011.10.008] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2011] [Revised: 09/21/2011] [Accepted: 10/06/2011] [Indexed: 10/14/2022] Open
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13
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Khaykin Y, Shamiss Y. Cost of AF Ablation: Where Do We Stand? Cardiol Res Pract 2011; 2011:589781. [PMID: 21403880 PMCID: PMC3051175 DOI: 10.4061/2011/589781] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2010] [Accepted: 01/15/2011] [Indexed: 11/22/2022] Open
Abstract
Atrial fibrillation (AF) is a common and frequently disabling chronic condition associated with significant patient morbidity and affecting an increasing stratum of our ageing society. Direct costs related to atrial fibrillation are comprised from direct cost of medical therapy, catheter ablation, and related hospitalizations and imaging procedures, with indirect costs related to complications of the primary therapeutic strategy, management of related conditions, as well as disability and loss in quality of life related to AF. Over the last decade, catheter ablation became a promising alternative to rate and rhythm control among symptomatic AF patients. The purpose of this paper is to describe the evidence on the financial implications related to ablation based on published data and authors' experience.
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Affiliation(s)
- Yaariv Khaykin
- Heart Rhythm Program, Southlake Regional Health Centre, Newmarket, ON, Canada L3Y 8C3
| | - Yana Shamiss
- Heart Rhythm Program, Southlake Regional Health Centre, Newmarket, ON, Canada L3Y 8C3
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14
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Khaykin Y, Oosthuizen R, Zarnett L, Wulffhart ZA, Whaley B, Hill C, Giewercer D, Verma A. CARTO-guided vs. NavX-guided pulmonary vein antrum isolation and pulmonary vein antrum isolation performed without 3-D mapping: effect of the 3-D mapping system on procedure duration and fluoroscopy time. J Interv Card Electrophysiol 2011; 30:233-40. [PMID: 21253840 DOI: 10.1007/s10840-010-9538-9] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2010] [Accepted: 12/21/2010] [Indexed: 02/01/2023]
Abstract
PURPOSE Pulmonary vein antrum isolation (PVAI) guided by intracardiac echocardiography and a roaming circular mapping catheter is an effective treatment modality for atrial fibrillation. Unfortunately, the complexity of this technique leads to long procedure times and high fluoroscopy exposure. This study examined the effect of two different mapping systems on the procedural characteristics and clinical outcomes of PVAI for atrial fibrillation. METHODS Referred patients underwent PVAI using a magnetic-based 3-dimensional (3-D) mapping (CARTO® System; group 1), a current-based system (EnSite NavX™; group 2), or fluoroscopy without 3-D mapping (group 3) between February 2004 and November 2009. RESULTS Data were analyzed from 71 patients in group 1, 165 patients in group 2, and 197 patients in group 3. Baseline characteristics and measured long-term outcomes did not differ between the groups. Although patients in group 1 were more likely to undergo a concurrent flutter ablation (P = 0.01), they had significantly shorter procedure time, fluoroscopy time, and radiofrequency energy delivery time compared with group 2 and 3 patients. No difference was detected among the groups with respect to recurrence, mean time to recurrence, or number of PVAI procedures. CONCLUSIONS Use of a magnetic-based 3-D mapping system, which allows precise spatial localization of the ablation catheter, was associated with significantly lower procedure time, fluoroscopy duration, and radiofrequency energy delivery time during catheter ablation for atrial fibrillation compared with a current-based system and ablation performed without 3-D mapping, although measured short- and long-term clinical outcomes were similar.
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Affiliation(s)
- Yaariv Khaykin
- Heart Rhythm Program, Southlake Regional Health Centre, Newmarket, Ontario, Canada.
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15
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Shamiss Y, Khaykin Y, Oosthuizen R, Tunney D, Sarak B, Beardsall M, Seabrook C, Frost L, Wulffhart Z, Tsang B, Verma A. Dofetilide is safe and effective in preventing atrial fibrillation recurrences in patients accepted for catheter ablation. ACTA ACUST UNITED AC 2009; 11:1448-55. [DOI: 10.1093/europace/eup293] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Khaykin Y, Wang X, Natale A, Wazni OM, Skanes AC, Humphries KH, Kerr CR, Verma A, Morillo CA. Cost Comparison of Ablation Versus Antiarrhythmic Drugs As First-Line Therapy for Atrial Fibrillation: An Economic Evaluation of the RAAFT Pilot Study. J Cardiovasc Electrophysiol 2009; 20:7-12. [PMID: 18803564 DOI: 10.1111/j.1540-8167.2008.01303.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Yaariv Khaykin
- Division of Cardiology, Southlake Regional Health Center, Newmarket, Ontario, Canada.
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Abstract
PURPOSE OF REVIEW The optimal treatments for atrial fibrillation have long been sought among rhythm control and rate control strategies. Unfortunately, rhythm control strategies with antiarrhythmic drugs have proven to be a disappointment. Catheter ablation techniques, however, have been rapidly advancing and have the potential to offer a permanent cure. Rhythm control with catheter ablation may in fact be a superior treatment modality for atrial fibrillation. The purpose of this review is to examine the evidence in favor of this argument. RECENT FINDINGS The dissatisfaction with poorly performing antiarrhythmic drug therapies for the treatment of atrial fibrillation has fueled the development of alternative therapies for rhythm control. Catheter ablation has emerged as a viable, efficacious, and safe alternative. In fact, in head to head comparisons with antiarrhythmic drugs, catheter ablation continues to come out on top with often markedly superior performances. In addition to efficacy and safety, catheter ablation also seems to be a fiscally viable alternative. SUMMARY On the basis of the outstanding performance of catheter ablation compared with antiarrhythmic drug therapy, it is not surprising to see its widespread adoption and ever expanding indications.
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18
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Andrikopoulos G, Tzeis S, Maniadakis N, Mavrakis HE, Vardas PE. Cost-effectiveness of atrial fibrillation catheter ablation. Europace 2008; 11:147-51. [DOI: 10.1093/europace/eun342] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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19
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Innervation of pulmonary veins: Morphologic pattern and pathways of nerves in the human fetus. Ann Anat 2008; 190:158-66. [DOI: 10.1016/j.aanat.2007.09.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2007] [Revised: 09/04/2007] [Accepted: 09/11/2007] [Indexed: 11/18/2022]
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Long-Term Follow-Up After Cryothermic Ostial Pulmonary Vein Isolation in Paroxysmal Atrial Fibrillation. J Am Coll Cardiol 2008; 51:850-5. [DOI: 10.1016/j.jacc.2007.08.065] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2007] [Revised: 07/27/2007] [Accepted: 08/17/2007] [Indexed: 10/22/2022]
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Moreira W, Timmermans C, Wellens HJJ, Mizusawa Y, Perez D, Philippens S, Rodriguez LM. Long term outcome of cavotricuspid isthmus cryoablation for the treatment of common atrial flutter in 180 patients: a single center experience. J Interv Card Electrophysiol 2008; 21:235-40. [PMID: 18236145 PMCID: PMC2292477 DOI: 10.1007/s10840-007-9197-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2007] [Accepted: 12/16/2007] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Recent literature has shown that common type atrial flutter (AFL) can recur late after cavotricuspid isthmus (CTI) catheter ablation using radiofrequency energy (RF). We report the long term outcome of a large group of patients undergoing CTI ablation using cryothermy for AFL in a single center. METHODS Patients with AFL referred for CTI ablation were recruited prospectively from July 2001 to July 2006. Cryoablation was performed using a deflectable, 10.5 F, 6.5 mm tip catheter. CTI block was reassessed 30 min after the last application during isoproterenol infusion. Recurrences were evaluated by 12-lead ECG and 24 h Holter recording every clinic visit (1/3/6/9 and 12 months after the procedure and yearly thereafter) or if symptoms developed. RESULTS The 180 enrolled patients had the following characteristics: 39 women (22%), mean age 58 years, no structural heart disease in 86 patients (48%), mean left atrium diameter 44+/-7 mm and mean left ventricular ejection fraction 57+/-7%. The average number of applications per patient was 7 (3 to 20) with a mean temperature and duration of -88 degrees C and 3 min, respectively. Acute success was achieved in 95% (171) of the patients. There were no complications. After a mean follow-up of 27+/-17 (from 12 to 60) months, the chronic success rate was 91%. The majority of the recurrences occurred within the first year post ablation. One hundred and twenty three patients had a history of atrial fibrillation (AF) prior to CTI ablation and 85 (69%) of those remained having AF after cryoablation. In 20 of 57 (35%) patients without a history of AF prior to CTI ablation, AF occurred during follow-up. CONCLUSIONS This prospective study showed a 91% chronic success rate (range 12 to 60 months) for cryoablation of the CTI in patients with common type AFL and ratified the frequent association of AF with AFL.
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Affiliation(s)
- Wendel Moreira
- Department of Cardiology, Academic Hospital Maastricht, P. Debyelaan 25, P.O. Box 5800, Maastricht, The Netherlands
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Khaykin Y, Morillo CA, Skanes AC, McCracken A, Humphries K, Kerr CR. Cost Comparison of Catheter Ablation and Medical Therapy in Atrial Fibrillation. J Cardiovasc Electrophysiol 2007; 18:907-13. [PMID: 17666065 DOI: 10.1111/j.1540-8167.2007.00902.x] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
INTRODUCTION There is emerging evidence for clinical superiority of catheter ablation over rate and rhythm control strategies in paroxysmal atrial fibrillation (PAF). The objective of this study was to compare costs related to medical therapy versus catheter ablation for PAF in Ontario (Canada). METHODS Costs related to medical therapy in the analysis included the cost of anticoagulation, rate and rhythm control medications, noninvasive testing, physician follow-up visits, and hospital admissions, as well as the cost of complications related to this management strategy. Costs related to catheter ablation were assumed to include the cost of the ablation tools (electroanatomic mapping or intracardiac echocardiography-guided pulmonary vein ablation), hospital and physician billings, and costs related to periprocedural medical care and complications. Costs related to these various elements were obtained from the Canadian Registry of Atrial Fibrillation (CARAF), government fee schedules, and published data. Sensitivity analyses looking at a range of initial success rates (50-75%) and late attrition rates (1-5%), prevalence of congestive heart failure (CHF) (20-60%), as well as discounting varying from 3% to 5% per year were performed. RESULTS The cost of catheter ablation ranged from $16,278 to $21,294, with an annual cost of $1,597 to $2,132. The annual cost of medical therapy ranged from $4,176 to $5,060. Costs of ongoing medical therapy and catheter ablation for PAF equalized at 3.2-8.4 years of follow-up. CONCLUSION Catheter ablation is a fiscally sensible alternative to medical therapy in PAF with cost equivalence after 4 years.
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Affiliation(s)
- Yaariv Khaykin
- Southlake Regional Health Center, Newmarket, Ontario, Canada.
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Wachtell K, Devereux RB, Lyle APA. The effect of angiotensin receptor blockers for preventing atrial fibrillation. Curr Hypertens Rep 2007; 9:278-83. [PMID: 17686377 DOI: 10.1007/s11906-007-0051-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Atrial fibrillation is the most common sustained cardiac arrhythmia in clinical practice, and causes significant burden to patients and health care systems. Clinicians treat existing atrial fibrillation with anticoagulation and/or drugs that utilize either a rate or rhythm control strategy. It remains unclear how best to reduce cardiovascular morbidity and mortality in this population. Prevention of atrial fibrillation using angiotensin receptor blockers, which affect ion currents and refractoriness in atrial myocytes, regress or prevent atrial fibrosis, decrease left atrial size, regress left ventricular hypertrophy, modulate sympathetic nerve activity, reduce inflammation, and reduce blood pressure, may become an important and desirable alternative.
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Affiliation(s)
- Kristian Wachtell
- Department of Cardiology B2142, Rigshospitalet, The Heart Center, 9 Blegdamsvej, DK-2100 Copenhagen, Denmark.
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Orlov MV, Ghali JK, Araghi-Niknam M, Sherfesee L, Sahr D, Hettrick DA. Asymptomatic Atrial Fibrillation in Pacemaker Recipients: Incidence, Progression, and Determinants Based on the Atrial High Rate Trial. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2007; 30:404-11. [PMID: 17367361 DOI: 10.1111/j.1540-8159.2007.00682.x] [Citation(s) in RCA: 94] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND The epidemiology and clinical implications of asymptomatic atrial tachyarrhythmias (AT) including both atrial fibrillation and flutter in pacemaker recipients with and without arrhythmia history are not well understood. The Atrial High Rate Episodes (A-HIRATE) in Pacemaker Patients Trial was designed to identify and compare the incidence of AT in patients with and without previously diagnosed AT and a standard indication for dual chamber pacing, and to provide useful diagnostic information for clinical management. METHODS Four hundred twenty-seven patients were implanted with a pacemaker (Kappa 7-900, Medtronic, Inc., Minneapolis, MN, USA) capable of detecting and storing multiple atrial high rate episodes (AHRE) and followed for 2 years. Group I included 331 patients without prior history of AT and Group II included 96 patients with prior AT history. RESULTS Pacemaker diagnostics appropriately detected 93% of reviewed AHRE. The rate of occurrence of first AHRE was significantly higher (P < 0.0001) in Group II patients, as was average AHRE burden. The rate of first AHRE occurrence was 88.6% for patients in Group II and 53.8% in Group I at 24 months post-implant. The rate of AHRE occurrence was similar in both groups after the first month post-implant. The majority of stored AHRE were asymptomatic; symptoms did not correspond to an actual AHRE in most patients. CONCLUSIONS The incidence of AT in pacemaker recipients is high. Most device-detected AHRE are asymptomatic. Prior history of AT is associated with higher arrhythmia burden. AHRE diagnostics have a high positive predictive value for identifying AT events.
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Affiliation(s)
- Michael V Orlov
- Tufts University School of Medicine, Boston, Massachusetts 02135, USA.
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Abstract
PURPOSE OF REVIEW Catheter ablation for atrial fibrillation is a rapidly evolving field. It has been adopted at many institutions worldwide. This review compares the efficacy and cost of catheter ablation and medical therapy in atrial fibrillation patients. RECENT FINDINGS There is emerging evidence for clinical superiority of catheter ablation over medical therapy for restoring and maintaining sinus rhythm in atrial fibrillation patients. Early analyses of costs related to catheter ablation in atrial fibrillation suggest that medical therapy and catheter ablation become cost-equivalent at about 5 years of follow-up. A recent cost-effectiveness study concluded that catheter ablation is a cost-effective alternative to medical care in younger and older patients at low and moderate risk of stroke, assuming that restoration and maintenance of sinus rhythm with ablation would have some protective effect with respect to embolic events. SUMMARY Catheter ablation is a potentially cost-effective strategy in select patients with atrial fibrillation. Long-term randomized studies that compare it to conventional care and focus on outcomes of morbidity and mortality are necessary prior to widespread application of this technique.
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Affiliation(s)
- Yaariv Khaykin
- Southlake Regional Health Center, Newmarket, Ontario, Canada.
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26
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Gonzalez-Zuelgaray J, Perez A. Regular supraventricular tachycardias associated with idiopathic atrial fibrillation. Am J Cardiol 2006; 98:1242-4. [PMID: 17056338 DOI: 10.1016/j.amjcard.2006.05.059] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2006] [Revised: 05/24/2006] [Accepted: 05/24/2006] [Indexed: 10/24/2022]
Abstract
The present study analyzed the recurrence rate of idiopathic atrial fibrillation (AF) after elimination by radiofrequency ablation of the substrate for a regular tachycardia. Forty consecutive patients with idiopathic AF and a history of regular palpitations or documented regular tachyarrhythmias were prospectively included. Regular tachyarrhythmias were induced in 82.5% of patients: atrial flutter (42.4% of the inducible arrhythmias), atrial tachycardia (24.2%), atrioventricular (AV) nodal reentry (18.2%), AV reentry through a concealed accessory pathway (9.1%), and AV nodal reentry associated with right atrial tachycardia (6.1%). Dual AV node physiology with single or dual AV node echoes was demonstrated in 6.1% of patients without inducible arrhythmias. During follow-up (92 +/- 11 months), AF recurred in 19.2% of patients after successful radiofrequency ablation and in 69.2% after unsuccessful or not performed procedures (p <0.05). Left atrial diameter did not change after successful ablation but increased significantly in the population without elimination of the substrate (initial diameter 37.5 +/- 2 mm, final diameter 46.4 +/- 3.2 mm; p <0.05). In conclusion, the systematic search for the substrate of regular tachyarrhythmias followed by their elimination by catheter ablation reduces the recurrence of idiopathic AF in patients with a history of regular palpitations or documented regular tachyarrhythmias.
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Wachtell K, Devereux RB, Lyle PA. Use of beta-blockers, angiotensin-converting enzyme inhibitors, and angiotensin receptor blockers to prevent atrial fibrillation. Curr Cardiol Rep 2006; 8:356-64. [PMID: 16956451 DOI: 10.1007/s11886-006-0075-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Atrial fibrillation, the most common cardiac arrhythmia in clinical practice, causes significant burden to patients and health care systems worldwide. Attention is being paid to prevention of atrial fibrillation using drugs that retard or prevent atrial fibrosis and arrhythmogenic remodeling, which lead to this arrhythmia. Agents that work through the renin-angiotensin-receptor system, the angiotensin-converting enzyme inhibitors and angiotensin receptor blockers, are showing promise in animal and human studies.
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Affiliation(s)
- Kristian Wachtell
- Rigshospitalet, Department of Cardiology B2142, The Heart Center, 9 Blegdamsvej, DK-2100 Copenhagen, Denmark.
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Stulak JM, Dearani JA, Daly RC, Zehr KJ, Sundt TM, Schaff HV. Left Ventricular Dysfunction in Atrial Fibrillation: Restoration of Sinus Rhythm by the Cox-Maze Procedure Significantly Improves Systolic Function and Functional Status. Ann Thorac Surg 2006; 82:494-500; discussion 500-1. [PMID: 16863752 DOI: 10.1016/j.athoracsur.2006.03.075] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2005] [Revised: 03/21/2006] [Accepted: 03/24/2006] [Indexed: 11/23/2022]
Abstract
BACKGROUND Atrial flutter or fibrillation with rapid, uncontrolled ventricular response may lead to left ventricular dysfunction, and conversion to sinus rhythm with control of heart rate can improve left ventricular ejection fraction. Little is known about the effects of the Cox-maze procedure on this form of tachycardia-induced cardiomyopathy. METHODS Four hundred forty-three patients underwent the Cox-maze procedure from 1993 to 2002. Ninety-nine had atrial flutter or fibrillation without associated valvular or congenital heart disease, and 37 (37%) had decreased left ventricular function (ejection fraction < 0.35 in 11 [severe], ejection fraction 0.36 to 0.45 in 8 [moderate], and ejection fraction 0.46 to 0.55 in 18 [mild]). Ages of these 37 patients (34 male) ranged from 35 to 74 years (median, 55 years). RESULTS Atrial flutter or fibrillation was present for 3 months to 19 years (median, 48 months) preoperatively, and 24 patients (65%) exhibited symptoms of heart failure. Preoperative ejection fraction ranged from 0.25 to 0.55 (median, 0.45). At last follow-up (median, 63 months), the Cox-maze procedure eliminated atrial flutter or fibrillation in all but 1 patient, and the greatest improvement was observed in patients with severe preoperative impairment (0.31 to 0.53; p = 0.01, preoperative versus follow-up), and patients with preoperative chronic atrial flutter or fibrillation (0.43 to 0.55; p < 0.05 preoperative versus follow-up). This improvement was observed immediately postoperatively and was sustained at last follow-up. Further, improvement in left ventricular function correlated with enhancement of functional status. CONCLUSIONS In some patients, atrial flutter or fibrillation may be the cause rather than the consequence of left ventricular dysfunction. Importantly, systolic function and functional status can be significantly improved with the restoration of sinus rhythm by the Cox-maze procedure.
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Affiliation(s)
- John M Stulak
- Division of Cardiovascular Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55905, USA
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29
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Abstract
The authors present practical and concise advice on initial diagnosis and management of arrhythmias, on arrhythmia devices, and on syncope. There is discussion of tachyarrhythmias, both wide and narrow, bradyarrhythmias, and management of pacemakers and defibrillators. Common pitfalls and concerns are addressed.
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Affiliation(s)
- R E Hood
- Division of Cardiology, Department of Medicine, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD 21201, USA
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Movahed MR, Hashemzadeh M, Jamal MM. Diabetes mellitus is a strong, independent risk for atrial fibrillation and flutter in addition to other cardiovascular disease. Int J Cardiol 2005; 105:315-8. [PMID: 16274775 DOI: 10.1016/j.ijcard.2005.02.050] [Citation(s) in RCA: 265] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2004] [Revised: 02/07/2005] [Accepted: 02/19/2005] [Indexed: 01/01/2023]
Abstract
BACKGROUND Diabetes mellitus (DM) is a major risk factor for atherosclerosis. There is a controversy in literature about correlation between DM and atrial fibrillation. The goal of this study was to evaluate DM as a risk factor for atrial fibrillation or flutter using a very large database. METHOD Patient treatment files (PTF) containing discharge diagnoses were utilized using ICD-9 codes of inpatient treatment from Veterans Health Administration Hospitals (VAH). Patients with type II DM (ICD-9 code 250.0) (293,124) discharged from the VAH between 1990 and 2000. Non-matched controls without DM but with hypertension (552,624) were selected from the same PTF. By using multi-variate logistic regressions, the occurrence of atrial fibrillation, atrial flutter, CHF, CAD and LVH was compared. RESULTS Atrial fibrillations occurred in 43,674 (14.9%) DM patients vs. 57,077 (10.3%) in the control group (p<0.0001). Atrial flutter occurred in 11,852 (4%) of DM patients vs. 13,554 (2.5%) of the control group (p<0.0001). Using multi-variant analysis, DM remained independently associated with atrial fibrillation with an OR of 2.13, (95% CI: 2.10 to 2.16; p<0.0001) and flutter (OR 2.20, CI: 2.15 to 2.26; p<0.0001). Furthermore, CHF (OR 3.12, CI: 3.09 to 3.16; p<0.0001), LVH (OR 1.85, CI: 1.77 to 1.92; p<0.0001) and CAD (OR 2.39, CI: 2.34 to 2.44; p<0.0001) were also independently associated with DM. CONCLUSION This is the first large-scale study finding DM as a strong, independent risk for the occurrence of atrial fibrillation and flutter and other cardiovascular disease.
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Affiliation(s)
- Mohammad-Reza Movahed
- Division of Cardiology, University of California, Irvine, Medical Center Department of Medicine, 101 The City Drive, Bldg. 53, Rm 100, Orange, CA 92868, United States.
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31
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Abstract
Atrial fibrillation (AF) is the most potent common risk factor for ischemic stroke. The number of Americans with nonvalvular AF is expected to increase markedly over the next several decades, making AF-related stroke an important public health concern. Given the individual and societal burden associated with AF-related stroke, efforts to identify and implement efficacious and acceptably safe therapeutic stroke prevention strategies are paramount. This article reviews the existing randomized trial evidence supporting the efficacy of oral vitamin K antagonists (ie, warfarin) or aspirin for preventing thromboembolism in AF, as well as completed and ongoing studies exploring novel antithrombotic agents including the oral direct thrombin inhibitor, ximelagatran, other antiplatelet agents (eg, clopidogrel), factor Xa inhibitors, and other pharmacological agents and additional therapeutic approaches such as mechanical devices and surgical procedures to obliterate the left atrial appendage.
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Affiliation(s)
- Alan S Go
- Division of Research, Kaiser Permanente of Northern California, 2000 Broadway St, 3rd Floor, Oakland, CA 94612-2304, USA.
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van der Velde ET, Vander VET, Vriend JWJ, Mannens MMAM, Uiterwaal CSPM, Brand R, Mulder BJM. CONCOR, an initiative towards a national registry and DNA-bank of patients with congenital heart disease in the Netherlands: Rationale, design, and first results. Eur J Epidemiol 2005; 20:549-57. [PMID: 16121765 DOI: 10.1007/s10654-005-4264-9] [Citation(s) in RCA: 188] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Survival of patients with congenital heart disease has dramatically improved after surgical repair became available 40 years ago. Instead of a mortality of 85% during childhood following the natural course, over 85% of these infants are now expected to reach adulthood. However, data on long-term outcome is scarce due to the lack of large, national registries. Moreover, little is known about the genetic basis of congenital heart defects. In 2000, the Interuniversity Cardiology Institute of the Netherlands and the Netherlands Heart Foundation have taken the initiative to develop a national registry and DNA-bank of patients with congenital heart disease in the Netherlands named CONCOR. OBJECTIVES The aims of the CONCOR project are to facilitate investigation of the prevalence and long-term outcome of specific congenital heart defects and their treatment, to develop an efficient organisational structure for the improvement of healthcare for patients with congenital heart disease, and to allow investigation of the molecular basis of congenital heart defects. METHODS After informed consent, research nurses enter data of participating patients into the CONCOR database using a web application. Data is transferred over the Internet via a secure connection. About 20 ml blood is withdrawn from the patient, and the DNA is isolated and stored. From each participating patient family history on congenital heart disease is obtained. RESULTS Within two and a half years more than 4200 patients have agreed to participate. More than 99% of the patients that were asked have given their consent to participate in CONCOR. From 60% of these patients DNA has already been obtained. Mean age of the patients included is 34 years; more than 85% of the patients are younger than 45 years. Late complications occur frequently and the incidence increases with advancing age. 18% of the patients are known with supraventricular or ventricular arrhythmias. 2% of the included patients suffered a cerebrovascular accident, 139 (3%) had endocarditis. 6% of the patients has pulmonary hypertension or Eisenmenger syndrome. More than 15% of the patients reported an affected family member with congenital heart disease in the first, second, or third degree. 6% has an affected first-degree relative, and 4% a second-degree relative. Already 10 research projects have started using the CONCOR data and DNA. CONCLUSION The population of patients with congenital heart disease is young and rapidly growing. Late complications occur frequently and the incidence increases with advances age. The CONCOR registry and DNA-bank facilitates research on prevalence and long-term outcome and allows investigation of the molecular basis of congenital heart disease.
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Affiliation(s)
- E T van der Velde
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands.
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33
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Abstract
Atrial fibrillation is the most common, serious, cardiac arrhythmia and increases the risk for ischemic stroke fivefold. Nonvalvular atrial fibrillation may be responsible for up to 15–20% of strokes. Antiplatelet agents and oral anticoagulants are used for stroke prevention in atrial fibrillation. The following review article discusses the potential risks and benefits of oral anticoagulants in nonvalvular atrial fibrillation with particular emphasis on accurate risk stratification tools for ischemic stroke.
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Affiliation(s)
- Bipinpreet S Nagra
- Albert Einstein Medical Center, Division of Cardiac Electrophysiology 5501 Old York Road, Levy 3-East, Philadelphia, PA 19118, USA
| | - Bharat K Kantharia
- Albert Einstein Medical Center, Division of Cardiac Electrophysiology 5501 Old York Road, Levy 3-EastPhiladelphia, PA 19118, USA
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Khaykin Y, Marrouche NF, Saliba W, Schweikert R, Bash D, Chen MS, Williams-Andrews M, Saad E, Burkhardt DJ, Bhargava M, Joseph G, Rossillo A, Erciyes D, Martin D, Natale A. Pulmonary vein antrum isolation for treatment of atrial fibrillation in patients with valvular heart disease or prior open heart surgery. Heart Rhythm 2004; 1:33-9. [PMID: 15851113 DOI: 10.1016/j.hrthm.2004.02.007] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2003] [Accepted: 02/04/2004] [Indexed: 11/24/2022]
Abstract
OBJECTIVES The goal of this study was to assess the safety and efficacy of pulmonary vein antrum isolation in patients with moderate valvular heart disease or open-heart surgery and atrial fibrillation (AF). BACKGROUND Valvular heart disease and open-heart surgery are commonly associated with AF and increase the risk of adverse events in AF patients. METHODS A total of 391 consecutive patients who had pulmonary vein antrum isolation performed between December 2000 and December 2002 were screened. A total of 142 of these patients had clinically significant valvular disease or prior cardiac surgery. End points included AF recurrence and pulmonary vein antrum isolation complication rates. RESULTS Patients with valvular heart disease or prior open-heart surgery were older, had larger left atria and a more advanced New York Heart Association class. They did not differ significantly with respect to gender, but had a longer history of AF. Procedure times were similar between patients with and without valvular heart disease or prior open-heart surgery. After 18 +/- 7 months in the lone AF patients, 11 +/- 5 months in patients with valvular heart disease, and 10 +/- 5 months in patients with prior open heart surgery, there was a trend toward lower recurrence of AF in patients with lone AF who enjoyed a 98% overall cure rate after up to 2 pulmonary vein antrum isolations versus 93% among patients with valvular heart disease (P = .04) and prior open heart surgery (P = .07). Complication rates were comparable between groups. CONCLUSIONS Pulmonary vein antrum isolation is safe and effective in patients with moderate valvular heart disease and the patients who developed AF after open-heart surgery. These results have implications for our understanding of the pathophysiology of AF in patients with moderate valvular heart disease or past cardiac surgery and should be considered when discussing treatment options in these patients.
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Affiliation(s)
- Yaariv Khaykin
- Center for Atrial Fibrillation, Department of Cardiovascular Medicine, The Cleveland Clinic Foundation, Ohio 44195, USA
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Rastas S, Mattila K, Verkkoniemi A, Niinistö L, Juva K, Sulkava R, Länsimies E. Association of apolipoprotein E genotypes, blood pressure, blood lipids and ECG abnormalities in a general population aged 85+. BMC Geriatr 2004; 4:1. [PMID: 15050032 PMCID: PMC404463 DOI: 10.1186/1471-2318-4-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2003] [Accepted: 03/29/2004] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Several studies have linked apolipoprotein E (ApoE) epsilon4 allele with elevated cholesterol and blood pressure levels. Data on the association of APOE genotypes with blood pressure, lipids, atrial fibrillation and ECG abnormalities in individuals aged 85 years and over is sparse. METHODS This cross sectional study consisted of all residents of the city of Vantaa (N = 601) aged 85 years or over of whom 505 participated in the study. Blood pressure was measured by using mercury sphygmomanometer. 12-Lead ECG, short ambulatory ECG, or both were taken from all study subjects to diagnose atrial fibrillation (AF). Ambulatory ECG was carried out home or in the institute. APOE genotyping was performed using a combination of the polymerase chain reaction (PCR) and solid-phase minisequencing technique. Statistical analysis was made by using Kruskall-Wallis-test (continuous data) and chi2-test (rates and proportions). RESULTS In these very elderly individuals, APOE 4 allele was significantly associated with elevated cholesterol and low-density lipoprotein (LDL) levels. Blood pressure or cardiac arrhythmias did not differ between APOE genotypes. CONCLUSIONS These observations suggest that the important role of APOE genotype still influences cardiovascular risk profile even among the very elderly people.
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Affiliation(s)
- Sari Rastas
- Department of Neuroscience and Neurology, University of Kuopio, Kuopio, Finland
| | - Kimmo Mattila
- Division of Infectious Diseases, Department of Medicine, Helsinki University Central Hospital, Helsinki, Finland
| | - Auli Verkkoniemi
- Department of Clinical Neurosciences, Helsinki University Central Hospital, Helsinki, Finland
| | | | - Kati Juva
- Department of Psychiatry, Helsinki University Central Hospital, Helsinki, Finland
| | - Raimo Sulkava
- Department of Public Health and General Practice, University of Kuopio, Kuopio, Finland
| | - Esko Länsimies
- Department of clinical Physiology and Nuclear Medicine, University and University Hospital, Kuopio, Finland
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Barthélémy J, Féasson‐Gérard S, Garnier P, Gaspoz J, Costa AD, Michel D, Roche F. Automatic cardiac event recorders reveal paroxysmal atrial fibrillation after unexplained strokes or transient ischemic attacks. Ann Noninvasive Electrocardiol 2004; 8:194-9. [PMID: 14510653 PMCID: PMC6932331 DOI: 10.1046/j.1542-474x.2003.08305.x] [Citation(s) in RCA: 95] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The etiology of stroke or transitory ischemic attack (TIA) remains frequently unknown. While paroxysmal atrial fibrillation (PAF) is often suspected, its presence remains difficult to establish. Therefore, we investigated the occurrence of PAF episodes in such a population using a long-term automatic cardiac event recorder. METHODS We prospectively investigated 60 consecutive subjects admitted in our university hospital for stroke (n=44) or TIA (n=16), adding long-term automatic cardiac event recorders, with a target duration of 4 days, to standard investigations, which included 12-lead ECGs and 24-hour Holter recordings. RESULTS In 28 patients no etiology was found for their stroke or TIA. However, one or more than one PAF episode was found in 4 of them (14.3%) using the long-term automatic event recorder. In the 32 remaining patients, 8 presented with PAF, and this was considered as the cause of their stroke. In both groups, AF was paroxysmal. The PAF episodes' duration went from 1 to 96 hours (mean +/- standard deviation, 18 hours and 30 minutes+/-30 hours). CONCLUSIONS Patients suffering PAF episodes after ischemic stroke or TIA were statistically less often recognized using the 24-hour Holter ECG recording alone than the R-Test Evolution alone.
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Affiliation(s)
- Jean‐Claude Barthélémy
- Service d'Exploration Fonctionnelle CardioRespiratoire, Laboratoire de Physiologie, CHU Nord, France
| | - Séverine Féasson‐Gérard
- Service d'Exploration Fonctionnelle CardioRespiratoire, Laboratoire de Physiologie, CHU Nord, France
| | - Pierre Garnier
- Service de Neurologie, CHU Bellevue, Faculté de Médecine Jacques Lisfranc, Université Jean Monnet, France
| | - Jean‐Michel Gaspoz
- Clinique de Médecine II et Division de Cardiologie, Département de Médecine Interne, Hôpitaux Universitaires, Switzerland
| | - Antoine Da Costa
- Service de Cardiologie, CHU Nord, Faculté de Médecine Jacques Lisfranc, Université Jean Monnet, France
| | - Daniel Michel
- Service de Neurologie, CHU Bellevue, Faculté de Médecine Jacques Lisfranc, Université Jean Monnet, France
| | - Frédéric Roche
- Service d'Exploration Fonctionnelle CardioRespiratoire, Laboratoire de Physiologie, CHU Nord, France
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Abstract
For over two decades, valuable insights have been accumulated from epidemiologic studies and randomized trials about the risks for and prevention of AF-related stroke. AF substantially raises the risk of stroke, most likely through an atrio-embolic mechanism. Warfarin and other members of its class of oral anticoagulants targeted at an INR of 2.5 can abrogate the risk of stroke attributable to AF effectively and fairly safely. High-quality management of anticoagulation can be achieved in usual clinical care. These insights have important implications for the care of individual patients and more generally for public health. Future research is needed to specify the risk of stroke and hemorrhage among patients with AF better, particularly among older individuals, to optimize use of antithrombotic agents, and to define the role of recently developed antithrombotic drugs and invasive nondrug approaches.
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Affiliation(s)
- Margaret C Fang
- University of California, San Francisco, 533 Parnassus Avenue, Box 0131, San Francisco, CA 94143, USA.
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Khaykin Y, Newman D, Kowalewski M, Korley V, Dorian P. Biphasic versus monophasic cardioversion in shock-resistant atrial fibrillation:. J Cardiovasc Electrophysiol 2003; 14:868-72. [PMID: 12890051 DOI: 10.1046/j.1540-8167.2003.03133.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
UNLABELLED Biphasic versus Monophasic Cardioversion. INTRODUCTION Cardioversion of atrial fibrillation using monophasic transthoracic shocks occasionally is ineffective. Biphasic cardioversion requires less energy than monophasic cardioversion, but its efficacy in shock-resistant atrial fibrillation is unknown. Thus, we compared the efficacy of cardioversion using biphasic versus monophasic waveform shocks in patients with atrial fibrillation previously refractory to monophasic cardioversion. METHODS AND RESULTS Fifty-six patients with prior failed monophasic cardioversion were randomized to either a 360-J monophasic damped sinusoidal shock or biphasic truncated exponential shocks at 150 J, followed by 200 J and then 360 J, if necessary. If either waveform failed, patients were crossed over to the other waveform. The primary endpoint was defined as the proportion of patients achieving sinus rhythm following initial randomized therapy. Stepwise multivariate logistic regression examined independent predictors of shock success, including patient age, sex, left atrial diameter, body mass index, drug therapy, and waveform. Twenty-eight patients were randomized to the biphasic shocks and 28 to the monophasic shocks. Sinus rhythm was restored in 61% of patients with biphasic versus 18% with monophasic shocks (P = 0.001). Seventy-eight percent success was achieved in patients who crossed over to the biphasic shock after failing monophasic cardioversion, whereas only 33% were successfully cardioverted with a monophasic shock after crossover from biphasic shock (P = 0.02). Overall, 69% of patients who received a biphasic shock at any point in the protocol were cardioverted successfully, compared to 21% with the monophasic shock (P < 0.0001). The type of shock was the strongest predictor of shock success (P = 0.0001) in multivariate logistic regression. CONCLUSION An ascending sequence of 150-, 200-, and 360-J transthoracic biphasic cardioversion shocks are successful more often than a single 360-J monophasic shock. Thus, biphasic shocks should be the recommended configuration of choice for all cardioversions.
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Affiliation(s)
- Yaariv Khaykin
- Terrence Donnelly Heart Center, Department of Medicine, St Michael's Hospital, Toronto, Ontario, Canada
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Josephson L, McMullen M. Atrial fibrillation: beyond irregularly irregular: the basis for acute and chronic treatment. Dimens Crit Care Nurs 2002; 21:180-9. [PMID: 12359992 DOI: 10.1097/00003465-200209000-00003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Today atrial fibrillation is the most prevalent sustained arrhythmia encountered in clinical practice; it places a heavy burden on the healthcare system. The purpose of this article is to explore the principles underlying the treatment of both acute and chronic atrial fibrillation.
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Affiliation(s)
- Linda Josephson
- Memorial Hospital, University of Messachusetts Memorial Health Center, 153 Uncatena Avenue, Worcester, MA 01606, USA.
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40
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Das MK, Cheriparambil K, Bedi A, Kassotis J, Reddy CVR, Saul B, Makan M. Cardioversion of atrial fibrillation with ibutilide: when is it most effective? Clin Cardiol 2002; 25:411-5. [PMID: 12269519 PMCID: PMC6653973 DOI: 10.1002/clc.4960250904] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2001] [Accepted: 11/21/2001] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Atrial fibrillation (AF) is found in 1% of persons above the age of 60 years. More than 5% of the population older than 69 years and about 14% of octogenarians are at risk for this arrhythmia. It is estimated that 1.5 to 3 million persons in the United States alone suffer from AF. The public health implications and attendant morbidity are a significant drain on our health care system. HYPOTHESIS The purpose of this study was to determine the clinical and echocardiographic predictors of success in converting AF of > or = 24 h duration. METHODS Demographic and clinical and echocardiographic parameters of 101 patients with recent onset AF (> 24 h) who received ibutilide were studied. RESULTS Of 101 patients, 56 (55%) converted to sinus rhythm. Age, gender, hypertension, diabetes mellitus, left ventricular ejection fraction (< or = 35%), congestive heart failure, and previous medication for rate control had no significant effect on the conversion rate. Conversion rate was only 30% (9/30 patients) in the presence of an enlarged left atrium (LA > or = 5 cm) and 37.7% (23/61 patients) in the presence of mitral valve disease (MVD), whereas the conversion rate was 82.5% (33/40 patients) in the absence of MVD and 85% (29/34 patients) in the absence of both enlarged LA and MVD (p = <0.001). Patients with coronary artery disease (CAD) also exhibited a significantly greater response to ibutilide than patients without CAD (77 vs. 46%, p-value 0.005). CONCLUSION As a therapy for cardioversion of AF, ibutilide is most effective in a selected subgroup patients, such as in patients with CAD and in patients without MVD and/or markedly enlarged left atrium.
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Affiliation(s)
- Mithilesh Kumar Das
- Division of Cardiology (Starr4), New York Presbyterian Hospital-Cornell University Medical College, New York 10021, USA.
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Khand AU, Cleland JGF, Deedwania PC. Prevention of and medical therapy for atrial arrhythmias in heart failure. Heart Fail Rev 2002; 7:267-83. [PMID: 12215732 DOI: 10.1023/a:1020097728178] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
A large proportion of heart failure patients suffer from atrial arrhythmias, prime amongst them being atrial fibrillation (AF). Ventricular dysfunction and the syndrome of heart failure can also be a concomitant pathology in up to 50% of patients with AF. However this association is more than just due to shared risk factors, research from animal and human studies suggest a causal relationship between AF and heart failure. There are numerous reports of tachycardia-induced heart failure where uncontrolled ventricular rate in AF results in heart failure, which is reversible with cardioversion to sinus rhythm or ventricular rate control. However the relationship extends beyond tachycardia-induced cardiomyopathy. Optimal treatment of AF may delay progressive ventricular dysfunction and the onset of heart failure whilst improved management of heart failure can prevent AF or improve ventricular rate control. Prevention and treatment of atrial arrhythmias, and in particular atrial fibrillation, is therefore an important aspect of the management of patients with heart failure. This review describes the incidence and possible predictors of AF and other atrial arrhythmias in patients with heart failure and discusses the feasibility of primary prevention. The evidence for the management of atrial fibrillation in heart failure is systematically reviewed and the strategies of rate versus rhythm control discussed in light of the prevailing evidence.
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Affiliation(s)
- A U Khand
- Department of Cardiology, Western Infirmary, Glasgow, UK.
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Viola N, Williams MR, Oz MC, Ad N. The technology in use for the surgical ablation of atrial fibrillation. Semin Thorac Cardiovasc Surg 2002; 14:198-205. [PMID: 12232858 DOI: 10.1053/stcs.2002.35292] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The purpose of this article is to present and evaluate the various technologies recently developed for the surgical treatment of atrial fibrillation as alternatives or adjuncts to the traditional Maze III procedure and other "cut and sew" techniques. The discussion contains a detailed consideration of the biophysical background of the most common ablation techniques, their mode of tissue injury, the methods of use, and the related complications through a review of the existing literature and analysis of experimental results. All of the current technologies presented are still being tested to augment the success rates and reduce the incidence of complications, although all are not available for clinical use. Radiofrequency and cryoablation have been used clinically on large numbers of patients with varying results. Microwave technology has been used in small groups of patients, and the results are to be evaluated. Laser technology is still in an experimental phase, and the clinical results are forthcoming. True transmurality, reduction of operative time, friendly use of ablation devices, and substantial reduction of complications appear to be the key factors for broad adoption of alternative energy sources for surgical ablation.
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Affiliation(s)
- Nicola Viola
- Cardiothoracic Surgery Department, Hadassah University Hospital, Jerusalem, Israel
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Domanovits H, Schillinger M, Thoennissen J, Nikfardjam M, Janata K, Brunner M, Laggner AN. Termination of recent-onset atrial fibrillation/flutter in the emergency department: a sequential approach with intravenous ibutilide and external electrical cardioversion. Resuscitation 2000; 45:181-7. [PMID: 10959017 DOI: 10.1016/s0300-9572(00)00180-5] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Safety and effectiveness are the goals in treating patients with arrhythmias. In an open prospective study, we observed the efficacy and safety of up to 2 mg intravenous ibutilide, a new class III antiarrhythmic agent in haemodynamically stable patients presenting in the emergency department (ED) with symptoms of recent-onset (<48 h) atrial fibrillation/flutter. Arrhythmia termination within 90 min, haemodynamic parameters and proarrhythmic effects were assessed. Non-responders to the ibutilide infusion underwent external electrical cardioversion. We included 51 patients. In 31 patients therapeutic intervention with intravenous ibutilide was successful within 90 min (61%). In another seven patients conversion to sinus rhythm occurred after 90 min without any other intervention (14%). Blood pressure remained stable and no relevant proarrhythmic effects were observed. The 13 patients who did not respond to ibutilide treatment underwent successful external electrical cardioversion. The overall conversion rate was 100%. Forty-seven patients (92%) were discharged within a median of 9 h and managed as outpatients. In conclusion, in haemodynamically stable patients with recent-onset atrial fibrillation/flutter intravenous ibutilide and external electrical cardioversion for conversion to sinus rhythm turned out to be effective and safe. The short duration of admission makes this strategy attractive for use in the ED.
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Affiliation(s)
- H Domanovits
- Department of Emergency Medicine, Vienna General Hospital, University of Vienna, Medical School, Austria.
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Kiryu K, Machida N, Kashida Y, Yoshihara T, Amada A, Yamamoto T. Pathologic and electrocardiographic findings in sudden cardiac death in racehorses. J Vet Med Sci 1999; 61:921-8. [PMID: 10487232 DOI: 10.1292/jvms.61.921] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Five racehorses in apparently normal condition succumbed to sudden cardiac death (SCD) during or shortly after intensive training exercise. Cardiopathologic examination was performed. In 1 of the 5 horses, the use of an electrocardiogram (ECG) recording taken continuously for 440 sec enabled us to analyze some of the arrhythmias in the terminal event of SCD. The ECG tracing exhibited the R-on-T phenomenon following a pair of ventricular premature contractions (VPCs). The phenomenon rapidly degenerated into ventricular fibrillation, which led to cardiac arrest. In all 5 horses cardiopathologic examination revealed the following lesions: (i) foci of myocardial fibrosis in the right atrium located close to the sinoatrial (SA) node, (ii) fibrotic and/or fibroplastic changes in the upper portion of the interventricular septum, including the atrioventricular (AV) conduction system, and (iii) arterio- and arteriolosclerosis of the SA and AV node vessels. Pathogenetically, the process by which the focal lesions of myocardial ischemia secondary to vascular sclerosis progressed into fibrosis and/or fibroplasia could play a major role in the genesis of arrhythmias. Presumably the fibrotic and/or fibroplastic changes in the area of the AV bundle and its bundle branches are closely related to the onset of fatal ventricular arrhythmias such as VPCs, deteriorating into ventricular fibrillation. SCD in training and racing Thoroughbred horses appears to be due to arrhythmia.
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Affiliation(s)
- K Kiryu
- Department of Veterinary Pathology, Tokyo University of Agriculture and Technology, Fuchu, Japan
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Chorro FJ, Mainar L, Sanchis J, Cánoves J, Porres JC, Guerrero J, Millet J, Llavador E, Such LM, Egea S, López-Merino V, Such L. [The activation patterns during atrial fibrillation in an experimental model]. Rev Esp Cardiol 1999; 52:327-38. [PMID: 10368584 DOI: 10.1016/s0300-8932(99)74923-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION AND OBJECTIVES In atrial fibrillation, along with the mechanisms of complete reentry and random activation focal activation patterns have been described which have been attributed both to propagation from the endocardium and to the existence of zones with automatic activity. The objectives of present study are to analyze and quantify the atrial activation patterns in an experimental model of atrial fibrillation. MATERIAL AND METHODS In 11 Langendorff-perfused rabbit hearts atrial fibrillation was induced by atrial burst pacing after right atrial dilatation with an intra-atrial balloon. A multiple electrode consisting of 121 electrodes and positioned in the right atrial free wall was used to construct the activation maps corresponding to 10 segments of 100 ms in 11 different episodes of sustained atrial fibrillation (one per experiment). RESULTS Of the 110 segments analyzed, 44 (40%) corresponded to random activation patterns. Fifteen segments (14%) corresponded to complete reentry, and in these cases the number of consecutive rotations ranged from 1 to 2.25 (mean 1.4 +/- 0.4). In 49 segments (44%) a single activation front was seen to pass through the recording area without block; alternatively, two simultaneous fronts were recorded that did not re-excite the zone activated by the other. In two segments (2%) there was a focal activation pattern without evidence of propagation from the epicardium surrounding the activated zone. CONCLUSIONS a) in the experimental atrial fibrillation model used, random activation patterns are more frequent than complete reentry patterns; b) complete reentry can occur in areas smaller than 1 cm2, and c) focal activation during atrial fibrillation is rare.
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Affiliation(s)
- F J Chorro
- Servicio de Cardiología, Hospital Clínico Universitario, Valencia
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Howard PA. Ibutilide: an antiarrhythmic agent for the treatment of atrial fibrillation or flutter. Ann Pharmacother 1999; 33:38-47. [PMID: 9972384 DOI: 10.1345/aph.18097] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To discuss the clinical pharmacology of the antiarrhythmic drug ibutilide in patients with atrial fibrillation (AF) or atrial flutter (AFl). DATA SOURCES A MEDLINE search (January 1983-December 1997) was used to identify pertinent English-language articles on ibutilide. Key search terms included ibutilide, AF, AFl, cardioversion, and sinus rhythm. The MEDLINE search was supplemented by references included in the bibliographies of comprehensive review articles and studies. STUDY SELECTION Studies and review articles describing the chemistry, pharmacology, and pharmacokinetics of ibutilide were selected. All abstracts and published clinical trials evaluating the efficacy and safety were reviewed. DATA EXTRACTION Pertinent information on the pharmacology and mechanism of action of ibutilide was summarized. Data were extracted from the clinical trials describing trial design, patient population, interventions, methods of evaluation, outcomes, and statistical significance. DATA SYNTHESIS Ibutilide is a Vaughan-Williams class III antiarrhythmic agent approved for intravenous use for the rapid termination of recent-onset AF or AFl. The drug is extensively metabolized by the liver, has a volume of distribution of 11-15 L/kg, is 40% protein bound, and has an elimination half-life of 6 hours (range 2-12). Data from two placebo-controlled trials demonstrated the efficacy of ibutilide for converting AF or AFl of short duration (< or = 90 d) to normal sinus rhythm. A third placebo-controlled trial demonstrated efficacy in patients who developed AF or AFl following cardiac surgery. Comparative trials with procainamide and sotalol have shown at least similar and perhaps superior efficacy with ibutilide. There are no comparative trials with other antiarrhythmic drugs or with direct current cardioversion (DCC). In 586 clinical trial patients receiving ibutilide, the most significant adverse effect was the development of torsade de pointes in 25 patients (4.3%) including 10 cases (1.7%) in which the rhythm was sustained. All cases of torsade de pointes were terminated electrically and none resulted in death or severe morbidity. No prospective cost-effectiveness studies are available; however, results from two decision models suggest that ibutilide may have advantages over other drugs and first-line electrical cardioversion. CONCLUSIONS Ibutilide appears to be an effective alternative method for rapid conversion of recent-onset AF or AFl. The drug may be particularly useful in patients who have undergone recent cardiac surgery or those who are not ideal candidates for DCC. Although studies suggest that the risk of proarrhythmia and in particular torsade de pointes is relatively low, caution is advised until additional experience is gained in clinical practice.
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Affiliation(s)
- P A Howard
- Department of Pharmacy Practice, University of Kansas Medical Center, Kansas City 66160, USA.
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Ganau G, Lenzi T. Intravenous propafenone for converting recent onset atrial fibrillation in emergency departments: a randomized placebo-controlled multicenter trial. FAPS Investigators Study Group. J Emerg Med 1998; 16:383-7. [PMID: 9610964 DOI: 10.1016/s0736-4679(98)00003-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Atrial fibrillation (AF) is one of the most frequent dysrhythmias in patients coming to emergency departments (EDs), and pharmacological treatment is frequently performed. The aim of this randomized placebo-controlled multicenter trial was to compare propafenone (a class 1C antidysrhythmic agent), administered i.v. in the ED, with placebo in the treatment of recent-onset AF (<72 h). We randomly allocated 156 patients (88 males; 68 females) from 18 to 80 years old, with recent-onset AF, to receive i.v. propafenone (2 mg/kg for 10 min) or the matching placebo. The patients were followed for 2 h. Exclusion criteria were the presence of one of the following: lack of informed consent, clinical evidence of heart failure, clinical hyperthyroidism, recent acute myocardial infarction, atrioventricular block, cardiac valve dysfunction, a history of bronchial asthma, and current treatment with antidysrhythmic agents including digitalis. The two groups did not differ significantly in terms of sex, age, body weight, or estimated time elapsed since the beginning of atrial fibrillation. Conversion to sinus rhythm occurred in 13 of the 75 patients who received the placebo (17.3%) and in 57 of the 81 patients who were given propafenone (70.3%). In conclusion, intravenous propafenone administration in the ED can be considered a safe and effective approach for converting AF to sinus rhythm.
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Affiliation(s)
- G Ganau
- Emergency Department, Ospedale Civile, Sassari, Italy
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Affiliation(s)
- S M Narayan
- Department of Internal Medicine, Washington University School of Medicine, Saint Louis, Missouri 63110, USA.
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