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Alcaraz R, Hornero F, Rieta JJ. Noninvasive time and frequency predictors of long-standing atrial fibrillation early recurrence after electrical cardioversion. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2011; 34:1241-50. [PMID: 21605132 DOI: 10.1111/j.1540-8159.2011.03125.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Several clinical factors have been studied to predict atrial fibrillation (AF) recurrence after electrical cardioversion (ECV) with limited predictive value. METHODS A method able to predict robustly long-standing AF early recurrence by characterizing noninvasively the electrical atrial activity (AA) with parameters related to its time course and spectral features is presented. To this respect, 63 patients (20 men and 43 women; mean age 73.4 ± 9.0 years; under antiarrhythmic drug treatment with amiodarone) who were referred for ECV of persistent AF were studied. During a 4-week follow-up, AF recurrence was observed in 41 patients (65.1%). RESULTS RR variability and the studied AA spectral features, including dominant atrial frequency (DAF), its first harmonic and their amplitude, provided poor statistical differences between groups. On the contrary, f waves power (fWP) and Sample Entropy (SampEn) of the AA behaved as very good predictors. Patients who relapsed to AF presented lower fWP (0.036 ± 0.019 vs 0.081 ± 0.029 n.u.(2) , P < 0.001) and higher SampEn (0.107 ± 0.022 vs 0.086 ± 0.033, P < 0.01). Furthermore, fWP presented the highest predictive accuracy of 82.5%, whereas SampEn provided a 79.4%. The remaining features revealed accuracies lower than 70%. A stepwise discriminant analysis (SDA) provided a model based on fWP and SampEn with 90.5% of accuracy. CONCLUSIONS The fWP has proved to predict long-standing AF early recurrence after ECV and can be combined with SampEn to improve its diagnostic ability. Furthermore, a thorough analysis of the results allowed outlining possible associations between these two features and the concomitant status of atrial remodeling.
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Affiliation(s)
- Raúl Alcaraz
- Innovation in Bioengineering Research Group, University of Castilla-La Mancha, Cuenca, Spain.
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Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA, Halperin JL, Kay GN, Le Huezey JY, Lowe JE, Olsson SB, Prystowsky EN, Tamargo JL, Wann LS. 2011 ACCF/AHA/HRS Focused Updates Incorporated Into the ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation. Circulation 2011; 123:e269-367. [PMID: 21382897 DOI: 10.1161/cir.0b013e318214876d] [Citation(s) in RCA: 595] [Impact Index Per Article: 45.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA, Halperin JL, Kay GN, Le Huezey JY, Lowe JE, Olsson SB, Prystowsky EN, Tamargo JL, Wann LS. 2011 ACCF/AHA/HRS Focused Updates Incorporated Into the ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation. J Am Coll Cardiol 2011; 57:e101-98. [PMID: 21392637 DOI: 10.1016/j.jacc.2010.09.013] [Citation(s) in RCA: 642] [Impact Index Per Article: 49.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Surgery for Lone Atrial Fibrillation: Present State-of-the-Art. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2009; 4:248-255. [PMID: 20473355 DOI: 10.1097/imi.0b013e3181bb370f] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
For two decades, the cut-and-sew Cox-Maze III procedure was the gold standard for the surgical treatment of atrial fibrillation (AF), and proved to be effective at curing lone AF and preventing its most dreaded complication, stroke. However, this procedure was not widely adopted due to its complexity and technical difficulty. Over the last 5-10 years, the introduction of new ablation technology has led to the development of the Cox-Maze IV procedure, as well as, more limited lesion sets, with the ultimate goal of performing a minimally-invasive lesion set on the beating heart, without the need for cardiopulmonary bypass. This review summarizes the current state of the art and future directions in the surgical treatment of lone atrial fibrillation. The hope is that as we learn more about the mechanisms of AF and develop preoperative diagnostic technologies capable of precisely locating the areas responsible for AF, it will become possible to tailor specific lesion sets and ablation modalities to individual patients, making the surgical treatment of lone AF available to a larger population of patients.
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Shen J, Bailey M, Damiano RJ. Surgery for Lone Atrial Fibrillation: Present State-of-the-Art. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2009. [DOI: 10.1177/155698450900400504] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Jeanne Shen
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO USA
| | - Marci Bailey
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO USA
| | - Ralph J. Damiano
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO USA
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Abstract
Pharmacologic antiarrhythmic therapy is the most commonly used treatment in most patients with atrial fibrillation (AF), but currently available agents are limited by risks that may offset the benefits of sinus rhythm. The development of antiarrhythmic agents with the potential for fewer adverse ventricular effects and less extracardiac toxicity is a primary aim of current investigations. At present, pharmacologic research is actively focused on developing antiarrhythmic agents with multiple or novel ion channel effects. There are 4 agents that act by simultaneously blocking multiple ion channels that are currently under regulatory review: azimilide dihydrochloride, tedisamil, dronedarone, and vernakalant (RSD-1235). In addition, agents with mechanisms of action that differ from those of existing agents (eg, gap junction modulators) are under review, as is the use of nonantiarrhythmic agents (eg, renin-angiotensin system antagonists, statins, n-3 polyunsaturated fatty acids) to alter the cardiac substrate and suppress AF in some patient subtypes.
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Affiliation(s)
- Emily Conway
- Division of Cardiovascular Diseases, Main Line Health Heart Center, Wynnewood, Pennsylvania 19096, USA
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7
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Sandesara CM, Roodneshin H, Sbaity S, Olshansky B. Antiarrhythmic effects of statins in heart failure. Heart Fail Clin 2008; 4:187-200. [PMID: 18433699 DOI: 10.1016/j.hfc.2008.01.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
In vitro heart failure models indicate that statins may be antiarrhythmic, but the mechanisms by which statins are antiarrhythmic are not completely understood. Several retrospective and post hoc analysis studies also indicate that statins can be antiarrhythmic in heart failure populations, but this was not confirmed by a recent large prospective randomized controlled clinical trial. Ongoing and future clinical trials will likely resolve the discrepancies between studies and further the understanding of how pleiotropic properties of statins can be antiarrhythmic in patients who have heart failure.
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Tamargo J, Caballero R, Gómez R, Núñez L, Vaquero M, Delpón E. Lipid-lowering therapy with statins, a new approach to antiarrhythmic therapy. Pharmacol Ther 2006; 114:107-26. [PMID: 17287023 DOI: 10.1016/j.pharmthera.2006.12.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2006] [Accepted: 12/08/2006] [Indexed: 11/17/2022]
Abstract
Inhibitors of 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase (statins) are the most effective and best-tolerated drugs to treat elevated levels of low-density lipoprotein cholesterol (LDL-C). In addition, they exhibit other effects unrelated to their lipid lowering effects (pleiotropic actions). In recent years, experimental and clinical evidence demonstrates that statins exert antiarrhythmic properties, reducing the recurrences of supraventricular and life-threatening ventricular arrhythmias both in patients with and without coronary artery disease (CAD). Thus, statins may constitute a novel therapeutic approach to cardiac arrhythmias. This article reviews the antiarrhythmic properties of statins as well as the possible mechanisms involved, including the lowering of LDL-C levels, the improvement of endothelial dysfunction and autonomic function, the stabilization of the atherosclerotic plaques, the antioxidant, antiinflammatory, antithrombotic and cardioprotective properties and the modulation of transmembrane ion fluxes.
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Affiliation(s)
- Juan Tamargo
- Department of Pharmacology, School of Medicine, Universidad Complutense, Madrid, Spain.
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Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA, Halperin JL, Le Heuzey JY, Kay GN, Lowe JE, Olsson SB, Prystowsky EN, Tamargo JL, Wann S, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Halperin JL, Hunt SA, Nishimura R, Ornato JP, Page RL, Riegel B, Priori SG, Blanc JJ, Budaj A, Camm AJ, Dean V, Deckers JW, Despres C, Dickstein K, Lekakis J, McGregor K, Metra M, Morais J, Osterspey A, Tamargo JL, Zamorano JL. ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Circulation 2006; 114:e257-354. [PMID: 16908781 DOI: 10.1161/circulationaha.106.177292] [Citation(s) in RCA: 1381] [Impact Index Per Article: 76.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Abstract
Although the maintenance of sinus rhythm would be the ideal scenario for patients with atrial fibrillation (AF), recent randomised trials have questioned the value of this approach. A careful interpretation of their results showed the limited efficacy of currently available antiarrhythmic drugs in maintaining sinus rhythm, as well as their potentially serious side effects. Therefore, it is imperative to develop safer and more effective drugs for AF. Based on our improved understanding of the pathophysiology of AF and the mechanism of action of antiarrhythmic drugs, significant efforts are being made to develop new antiarrhythmic agents that would prevent electrophysiological remodelling, would be selective for the atria and, therefore, would not prolong ventricular repolarisation, thus lacking any proarrhythmic effect.
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Affiliation(s)
- Panos E Vardas
- Department of Cardiology, Heraklion University Hospital, 71000, Voutes, Heraklion, Crete, Greece.
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Ninio DM, Murphy KJ, Howe PR, Saint DA. Dietary fish oil protects against stretch-induced vulnerability to atrial fibrillation in a rabbit model. J Cardiovasc Electrophysiol 2006; 16:1189-94. [PMID: 16302902 DOI: 10.1111/j.1540-8167.2005.50007.x] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Dietary fish oil is thought to reduce sudden cardiac death by suppressing ventricular arrhythmias but little is known about its impact on atrial arrhythmias. We examined the effect of dietary fish oil on the rabbit model of stretch-induced vulnerability to atrial fibrillation (AF). METHODS AND RESULTS Six-week-old rabbits were fed standard rabbit pellets supplemented with 5% tuna fish oil (n = 6) or supplemented with 5% sunflower oil (n = 6) for 12 weeks. Six rabbits raised on the standard diet were used as controls. In Langendorff-perfused hearts intraatrial pressures were increased in a stepwise manner and rapid burst pacing applied to induce AF at increasing intraatrial pressures until AF was sustained (>1 minute). Atrial refractory periods were recorded at each pressure. Increased atrial pressure resulted in a reduction in atrial refractory period and a propensity for induction of sustained AF. Higher pressures were needed to induce and sustain AF in the fish oil group compared with the sunflower oil and control groups. The stretch-induced drop in refractory period was also less marked in the fish oil group. Red blood cell, atrial, and ventricular omega-3 fatty acid levels were significantly higher in the fish oil group. The ratio of atrial n-6/n-3 polyunsaturated fatty acids was 13 +/- 0.9 with sunflower oil and 1.5 +/- 0.01 with fish oil (P < 0.001). CONCLUSIONS Incorporation of dietary omega-3 fatty acids into atrial tissue reduces stretch-induced susceptibility to AF.
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Affiliation(s)
- Daniel M Ninio
- Discipline of Physiology, School of Molecular and Biomedical Science, University of Adelaide, Australia.
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Abstract
A rhythm control strategy based on a combination of antiarrhythmic drugs and electrical cardioversion(s) has emerged as a viable alternative for treatment of atrial fibrillation, particularly when the arrhythmia is associated with symptoms, which may be poorly tolerated, or with congestive heart failure. Several classes of antiarrhythmic drugs are available to restore sinus rhythm by chemical cardioversion and to help maintain it once it has been achieved. In our discussion, we will detail aspects of their efficacy and safety, and attempt to outline a pragmatic clinical approach to their use. Some newer drugs are currently under investigation and hold promise for improved efficacy and/or more favorable side effect profile and will be mentioned in this article.
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Affiliation(s)
- Peter R Kowey
- Department of Cardiology, Lankenau Hospital, MOBE Suite 558, 100 Lancaster Avenue, Wynnewood, PA 19096, USA.
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Husser D, Stridh M, Sornmo L, Platonov P, Olsson SB, Bollmann A. Analysis of the surface electrocardiogram for monitoring and predicting antiarrhythmic drug effects in atrial fibrillation. Cardiovasc Drugs Ther 2005; 18:377-86. [PMID: 15717140 DOI: 10.1007/s10557-005-5062-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Specific antiarrhythmic therapy with class I and III drugs for atrial fibrillation (AF) conversion and prevention of its recurrence is frequently utilized in clinical practice. Besides being only moderate effective, the utilization of antiarrhythmic drugs may be associated with serious side effects. In the clinical setting it is difficult to directly evaluate the effects of antiarrhythmic drugs on the individual patient's atrial electrophysiology, thereby predicting their efficacy in restoring and maintaining sinus rhythm. Analysis of the surface electrocardiogram in terms of P-wave signal averaged ECG during sinus rhythm and spectral characterization of fibrillatory waves during AF for evaluation of atrial antiarrhythmic drug effects is a new field of investigation. Both techniques provide reproducible parameters for characterizing atrial electrical abnormalities and seem to contain prognostic information regarding antiarrhythmic drug efficacy. Further research is needed which elucidates the most challenging clinical questions in AF management whom to place on antiarrhythmic drug treatment and what antiarrhythmic drug to prescribe. Analysis of the surface ECG might have the potential to answer these questions.
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Affiliation(s)
- Daniela Husser
- Los Angeles Biomedical Research Institute at Harbor-UCLA, Los Angeles, CA, USA
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Bauer A, Koch M, Kraft P, Becker R, Kelemen K, Voss F, Senges JC, Gerlach U, Katus HA, Schoels W. The new selective IKs?blocking agent HMR 1556 restores sinus rhythm and prevents heart failure in pigs with persistent atrial fibrillation. Basic Res Cardiol 2005; 100:270-8. [PMID: 15795798 DOI: 10.1007/s00395-005-0522-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2004] [Revised: 02/08/2005] [Accepted: 02/14/2005] [Indexed: 11/30/2022]
Abstract
BACKGROUND Antiarrhythmic drugs for treatment of atrial fibrillation in patients with heart failure are limited by proarrhythmia and low efficacy. Experimental studies indicate that the pure I(Ks) blocking agents chromanol 293b and HMR 1556 prolong repolarization more markedly at fast than at slow heart rates and during beta-adrenergic stimulation. These properties may overcome some of the above quoted limitations. METHODS AND RESULTS Ten domestic swine underwent pacemaker implantation (PM) and atrial burst pacing to induce persistent AF. Four days after onset of persistent AF, pigs were randomized to HMR 1556 (30 mg/kg, p.o., 10 days) or placebo. All animals receiving HMR 1556 converted to SR (5.2 +/- 1.9 days), whereas placebo pigs remained in AF. Pigs treated with placebo developed high ventricular rates (297 +/- 5 bpm) and severe heart failure, whereas pigs treated with HMR 1556 remained hemodynamically stable. Left ventricular ejection fraction on the day of euthanization was significantly lower in the placebo compared to the HMR 1556 group (30 +/- 4% vs. 69 +/- 5%, p < 0.005). Similar results were seen with epinephrine levels (placebo 1563 +/- 193 pmol/l vs. HMR 613 +/-196 pmol/l, p < 0.05). Right atrial monophasic action potentials were significantly longer in the HMR 1556 compared to the placebo group (230 +/- 7 ms vs. 174 +/- 13 ms, p < 0.05). CONCLUSIONS The new I(Ks) blocker HMR 1556 efficiently and safely restores SR and prevents CHF in a model of persistent AF. Restoration of SR is most likely linked to a marked prolongation of atrial repolarization even at high heart rates.
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Affiliation(s)
- Alexander Bauer
- Department of Cardiology, University of Heidelberg, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany.
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Madrid AH, Marín IM, Cervantes CE, Morell EB, Estévez JE, Moreno G, Parajón JR, Peng J, Limón L, Nannini S, Moro C. Prevention of recurrences in patients with lone atrial fibrillation. The dose-dependent effect of angiotensin II receptor blockers. J Renin Angiotensin Aldosterone Syst 2005; 5:114-20. [PMID: 15526246 DOI: 10.3317/jraas.2004.027] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Atrial fibrillation (AF) leads to the activation of the renin-angiotensin system (RAS), which seems to play an important role in atrial remodelling. It is not known yet whether RAS blockade may prevent recurrences in patients with lone AF. METHODS AND RESULTS Patients with an episode of persistent AF for >7 days, in the absence of cardiac or extracardiac causes and with normal blood pressure values (lone AF), were recruited. Ninety patients were randomised and scheduled for electrical cardioversion. Three groups of patients were compared: Group I was treated with amiodarone 400 mg daily (30 patients), group II was treated with amiodarone 400 mg daily plus irbesartan 150 mg daily (30 patients) and group III with amiodarone 400 mg daily plus irbesartan 300 mg daily (30 patients). The primary endpoint was the time to a first recurrence of AF. The patients were cardioverted and followed. The Kaplan-Meier analysis of time to first recurrence during the follow-up period showed that patients treated with amiodarone 400 mg plus irbesartan 300 mg had a greater probability of remaining free of AF (77% vs. 52% for amiodarone and 65% for amiodarone+irbesartan 150 mg), hazard ratio for a recurrence in group III: 0.47 (95% CI 0.27-0.82; p=0.001). CONCLUSIONS The combination of irbesartan plus amiodarone decreased the rate of AF recurrences, with a dose-dependent effect, in lone AF patients.
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Affiliation(s)
- Antonio H Madrid
- Arrythmia Unit, Rámon y Cajal Hospital, Department of Medicine, Madrid 28034, Spain
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Burashnikov A, Mannava S, Antzelevitch C. Transmembrane action potential heterogeneity in the canine isolated arterially perfused right atrium: effect of IKr and IKur/Ito block. Am J Physiol Heart Circ Physiol 2004; 286:H2393-400. [PMID: 15148061 DOI: 10.1152/ajpheart.01242.2003] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The role of electrical heterogeneity in development of cardiac arrhythmias is well recognized. The extent to which transmembrane action potential (TAP) heterogeneity contributes to the normal electrophysiology of well-oxygenated atria is not well defined. The principal objective of the present study was to define regional and transmural differences in characteristics of the TAP in isolated superfused and arterially perfused canine right atrial (RA) preparations under baseline, rapidly activating delayed rectifier K(+) current (I(Kr)) block, and combined block of ultrarapid delayed rectifier and transient outward K(+) current (I(Kur)/I(to) block). Superfused preparations that survived generally displayed a triangle-shaped TAP. Exceptions included cells from the crista terminalis, where TAPs with a normal plateau could be recorded. In contrast, most TAPs recorded from throughout the perfused RA displayed a spike-and-dome and/or plateau morphology. The perfused RA displayed a heterogeneous distribution of repolarization, V(max), and spike-and-dome morphology along the epicardial and endocardial surfaces as well as transmurally, in the region of the upper crista terminalis. I(Kr) block with E-4031 prolonged repolarization homogeneously in the perfused RA, whereas I(Kur)/I(to) block using low concentrations of 4-aminopyridine abbreviated action potential duration at 90% repolarization heterogeneously, leading to a reduction in dispersion of repolarization. Our data indicate that the electrical heterogeneities, previously described for the canine ventricle, also exist within the atria and that I(Kr) block does not accentuate and I(Kur)/I(to) block reduces RA dispersion of repolarization. Our study also points to major differences in the transmembrane activity recorded using superfused vs. arterially perfused atrial preparations.
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