Dulaglutide and incident atrial fibrillation or flutter in patients with type 2 diabetes: A post hoc analysis from the REWIND randomized trial

AIM

To assess the occurrence of atrial fibrillation or atrial flutter (atrial arrhythmias [AA]) in patients with type 2 diabetes treated with once-weekly subcutaneous dulaglutide versus placebo.

MATERIALS AND METHODS

Patients without electrocardiographic (ECG)-confirmed AA at baseline and randomized in the REWIND trial were assessed for the development of AA based on an annual ECG. Additional analyses included whether dulaglutide compared with placebo reduced the composite outcome of AA or death, AA or cardiovascular death, AA or stroke and AA or heart failure.

RESULTS

Among 9543 participants (mean age 66 ± 7 years, with cardiovascular risk factors and 31% with previous cardiovascular disease) without AA at entry in the trial, 524 patients (5.5%) had at least one episode of AA during the median 5.4 years of follow-up. Incident AA occurred in 269 of the 4769 participants allocated to dulaglutide (5.6%), at a rate of 10.7 per 1000 person-years, versus 255 of the 4774 allocated to placebo (5.3%), at a rate of 10.5 per 1000 person-years (P = .59). There was also no effect of dulaglutide on the composite outcome of AA and death or AA and heart failure.

CONCLUSION

This post hoc analysis of data from the REWIND trial showed that treatment with dulaglutide was not associated with a reduced incidence of AA in this at-risk group of patients with type 2 diabetes.

Frontal plane QRS-T angle predicts early recurrence of acute atrial fibrillation after successful pharmacological cardioversion with intravenous amiodarone

WHAT IS KNOWN AND OBJECTIVE

Although restoration of sinus rhythm is the integral part of the atrial fibrillation (Af) management, recurrence frequency of Af is high after cardioversion. However, little is known about the association of electrocardiography (ECG) parameters with Af recurrence after restoration of sinus rhythm. The present study aimed to investigate whether frontal plane QRS-T (fQRST) angle, as a marker of ventricular repolarization heterogeneity, predicts Af recurrence after successful pharmacological cardioversion.

METHODS

One hundred and sixty-five paroxysmal Af patients with an acute Af episode who underwent successful pharmacological cardioversion with intravenous amiodarone infusion were included into the study. Patients were divided into two groups according to presence or absence of in-hospital Af recurrence. The association between fQRST angle and Af recurrence was investigated.

RESULTS AND DISCUSSION

Af recurrence was observed in 42 (25.4%) patients. The mean fQRST angle was significantly higher in patients with Af recurrence compared to those without Af recurrence (90 ± 45.8 vs. 51 ± 38.2, p < 0.001). Also, Af recurrence was more frequent in patients who had fQRST angle >90˚, compared to patients with fQRST angle ≤90˚ (54.1% vs. 13.7%, p < 0.001). Moreover, ROC curve analysis demonstrated that an increased fQRST angle >92.5˚ predicted in-hospital Af recurrence with a sensitivity of 76.2% and a specificity of 81.4% (AUC:0.728, p < 0.001). Furthermore, multivariate analysis demonstrated that fQRST angle was an independent predictor of in-hospital Af recurrence after successful pharmacological cardioversion (OR: 1.892, 95% CI: 1.361-2.917, p < 0.001).

WHAT IS NEW AND CONCLUSION

As a parameter that can be easily calculated from automated ECG recordings, fQRST angle may be useful in the prediction of early Af recurrence after successful pharmacological cardioversion with amiodarone.

Accuracy and usability of single-lead ECG from smartphones - A clinical study

Background

Several wireless ECG devices are commercially available for possible screening, monitoring and diagnosis of rhythms. The field is rapidly expanding, and some devices have demonstrated acceptable qualities. The objective was to evaluate the accuracy, usability and diagnostic capabilities of smartphone ECG in both patients and healthy controls.

Methods

We used a commercially available smartphone ECG device, connected wirelessly to a tablet, to record a 30-s lead I ECG in 144 subjects—20 of whom repeated the test after vigorous exercise. The subjects included 94 patients under standard calculated 12-lead ECG surveillance; transcripts were obtained shortly after the smartphone ECG was acquired.

Results

No significant differences were found in the QRS, frequency and QT intervals between the two modalities. Smartphone ECG recordings separated pathologic rhythms (atrial fibrillation (AF)/flutter, atrioventricular block, regular supraventricular rhythm, and pacing) from sinus rhythms with a sensitivity of 0.75 and a specificity of 0.97. The specific diagnosis of AF appeared in 11 patients and was detected with a sensitivity of 1 and a specificity of 0.94. There was a marginal decrease in the interpretability of the smartphone ECG after exercise. Inter- and intraobserver variability was low.

Conclusions

Smartphone ECG accurately measures most baseline intervals and has acceptable sensitivity and specificity for pathological rhythms, especially for AF. Vigorous activity has a minor influence on the readability of the PR interval. Elderly patients may face challenges in recording a smartphone ECG correctly without assistance. According to our findings, the smartphone ECG would be applicable as a screening device for pathological rhythms.

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ECG Check presented a sensitivity of 0.75 and a specificity of 0.97.

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The sensitivity for atrial fibrillation alone was 1, the specificity 0.94.

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The smartphone ECG is applicable as a screening device for pathological rhythms.

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Elderly subjects experience difficulties handling the device.

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ECG acquisition directly after activity did not significantly affect readability.

Assessing aeromedical risk: a three-dimensional risk matrix approach

Early aeromedical risk i was based on aeromedical standards designed to eliminate individuals ii from air operations with any identifiable medical risk, and led to frequent medical disqualification. The concept of considering aeromedical risk as part of the spectrum of risks that could lead to aircraft accidents (including mechanical risks and human factors) was first proposed in the 1980s and led to the development of the 1% rule which defines the maximum acceptable risk for an incapacitating medical event as 1% per year (or 1 in 100 person-years) to align with acceptable overall risk in aviation operations. Risk management has subsequently evolved as a formal discipline, incorporating risk assessment as an integral part of the process. Risk assessment is often visualised as a risk matrix, with the level of risk, urgency or action required defined for each cell, and colour-coded as red, amber or green depending on the overall combination of risk and consequence. This manuscript describes an approach to aeromedical risk management which incorporates risk matrices and how they can be used in aeromedical decision-making, while highlighting some of their shortcomings.

microRNA expression changes after atrial fibrillation catheter ablation

Atrial fibrillation (AF) is most common arrhythmia in general population, with increasing trend in mortality and morbidity. Electrophysiological and structural abnormalities, promoting abnormal impulse formation and propagation, lead to this disease. AF catheter ablation is related to a not small percentage of nonresponder patients. microRNAs (miRs) have been used as AF fibrotic and electrical alterations biomarkers. miRs may differentiate responders patients to ablative approach. Selective miR target therapy, as upregulation by adenovirus transfection and/or miR downregulation by antagomiR, may be used to treat AF patients. Catheter ablation of triggering electrical pulmonary veins activity or fibrotic areas defragmentation may be upgraded by miR therapy to prevent cardiac electrical and fibrotic remodeling after AF ablation.

Long-term outcomes of secondary atrial fibrillation in the community: the Framingham Heart Study

BACKGROUND

Guidelines have proposed that atrial fibrillation (AF) can occur as an isolated event, particularly when precipitated by a secondary, or reversible, condition. However, knowledge of long-term AF outcomes after diagnosis during a secondary precipitant is limited.

METHODS AND RESULTS

In 1409 Framingham Heart Study participants with new-onset AF, we examined associations between first-detected AF episodes occurring with and without a secondary precipitant and both long-term AF recurrence and morbidity. We selected secondary precipitants based on guidelines (surgery, infection, acute myocardial infarction, thyrotoxicosis, acute alcohol consumption, acute pericardial disease, pulmonary embolism, or other acute pulmonary disease). Among 439 patients (31%) with AF diagnosed during a secondary precipitant, cardiothoracic surgery (n=131 [30%]), infection (n=102 [23%]), noncardiothoracic surgery (n=87 [20%]), and acute myocardial infarction (n=78 [18%]) were most common. AF recurred in 544 of 846 eligible individuals without permanent AF (5-, 10-, and 15-year recurrences of 42%, 56%, and 62% with versus 59%, 69%, and 71% without secondary precipitants; multivariable-adjusted hazard ratio, 0.65 [95% confidence interval, 0.54-0.78]). Stroke risk (n=209/1262 at risk; hazard ratio, 1.13 [95% confidence interval, 0.82-1.57]) and mortality (n=1098/1409 at risk; hazard ratio, 1.00 [95% confidence interval, 0.87-1.15]) were similar between those with and without secondary precipitants, although heart failure risk was reduced (n=294/1107 at risk; hazard ratio, 0.74 [95% confidence interval, 0.56-0.97]).

CONCLUSIONS

AF recurs in most individuals, including those diagnosed with secondary precipitants. Long-term AF-related stroke and mortality risks were similar between individuals with and without secondary AF precipitants. Future studies may determine whether increased arrhythmia surveillance or adherence to general AF management principles in patients with reversible AF precipitants will reduce morbidity.

Nighttime ambulatory blood pressure is associated with atrial remodelling and neurohormonal activation in patients with idiopathic atrial fibrillation

INTRODUCTION AND OBJECTIVES

Hypertension is a risk factor for atrial fibrillation. Activation of the renin-angiotensin-system seems to be involved in atrial enlargement, with release of atrial and brain natriuretic peptides. The aim of this study was to evaluate the relationship between ambulatory blood pressure and levels of natriuretic peptides, with left atrial size in normotensives with idiopathic atrial fibrillation.

METHODS

This was a cross-sectional study in patients with idiopathic atrial fibrillation. The following measurements were recorded during the course of the study: office and 24-h ambulatory blood pressure, atrial and brain natriuretic peptides, plasma renin, aldosterone, and angiotensin-converting enzyme.

RESULTS

Forty-eight patients (mean age 55 [10] years; 70.6% male) were included in the study. Mean office sitting blood pressure values were 132.49 (14.9)/80.96 (9.2) mmHg. Mean 24-h ambulatory systolic and diastolic blood pressure values were 121.10 (8.3)/72.11 (6.8) mmHg (daytime, 126.8 [9.7]/77.58 [7.9] mmHg; nighttime, 114.56 [11.6]/68.6 [8.8] mmHg). A clear trend towards increased left atrial size with higher ambulatory blood pressure values was noted, which was statistically significant for nighttime values (r=0.34; P=.020 for systolic and r=0.51; p=.0001 for diastolic). A significant correlation between atrial natriuretic peptide and nighttime systolic (r=0.297; P=.047) and diastolic (r=0.312; P=.037) blood pressure was observed. Significant correlations were also observed between left atrial size and atrial natriuretic peptide levels (r=0.577; p<.0001) and brain natriuretic peptide levels (r=0.379; P=.012).

CONCLUSIONS

Nighttime blood pressure is associated with left atrial size and the release of natriuretic peptides in normotensive patients with idiopathic atrial fibrillation.

Association of angiotensin-converting enzyme gene I/D and CYP11B2 gene -344T/C polymorphisms with lone atrial fibrillation and its recurrence after catheter ablation

The renin-angiotensin-aldosterone system (RAAS) plays a key role in atrial structural and electrical remodeling. The aim of this study was to investigate the potential associations of angiotensin-converting enzyme (ACE) gene insertion/ deletion (I/D) and aldosterone synthase (CYP11B2) gene −344T/C polymorphisms with the risk and recurrence of lone atrial fibrillation (AF). One hundred and ninety-three patients who underwent successful catheter ablation for lone AF were recruited. Two hundred and ninety-seven sinus rhythm subjects without a history of arrhythmia served as controls. The subjects were genotyped for ACE gene I/D and CYP11B2 gene −344T/C polymorphisms. Results showed that the ACE gene DD genotype and D allele were associated with a greater prevalence of lone AF (both P<0.01). In addition, the ACE gene DD genotype had a significantly larger left atrial dimension (LAD; 41.6±5.7 mm vs. 39.6±5.2 mm; P=0.043) and higher risk of AF recurrence [44.7% vs. 23.2%; odds ratio (OR), 2.68; 95% confidence interval (CI), 1.28–5.61; P=0.008] compared with the II+ID genotype in lone AF patients. After adjustment for a variety of risk factors, the ACE gene DD genotype had a 1.97-fold increased risk for lone AF (OR, 1.97; 95% CI, 1.15–3.37; P= 0.013) and 2.35-fold increased risk for AF recurrence (RR, 2.35; 95% CI, 1.10–5.04; P=0.028) compared with the ACE gene II+ID genotype. However, no correlation between the CYP11B2 gene −344T/C polymorphism and lone AF or its recurrence was observed in this cohort. In conclusion, the ACE gene DD genotype was associated with an increased incidence of lone AF and its recurrence following ablation, which was partly mediated by LAD.

Right ventricular echocardiographic predictors of postoperative supraventricular arrhythmias after thoracic surgery: a pilot study

BACKGROUND

We used echocardiographically derived myocardial performance index (MPI) to assess changes in global right ventricular function with lung isolation. We hypothesized that changes in MPI with lung isolation may be related to the incidence of postoperative supraventricular tachycardia (SVT).

METHODS

Transesophageal echocardiographic examinations were performed after induction of general anesthesia in patients undergoing elective lung resections. Doppler tissue imaging was used to calculate MPI at baseline and 10 minutes after institution of one-lung ventilation (OLV). Arrhythmias occurring within the first 5 postoperative days were recorded.

RESULTS

Fifty-nine patients completed the study. Nineteen of 59 patients with a normal baseline MPI (<0.40) had a higher incidence of SVT as compared with patients with an abnormal baseline MPI (42% versus 10%; p = 0.012). The MPI worsened during OLV in 46 patients; a worsening of MPI with lung isolation that was normal at baseline was associated with higher incidence of SVT (57% versus 0%; p = 0.045) compared with a worsening of MPI in patients with an abnormal baseline MPI (13% versus 6%; p = 0.62). A normal baseline MPI value that worsened after OLV, left atrial dilation, and advanced age were identified as predictors of postoperative SVT.

CONCLUSIONS

Lung isolation is associated with acute changes in global right ventricular function. A normal baseline MPI that worsens after lung isolation is a better predictor of postoperative SVT as compared with baseline abnormal MPI that does not worsen after lung isolation. Myocardial performance index has a potential to be used as a right ventricular stress test to tolerate OLV before thoracic surgery.

Left atrial volume calculated by multi-detector computed tomography may predict successful pulmonary vein isolation in catheter ablation of atrial fibrillation

AIMS

Catheter ablation (CA) of atrial fibrillation (AF) might be a definitive curative therapy for selected groups of patients (pts). However, current ablation protocols are not standardized and predictors of CA success and sinus rhythm maintenance are not clearly defined. To evaluate whether left atrium (LA) volume quantification provided by multi-detector computed tomography (MDCT) might predict the success of pulmonary vein (PV) isolation procedure.

METHODS AND RESULTS

We evaluated 99 pts, 66 male, mean age 54.4 +/- 10.1 years, referred for CA because of drug resistant AF. All pts were submitted to 64-slice MDCT scan for electroanatomic mapping integration, pulmonary veins anatomy delineation, LA thrombi exclusion, and LA volume estimation. Complete isolation of all the PVs was always performed with eventual cavo-tricuspid isthmus ablation. For a mean follow-up period (Fup) of 16.7 +/- 6.6 months, clinical success was assessed after a 3-month blanking period. Anti-arrhythmic drug therapy was discontinued or modified at the clinician's criteria. At the end of the Fup, 29 pts suspended anti-arrhythmic drug therapy and 26% were of oral anticoagulation. Univariate analysis showed that the probability of AF relapse after CA was higher in pts with non-paroxysmal forms of AF. The probability of relapse was significantly higher in pts with LA volumes greater than 100 mL when assessed by MDCT. We found that the LA volume of 145 mL was a good cut-off value for AF recurrence prediction. Patients with LA volumes greater than 145 mL had significantly higher recurrence rates of arrhythmia, even when adjusted for the effect of age, gender, body mass index, hypertension, and type of AF.

CONCLUSION

Left atrium volume estimated by MDCT may be useful to identify pts in whom successful AF ablation can be achieved with simpler ablation procedures, restricted to PV isolation.

[Rate versus rhythm control with and without heart failure]

Atrial fibrillation and congestive heart failure are frequently associated with complex interactions. Patients with both diseases bear a sophisticated therapeutic challenge for the attending physician. The approach to treat atrial fibrillation differs for patients with and without heart failure in several aspects. Basic requirements are the treatment of the underlying diseases and prophylaxis of thromboembolic complications. Rate and rhythm control are the two main therapeutic strategies for atrial fibrillation according to the current guidelines. Large trials including the recently published AF-CHF study (Atrial Fibrillation - Congestive Heart Failure) failed to demonstrate a difference in mortality for both strategies. Thus, the therapeutic decision is mainly based on the patient's symptoms to improve quality of life. Rate control should be applied to asymptomatic patients or if rhythm control has already failed. If beta-blockers and digoxin have failed to control heart rate, His ablation with pacemaker implantation can be considered. In patients without heart disease, class I antiarrhythmic drugs and, in case of ineffectiveness, amiodarone or catheter ablation are recommended for rhythm control. First data concerning catheter ablation of atrial fibrillation in heart failure are promising and randomized studies are on the way. Rhythm control remains first-line therapy in recent-onset or highly symptomatic paroxysmal or persistent atrial fibrillation patients with and without heart failure.