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Griffith Brookles C, De Ponti R, Russo V, Ziacchi M, Pelargonio G, Casella M, Lauretti M, Vilotta M, Themistoclakis S, D’Onofrio A, Boriani G, Anselmino M. Atrial High-Rate Episodes and Subclinical Atrial Fibrillation: State of the Art and Clinical Questions with Complex Solutions. Rev Cardiovasc Med 2024; 25:305. [PMID: 39228483 PMCID: PMC11366991 DOI: 10.31083/j.rcm2508305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 05/03/2024] [Accepted: 05/14/2024] [Indexed: 09/05/2024] Open
Abstract
Atrial high-rate episodes (AHREs) and subclinical atrial fibrillation (AF) are frequently registered in asymptomatic patients with cardiac implantable electronic devices (CIEDs) and insertable cardiac monitors (ICMs). While an increased risk of thromboembolic events (e.g., stroke) and benefits from anticoagulation have been widely assessed in the setting of clinical AF, concerns persist about optimal clinical management of subclinical AF/AHREs. As a matter of fact, an optimal threshold of subclinical episodes' duration to predict stroke risk is still lacking and recently published randomized clinical trials assessing the impact of anticoagulation on thromboembolic events in this specific setting have shown contrasting results. The aim of this review is to summarize current evidence regarding classification and clinical impact of subclinical AF/AHREs and to discuss the latest evidence regarding the potential benefit of anticoagulation in this setting, highlighting which clinical questions are still unanswered.
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Affiliation(s)
- Carola Griffith Brookles
- Cardiology Division, Department of Medical Sciences, “Città della Salute e della Scienza” Hospital, Univerisity of Turin, 10116 Turin, Italy
| | - Roberto De Ponti
- Department of Medicine and Surgery, University of Insubria, 21100 Varese, Italy
| | - Vincenzo Russo
- Cardiology Unit, Department of Translational Medical Sciences, Monaldi Hospital, University of Campania “Luigi Vanvitelli”, 80131 Naples, Italy
| | - Matteo Ziacchi
- Institute of Cardiology, IRCCS Azienda Ospedaliero Universitaria di Bologna, 40138 Bologna, Italy
| | - Gemma Pelargonio
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, University “Cattolica del Sacro Cuore”, 00168 Rome, Italy
| | - Michela Casella
- Cardiology and Arrhythmology Clinic, Department of Clinical, Special and Dental Sciences, Marche Polytechnic University, Marche University Hospital, 60126 Ancona, Italy
| | | | - Manola Vilotta
- Department of Heart and Vessels, Ospedale di Circolo, 21100 Varese, Italy
| | - Sakis Themistoclakis
- Department of Cardiothoracic, Vascular Medicine and Intensive Care, Dell'Angelo Hospital, 30174 Mestre-Venice, Italy
| | - Antonio D’Onofrio
- Electrophysiology and Cardiac Pacing Unit, Cardiology Division, Monaldi Hospital, 80131 Naples, Italy
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, 41124 Modena, Italy
| | - Matteo Anselmino
- Cardiology Division, Department of Medical Sciences, “Città della Salute e della Scienza” Hospital, Univerisity of Turin, 10116 Turin, Italy
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Chinitz L, Böhm M, Evonich R, Saba S, Sangriogoli R, Augostini R, O'Neill PG, Fellows C, Kim MY, Hettrick DA, Viktorova E, Ukena C. Long-Term Changes in Atrial Arrhythmia Burden After Renal Denervation Combined With Pulmonary Vein Isolation: SYMPLICITY-AF. JACC Clin Electrophysiol 2024:S2405-500X(24)00383-9. [PMID: 38934973 DOI: 10.1016/j.jacep.2024.04.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 04/22/2024] [Accepted: 04/27/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND The autonomic nervous system plays an important role in atrial fibrillation (AF) and hypertension. Renal denervation (RDN) lowers blood pressure (BP), but its role in AF is poorly understood. OBJECTIVES The purpose of this study was to investigate whether RDN reduces AF recurrence after pulmonary vein isolation (PVI). METHODS This study randomized patients from 8 centers (United States, Germany) with drug-refractory AF for treatment with PVI+RDN vs PVI alone. A multielectrode radiofrequency Spyral catheter system was used for RDN. Insertable cardiac monitors were used for continuous rhythm monitoring. The primary efficacy endpoint was ≥2 minutes of AF recurrence or repeat ablation during all follow-up. The secondary endpoints included atrial arrhythmia (AA) burden, discontinuation of class I/III antiarrhythmic drugs, and BP changes from baseline. RESULTS A total of 70 patients with AF (52 paroxysmal, 18 persistent) and uncontrolled hypertension were randomized (RDN+PVI, n = 34; PVI, n = 36). At 3.5 years, 26.2% and 21.4% of patients in RDN+PVI and PVI groups, respectively, were free from the primary efficacy endpoint (log rank P = 0.73). Patients with mean ≥1 h/d AA had less daily AA burden after RDN+PVI vs PVI (4.1 hours vs 9.2 hours; P = 0.016). More patients discontinued class I/III antiarrhythmic drugs after RDN+PVI vs PVI (45% vs 14%; P = 0.040). At 1 year, systolic BP changed by -17.8 ± 12.8 mm Hg and -13.7 ± 18.8 mm Hg after RDN+PVI and PVI, respectively (P = 0.43). The composite safety endpoint was not significantly different between groups. CONCLUSIONS In patients with AF and uncontrolled BP, RDN+PVI did not prevent AF recurrence more than PVI alone. However, RDN+PVI may reduce AF burden and antiarrhythmic drug usage, but this needs further prospective validation.
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Affiliation(s)
- Larry Chinitz
- New York University Langone Medical Center, New York, New York, USA.
| | - Michael Böhm
- Universitätsklinikum des Saarlandes, Saarland University, Homburg, Germany
| | | | - Samir Saba
- University of Pittsburgh Heart and Vascular Institute, Pittsburgh, Pennsylvania, USA
| | | | - Ralph Augostini
- The Ohio State University Wexner, Medical Center, Columbus, Ohio, USA
| | | | | | | | | | | | - Christian Ukena
- Universitätsklinikum des Saarlandes, Saarland University, Homburg, Germany; Marien Hospital Herne, Ruhr University Bochum, Herne, Germany
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Betz K, Linz D, Duncker D, Hillmann HAK. [Characterization of atrial fibrillation burden using wearables]. Herzschrittmacherther Elektrophysiol 2024; 35:111-117. [PMID: 38334830 PMCID: PMC11161421 DOI: 10.1007/s00399-024-00995-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Accepted: 01/16/2024] [Indexed: 02/10/2024]
Abstract
The characterization of atrial fibrillation (AF) according to current guidelines categorically refers to the differentiation between paroxysmal, persistent, and permanent AF. A more precise characterization of AF, including the evaluation of AF burden, is playing an increasingly significant role in both scientific research and clinical practice. Digital devices, especially those with the capability of passive (semi-)continuous recording, can contribute to a more accurate quantification of AF burden. Particularly in patients with an already established diagnosis of AF, the evaluation of AF burden can be used to monitor the success of antiarrhythmic therapy including antiarrhythmic drugs or pulmonary vein isolation. However, important questions remain unanswered: In addition to a uniform, evidence-based definition of AF burden, clinically relevant cut-offs for AF burden and resulting therapeutic consequences (e.g., subclinical AF) need to be elaborated. Furthermore, the establishment and evaluation of care structures for assessing and integrating AF burden in clinical care, especially by incorporating data from wearable medical devices, should take place.
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Affiliation(s)
- Konstanze Betz
- Department of Cardiology and Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Universiteitssingel 50, 6229 ER, Maastricht, Niederlande.
- Klinik für Innere Medizin, Eifelklinik St. Brigida GmbH & Co. KG, Simmerath, Deutschland.
- Netherlands Heart Institut, Utrecht, Niederlande.
| | - Dominik Linz
- Department of Cardiology and Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Universiteitssingel 50, 6229 ER, Maastricht, Niederlande
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australien
- Department of Biomedical Science, Faculty of Health and Medical Sciences, University of Copenhagen, Kopenhagen, Dänemark
| | - David Duncker
- Hannover Herzrhythmus Centrum, Klinik für Kardiologie und Angiologie, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - Henrike A K Hillmann
- Hannover Herzrhythmus Centrum, Klinik für Kardiologie und Angiologie, Medizinische Hochschule Hannover, Hannover, Deutschland
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Stazi F. Management of atrial arrhythmias identified by cardiac devices. Eur Heart J Suppl 2024; 26:i123-i126. [PMID: 38867861 PMCID: PMC11167958 DOI: 10.1093/eurheartjsupp/suae029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2024]
Abstract
Implantable cardiac devices have shown that atrial fibrillation (AF) is more frequent than previously assumed, with subclinical, asymptomatic, self-limiting manifestations called atrial high-rate events (AHREs) or subclinical AF. The clinical significance and correct therapeutic management of these episodes of subclinical AF is less well defined than in the case of clinically manifest AF. Two important randomized studies on the topic have recently been published, NOAH-AFNET 6 and ARTESIA, which, however, have not definitively clarified the topic. In patients with AHRE or subclinical AF, the average thrombo-embolic risk is lower than that in patients with clinically manifest AF and is ∼1%. For this reason, in these patients, the possibility that the benefit of anticoagulant therapy is overshadowed by the risk of bleeding is very high. Therefore, while waiting for new tools that allow a better stratification of low-risk patients, we must rely on individual clinical evaluation and overcome the qualitative dichotomy (AHRE yes vs. AHRE no), preferring instead an approach that is as quantitative as possible and takes into account the number of episodes, their duration, and the patient's CHADSVASC score, before deciding, in each individual case, whether or not to use anticoagulant therapy.
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Affiliation(s)
- Filippo Stazi
- UOS Week Cardiology, UOC Cardiology, San Giovanni Addolorata Hospital, Rome
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Jiang J, Mi L, Chen K, Hua W, Su Y, Xu W, Zhao S, Zhang S. Association of Device-Detected Atrial High-Rate Episodes With Long-term Cardiovascular and All-Cause Mortality: A Cohort Study. Can J Cardiol 2024; 40:598-607. [PMID: 38092191 DOI: 10.1016/j.cjca.2023.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 11/11/2023] [Accepted: 12/07/2023] [Indexed: 03/07/2024] Open
Abstract
BACKGROUND Device-detected atrial high-rate episodes (AHREs) were associated with an increased thromboembolic risk. Although limited data regarding the long-term prognosis of patients with AHRE were controversial, this study aimed to identify the association of device-detected AHRE with mortality. METHODS This observational study included patients with implantable cardioverter defibrillator (ICD) or cardiac resynchronization therapy defibrillator (CRT-D) placement and no history of atrial fibrillation (AF), atrial flutter (AFL), or atrial tachycardia (AT). During follow-up, patients with at least 1 day of AHRE duration ≥ 15 minutes were identified. The primary endpoint was cardiovascular mortality, and the secondary endpoint was all-cause mortality. RESULTS During a mean follow-up period of 4.2 years, AHREs were detected in 124 of 343 (36.2%) patients. Of these, 44 deaths (35.5%) occurred in 124 patients with AHREs, which was significantly higher than those without AHREs (43 of 219; 19.6%; P = 0.001). The multivariate analysis revealed that patients with AHRE had a significantly higher risk of cardiovascular (hazard ratio [HR], 2.40; 95% confidence interval [CI], 1.23-4.67; P = 0.010), and all-cause mortality (HR, 2.31; 95% CI, 1.49-3.59; P < 0.001). Further analysis indicated that this association remained significant in patients with higher burden (≥ 6 hours) but not in patients with lower burden (≥ 15 minutes to 6 hours). Notably, even after excluding the patients diagnosed with clinical AF during follow-up, the remaining patients with AHREs still exhibited a higher risk of cardiovascular and all-cause mortality compared with patients without AHREs. CONCLUSIONS AHREs were prevalent in ICD or CRT-D recipients with no history of clinical AF, AFL, or AT and were associated with more than twice the risk of cardiovascular and all-cause mortality. CLINICAL TRIAL REGISTRATION No. ChiCTR-ONRC-13003695.
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Affiliation(s)
- Jiang Jiang
- State Key Laboratory of Cardiovascular Disease, Arrhythmia Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lijie Mi
- State Key Laboratory of Cardiovascular Disease, Arrhythmia Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Keping Chen
- State Key Laboratory of Cardiovascular Disease, Arrhythmia Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wei Hua
- State Key Laboratory of Cardiovascular Disease, Arrhythmia Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yangang Su
- Cardiology, Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wei Xu
- Department of Cardiology, Nanjing Drum Tower Hospital, Nanjing, China
| | - Shuang Zhao
- State Key Laboratory of Cardiovascular Disease, Arrhythmia Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Shu Zhang
- State Key Laboratory of Cardiovascular Disease, Arrhythmia Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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Ho JE, Sanders P. Subclinical Atrial Fibrillation in HFpEF: Malicious Accomplice or Innocent Bystander? JACC. HEART FAILURE 2024; 12:505-507. [PMID: 38340134 DOI: 10.1016/j.jchf.2023.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 12/20/2023] [Indexed: 02/12/2024]
Affiliation(s)
- Jennifer E Ho
- CardioVascular Institute, Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
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Dlima J, Kitisarn R, Lim H, Thijs V. Is there a temporal relationship between atrial fibrillation and stroke? A review. BMJ Neurol Open 2024; 6:e000512. [PMID: 38288314 PMCID: PMC10823921 DOI: 10.1136/bmjno-2023-000512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Accepted: 01/01/2024] [Indexed: 01/31/2024] Open
Abstract
Importance Atrial fibrillation (AF) is an established risk factor for ischaemic stroke. The introduction of continuous cardiac rhythm monitoring devices has enabled detection of brief and asymptomatic episodes of AF. Observations The search yielded 727 studies, 11 of which met the inclusion criteria. Four studies suggested a strong temporal association between episodes of AF and stroke, while seven indicated a weak relationship. The conflicting nature of the studies may be attributed to inconsistencies in ischaemic stroke verification (n=5/11), event rate and power (n=6/11) and lack of controlling for anticoagulation (n=10/11), mitigating the relationship between AF episodes and stroke. Conclusions and relevance The temporal relationship between AF and stroke still remains unclear due to varying study methodology, lack of control for anticoagulation and inconsistent stroke subtyping. Our review identifies limitations to the current literature and makes recommendations for future studies assessing the temporal relationship between AF episodes and cardioembolic stroke.
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Affiliation(s)
- Jessica Dlima
- The University of Melbourne—Parkville Campus, Melbourne, Victoria, Australia
- Melbourne Brain Centre—Austin Campus, Heidelberg, Victoria, Australia
| | - Rooj Kitisarn
- Grampians Health Ballarat, Ballarat, Victoria, Australia
| | - Han Lim
- The University of Melbourne—Parkville Campus, Melbourne, Victoria, Australia
- Department of Cardiology, Austin Health, Melbourne, VIC, Australia
| | - Vincent Thijs
- Melbourne Brain Centre—Austin Campus, Heidelberg, Victoria, Australia
- Department of Neurology, Austin Health, Heidelberg, Victoria, Australia
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Leung ANW, Bhat A. Use of Anticoagulation for Thromboembolic Prophylaxis in Patients With Atrial High-Rate Episodes on Device Monitoring: A Narrative Review. Am J Cardiol 2024; 211:183-190. [PMID: 37944778 DOI: 10.1016/j.amjcard.2023.11.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 10/21/2023] [Accepted: 11/01/2023] [Indexed: 11/12/2023]
Abstract
Ischemic stroke and systemic thromboembolism are primary drivers of significant morbidity and mortality in patients with atrial fibrillation (AF). Although stroke is commonly the first index presentation of clinically silent AF, the growing use of continuous rhythm monitoring through cardiac implanted electronic devices has enabled earlier and increased detection of AF in patients who are otherwise asymptomatic before stroke development. Atrial high-rate episodes (AHREs) are atrial tachyarrhythmias frequently detected by cardiac implanted electronic devices; these events represent subclinical AF and other atrial tachyarrhythmias that can lead to stroke development and AF. Although the presence of AHREs increases the risk of developing both clinical AF and stroke compared with absence of AHREs, there has been a significant clinical variability in anticoagulation initiation in these subjects. In this narrative review, we explore the current evidence and published research surrounding the association between AHREs and stroke development in addition to the utility of anticoagulation in this population for thromboembolic prophylaxis.
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Affiliation(s)
- Alice Ngar Wing Leung
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales, Australia; School of Medicine, Western Sydney University, Sydney, New South Wales, Australia
| | - Aditya Bhat
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales, Australia; School of Medicine, Western Sydney University, Sydney, New South Wales, Australia; School of Public Health and Community Medicine, University of New South Wales, Sydney, New South Wales, Australia.
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Saglietto A, Ballatore A, Griffith Brookles C, Xhakupi H, De Ferrari GM, Anselmino M. Role of atrial high-rate episodes in stratifying thromboembolic risk: a multiple cut-off diagnostic meta-analysis. Front Cardiovasc Med 2023; 10:1289372. [PMID: 38028457 PMCID: PMC10662047 DOI: 10.3389/fcvm.2023.1289372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 10/03/2023] [Indexed: 12/01/2023] Open
Abstract
Aims Despite the high prevalence rate of atrial high-rate episodes (AHREs) detected using cardiac implantable electronic devices (CIEDs), clinical guidelines and consensus documents have disagreed on a universal AHRE definition and a temporal cut-off related to subsequent thromboembolic events. This diagnostic test accuracy meta-analysis aims to derive the optimal temporal threshold of clinically significant AHREs from the available literature. Methods The PubMed/MEDLINE and EMBASE databases were screened for studies on CIED patients reporting the incidence of thromboembolic events related to at least one AHRE temporal cut-off. A total of 23 studies were included: 19 considering the longest single AHRE and four the AHRE burden, respectively. A random-effect diagnostic test accuracy meta-analysis with multiple cut-offs was performed. Two analyses were performed according to the AHRE temporal cut-off subtype (longest episode vs. cumulative burden). Results The analysis on the longest single AHRE indicated 0.07 min as the optimal duration to differentiate AHRE associated or not with thromboembolic events [sensitivity 65.4% (95% CI 48.8%-79.0%), specificity 52.7% (95% CI 46.0%-59.4%), and area under the summary receiver operating characteristic curve (AUC-SROC): 0.62]. The analysis on AHRE burden indicated 1.4 min as the optimal cut-off [sensitivity 58.2% (95% CI 25.6%-85.0%), specificity 57.5% (95% CI 42.0%-71.7%), and AUC-SROC 0.60]. A sensitivity analysis excluding patients with a history of atrial fibrillation and including high-quality studies only yielded similar results. Conclusion The presence of AHRE, rather than a specific duration, relates to an increased, albeit low, thromboembolic risk in CIED patients. Any AHRE should constitute an additional element in patient-specific thromboembolic risk assessment.
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Affiliation(s)
- Andrea Saglietto
- Division of Cardiology, Cardiovascular and Thoracic Department, “Citta Della Salute e Della Scienza” Hospital, Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Andrea Ballatore
- Division of Cardiology, Cardiovascular and Thoracic Department, “Citta Della Salute e Della Scienza” Hospital, Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Carola Griffith Brookles
- Division of Cardiology, Cardiovascular and Thoracic Department, “Citta Della Salute e Della Scienza” Hospital, Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Henri Xhakupi
- Dipartimento di Medicina Interna, Università Degli Studi di Genova, Genova, Italia
| | - Gaetano Maria De Ferrari
- Division of Cardiology, Cardiovascular and Thoracic Department, “Citta Della Salute e Della Scienza” Hospital, Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Matteo Anselmino
- Division of Cardiology, Cardiovascular and Thoracic Department, “Citta Della Salute e Della Scienza” Hospital, Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
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Razina TV, Serova MV, Andreev DA, Sazonova YS, Komarova AG. [Tactics of anticoagulant therapy in patients with cardiac implantable electronic devices and subclinical atrial fibrillation: A review]. TERAPEVT ARKH 2023; 95:472054. [PMID: 38158984 DOI: 10.26442/00403660.2023.04.202189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 05/31/2023] [Indexed: 01/03/2024]
Abstract
Screening for atrial fibrillation (AF) has attracted considerable attention recently. Of special interest are patients with cardiac implantable electronic devices (CIEDs) that allow for recording episodes of atrial arrhythmias of various durations, including asymptomatic ones, in which case they are referred to as subclinical atrial fibrillation (SCAF). The available data suggest that the risk of thromboembolic events varies between patients with SCAF and clinically overt AF. As of today, the question regarding anticoagulant therapy in patients with SCAF remains unresolved. The article presents an overview of previous and ongoing studies on this issue, as well as current guidelines on anticoagulant use in patients with SCAF and CIEDs.
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Affiliation(s)
- T V Razina
- Sechenov First Moscow State Medical University (Sechenov University)
| | - M V Serova
- Sechenov First Moscow State Medical University (Sechenov University)
- Pirogov City Clinical Hospital №1 Moscow
| | - D A Andreev
- Sechenov First Moscow State Medical University (Sechenov University)
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Meng Y, Zhang Y, Zhu C, Nie C, Liu P, Chang S, Wang S. Atrial high-rate episode burden and stroke risks for patients with device-detected subclinical atrial fibrillation: A systematic review and meta-analysis. Int J Cardiol 2023; 371:211-220. [PMID: 36243183 DOI: 10.1016/j.ijcard.2022.09.046] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 09/10/2022] [Accepted: 09/20/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Atrial high-rate episode (AHRE) and stroke are related; however, the magnitude of the correlations between different AHRE burdens and stroke remains unknown. We analysed studies that evaluated this relationship. METHODS We searched for observational controlled studies that reported the associations of different AHRE burdens with stroke in populations with cardiac implantable electronic devices (CIEDs). The primary endpoint was stroke or thrombosis during follow-up. We performed subgroup analyses according to the classification criteria and research design of the included studies. RESULTS Of the 5985 studies identified, 9 met the eligibility criteria and included 42,958 patients. Patients with low and high AHRE burdens had a 1.2-fold risk of stroke (no heterogeneity) and a 2.52-fold risk of stroke (moderate heterogeneity), respectively. After excluding studies analysing the atrial fibrillation history, no significant difference in progressive stroke risk was observed for patients with a low AHRE burden (without significant heterogeneity). An increased likelihood of stroke was observed for patients with a high AHRE burden (decreased heterogeneity). Four of the nine studies classified high and low AHRE burdens using the longest AHRE time. Five studies classified high and low AHRE burdens based on the median of the total AHRE time as the cutoff value. Low and high AHRE burdens were more closely related to stroke when classified by the total AHRE duration than when classified by the single longest AHRE duration. CONCLUSIONS For populations with CIEDs without an atrial fibrillation history, a high AHRE burden was significantly associated with stroke.
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Affiliation(s)
- Yanhai Meng
- Surgical Intensive Care Unit, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; Surgical Intensive Care Unit, Fuwai Yunnan Cardiovascular Hospital, Kunming, China
| | - Yanbo Zhang
- Surgical Intensive Care Unit, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Changsheng Zhu
- Department of Cardiovascular Surgery, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Changrong Nie
- Department of Cardiovascular Surgery, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ping Liu
- Surgical Intensive Care Unit, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shuo Chang
- Surgical Intensive Care Unit, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shuiyun Wang
- Department of Cardiovascular Surgery, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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Abstract
INTRODUCTION Stroke is one of the leading causes of mortality and morbidity globally. Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia. It is set to reach epidemic proportions. AF is associated with a five-fold increase in risk of stroke. Strokes caused by AF more often are fatal or result in severe disability. Even though the incidence of stroke has been significantly reduced by oral anticoagulation, AF is thought to account for a significant proportion of cryptogenic strokes where no etiology is identified. AREAS COVERED This article reviews the literature related to AF and stroke, pathophysiological insights, diagnosis of AF in stroke patients, and its management (Graphical Abstract). EXPERT OPINION The pathophysiology of thrombogenesis that links AF and stroke is not well understood and is an area of active research to identify new therapeutic targets to prevent AF and stroke. As the nature of AF and stroke is multifaceted, an integrated care approach to managing AF and stroke is increasingly essential.
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Affiliation(s)
- Sylvia E Choi
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Dimitrios Sagris
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Andrew Hill
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK.,Stroke Division, Department of Medicine for Older People, Whiston Hospital, St Helens and Knowsley Teaching Hospitals NHS Trust, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Azmil H Abdul-Rahim
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.,Stroke Division, Department of Medicine for Older People, Whiston Hospital, St Helens and Knowsley Teaching Hospitals NHS Trust, UK
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13
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Vio R, Giordani AS, Alturki A, Čulić V, Vitale R, China P, Themistoclakis S, Vanoli E, Proietti R. Prevalence of asymptomatic atrial fibrillation among multimorbid elderly patients: diagnostic implications. Minerva Cardiol Angiol 2022; 70:583-593. [PMID: 35212509 DOI: 10.23736/s2724-5683.22.05894-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Advancing age of the global population is one of the main reasons for the uprising trend in atrial fibrillation (AF) prevalence worldwide leading to a proper "AF epidemic". Strictly related to the increasing prevalence of AF in the elderly is the relevant burden of cardiac end extra-cardiac comorbidities that these patients show. Patients with AF are frequently asymptomatic (i.e., asymptomatic or silent AF) and thus the arrhythmia is generally underdiagnosed. Detainment of proper treatment in elderly and comorbid patients may potentially result in significant morbidity and mortality. Therefore, in recent years, several screening strategies (systematic vs opportunistic screening) for asymptomatic AF have been developed and early diagnosis of AF is an important treatment goal that can improve prognosis. This review will focus on the prevalence of asymptomatic AF in the elderly, frequently associated comorbidities, screening strategies, and implications for a correct AF diagnosis.
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Affiliation(s)
- Riccardo Vio
- Unit of Cardiology, Department of Cardiothoracic, Vascular Medicine & Intensive Care, Dell'Angelo Hospital, Mestre, Venice, Italy -
| | - Andrea S Giordani
- Department of Cardiac, Thoracic, Vascular Science and Public Health, University of Padova, Padova, Italy
| | - Ahmed Alturki
- Division of Cardiology, McGill University Health Center, Montreal, Canada
| | - Viktor Čulić
- University of Split School of Medicine, Split, Croatia.,Department of Cardiology and Angiology, University Hospital Centre Split, Split, Croatia
| | - Raffaele Vitale
- Unit of Cardiology, Department of Cardiothoracic, Vascular Medicine & Intensive Care, Dell'Angelo Hospital, Mestre, Venice, Italy
| | - Paolo China
- Unit of Cardiology, Department of Cardiothoracic, Vascular Medicine & Intensive Care, Dell'Angelo Hospital, Mestre, Venice, Italy
| | - Sakis Themistoclakis
- Unit of Cardiology, Department of Cardiothoracic, Vascular Medicine & Intensive Care, Dell'Angelo Hospital, Mestre, Venice, Italy
| | - Emilio Vanoli
- Sacra Famiglia Fatebenefratelli Hospital, Erba, Como, Italy
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14
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Nogami A, Kurita T, Kusano K, Goya M, Shoda M, Tada H, Naito S, Yamane T, Kimura M, Shiga T, Soejima K, Noda T, Yamasaki H, Aizawa Y, Ohe T, Kimura T, Kohsaka S, Mitamura H. JCS/JHRS 2021 guideline focused update on non-pharmacotherapy of cardiac arrhythmias. J Arrhythm 2022; 38:1-30. [PMID: 35222748 PMCID: PMC8851582 DOI: 10.1002/joa3.12649] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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15
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Yang SY, Huang M, Wang AL, Ge G, Ma M, Zhi H, Wang LN. Atrial fibrillation burden and the risk of stroke: A systematic review and dose-response meta-analysis. World J Clin Cases 2022; 10:939-953. [PMID: 35127908 PMCID: PMC8790433 DOI: 10.12998/wjcc.v10.i3.939] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 10/26/2021] [Accepted: 12/23/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The increased stroke risk associated with atrial fibrillation (AF) burden exceeding 5 min is a matter of debate. In addition, the potential linear or nonlinear relationship between AF burden and stroke risk has been largely unexplored.
AIM To determine the association between AF burden > 5 min and the increased risk of stroke and explore the potential dose-response relationship between these two factors.
METHODS Sixteen studies from six databases with 53141 subjects (mean age 65 years) were included. Fifteen studies were observational studies, and one was a randomized controlled trial study. The potential nonlinear dose-response association was characterized using a restricted cubic splines regression model. AF burden for each 1 h and 2 h was associated with an increased risk of stroke. Trial sequential analysis with a random-effect model was used to evaluate the robustness of the evidence from the included 16 studies.
RESULTS AF burden > 5 min was associated with an increased risk of clinical AF [adjusted risk ratio (RR) = 4.18, 95% confidence interval (CI): 2.26-7.74]. However, no association was found with an increased risk of all-cause mortality (adjusted RR = 1.55, 95%CI: 0.87-2.75). Patients with AF burden > 5 min had an increased risk of stroke (adjusted RR = 2.49, 95%CI: 1.79-3.47). Moreover, a dose-response analysis showed that the increased stroke risk was paralleled by an increase in AF burden at a rate of 2.0% per hour (Pnonlinear = 0.656, RR = 1.02, 95%CI: 1.01-1.03). Trial sequential analysis provided robust evidence of the association between AF burden > 5 min and an increased risk of stroke.
CONCLUSION AF burden was a significant risk factor for clinical AF and future stroke. A significant linear association was documented between increased AF burden and risk of future stroke.
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Affiliation(s)
- Sheng-Yi Yang
- Department of Epidemiology and Biostatistics, Southeast University, Nanjing 210009, Jiangsu Province, China
| | - Min Huang
- Department of Epidemiology and Biostatistics, Southeast University, Nanjing 210009, Jiangsu Province, China
| | - Ai-Lian Wang
- Yaohua Community Healthcare Center, Nanjing 210046, Jiangsu Province, China
| | - Ge Ge
- Department of Epidemiology and Biostatistics, Southeast University, Nanjing 210009, Jiangsu Province, China
| | - Mi Ma
- Department of Epidemiology and Biostatistics, Southeast University, Nanjing 210009, Jiangsu Province, China
| | - Hong Zhi
- Department of Cardiology, Zhongda Hospital, Nanjing 210009, Jiangsu Province, China
| | - Li-Na Wang
- School of Public Health, Southeast University, Nanjing 210009, Jiangsu Province, China
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16
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Nogami A, Kurita T, Kusano K, Goya M, Shoda M, Tada H, Naito S, Yamane T, Kimura M, Shiga T, Soejima K, Noda T, Yamasaki H, Aizawa Y, Ohe T, Kimura T, Kohsaka S, Mitamura H. JCS/JHRS 2021 Guideline Focused Update on Non-Pharmacotherapy of Cardiac Arrhythmias. Circ J 2022; 86:337-363. [PMID: 34987141 DOI: 10.1253/circj.cj-21-0162] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Akihiko Nogami
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
| | | | - Kengo Kusano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Masahiko Goya
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University
| | - Morio Shoda
- Department of Cardiology, Tokyo Women's Medical University
| | - Hiroshi Tada
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui
| | | | - Teiichi Yamane
- Department of Cardiology, Jikei University School of Medicine
| | - Masaomi Kimura
- Advanced Management of Cardiac Arrhythmias, Hirosaki University Graduate School of Medicine
| | - Tsuyoshi Shiga
- Department of Clinical Pharmacology and Therapeutics, The Jikei University School of Medicine
| | - Kyoko Soejima
- Arrhythmia Center, Second Department of Internal Medicine, Kyorin University Hospital
| | - Takashi Noda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Hiro Yamasaki
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
| | | | | | - Takeshi Kimura
- Department of Cardiology, Graduate School of Medicine and Faculty of Medicine, Kyoto University
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine
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17
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Özge G, Kepez A, Uğur K, Görenek B. What to do with device-detected atrial high-rate episodes: Summary of the evidences. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2021; 45:250-261. [PMID: 34927268 DOI: 10.1111/pace.14428] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 10/17/2021] [Accepted: 12/05/2021] [Indexed: 11/28/2022]
Abstract
Cardiac implanted electronic devices (CIEDs), that perform atrial sensing via an atrial electrode, commonly detect self-terminating atrial arrhythmias. Nomenclature of these arrhythmias is defined as atrial high-rate episodes (AHREs) and subclinical atrial fibrillation (SCAF). We have provided a comprehensive summation of the trials regarding the incidence and adverse outcomes of AHREs. The reported incidence of AHRE varies considerably (approximately 10% to %70) between studies depending on the definition of AHRE, duration of follow-up and the clinical profile of the population. There is increasing evidence related with the association between AHREs' and stroke and/or systemic embolism. However, risk of stroke and/or systemic embolism seems to be less than the risk associated with clinical AF. There is still lack of sufficient evidence related with oral anticoagulation (OAC) in patients with AHRE to reduce thromboembolic risk. Although, the strongest association of OAC treatment with reduction in stroke has been reported to be observed among patients with device detected SCAF episodes of >24 hours; it is still questionable whether AHRE is a direct cause of thromboembolic event or just a marker of increased risk. Results of ongoing randomized clinical trials (NOAH-AFNET 6 and ARTESIA) will provide robust evidence on effect of OAC therapy on AHREs. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Gurbet Özge
- Eskişehir Osmangazi University, Faculty of Medicine, Department of Cardiology, Eskişehir, Turkey
| | - Alper Kepez
- Marmara University, Faculty of Medicine, Department of Cardiology, İstanbul, Turkey
| | - Kadir Uğur
- Eskişehir Osmangazi University, Faculty of Medicine, Department of Cardiology, Eskişehir, Turkey
| | - Bülent Görenek
- Eskişehir Osmangazi University, Faculty of Medicine, Department of Cardiology, Eskişehir, Turkey
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18
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Sagris D, Georgiopoulos G, Pateras K, Perlepe K, Korompoki E, Milionis H, Tsiachris D, Chan C, Lip GYH, Ntaios G. Atrial High-Rate Episode Duration Thresholds and Thromboembolic Risk: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2021; 10:e022487. [PMID: 34755543 PMCID: PMC8751956 DOI: 10.1161/jaha.121.022487] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Background Available evidence supports an association between atrial high‐rate episode (AHRE) burden and thromboembolic risk, but the necessary extent and duration of AHREs to increase the thromboembolic risk remain to be defined. The aim of this systematic review and meta‐analysis was to identify the thromboembolic risk associated with various AHRE thresholds. Methods and Results We searched PubMed and Scopus until January 9, 2020, for literature reporting AHRE duration and thromboembolic risk in patients with implantable electronic devices. The outcome assessed was stroke or systemic embolism. Risk estimates were reported as hazard ratio (HR) or relative risk alongside 95% CIs. We used the Paule‐Mandel estimator, and heterogeneity was calculated with I2 index. Among 27 studies including 61 919 patients, 23 studies reported rates according to the duration of the longest AHRE and 4 studies reported rates according to the cumulative day‐level AHRE duration. In patients with cardiac implantable devices, AHREs lasting ≥30 seconds significantly increased the risk of stroke or systemic embolism (HR, 4.41; 95% CI, 2.32–8.39; I2, 5.5%), which remained consistent for the thresholds of 5 minutes and 6 and 24 hours. Patients with previous stroke or transient ischemic attack and AHREs lasting ≥2 minutes had a marginally increased risk of recurrent stroke or transient ischemic attack. The risk of stroke or systemic embolism was higher in patients with cumulative AHRE ≥24 hours compared with those of shorter duration or no AHRE (HR, 1.25; 95% CI, 1.04–1.52; I2, 0%). Conclusions This systematic review and meta‐analysis suggests that single AHRE episodes ≥30 seconds and cumulative AHRE duration ≥24 hours are associated with increased risk of stroke or systemic embolism.
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Affiliation(s)
- Dimitrios Sagris
- Department of Internal Medicine School of Health Sciences Faculty of Medicine University of Thessaly Larissa Greece
| | - Georgios Georgiopoulos
- School of Biomedical Engineering and Imaging Sciences King's College London United Kingdom
| | - Konstantinos Pateras
- Department of Biostatistics and Research Support Julius Center for Health Sciences and Primary Care University Medical Center Utrecht Utrecht the Netherlands
| | - Kalliopi Perlepe
- Department of Internal Medicine School of Health Sciences Faculty of Medicine University of Thessaly Larissa Greece
| | - Eleni Korompoki
- Department of Clinical Therapeutics National and Kapodistrian University of Athens Athens Greece
| | - Haralampos Milionis
- Department of Internal Medicine University Hospital of Ioannina Ioannina Greece
| | - Dimitrios Tsiachris
- Athens Heart Center Athens Medical Center Athens Greece.,1st Cardiology Department Athens Medical School National and Kapodistrian University of Athens Athens Greece
| | - Cheuk Chan
- School of Biomedical Engineering and Imaging Sciences King's College London United Kingdom
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science University of Liverpool and Liverpool Heart and Chest Hospital Liverpool United Kingdom.,Aalborg Thrombosis Research Unit Department of Clinical Medicine Aalborg University Aalborg Denmark
| | - George Ntaios
- Department of Internal Medicine School of Health Sciences Faculty of Medicine University of Thessaly Larissa Greece
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19
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Vitolo M, Imberti JF, Maisano A, Albini A, Bonini N, Valenti AC, Malavasi VL, Proietti M, Healey JS, Lip GY, Boriani G. Device-detected atrial high rate episodes and the risk of stroke/thrombo-embolism and atrial fibrillation incidence: a systematic review and meta-analysis. Eur J Intern Med 2021; 92:100-106. [PMID: 34154879 DOI: 10.1016/j.ejim.2021.05.038] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 05/18/2021] [Accepted: 05/26/2021] [Indexed: 01/09/2023]
Abstract
BACKGROUND Atrial High Rate Episodes (AHRE) are asymptomatic atrial tachy-arrhythmias detected through continuous monitoring with a cardiac implantable electronic device. The risks of stroke/Thromboembolic (TE) events and incident clinical Atrial Fibrillation (AF) associated with AHRE varies markedly. OBJECTIVES To assess the relationship between AHRE and TE events, and between AHRE and incident clinical AF. METHODS This systematic review and meta-analysis was conducted following the PRISMA recommendations. PubMed, Scopus, and Google Scholar were searched from inception to 18/02/2021 for studies reporting TE events and incident clinical AF in patients with AHRE, as compared with patients without. RESULTS Ten out of 8081 records fulfilled the inclusion criteria, for a total of 37 266 patients. Seven out of ten studies excluded patients with prior history of clinical AF (4961 patients), embracing the most recent definition of AHRE. The risk ratio (RR) for TE events in AHRE patients was 2.13 (95% CI: 1.53-2.95, I2: 0%). The incidence of clinical AF was reported in four studies excluding patients with a history of clinical AF (3574 patients). The RR for incident clinical AF was 3.34 (95%CI: 1.89-5.90, I2: 73%). CONCLUSIONS AHRE are significantly associated with systemic thromboembolism and incident clinical AF. Further studies are needed to improve patients' risk stratification and management.
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Affiliation(s)
- Marco Vitolo
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy.; Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy; Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Jacopo F Imberti
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy.; Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Anna Maisano
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Alessandro Albini
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Niccolò Bonini
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Anna Chiara Valenti
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Vincenzo L Malavasi
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Marco Proietti
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy; Geriatric Unit, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy
| | - Jeff S Healey
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Gregory Yh Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy..
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20
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Sun X, Zhao S, Chen K, Hua W, Su Y, Xu W, Wang F, Fan X, Dai Y, Liu Z, Zhang S. Association Between Changes in Physical Activity and New-Onset Atrial Fibrillation After ICD/CRT-D Implantation. Front Cardiovasc Med 2021; 8:693458. [PMID: 34513943 PMCID: PMC8426902 DOI: 10.3389/fcvm.2021.693458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 08/03/2021] [Indexed: 12/04/2022] Open
Abstract
Background: Changes in physical activity (PA) after implantable cardioverter defibrillator (ICD) or cardiac resynchronization therapy defibrillators (CRT-D) implantation were unknown. The association of PA changes with new-onset atrial fibrillation (AF), cardiac death and all-cause mortality was unclear in patients at high risk of sudden cardiac death. Methods: Patients receiving ICD/CRT-D implantation from SUMMIT registry were retrospectively analyzed. Changes in PA were considered from baseline status to 1 year after implantation. New-onset AF was defined as the first atrial high-rate episode ≥1% of the daily AF burden detected after implantation. Results: Over a mean follow-up of 50.3 months, 124 new-onset AF events (36.2%), 61 cardiac deaths (17.8%), and 87 all-cause deaths (25.4%) were observed in 343 patients with ICD/CRT-D implantation. PA at 1 year after implantation was increased compared with PA at baseline (11.97 ± 5.83% vs. 10.82 ± 5.43%, P = 0.008), and PA at 1 year was improved in 210 patients (61.2%). Per 1% decrease in PA was associated with 12.4, 18.3, and 14.3% higher risks of new-onset AF, cardiac death and all-cause mortality, regardless of different baseline characteristics. Patients with decreased PA had 2-fold risks of new-onset AF (hazard ratio [HR] = 1.972, 95% confidence interval [CI]: 1.352–2.877, P < 0.001) as high as those with unchanged/increased PA. Decreased PA was an independent risk factor for cardiac death (HR = 3.358, 95% CI: 1.880–5.996, P < 0.001) and all-cause mortality (HR = 2.803, 95% CI:1.732–4.535, P < 0.001). Conclusion: PA decrease after ICD/CRT-D implantation is associated with a higher incidence of new-onset AF, resulting in worsened outcomes in cardiac death and all-cause mortality.
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Affiliation(s)
- Xuerong Sun
- Arrhythmia Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shuang Zhao
- Arrhythmia Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Keping Chen
- Arrhythmia Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wei Hua
- Arrhythmia Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yangang Su
- Department of Cardiology, Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wei Xu
- Department of Cardiology, Nanjing Drum Tower Hospital, Nanjing, China
| | - Fang Wang
- Department of Cardiology, Shanghai First People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaohan Fan
- Arrhythmia Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yan Dai
- Arrhythmia Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhimin Liu
- Arrhythmia Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shu Zhang
- Arrhythmia Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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21
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Tiver KD, Quah J, Lahiri A, Ganesan AN, McGavigan AD. Atrial fibrillation burden: an update-the need for a CHA2DS2-VASc-AFBurden score. Europace 2021; 23:665-673. [PMID: 33351904 DOI: 10.1093/europace/euaa287] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 12/16/2020] [Indexed: 01/31/2023] Open
Abstract
Atrial fibrillation (AF) is an established independent risk factor for stroke. Current guidelines regard AF as binary; either present or absent, with the decision for anti-coagulation driven by clinical variables alone. However, there are increasing data to support a biological gradient of AF burden and stroke risk, both in clinical and non-clinical AF phenotypes. As such, this raises the concept of combining AF burden assessment with a clinical risk score to refine and individualize the assessment of stroke risk in AF-the CHA2DS2VASc-AFBurden score. We review the published data supporting a biological gradient to try and construct a putative schema of risk attributable to AF burden.
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Affiliation(s)
- Kathryn D Tiver
- Department of Cardiovascular Medicine, Flinders Medical Centre, Bedford Park, South Australia 5042, Australia
| | - Jing Quah
- Department of Cardiovascular Medicine, Flinders Medical Centre, Bedford Park, South Australia 5042, Australia.,College of Medicine and Public Health, Flinders University of South Australia, Bedford Park, South Australia 5042, Australia
| | - Anandaroop Lahiri
- Department of Cardiovascular Medicine, Flinders Medical Centre, Bedford Park, South Australia 5042, Australia
| | - Anand N Ganesan
- Department of Cardiovascular Medicine, Flinders Medical Centre, Bedford Park, South Australia 5042, Australia.,College of Medicine and Public Health, Flinders University of South Australia, Bedford Park, South Australia 5042, Australia
| | - Andrew D McGavigan
- Department of Cardiovascular Medicine, Flinders Medical Centre, Bedford Park, South Australia 5042, Australia.,College of Medicine and Public Health, Flinders University of South Australia, Bedford Park, South Australia 5042, Australia
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22
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Botto GL, Tortora G, Casale MC, Canevese FL, Brasca FAM. Impact of the Pattern of Atrial Fibrillation on Stroke Risk and Mortality. Arrhythm Electrophysiol Rev 2021; 10:68-76. [PMID: 34401178 PMCID: PMC8335885 DOI: 10.15420/aer.2021.01] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 03/15/2021] [Indexed: 12/22/2022] Open
Abstract
Thromboembolism is the most serious complication of AF, and oral anticoagulation is the mainstay therapy. Current guidelines place all AF types together in terms of anticoagulation with the major determinants being associated comorbidities translated into risk marker. Among patients in large clinical trials, those with non-paroxysmal AF appear to be at higher risk of stroke than those with paroxysmal AF. Higher complexity of the AF pattern is also associated with higher risk of mortality. Moreover, continuous monitoring of AF through cardiac implantable devices provided us with the concept of 'AF burden'. Usually, the larger the AF burden, the higher the risk of stroke; however, the relationship is not well characterised with respect to the threshold value above which the risk increases. The picture is more complex than it appears: AF and underlying disorders must act synergically respecting the magnitude of its own characteristics, which are the amount of time a patient stays in AF and the severity of associated comorbidities.
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Affiliation(s)
- Giovanni Luca Botto
- Department of Cardiology - Electrophysiology, ASST Rhodense, Civile Hospital Rho and Salvini Hospital Garbagnate Milanese Hospital, Milan, Italy
| | - Giovanni Tortora
- Department of Cardiology - Electrophysiology, ASST Rhodense, Civile Hospital Rho and Salvini Hospital Garbagnate Milanese Hospital, Milan, Italy
| | - Maria Carla Casale
- Department of Cardiology - Electrophysiology, ASST Rhodense, Civile Hospital Rho and Salvini Hospital Garbagnate Milanese Hospital, Milan, Italy
| | - Fabio Lorenzo Canevese
- Department of Cardiology - Electrophysiology, ASST Rhodense, Civile Hospital Rho and Salvini Hospital Garbagnate Milanese Hospital, Milan, Italy
| | - Francesco Angelo Maria Brasca
- Department of Cardiology - Electrophysiology, ASST Rhodense, Civile Hospital Rho and Salvini Hospital Garbagnate Milanese Hospital, Milan, Italy
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23
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Gruska M, Aigner G, Altenberger J, Burkart-Küttner D, Fiedler L, Gwechenberger M, Lercher P, Martinek M, Nürnberg M, Pölzl G, Porenta G, Sauermann S, Schukro C, Scherr D, Steinwender C, Stühlinger M, Teubl A. Recommendations on the utilization of telemedicine in cardiology. Wien Klin Wochenschr 2020; 132:782-800. [PMID: 33259003 DOI: 10.1007/s00508-020-01762-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 10/19/2020] [Indexed: 01/08/2023]
Abstract
The enormous progress made in recent years in the field of information and communication technology and also in sensor and computer technology has affected numerous fields of medicine and is capable of inducing even radical changes in diagnostic and therapeutic processes. This is particularly true for cardiology, where, for example, telemetric monitoring of cardiac and circulatory functions has been in use for many years. Nevertheless, broad application of newer telemedical processes has not yet been achieved to the extent one would expect from the encouraging results of numerous clinical studies in this field and the state of the art of the underlying technology. In the present paper, the Working Group on Rhythmology of the Austrian Cardiological Society aims to provoke a critical discussion of the digital change in cardiology and to make recommendations for the implementation of those telemedical processes that have been shown to exert positive effects on a wide variety of medical and economic parameters. The greatest benefit of telecardiological applications is certainly to be found in the long-term care of patients with chronic cardiovascular diseases. Accordingly, follow-up care of patients with cardiological rhythm implants, management of chronic heart failure and secondary prevention following an acute cardiac event during rehabilitation are currently the most important fields of application. Telemedicine is intended to enable high-quality and cost-efficient care for an increasing number of patients, whose care poses one of the greatest challenges to our healthcare system. Not least of all, telemedicine should make a decisive contribution to improving the quality of life of this segment of the population by favorably influencing mortality, morbidity and hospitalization as well as the patient's contribution to treatment.
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Affiliation(s)
- Michael Gruska
- Hauptstelle-Abt. Forschung, Innovation, Leistungsentwicklung, Pensionsversicherungsanstalt, Friedrich Hillegeist-Straße 1, 1021, Vienna, Austria.
| | - Gerhard Aigner
- Institut für Ethik und Recht in der Medizin, Universität Wien, Spitalgasse 2-4, Hof 2.8, 1090, Vienna, Austria
| | - Johann Altenberger
- SKA-Rehabilitationszentrum Großgmain, Salzburger Straße 520, 5084, Großgmain, Austria
| | - Dagmar Burkart-Küttner
- 2. Med. Abteilung, Hanusch Krankenhaus, Heinrich-Collin-Straße 30, 1140, Vienna, Austria
| | - Lukas Fiedler
- 2. Interne Abteilung, Landesklinikum Wr. Neustadt, Corvinusring 3-5, 2700, Wiener Neustadt, Austria
| | - Marianne Gwechenberger
- Universitätsklinik für Innere Medizin II, Klinische Abteilung für Kardiologie, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Peter Lercher
- Klinische Abteilung für Kardiologie, Medizinische Universität Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | - Martin Martinek
- 2. Interne Abteilung, Ordensklinikum Linz, Krankenhaus der Elisabethinen, Fadingerstraße 1, 4020, Linz, Austria
| | - Michael Nürnberg
- 3. Medizinische Abteilung, Wilheminenspital der Stadt Wien, Montleartstraße 37, 1160, Vienna, Austria
| | - Gerhard Pölzl
- Universitätsklinik für Innere Medizin III, Medizinische Universität Innsbruck, Anichstraße, 6020, Innsbruck, Austria
| | - Gerold Porenta
- Privatkrankenanstalt Rudolfinerhaus, Billrothstraße 78, 1190, Vienna, Austria
| | - Stefan Sauermann
- Medical Engineering & eHealth, FH Technikum Wien, Höchstädtplatz 6, 1200, Vienna, Austria
| | - Christoph Schukro
- Universitätsklinik für Innere Medizin II, Klinische Abteilung für Kardiologie, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Daniel Scherr
- Klinische Abteilung für Kardiologie, Medizinische Universität Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | - Clemens Steinwender
- Klinik für Kardiologie und internistische Intensivmedizin, Med Campus III, Kepler Universitätsklinikum, Krankenhausstraße 9, 4021, Linz/Donau, Austria
| | - Markus Stühlinger
- Universitätsklinik für Innere Medizin III, Medizinische Universität Innsbruck, Anichstraße, 6020, Innsbruck, Austria
| | - Alexander Teubl
- 2. Interne Abteilung, Landesklinikum Wr. Neustadt, Corvinusring 3-5, 2700, Wiener Neustadt, Austria
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Abstract
Atrial high rate episodes (AHREs) are defined as asymptomatic atrial tachyarrhythmias detected by cardiac implantable electronic devices with atrial sensing, providing automated continuous monitoring and tracings storage, occurring in subjects with no previous clinical atrial fibrillation (AF) and with no AF detected at conventional electrocardiogram recordings. AHREs are associated with an increased thrombo-embolic risk, which is not negligible, although lower than that of clinical AF. The thrombo-embolic risk increases with increasing burden of AHREs, and moreover, AHREs burden shows a dynamic pattern, with tendency to progression along with time, with potential transition to clinical AF. The clinical management of AHREs, in particular with regard to prophylactic treatment with oral anticoagulants (OACs), remains uncertain and heterogeneous. At present, in patients with confirmed AHREs, as a result of device tracing analysis, an integrated, individual and clinically-guided assessment should be applied, taking into account the patients' risk of stroke (to be reassessed regularly) and the AHREs burden. The use of OACs, preferentially non-vitamin K antagonists OACs, may be justified in selected patients, such as those with longer AHREs durations (in the range of several hours or ≥24 h), with no doubts on AF diagnosis after device tracing analysis and with an estimated high/very high individual risk of stroke, accounting for the anticipated net clinical benefit, and informed patient's preferences. Two randomized clinical trials on this topic are currently ongoing and are likely to better define the role of anticoagulant therapy in patients with AHREs.
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Affiliation(s)
- Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Via del Pozzo, 71, 41124 Modena, Italy
| | - Marco Vitolo
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Via del Pozzo, 71, 41124 Modena, Italy
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, William Henry Duncan Building, 6 West Derby Street, Liverpool, L7 8TX, UK
| | - Jacopo Francesco Imberti
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Via del Pozzo, 71, 41124 Modena, Italy
| | - Tatjana S Potpara
- School of Medicine, Belgrade University, dr Subotica 8, 11000 Belgrade, Serbia
- Cardiology Clinic, Clinical Centre of Serbia, Visegradska 26, 11000 Belgrade, Serbia
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, William Henry Duncan Building, 6 West Derby Street, Liverpool, L7 8TX, UK
- Department of Clinical Medicine, Aalborg University, Søndre Skovvej 15, 9000 Aalborg, Denmark
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High-Sensitivity C-Reactive Protein is a Predictor of Subsequent Atrial High-Rate Episodes in Patients with Pacemakers and Preserved Ejection Fraction. J Clin Med 2020; 9:jcm9113677. [PMID: 33207668 PMCID: PMC7696571 DOI: 10.3390/jcm9113677] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 11/04/2020] [Accepted: 11/13/2020] [Indexed: 12/16/2022] Open
Abstract
Atrial fibrillation (AF) is associated with morbidity and mortality. Modern pacemakers can detect atrial high-rate episodes (AHREs) as a surrogate for AF. It remains controversial whether inflammation is a cause or a consequence of AF. This study investigated whether the inflammatory biomarker high-sensitivity C-reactive protein (hs-CRP) can predict subsequent AHREs. This study gathered prospective data from patients with pacemakers and a left ventricle EF ≥ 50% between 2015 and 2019. The hs-CRP and other cardiac biomarkers at baseline and device-detected AHREs, defined as atrial rate ≥ 180 bpm and duration ≥ 6 min, were determined. Cox regression analysis was used to estimate the independent predictors for AHREs. A total of 171 consecutive patients were included. During the median follow-up of 614 days, 66 patients (39%) developed subsequent AHREs. In the univariate Cox regression analysis, sick sinus syndrome (p = 0.005), prior AF (p < 0.001), mitral A velocity (p = 0.008), and hs-CRP (p = 0.013) showed significant association with the increased risk of AHREs. In the multivariate Cox regression model, hs-CRP (HR = 1.121, 95% confidence interval = 1.015-1.238, p = 0.024) retained its significance. Our results suggest that elevated hs-CRP could predict subsequent AHREs and that inflammation could play a role in AF pathogenesis in patients with preserved EF.
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Mathen PG, Chase D. Pacemaker detected prolonged atrial high rate episodes - Incidence, predictors and implications; a retrospective observational study. J Saudi Heart Assoc 2020; 32:157-165. [PMID: 33154910 PMCID: PMC7640543 DOI: 10.37616/2212-5043.1064] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 08/21/2019] [Accepted: 02/29/2020] [Indexed: 01/31/2023] Open
Abstract
Introduction Atrial tachyarrhythmias especially atrial fibrillation are the most commonly encountered arrhythmias in clinical practice. Most atrial tachyarrhythmia episodes are subclinical. Cardiac implantable electronic devices with atrial sensing function enable detection of atrial tachyarrhythmias through means of atrial high rate event algorithms. Prolonged atrial high rate episodes(AHRE) above a defined rate and duration threshold represent episodes of atrial fibrillation, atrial flutter, and longer atrial tachycardias that correlate strongly with risk for thromboembolic events. Objective 1. To examine the occurrence of prolonged AHRE in dual-chamber pacemaker recipients over the study period. 2. To examine the factors which influence the occurrence of prolonged AHRE in these patients. Methods In this study, we analyzed data of 398 patients without valvular heart disease or history of atrial fibrillation who underwent dual chamber permanent pacemaker implantation at our center from January 2013 to June 2018. Patient demographics, cardiovascular comorbidities, medications, echocardiographic parameters such as ejection fraction and left atrial(LA) dimension were obtained. Also, we collected pacing characteristics such as paced QRS duration(QRSd), ventricular pacing site and cumulative percentage ventricular paced beats. Results Prolonged AHRE occurred in 59 patients(14.8%). Baseline LA dimension was greater in patients with prolonged AHRE(median 35 mm, IQR 33-37 vs median 35 mm, IQR 34-38, P = 0.004) compared to those without. Paced QRSd was significantly longer in patients with prolonged AHRE (median of 147 ms, IQR 139-160 ms vs 140 ms, IQR 132-150 ms; P < 0.001). On multivariable logistic regression, paced QRSd(OR 1.04, 95%CI 1.02-1.06; P = 0.001) and baseline LA dimension(OR 1.14, 95%CI 1.03-1.27; P = 0.01) significantly co-predicted AHRE. On Kaplan Meier analysis, patients with paced QRSd≥142 ms had more likelihood of developing prolonged AHRE during follow up (HR 2.46, CI 1.40-4.3, P = 0.001). After adjusting for baseline values, patients with paced QRSd≥142 ms had significant decline in left ventricular ejection fraction (adjusted mean difference -1.27%; P = 0.02) and significant LA dilation (adjusted mean difference 0.62 mm; P = 0.05). Conclusion In our study, paced QRSd and LA dimension were the strongest predictors for prolonged AHRE. The incidence of AHRE may be reduced by achieving the narrowest possible paced QRSd during device implantation.
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Affiliation(s)
- Pratheesh George Mathen
- Department of Cardiology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - David Chase
- Department of Cardiology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
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M Kochav S, A Reiffel J. The Link Between CHA 2DS 2-VASc Score and Thromboembolic Risk in Patients Without Known Atrial Fibrillation: Are We Missing a Silent Culprit? J Atr Fibrillation 2020; 12:2303. [PMID: 33024492 DOI: 10.4022/jafib.2303] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 12/19/2019] [Accepted: 02/25/2020] [Indexed: 11/10/2022]
Abstract
Stroke is a leading cause of morbidity and mortality. The majority of strokes are ischemic and a subset of these are due to atrial fibrillation (AF). Other etiologies include a variety of cardiovascular disorders. The CHA2DS2-VASc score is a validated stroke prediction tool for patients with non-valvular AF. However, it has also been shown to predict increased risk for stroke or thromboembolism in the absence of AF. Given how common subclinical AF (SCAF) is when looked for in patients with elevated CHA2DS2-VaSc scores who are not known to have AF, (especially when implanted monitors are used), the stroke/thromboembolism risk that has been associated with CHA2DS2-VASc scores absent known AF may be an overestimate of the true risk due to the likely presence of SCAF in some of the subjects included. This has not yet been adequately addressed in the literature. Finally, the risk of a left atrial thromboembolic event is a consequence of the altered atrial anatomy and physiology (atrial cardiomyopathy) that may result from comorbid disorders and AF itself, or, additively from both - whether or not the AF has been already recognized clinically.
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Affiliation(s)
- Stephanie M Kochav
- Columbia University, Vagelos College of Physicians and Surgeons Division of Cardiology, Department of Medicine, New York, New York
| | - James A Reiffel
- Columbia University, Vagelos College of Physicians and Surgeons Division of Cardiology, Department of Medicine, New York, New York
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Aksan G, Yanık A, Yontar OC, Gedikli Ö, Arslan U, Soylu K. Galectin-3 levels and the prediction of atrial high-rate episodes in patients with cardiac resynchronization therapy. J Investig Med 2020; 69:20-27. [PMID: 32994201 DOI: 10.1136/jim-2020-001459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2020] [Indexed: 11/04/2022]
Abstract
Galectin-3 is an inflammation biomarker associated with atrial remodeling which plays a role in the development of atrial fibrillation (AF). Atrial high-rate episode (AHRE) is related to development of clinically documented AF and stroke. The present study aimed to determine the relationship between the presence of AHRE and the coronary sinus (CS) serum sampling of galectin-3 levels in the long-term follow-up of cardiac resynchronization therapy (CRT) patients. A total of 108 consecutive CRT patients were included prospectively in the study. AHREs were defined as atrial tachyarrhythmia episodes lasting at least 6 min with atrial rate >190 beats/min detected by cardiac implantable electronic device. CS blood samples were drawn from the CS guiding catheter to perform galectin-3 measurements. Galectin-3 levels were measured via ELISA. During a mean follow-up 12.6±4.9 months, AHRE was observed in 31 (28.7%) patients and not observed in 77 (72.3%) patients. CS galectin-3 levels were significantly higher in patients with AHRE than those without AHRE (18.09±2.62 vs 13.17±3.17, respectively, p<0.001). Moreover, CS galectin-3 levels showed significant positive correlation with percent of time spent in total AHRE (r=0.436, p<0.001). Multivariate logistic regression analysis demonstrated that left atrium (LA) volume and CS galectin-3 levels were significant and independent predictors for AHRE (OR=1.127, 95% CI: 1.045 to 1.216; p=0.002, OR=1.799, 95% CI: 1.388 to 2.330; p<0.001, respectively). In this study, we determined that high CS galectin-3 levels were a predictor for the development of AHRE in CRT patients.
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Affiliation(s)
- Gokhan Aksan
- Cardiology, Samsun Education and Research Hospital, Samsun, Turkey
| | - Ahmet Yanık
- Cardiology, Samsun Education and Research Hospital, Samsun, Turkey
| | - Osman Can Yontar
- Cardiology, Samsun Education and Research Hospital, Samsun, Turkey
| | - Ömer Gedikli
- Cardiology, Ondokuz Mayis University Faculty of Medicine, Samsun, Turkey
| | - Ugur Arslan
- Cardiology, Samsun Education and Research Hospital, Samsun, Turkey
| | - Korhan Soylu
- Cardiology, Ondokuz Mayis University Faculty of Medicine, Samsun, Turkey
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Botto GL, Healey JS. Clinical outcomes in patients with systolic heart failure. Are atrial high rate episodes a common marker of disease progression? Int J Cardiol 2020; 316:184-185. [PMID: 32380251 DOI: 10.1016/j.ijcard.2020.04.077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 04/24/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Giovanni L Botto
- Department of Electrophysiology and Clinical Arrhythmology, ASST Rhodense, Milan, Italy.
| | - Jeff S Healey
- Population Health Research Institute, Mc Master University, Hamilton, Ontario, Canada
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Freitas EL, Sampaio EES, Oliveira MMC, Oliveira LH, Guimarães MSDS, Pinheiro JDO, Magalhães LPD, Albuquerque GSB, Macedo C, Aras R. Atrial High-Rate Episodes and Their Association with Cerebral Ischemic Events in Chagasic Patients. Arq Bras Cardiol 2020; 115:1072-1079. [PMID: 32935737 PMCID: PMC8133741 DOI: 10.36660/abc.20190647] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 11/26/2019] [Indexed: 11/22/2022] Open
Abstract
Fundamento Episódios de alta frequência atrial (EAFAs) estão associados a um risco elevado de eventos isquêmicos cerebrais, porém não existem estudos relacionados com a presença de EAFAs e eventos isquêmicos cerebrais em pacientes chagásicos. Objetivo Investigar a associação entre a presença de EAFAs ≥ 6 minutos e eventos isquêmicos cerebrais em pacientes chagásicos. Métodos Estudo de coorte com pacientes chagásicos, portadores de dispositivos cardíacos eletrônicos implantáveis (DCEIs), acompanhados no ambulatório de arritmias de um hospital universitário, na cidade de Salvador/BA, entre maio de 2016 e junho de 2017. Pacientes com diagnóstico de flutter atrial/fibrilação atrial, com DCEI unicameral e em uso de anticoagulação oral foram excluídos. Foram considerados EAFAs com frequência atrial ≥ 190 batimentos por minuto e duração ≥ 6 minutos (min), e os eventos isquêmicos cerebrais foram identificados por meio de tomografia computadorizada (TC) de crânio. Resultados Os 67 participantes da pesquisa (67,2% do sexo feminino, com idade média de 63,6 ± 9,2 anos) foram acompanhados por 98 ± 28,8 dias e 11,9% dos pacientes apresentaram EAFAs ≥ 6 minutos. A TC de crânio evidenciou eventos isquêmicos cerebrais silenciosos em 16,4% dos pacientes, sendo que, destes, 63,6% haviam apresentado os EAFAs ≥ 6 minutos na análise dos DCEIs. A idade avançada (OR 1,12 [IC 95% 1,03-1,21; p=0,009) e a presença de EAFAs ≥ 6 minutos (OR 96,2 [IC 95% 9,4-987,4; p<0,001]) foram preditores independentes para eventos isquêmicos. Conclusão EAFAs detectados por DCEIs estavam associados à presença de eventos isquêmicos cerebrais silenciosos em pacientes chagásicos. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0)
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Affiliation(s)
| | | | | | | | | | | | | | | | - Cristiano Macedo
- Hospital Universitário Professor Edgard Santos, Salvador, BA - Brasil
| | - Roque Aras
- Universidade Federal da Bahia Faculdade de Medicina de Bahia, Salvador, BA - Brasil
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Prevalence and prognostic significance of device-detected subclinical atrial fibrillation in patients with heart failure and reduced ejection fraction. Int J Cardiol 2020; 312:64-70. [PMID: 32169346 DOI: 10.1016/j.ijcard.2020.03.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 01/03/2020] [Accepted: 03/02/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Cardiac implanted electronic devices (CIEDs) can detect short durations of previously unrecognised atrial fibrillation (AF). The prognostic significance of device-detected subclinical AF, in the context of contemporary heart failure (HF) therapy, is unclear. METHODS Amongst patients enrolled in the Remote Monitoring in HF with implanted devices (REM-HF) trial, three categories were defined based on total AF duration in the first year of follow-up: no AF, subclinical AF (≥6 min to ≤24 h), and AF >24 h. All-cause mortality, stroke, and cardiovascular hospitalisation were assessed. RESULTS 1561 patients (94.6%) had rhythm data: 71 (4.6%) had subclinical AF (median of 4 episodes, total duration 3.1 h) and 279 (17.9%) had AF >24 h. During 2.8 ± 0.8 years' follow-up, 39 (2.5%) patients had a stroke. Stroke rate was highest amongst patients with subclinical AF (2.0 per 100-person years) versus no AF or AF >24 h (0.8 and 1.0 per 100-person years, respectively). In the overall cohort, AF >24 h was not an independent predictor of stroke. However, amongst patients with no history of AF (n = 932), new-onset subclinical AF conferred a three-fold higher stroke risk (adjusted HR 3.35, 95%CI 1.15-9.77, p = 0.027). AF >24 h was associated with more frequent emergency cardiovascular hospitalisation (adjusted HR 1.46, 95%CI 1.19-1.79, p < 0.0005). Neither AF classification was associated with mortality. CONCLUSIONS In patients with HF and a CIED, subclinical AF was infrequent but, as a new finding, was associated with an increased risk of stroke. Anticoagulation remains an important consideration in this population, particularly when the clinical profile indicates a high stroke risk.
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Bertaglia E, Blank B, Blomström-Lundqvist C, Brandes A, Cabanelas N, Dan GA, Dichtl W, Goette A, de Groot JR, Lubinski A, Marijon E, Merkely B, Mont L, Piorkowski C, Sarkozy A, Sulke N, Vardas P, Velchev V, Wichterle D, Kirchhof P. Atrial high-rate episodes: prevalence, stroke risk, implications for management, and clinical gaps in evidence. Europace 2019; 21:1459-1467. [PMID: 31377792 PMCID: PMC6788209 DOI: 10.1093/europace/euz172] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 07/15/2019] [Indexed: 12/20/2022] Open
Abstract
Self-terminating atrial arrhythmias are commonly detected on continuous rhythm monitoring, e.g. by pacemakers or defibrillators. It is unclear whether the presence of these arrhythmias has therapeutic consequences. We sought to summarize evidence on the prevalence of atrial high-rate episodes (AHREs) and their impact on risk of stroke. We performed a comprehensive, tabulated review of published literature on the prevalence of AHRE. In patients with AHRE, but without atrial fibrillation (AF), we reviewed the stroke risk and the potential risk/benefit of oral anticoagulation. Atrial high-rate episodes are found in 10-30% of AF-free patients. Presence of AHRE slightly increases stroke risk (0.8% to 1%/year) compared with patients without AHRE. Atrial high-rate episode of longer duration (e.g. those >24 h) could be associated with a higher stroke risk. Oral anticoagulation has the potential to reduce stroke risk in patients with AHRE but is associated with a rate of major bleeding of 2%/year. Oral anticoagulation is not effective in patients with heart failure or survivors of a stroke without AF. It remains unclear whether anticoagulation is effective and safe in patients with AHRE. Atrial high-rate episodes are common and confer a slight increase in stroke risk. There is true equipoise on the best way to reduce stroke risk in patients with AHRE. Two ongoing trials (NOAH-AFNET 6 and ARTESiA) will provide much-needed information on the effectiveness and safety of oral anticoagulation using non-vitamin K antagonist oral anticoagulants in patients with AHRE.
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Affiliation(s)
- Emanuele Bertaglia
- Department of Cardiac, Vascular and Thoracic Sciences, Azienda Ospedaliera, Padua, Italy
| | | | | | - Axel Brandes
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Nuno Cabanelas
- Arrhythmias Unit of Cardiology Department, Hospital Prof. Dr. Fernando Fonseca, Amadora-Sintra, Portugal
| | - G -Andrei Dan
- Colentina University Hospital, Medicine University “Carol Davila”, Bucharest, Romania
| | - Wolfgang Dichtl
- University Hospital of Internal Medicine III, Medical University Innsbruck, Innsbruck, Austria
| | - Andreas Goette
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
- St. Vincenz Hospital Paderborn, Cardiology and Intensive Care Medicine, Paderborn, Germany
| | - Joris R de Groot
- Department of Cardiology, Heart Center, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Andrzej Lubinski
- Department of Interventional Cardiology and Arrhythmias, Medical University of Lodz, Lodz, Poland
| | - Eloi Marijon
- Cardiac Electrophysiology Section, European Georges Pompidou Hospital, Paris, France
| | - Béla Merkely
- Heart and Vascular Center, Semmelweis University Budapest, Budapest, Hungary
| | - Lluis Mont
- Cardiovascular Clinical Institute, Hospital Clinic, Universitat de Barcelona, Catalonia, Spain
| | | | | | - Neil Sulke
- Eastbourne District General Hospital, Eastbourne, UK
| | - Panos Vardas
- Heart Sector, Hygeia Group Hospitals, Athens, Greece
| | - Vasil Velchev
- Cardiology Clinic, St. Anna University Hospital, Medical University Sofia, Sofia, Bulgaria
| | - Dan Wichterle
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Paulus Kirchhof
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
- Institute of Cardiovascular Sciences, University of Birmingham, UHB and Sandwell & West Birmingham Hospitals NHS Trusts, IBR 126a, Wolfson Drive, Birmingham B15 2TT, UK
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Go AS, Reynolds K, Yang J, Gupta N, Lenane J, Sung SH, Harrison TN, Liu TI, Solomon MD. Association of Burden of Atrial Fibrillation With Risk of Ischemic Stroke in Adults With Paroxysmal Atrial Fibrillation: The KP-RHYTHM Study. JAMA Cardiol 2019; 3:601-608. [PMID: 29799942 DOI: 10.1001/jamacardio.2018.1176] [Citation(s) in RCA: 170] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Importance Atrial fibrillation is a potent risk factor for stroke, but whether the burden of atrial fibrillation in patients with paroxysmal atrial fibrillation independently influences the risk of thromboembolism remains controversial. Objective To determine if the burden of atrial fibrillation characterized using noninvasive, continuous ambulatory monitoring is associated with the risk of ischemic stroke or arterial thromboembolism in adults with paroxysmal atrial fibrillation. Design, Setting, and Participants This retrospective cohort study conducted from October 2011 and October 2016 at 2 large integrated health care delivery systems used an extended continuous cardiac monitoring system to identify adults who were found to have paroxysmal atrial fibrillation on 14-day continuous ambulatory electrocardiographic monitoring. Exposures The burden of atrial fibrillation was defined as the percentage of analyzable wear time in atrial fibrillation or flutter during the up to 14-day monitoring period. Main Outcomes and Measures Ischemic stroke and other arterial thromboembolic events occurring while patients were not taking anticoagulation were identified through November 2016 using electronic medical records and were validated by manual review. We evaluated the association of the burden of atrial fibrillation with thromboembolism while not taking anticoagulation after adjusting for the Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) or CHA2DS2-VASc stroke risk scores. Results Among 1965 adults with paroxysmal atrial fibrillation, the mean (SD) age was 69 (11.8) years, 880 (45%) were women, 496 (25%) were persons of color, the median ATRIA stroke risk score was 4 (interquartile range [IQR], 2-7), and the median CHA2DS2-VASc score was 3 (IQR, 1-4). The median burden of atrial fibrillation was 4.4% (IQR ,1.1%-17.23%). Patients with a higher burden of atrial fibrillation were less likely to be women or of Hispanic ethnicity, but had more prior cardioversion attempts compared with those who had a lower burden. After adjusting for either ATRIA or CHA2DS2-VASc stroke risk scores, the highest tertile of atrial fibrillation burden (≥11.4%) was associated with a more than 3-fold higher adjusted rate of thromboembolism while not taking anticoagulants (adjusted hazard ratios, 3.13 [95% CI, 1.50-6.56] and 3.16 [95% CI, 1.51-6.62], respectively) compared with the combined lower 2 tertiles of atrial fibrillation burden. Results were consistent across demographic and clinical subgroups. Conclusions and Relevance A greater burden of atrial fibrillation is associated with a higher risk of ischemic stroke independent of known stroke risk factors in adults with paroxysmal atrial fibrillation.
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Affiliation(s)
- Alan S Go
- Division of Research, Kaiser Permanente Northern California, Oakland.,Departments of Epidemiology, Biostatistics and Medicine, University of California-San Francisco, San Francisco.,Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California
| | - Kristi Reynolds
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Jingrong Yang
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Nigel Gupta
- Department of Cardiac Electrophysiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California
| | | | - Sue Hee Sung
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Teresa N Harrison
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Taylor I Liu
- Department of Cardiac Electrophysiology, Kaiser Permanente Santa Clara Medical Center, Santa Clara, California
| | - Matthew D Solomon
- Division of Research, Kaiser Permanente Northern California, Oakland.,Department of Cardiology, Kaiser Permanente Oakland Medical Center, Oakland, California
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AlTurki A, Marafi M, Russo V, Proietti R, Essebag V. Subclinical Atrial Fibrillation and Risk of Stroke: Past, Present and Future. ACTA ACUST UNITED AC 2019; 55:medicina55100611. [PMID: 31547078 PMCID: PMC6843329 DOI: 10.3390/medicina55100611] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 08/24/2019] [Accepted: 09/17/2019] [Indexed: 12/12/2022]
Abstract
Subclinical atrial fibrillation (SCAF) describes asymptomatic episodes of atrial fibrillation (AF) that are detected by cardiac implantable electronic devices (CIED). The increased utilization of CIEDs renders our understanding of SCAF important to clinical practice. Furthermore, 20% of AF present initially as a stroke event and prolonged cardiac monitoring of stroke patients is likely to uncover a significant prevalence of SCAF. New evidence has shown that implanting cardiac monitors into patients with no history of atrial fibrillation but with risk factors for stroke will yield an incidence of SCAF approaching 30–40% at around three years. Atrial high rate episodes lasting longer than five minutes are likely to represent SCAF. SCAF has been associated with an increased risk of stroke that is particularly significant when episodes of SCAF are greater than 23 h in duration. Longer episodes of SCAF are incrementally more likely to progress to episodes of SCAF >23 h as time progresses. While only around 30–40% of SCAF events are temporally related to stroke events, the presence of SCAF likely represents an important risk marker for stroke. Ongoing trials of anticoagulation in patients with SCAF durations less than 24 h will inform clinical practice and are highly anticipated. Further studies are needed to clarify the association between SCAF and clinical outcomes as well as the factors that modify this association.
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Affiliation(s)
- Ahmed AlTurki
- Division of Cardiology, McGill University Health Center, Montreal, QC H3G1A4, Canada.
| | - Mariam Marafi
- Department of Neurology and Neurosurgery, Montreal Neurological Institute, Montreal, QC H3A2B4, Canada.
| | - Vincenzo Russo
- Depatment of Medical Translational Sciences, University of Campania "Luigi Vanvitelli"-Monaldi Hospital, 80131 Naples, Italy.
| | - Riccardo Proietti
- Department of Cardiac, Thoracic, and Vascular Sciences, University of Padua, 35121 Padua, Italy.
| | - Vidal Essebag
- Division of Cardiology, McGill University Health Center, Montreal, QC H3G1A4, Canada.
- Hôspital Sacré-Coeur de Montréal, Montreal, QC H4J1C5, Canada.
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Xu C, Chen K, Yu F, Wang Q, Su H, Yang D, Xu J, Yan J. Atrial Dyssynchrony: A New Predictor for Atrial High-Rate Episodes in Patients with Cardiac Resynchronization Therapy. Cardiology 2019; 144:18-26. [DOI: 10.1159/000502541] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 08/06/2019] [Indexed: 11/19/2022]
Abstract
Background: Heart failure may induce atrial dyssynchrony. We aim to investigate whether preimplantation left atrial (LA) dyssynchrony could predict newly detected atrial high-rate episodes (AHRE) after receiving cardiac resynchronization therapy defibrillator (CRT-D). Methods: We conducted a retrospective analysis of consecutive patients who received CRT-D for standard indications and without a history of atrial fibrillation. The standard deviation of the time-to-peak strain in each LA segment during ventricular systole (SDs) and late diastole (SDa) were calculated to quantify LA dyssynchrony using two-dimensional speckle tracking echocardiography before device implantation. Patients were divided into the AHRE group and the AHRE-free group, depending on the presence of AHRE during device interrogation. Results: Thirty-one patients (28%) had newly detected AHRE during a mean follow-up of 21 ± 9 months. Patients in the AHRE group had higher SDs (8.2 ± 2.6% vs. 6.3 ± 2.3%, p < 0.001) and SDa (5.4 ± 1.8% vs. 4.1 ± 1.4%, p < 0.001) values before implantation than patients in the AHRE-free group. In the multivariate logistic analysis, both SDs (OR 1.325, 95% CI: 1.074–1.636, p =0.009) and SDa (OR: 1.499, 95% CI: 1.071–2.098, p= 0.018) were independent predictors of newly detected AHRE. At a cutoff value of 7.4% for SDs and 5.3% for SDa, the Kaplan-Meier survival analysis showed that patients with higher SDs and SDa had significantly increased risks of newly detected AHRE after receiving CRT-D. Conclusions: Dyssynchronous LA lengthening and contraction could assist in the prediction of newly detected AHRE in patients with CRT-D.
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Shiyovich A, Axelrod M, Gilutz H, Plakht Y. Early Versus Late New-Onset Atrial Fibrillation in Acute Myocardial Infarction: Differences in Clinical Characteristics and Predictors. Angiology 2019; 70:921-928. [DOI: 10.1177/0003319719867542] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
New-onset atrial fibrillation (NOAF) during acute myocardial infarction (AMI) has significant consequences but is often misdiagnosed. The aim of the study was to evaluate predictors of NOAF throughout different phases of AMI. Patients with AMI admitted to a tertiary medical center were analyzed. Exclusion criteria were preexisting AF, AMI onset ≥24 hours prior to admission, in-hospital death, significant valvular disease, and in-hospital coronary artery bypass graft. Study population were AMI without-NOAF, early-AF (AF terminated within 24 hours of admission), and late-AF (beyond the first 24 hours). Overall 5946 patients were included, age: 64.8 ±14.8 years; 30% women. The incidence of NOAF was 4.6%: 1.6% early-AF, and 3% late-AF. Patients with NOAF comprised greater rate of women, cardiovascular risk-factors burden, severe left ventricular-dysfunction, pulmonary hypertension, valvular disorders, and left atrial enlargement compared with patients without-NOAF. Non-ST-elevation myocardial infarction and inferior-ST-elevation myocardial infarction (STEMI) were significantly more prevalent among early-AF group, while anterior-STEMI, in late-AF. The final multivariate models showed c-statistics of 0.73 and 0.76 for the prediction of new-onset early-AF and late-AF, respectively. In conclusion, there are different clinical predictors of early- versus late-NOAF. The study points out “high risk” AMI population for more meticulous heart rate monitoring for NOAF.
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Affiliation(s)
- Arthur Shiyovich
- Department of Cardiology, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, and “Sackler” Faculty of Medicine, Tel-Aviv University Israel, Tel Aviv-Yafo, Israel
| | - Michal Axelrod
- Goldman Medical School, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Harel Gilutz
- Goldman Medical School, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Ygal Plakht
- Goldman Medical School, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- Department of Nursing, Faculty of Health Sciences, Ben-Gurion University of the Negev, and Soroka University Medical Center, Beer-Sheva, Israel
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Smietana J, Plitt A, Halperin JL. Thromboembolism in the Absence of Atrial Fibrillation. Am J Cardiol 2019; 124:303-311. [PMID: 31060729 DOI: 10.1016/j.amjcard.2019.04.027] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 03/30/2019] [Accepted: 04/04/2019] [Indexed: 11/15/2022]
Abstract
Atrial fibrillation (AF) is associated with thrombus formation in the left atrial appendage and systemic embolic events including ischemic stroke. Cardiogenic thromboembolism can also occur in the absence of clinical AF as a result of various pathological conditions affecting the endocardium. The inconsistent temporal relation between AF and ischemic events has stimulated exploration for factors other than clinical AF that contribute to thromboembolism. These include subclinical AF, a thrombogenic atrial cardiomyopathy, and left atrial appendage dysfunction and embolism from other sources. In conclusion, thromboembolism during normal sinus rhythm is likely multifactorial, involving intertwined pathologic processes. Patients at risk, if accurately identified, could theoretically benefit from anticoagulation.
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Affiliation(s)
- Jeffrey Smietana
- The Cardiovascular Institute, Mount Sinai Medical Center, New York, New York
| | - Anna Plitt
- The Cardiovascular Institute, Mount Sinai Medical Center, New York, New York
| | - Jonathan L Halperin
- The Cardiovascular Institute, Mount Sinai Medical Center, New York, New York.
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Reiffel JA, Verma A, Kowey PR, Halperin JL, Gersh BJ, Wachter R, Pouliot E, Ziegler PD. Incidence of Previously Undiagnosed Atrial Fibrillation Using Insertable Cardiac Monitors in a High-Risk Population: The REVEAL AF Study. JAMA Cardiol 2019; 2:1120-1127. [PMID: 28842973 DOI: 10.1001/jamacardio.2017.3180] [Citation(s) in RCA: 187] [Impact Index Per Article: 37.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Importance In approximately 20% of atrial fibrillation (AF)-related ischemic strokes, stroke is the first clinical manifestation of AF. Strategies are needed to identify and therapeutically address previously undetected AF. Objective To quantify the incidence of AF in patients at high risk for but without previously known AF using an insertable cardiac monitor. Design, Setting, and Participants This prospective, single-arm, multicenter study was conducted from November 2012 to January 2017. Visits took place at 57 centers in the United States and Europe. Patients with a CHADS2 score of 3 or greater (or 2 with at least 1 additional risk factor) were enrolled. Approximately 90% had nonspecific symptoms potentially compatible with AF, such as fatigue, dyspnea, and/or palpitations. Exposures Patients underwent monitoring with an insertable cardiac monitor for 18 to 30 months. Main Outcomes and Measures The primary end point was adjudicated AF lasting 6 or more minutes and was assessed at 18 months. Other analyses included detection rates at points from 30 days to 30 months and among CHADS2 score subgroups. Median time from insertion to detection and the percentage of patients subsequently prescribed oral anticoagulation therapy was also determined. Results A total of 446 patients were enrolled; 233 (52.2%) were male, and the mean (SD) age was 71.5 (9.9) years. A total of 385 patients (86.3%) received an insertable cardiac monitor, met the primary analysis cohort definition, and were observed for a mean (SD) period of 22.5 (7.7) months. The detection rate of AF lasting 6 or more minutes at 18 months was 29.3%. Detection rates at 30 days and 6, 12, 24, and 30 months were 6.2%, 20.4%, 27.1%, 33.6%, and 40.0%, respectively. At 18 months, AF incidence was similar among patients with CHADS2 scores of 2 (24.7%; 95% CI, 17.3-31.4), 3 (32.7%; 95% CI, 23.8-40.7), and 4 or greater (31.7%; 95% CI, 22.0-40.3) (P = .23). Median (interquartile) time from device insertion to first AF episode detection was 123 (41-330) days. Of patients meeting the primary end point, 13 (10.2%) had 1 or more episodes lasting 24 hours or longer, and oral anticoagulation therapy was prescribed for 72 patients (56.3%). Conclusions and Relevance The incidence of previously undiagnosed AF may be substantial in patients with risk factors for AF and stroke. Atrial fibrillation would have gone undetected in most patients had monitoring been limited to 30 days. Further trials regarding the value of detecting subclinical AF and of prophylactic therapies are warranted. Trial Registration clinicaltrials.gov Identifier: NCT01727297.
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Affiliation(s)
- James A Reiffel
- Columbia University College of Physicians and Surgeons, New York, New York
| | - Atul Verma
- Southlake Regional Health Centre, Newmarket, Ontario, Canada
| | - Peter R Kowey
- Lankenau Institute for Medical Research, Wynnewood, Pennsylvania
| | | | | | - Rolf Wachter
- Clinic for Cardiology and Pneumology, University Medicine Göttingen, Göttingen, Germany
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39
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Affiliation(s)
- Kazem Rahimi
- The George Institute for Global Health, University of Oxford, Oxford, UK
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40
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Miyazawa K, Pastori D, Li YG, Székely O, Shahid F, Boriani G, Lip GYH. Atrial high rate episodes in patients with cardiac implantable electronic devices: implications for clinical outcomes. Clin Res Cardiol 2019; 108:1034-1041. [PMID: 30759274 PMCID: PMC6694071 DOI: 10.1007/s00392-019-01432-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 02/04/2019] [Indexed: 01/02/2023]
Abstract
Background Atrial high rate episodes (AHREs) detected by cardiac implantable electronic devices (CIEDs) are associated with an increased risk of stroke. However, the impact of AHRE on improving stroke risk stratification scheme remains uncertain. Objective The purpose of this study was to assess the impact of AHRE on prognosis in relation with cardiovascular events and risk stratification. Methods A total of 856 consecutive patients who had dual-chamber CIEDs implanted were retrospectively analyzed. To detect AHREs, they were monitored for 6 months after CIEDs’ implantation and were followed for a mean of 4.0 years for clinical outcomes such as thromboembolism or death. Results Overall, 125 (14.6%) of patients developed AHREs within the first 6 months (median age 72.0 years, 39.3% female). Patients with AHREs had a high rate of thromboembolism (2.6%/year) and mortality (3.0%/year). On multivariate analysis, AHRE was significantly associated with increased risk of thromboembolism [hazard ratio (HR) 3.40; 95% confidence interval (CI) 1.38–8.37, P = 0.01] and death (HR 3.47; 95% CI 1.51–7.95; P < 0.01). The predictive abilities of the CHADS2 and CHA2DS2-VASc scores were modest, with no significant improvements by adding AHRE to those scores. However, the integrated discrimination improvement and net reclassification improvement showed that the addition of AHRE to the CHADS2 and CHA2DS2-VASc scores statistically improved their predictive ability for the composite outcome. Conclusions AHRE was an independent factor associated with increased risk of clinical outcomes. The addition of AHRE to the clinical risk scores significantly improved discrimination for thromboembolism or death. Electronic supplementary material The online version of this article (10.1007/s00392-019-01432-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kazuo Miyazawa
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Daniele Pastori
- Department of Internal Medicine and Medical Specialties, I Clinica Medica, Atherothrombosis Center, Sapienza University of Rome, Rome, Italy
| | - Yan-Guang Li
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
- Department of Cardiology, Chinese PLA Medical School, Chinese PLA General Hospital, Beijing, China
| | - Orsolya Székely
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Farhan Shahid
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK.
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, UK.
- Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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Döring M, Richter S, Knopp H, Hindricks G. [Telemonitoring of implanted cardiac devices : Clinical necessity or senseless luxury?]. Herzschrittmacherther Elektrophysiol 2018; 29:383-392. [PMID: 30306305 DOI: 10.1007/s00399-018-0599-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 09/12/2018] [Indexed: 05/13/2023]
Abstract
In addition to the telemedical follow-up at a fixed point in time, there is the possibility of a close-meshed telemetric monitoring in modern devices. By transferring device and patient-specific data, errors in the integrity of the device or electrodes and cardiac arrhythmias can be detected early, in various studies significantly reducing the number of outpatient or inpatient visits and the rate of inadequate implantable cardioverter-defibrillator (ICD) therapies. Measurement of various surrogate parameters allows better clinical assessment of heart failure patients, yet no improvement in outcome with therapy guided by telemetric data has been demonstrated. Retrospective analyzes, a prospective randomized study, and various meta-analyzes identified a reduction in all-cause mortality through the use of remote monitoring. This effect is mainly due to monitoring as closely as possible, timely examination of the findings, accordingly early interventions and specification of clear therapeutic regimens in certain clinical scenarios. Such comprehensive patient care requires the creation of telemonitoring centers with appropriate structural and personal equipment, whereby the creation of such structures has not yet been remunerated in the German healthcare system. In this paper, an overview of remote monitoring and identify possibilities and limitations of device-based telemedical monitoring is provided.
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Affiliation(s)
- Michael Döring
- Abteilung für Rhythmologie, Herzzentrum Leipzig, Strümpellstr. 39, 04289, Leipzig, Deutschland.
| | - Sergio Richter
- Abteilung für Rhythmologie, Herzzentrum Leipzig, Strümpellstr. 39, 04289, Leipzig, Deutschland
| | - Helge Knopp
- Abteilung für Rhythmologie, Herzzentrum Leipzig, Strümpellstr. 39, 04289, Leipzig, Deutschland
| | - Gerhard Hindricks
- Abteilung für Rhythmologie, Herzzentrum Leipzig, Strümpellstr. 39, 04289, Leipzig, Deutschland
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Gherasim L. Subclinical Atrial Fibrillation, Embolic Risk, and Anticoagulant Treatment. MAEDICA 2018; 13:261-265. [PMID: 30774723 PMCID: PMC6362888 DOI: 10.26574/maedica.2018.13.4.261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Professor Leonida Gherasim, MD, PhD, is a member of the Romanian Academy. We invited him to write the editorial review for this issue. The subject - how to treat the silent atrial fibrillation (that fibrillation discovered only by devices) and take the decision to anti coagulate or not - is a very important clinical judgement. Professor Gherasim was the editor of several editions of the Romanian Handbook of Internal Medicine - the Romanian equivalent of Harrison's, or Cecil and Loeb's Handbooks. He remains one of the most outstanding professors of internal medicine in Romania. In 2019, professor Leonida Gherasim will be 90 years old. Prof. Mircea Cinteza Chief Editor, MAEDICA J Clin Med.
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Affiliation(s)
- Leonida Gherasim
- Honorary Member of the Romanian Academy Professor, "Carol Davila" University of Medicine and Pharmacy, Senior consultant, Emergency University Hospital, Bucharest, Romania
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Okada M, Kashiwase K, Hirata A, Takeda Y, Amiya R, Ueda Y, Higuchi Y, Yasumura Y. Clinical Influence and Predictors of Pacing-Induced Mechanical Asynchrony in Patients with Normal Cardiac Function with Ventricular Lead Placed in Non-Apical Position. Int Heart J 2018; 59:1275-1287. [PMID: 30393263 DOI: 10.1536/ihj.17-672] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Right ventricular apical (RVA) pacing often causes left ventricular (LV) mechanical asynchrony, which is enhanced by impaired cardiac contraction and intrinsic conduction abnormality. However, data on patients with normal cardiac function and under RV non-apical (non-RVA) pacing are limited.We retrospectively investigated 97 consecutive patients with normal ejection fraction who received pacemaker implantation for atrioventricular block with the ventricular lead placed in a non-RVA position. We defined mechanical asynchrony as discoordinate contraction between opposing regions of the LV wall evaluated by echocardiography. Asynchrony was detected in 9 (9%) patients at baseline and in 38 (39%) under non-RVA pacing (P < 0.001). Asynchrony at baseline was significantly associated with complete left bundle branch block (CLBBB) [odds ratio (OR) = 20.8, P < 0.001]. Asynchrony under non-RVA pacing was significantly associated with left anterior fascicular block (LAFB) (OR = 7.14, P < 0.001) and CLBBB (OR = 13.3, P = 0.002) at baseline. New occurrence of asynchrony was significantly associated with LAFB at baseline (OR = 5.88, P = 0.001). During a median follow-up period of 4.8 years, the incidence of device-detected atrial fibrillation (AF) was more frequent in patients who developed asynchrony than in those who did not (53.3% versus 27.5%, hazard ratio = 2.17, 95% confidence interval = 1.02-4.61, P = 0.03).In patients with normal cardiac function, LAFB at baseline was significantly associated with new occurrence of mechanical asynchrony under non-RVA pacing. Abnormal contraction had a significant influence on the incidence of device-detected AF.
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Affiliation(s)
| | | | - Akio Hirata
- Cardiovascular Division, Osaka Police Hospital
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The Importance and Future of Population Screening for Atrial Fibrillation. Can J Cardiol 2018; 34:1407-1411. [DOI: 10.1016/j.cjca.2018.08.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 08/09/2018] [Accepted: 08/09/2018] [Indexed: 01/16/2023] Open
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Lip GY, Banerjee A, Boriani G, Chiang CE, Fargo R, Freedman B, Lane DA, Ruff CT, Turakhia M, Werring D, Patel S, Moores L. Antithrombotic Therapy for Atrial Fibrillation. Chest 2018; 154:1121-1201. [DOI: 10.1016/j.chest.2018.07.040] [Citation(s) in RCA: 481] [Impact Index Per Article: 80.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 07/11/2018] [Accepted: 07/24/2018] [Indexed: 02/08/2023] Open
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Mairesse GH, Moran P, Van Gelder IC, Elsner C, Rosenqvist M, Mant J, Banerjee A, Gorenek B, Brachmann J, Varma N, Glotz de Lima G, Kalman J, Claes N, Lobban T, Lane D, Lip GYH, Boriani G. Screening for atrial fibrillation: a European Heart Rhythm Association (EHRA) consensus document endorsed by the Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulación Cardíaca y Electrofisiología (SOLAECE). Europace 2018; 19:1589-1623. [PMID: 29048522 DOI: 10.1093/europace/eux177] [Citation(s) in RCA: 182] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 05/06/2017] [Indexed: 01/21/2023] Open
Affiliation(s)
- Georges H Mairesse
- Department of Cardiology, Cliniques du Sud-Luxembourg, 137 rue des déportés, B6700 Arlon, Belgium
| | - Patrick Moran
- Health Information and Quality Authority, George's Lane, Dublin 7, D07 E98Y, Ireland
| | - Isabelle C Van Gelder
- University of Groningen, University Medical Center Groningen, Hanzeplein 1, Groningen, 9713 GZ, The Netherlands
| | - Christian Elsner
- University Clinic Of Schleswig Holstein, Maria Goeppert Strasse 7a-b, Luebeck, 23538, Germany
| | | | - Jonathan Mant
- Primary Care Unit, University of Cambridge, Strangeways Research Laboratory, Wort's Causeway, Cambridge, CB1 8RN, United Kingdom
| | - Amitava Banerjee
- University College London, Farr Institute of Health Informatics Research, 222 Euston Road, London, West Midlands NW1 2DA, United Kingdom
| | - Bulent Gorenek
- Eskisehir Osmangazi University, ESOGÜ Meselik Yerleskesi, 26480 ESKISEHIR, Turkey
| | - Johannes Brachmann
- Klinikum Coburg, Chefarzt der II. Medizinischen Klinik, Ketschendorfer Str. 33, Coburg, DE-96450, Germany
| | - Niraj Varma
- Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, Ohio 44195, USA
| | - Gustavo Glotz de Lima
- Instituto de Cardiologia do RS / FUC, Eletrofisiologia Dept., Av. Princesa Isabel 370, Porto Alegre, 90620-001, Brazil
| | - Jonathan Kalman
- The Royal Melbourne Hospital, Melbourne Heart Center, Royal Parade Suite 1, Parkville, Victoria, 3050, Australia
| | - Neree Claes
- University of Hasselt, Patient Safety in General Practice and Hospitals, Diepenbeek, Belgium, Antwerp Management School, Clinical Leadership, Antwerp, Belgium
| | - Trudie Lobban
- Arrhythmia Alliance & AF Association, Unit 6B, Essex House, Cromwell Business Park, Chipping Norton, Oxfordshire OX7 5SR, UK
| | - Deirdre Lane
- Institute of Cardiovascular Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, United Kingdom; and Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Fredrik Bajers Vej 5, 9100 Aalborg, Denmark
| | - Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, United Kingdom; and Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Fredrik Bajers Vej 5, 9100 Aalborg, Denmark
| | - Giuseppe Boriani
- Cardiology Division, Department of Diagnostics, Clinical and Public Health Medicine, University of Modena and Reggio Emilia, Policlinico di Modena, Largo del Pozzo, 71, 41125 Modena, Italy
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Icen YK, Koc AS. Silent ischemic brain lesions detected by multi-slice computed tomography are associated with subclinical atrial fibrillation in patients with cardiac resynchronization therapy. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2018; 14:285-290. [PMID: 30302105 PMCID: PMC6173091 DOI: 10.5114/aic.2018.78332] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 06/17/2018] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION There is insufficient research on the relationship between subclinical atrial fibrillation (SCAF) and silent ischemic brain lesions (IBLs). AIM To investigate the relationship between SCAF and silent IBLs in patients with cardiac resynchronization therapy (CRT). MATERIAL AND METHODS Of 720 CRT implanted patients in our department between 2012 and 2018, 121 patients who underwent elective cranial multi-slice computed tomography (MSCT) during their follow-up were included in our study. Atrial high-rate episodes (AHRE) were detected by the CRT device. Subclinical atrial fibrillation was defined as asymptomatic AHRE longer than 6 min and shorter than 24 h. A cranial MSCT scan was performed using a 128-section scanner with contiguous 2-5 mm axial images. Patients were divided into two groups - with and without silent IBL. RESULTS Silent IBLs were detected in 21 (17.4%) of 121 patients with CRT. Ischemic brain lesion presence was found to be associated with age, CHA2DS2-VASc score, left ventricular (LV) ejection fraction (EF), hypertension and SCAF in univariate analysis (p < 0.05). In multivariate regression analysis, presence of SCAF and LVEF were found to be independent parameters predicting the risk of silent IBLs. According to this analysis, the presence of SCAF and every 1% decrease in LVEF were found to increase the risk of silent IBL by 3.5 times and 14.8%, respectively. CONCLUSIONS Subclinical atrial fibrillation is independently associated with silent IBL presence. Patients with CRT should be closely monitored for SCAF. Patients diagnosed with SCAF should be evaluated for IBL development and treated with the appropriate oral anticoagulant.
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Affiliation(s)
- Yahya Kemal Icen
- Department of Cardiology, Adana Health Practices and Research Center, Health Sciences University, Adana, Turkey
| | - Ayse Selcan Koc
- Department of Radiology, Adana Health Practices and Research Center, University of Health Sciences, Adana, Turkey
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Sanna T. Long-term monitoring to detect atrial fibrillation with the indwelling implantable cardiac monitors. Int J Stroke 2018; 13:893-904. [PMID: 30091680 DOI: 10.1177/1747493018790023] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
An increasing number of detection tools are available and several detection strategies have been described to pursue the diagnosis of atrial fibrillation to prevent ischemic stroke. Monitoring tools include standard electrocardiography, snapshot single-lead recordings with professional or personal devices (e.g. smartphone-based), Holter monitor, external devices with long-term recording capabilities, and cardiac implantable electronic devices, including pacemakers, implantable cardioverter defibrillators and insertable cardiac monitors. Insertable cardiac monitors have shown high sensitivity and specificity for the detection of atrial fibrillation, allow up to three years of continuous monitoring, do not require cooperation of the patient, are well tolerated, have a short device-related time delay between detection of atrial fibrillation and notification to the physician, provide information on atrial fibrillation burden and are minimally invasive. On the other hand, insertable cardiac monitors require a considerable use of resources to process the recordings and have a significant initial cost. Studies conducted with insertable cardiac monitors on patients with prior stroke and on patients with risk factors for stroke but no prior cerebrovascular events or atrial fibrillation have consistently shown a measurable incidence of atrial fibrillation at follow-up. However, the effectiveness of oral anticoagulations in reducing the incidence of ischemic stroke in patients with atrial fibrillation lasting less than 24 h, though reasonable, is currently unproven. The future of atrial fibrillation detection tools and atrial fibrillation detection strategies will be influenced by ongoing studies exploring whether oral anticoagulations reduce the incidence of stroke in patients with atrial fibrillation burden lower than 24 h.
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Yang Y, Xu F, Tong J, Cai L, Jiang W, Sheng X, Pan Y, Jiang J, Zhang J, Jiang D, Zhao L, Fu G. Rationale and Design of the Evaluation of Oral Anticoagulation for Reduction of Thrombo-embolism in Chinese Patients with Device-Detected Subclinical Atrial Fibrillation (ART-CAF) Trial: an Open-Label Registry-Based Clinical Trial. Cardiovasc Drugs Ther 2018; 32:389-396. [PMID: 30027309 DOI: 10.1007/s10557-018-6807-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE Subclinical atrial fibrillation (AF) was found in a large number of pacemaker patients. It is not certain whether there is a similar risk/benefit ratio for oral anticoagulation in patients with subclinical AF compared to patients with similar risk profiles and clinically diagnosed AF. Given the weakness of clinical evidence for oral anticoagulation in patients with device-detected subclinical AF, specific recommendations in most guidelines for this population are scarce and rarely similar. METHODS ART-CAF trial was primarily designed to evaluate the efficacy and safety of oral anticoagulant agent use in patients with device-detected subclinical AF at the approved dosage to prevent stroke and systemic arterial embolism. It is an open-label, registry-based, prospective, multicenter, cohort study, recruiting patients with subclinical AF first detected by a pacemaker, implantable cardioverter-defibrillator, or insertable cardiac monitor after device implantation for more than 3 months. The primary outcome is a composite of ischemic stroke and systemic arterial embolism. The primary safety outcome is the occurrence of clinically overt major bleeding. Approximately 750 patients will be needed to be enrolled to the two treatment groups in a 1:1 ratio until 66 primary efficacy outcomes are observed. The anticipated follow-up period is approximately 70 months from the enrollment of the first patient. CONCLUSIONS ART-CAF evaluates the feasibility of selecting high-risk patients suitable for anticoagulation by AF burden combined with CHA2DS2-VASc score after pacemaker implantation and aims to select patients who could benefit from anticoagulation. TRIAL REGISTRATION http://www.chictr.org.cn/index.aspx ChiCTR1800016221.
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Affiliation(s)
- Ying Yang
- Department of Cardiology, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, No. 3 Qingchun East Road, Hangzhou, 310016, Zhejiang, China.
| | - Fen Xu
- Department of Cardiology, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, No. 3 Qingchun East Road, Hangzhou, 310016, Zhejiang, China
| | - Jinshan Tong
- Department of Cardiology, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, No. 3 Qingchun East Road, Hangzhou, 310016, Zhejiang, China
| | - Leyan Cai
- Deqing County PPL Hospital, Huzhou, Zhejiang, China
| | - Wenbing Jiang
- Department of Cardiology, Wenzhou People's Hospital, Wenzhou, Zhejiang, China
| | - Xia Sheng
- Department of Cardiology, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, No. 3 Qingchun East Road, Hangzhou, 310016, Zhejiang, China
| | - Yiwen Pan
- Department of Cardiology, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, No. 3 Qingchun East Road, Hangzhou, 310016, Zhejiang, China
| | - Jiangfen Jiang
- Department of Cardiology, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, No. 3 Qingchun East Road, Hangzhou, 310016, Zhejiang, China
| | - Jiefang Zhang
- Department of Cardiology, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, No. 3 Qingchun East Road, Hangzhou, 310016, Zhejiang, China
| | - Dongmei Jiang
- Department of Cardiology, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, No. 3 Qingchun East Road, Hangzhou, 310016, Zhejiang, China
| | - Linlin Zhao
- Department of Cardiology, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, No. 3 Qingchun East Road, Hangzhou, 310016, Zhejiang, China
| | - Guosheng Fu
- Department of Cardiology, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, No. 3 Qingchun East Road, Hangzhou, 310016, Zhejiang, China.
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Terricabras M, Verma A, Morillo CA. Measuring Success in Ablation of Atrial Fibrillation. Circ Arrhythm Electrophysiol 2018; 11:e006582. [DOI: 10.1161/circep.118.006582] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Maria Terricabras
- Southlake Regional Health Centre, Newmarket, ON, Canada (M.T., A.V.)
- Department of Surgery, University of Toronto, ON, Canada (M.T., A.V.)
| | - Atul Verma
- Southlake Regional Health Centre, Newmarket, ON, Canada (M.T., A.V.)
- Department of Surgery, University of Toronto, ON, Canada (M.T., A.V.)
| | - Carlos A. Morillo
- Foothills Medical Centre and Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Canada (C.A.M.)
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