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Gonzalo A, Augustin CM, Bifulco SF, Telle Å, Chahine Y, Kassar A, Guerrero-Hurtado M, Durán E, Martínez-Legazpi P, Flores O, Bermejo J, Plank G, Akoum N, Boyle PM, Del Alamo JC. Patient-specific multi-physics simulations of fibrotic changes in left atrial tissue mechanics impact on hemodynamics. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.05.29.596526. [PMID: 38853952 PMCID: PMC11160719 DOI: 10.1101/2024.05.29.596526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2024]
Abstract
Stroke is a leading cause of death and disability worldwide. Atrial myopathy, including fibrosis, is associated with an increased risk of ischemic stroke, but the mechanisms underlying this association are poorly understood. Fibrosis modifies myocardial structure, impairing electrical propagation and tissue biomechanics, and creating stagnant flow regions where clots could form. Fibrosis can be mapped non-invasively using late gadolinium enhancement magnetic resonance imaging (LGE-MRI). However, fibrosis maps are not currently incorporated into stroke risk calculations or computational electro-mechano-fluidic models. We present multi-physics simulations of left atrial (LA) myocardial motion and hemodynamics using patient-specific anatomies and fibrotic maps from LGE-MRI. We modify tissue stiffness and active tension generation in fibrotic regions and investigate how these changes affect LA flow for different fibrotic burdens. We find that fibrotic regions and, to a lesser extent, non-fibrotic regions experience reduced myocardial strain, resulting in decreased LA emptying fraction consistent with clinical observations. Both fibrotic tissue stiffening and hypocontractility independently reduce LA function, but together, these two alterations cause more pronounced effects than either one alone. Fibrosis significantly alters flow patterns throughout the atrial chamber, and particularly, the filling and emptying jets of the left atrial appendage (LAA). The effects of fibrosis in LA flow are largely captured by the concomitant changes in LA emptying fraction except inside the LAA, where a multi-factorial behavior is observed. This work illustrates how high-fidelity, multi-physics models can be used to study thrombogenesis mechanisms in a patient-specific manner, shedding light onto the link between atrial fibrosis and ischemic stroke. Key points Left atrial (LA) fibrosis is associated with arrhythmogenesis and increased risk of ischemic stroke; its extent and pattern can be quantified on a patient-specific basis using late gadolinium enhancement magnetic resonance imaging.Current stroke risk prediction tools have limited personalization, and their accuracy could be improvedfib by incorporating patient-specific information like fibrotic maps and hemodynamic patterns.We present the first electro-mechano-fluidic multi-physics computational simulations of LA flow, including fibrosis and anatomies from medical imaging.Mechanical changes in fibrotic tissue impair global LA motion, decreasing LA and left atrial appendage (LAA) emptying fractions, especially in subjects with higher fibrosis burdens.Fibrotic-mediated LA motion impairment alters LA and LAA flow near the endocardium and the whole cavity, ultimately leading to more stagnant blood regions in the LAA.
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Jimenez-Candil J, Hernandez Hernandez J, Cruz Galban A, Blanco F, Moriñigo JL, Sanchez García M, Oterino A, Sanchez PL. Clinical and economic outcomes of a systematic same-day discharge programme after pulmonary vein isolation: comparison between cryoballoon vs. radiofrequency ablation. Europace 2023; 25:euad265. [PMID: 37669318 PMCID: PMC10498138 DOI: 10.1093/europace/euad265] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 08/28/2023] [Indexed: 09/07/2023] Open
Abstract
AIMS Same-day discharge (SDD) is feasible after pulmonary vein isolation (PVI). We aim to compare prospectively cryoballoon (CRYO) vs. radiofrequency (RF) ablation in a systematic SDD programme. METHODS AND RESULTS We prospectively analysed the 617 scheduled PVI performed consecutively at our institution (n = 377 CRYO, n = 240 RF) from 1 April 2019 to 31 December 2022 within a systematic programme of SDD. The feasibility of SDD, the 10-day incidence of urgent/unplanned medical care after discharge (UUC-10), and the cost per procedure due to hospital resource use were studied. The 100 procedures performed during the previous year, in which patients were systematically hospitalized, were used as a control group. Same-day discharge was achieved in 585/617 (95%) procedures, with a significant trend towards a higher monthly SDD rate from 2019 to 2022 (P = 0.03). The frequency of SDD was similar in CRYO (356/377; 94%) vs. RF (229/240; 95%). After SDD, the UUC-10 was 66/585 (11.3%), being similar for CRYO (41/356; 11.5%) and RF (25/229; 10.9%); P = 0.8 (log-rank test). Of these, 10 patients were re-hospitalized, with an identical rate in CRYO-treated (6/356; 1.7%) and RF-treated (4/229; 1.7%) patients and owing to similar causes (4 haematomas, 4 pericarditis, and 2 symptomatic sinus node dysfunction). Same-day discharge was associated with an average savings per procedure of 63% (P < 0.001), but no differences were found between the CRYO and RF (P = 0.8). CONCLUSION In a systematic SDD programme, feasibility (95%, increasing over time), safety (11% UUC-10, 1.7% re-hospitalizations), and savings (63% per procedure) were similar for CRYO and RF ablation procedures.
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Affiliation(s)
- Javier Jimenez-Candil
- Servicio de Cardiología, IBSAL-Hospital Universitario, Paseo de San Vicente, 58-182, 37007 Salamanca, Spain
- CIBER-CV
- Universidad de Salamanca, Salamanca, Spain
| | - Jesus Hernandez Hernandez
- Servicio de Cardiología, IBSAL-Hospital Universitario, Paseo de San Vicente, 58-182, 37007 Salamanca, Spain
| | - Alba Cruz Galban
- Servicio de Cardiología, IBSAL-Hospital Universitario, Paseo de San Vicente, 58-182, 37007 Salamanca, Spain
| | - Fabian Blanco
- Servicio de Cardiología, IBSAL-Hospital Universitario, Paseo de San Vicente, 58-182, 37007 Salamanca, Spain
| | - Jose Luis Moriñigo
- Servicio de Cardiología, IBSAL-Hospital Universitario, Paseo de San Vicente, 58-182, 37007 Salamanca, Spain
- Universidad de Salamanca, Salamanca, Spain
| | - Manuel Sanchez García
- Servicio de Cardiología, IBSAL-Hospital Universitario, Paseo de San Vicente, 58-182, 37007 Salamanca, Spain
| | - Armando Oterino
- Servicio de Cardiología, IBSAL-Hospital Universitario, Paseo de San Vicente, 58-182, 37007 Salamanca, Spain
| | - Pedro L Sanchez
- Servicio de Cardiología, IBSAL-Hospital Universitario, Paseo de San Vicente, 58-182, 37007 Salamanca, Spain
- CIBER-CV
- Universidad de Salamanca, Salamanca, Spain
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3
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Börschel CS, Ortega-Alonso A, Havulinna AS, Jousilahti P, Salmi M, Jalkanen S, Veikko S, Niiranen T, Schnabel RB. Inflammatory proteomics profiling for prediction of incident atrial fibrillation. Heart 2023:heartjnl-2022-321959. [PMID: 36801832 DOI: 10.1136/heartjnl-2022-321959] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 02/03/2023] [Indexed: 02/19/2023] Open
Abstract
OBJECTIVE Atrial fibrillation (AF) has emerged as a common condition in older adults. Cardiovascular risk factors only explain about 50% of AF cases. Inflammatory biomarkers may help close this gap as inflammation can alter atrial electrophysiology and structure. This study aimed to determine a cytokine biomarker profile for this condition in the community using a proteomics approach. METHODS This study uses cytokine proteomics in participants of the Finnish population-based FINRISK cohort studies 1997/2002. Risk models for 46 cytokines were developed to predict incident AF using Cox regressions. Furthermore, the association of participants' C reactive protein (CRP) and N-terminal pro B-type natriuretic peptide (NT-proBNP) concentrations with incident AF was examined. RESULTS In 10 744 participants (mean age of 50.9 years, 51.3% women), 1246 cases of incident AF were observed (40.5% women). The main analyses, adjusted for participants' sex and age, suggested that higher concentrations of macrophage inflammatory protein-1β (HR=1.11; 95% CI 1.04, 1.17), hepatocyte growth factor (HR=1.12; 95% CI 1.05, 1.19), CRP (HR=1.17; 95% CI 1.10, 1.24) and NT-proBNP (HR=1.58; 95% CI 1.45, 1.71) were associated with increased risk of incident AF. In further clinical variable-adjusted models, only NT-proBNP remained statistically significant. CONCLUSION Our study confirmed NT-proBNP as a strong predictor for AF. Observed associations of circulating inflammatory cytokines were primarily explained by clinical risk factors and did not improve risk prediction. The potential mechanistic role of inflammatory cytokines measured in a proteomics approach remains to be further elucidated.
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Affiliation(s)
- Christin S Börschel
- Department of Cardiology, University Heart and Vascular Centre Hamburg-Eppendorf, Hamburg, Germany .,German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Alfredo Ortega-Alonso
- Department of Public Health and Welfare, Finnish Institute for Health and Welfare, Helsinki, Finland.,Neuroscience Center, University of Helsinki, Helsinki, Finland.,Faculty of Sport and Health Sciences, University of Jyväskylä, Jyväskylä, Finland
| | - Aki S Havulinna
- Department of Public Health and Welfare, Finnish Institute for Health and Welfare, Helsinki, Finland.,Institute for Molecular Medicine Finland, FIMM - HiLIFE, Helsinki, Finland
| | - Pekka Jousilahti
- Department of Public Health and Welfare, Finnish Institute for Health and Welfare, Helsinki, Finland
| | - Marko Salmi
- MediCity Research Laboratory, Institute of Biomedicine and InFLAMES flagship, Turku, Finland
| | - Sirpa Jalkanen
- MediCity Research Laboratory, Institute of Biomedicine and InFLAMES flagship, Turku, Finland
| | - Salomaa Veikko
- Department of Public Health and Welfare, Finnish Institute for Health and Welfare, Helsinki, Finland
| | - Teemu Niiranen
- Department of Public Health and Welfare, Finnish Institute for Health and Welfare, Helsinki, Finland.,Department of Internal Medicine, University of Turku, Turku, Finland.,Division of Medicine, Turku University Hospital, Turku, Finland
| | - Renate B Schnabel
- Department of Cardiology, University Heart and Vascular Centre Hamburg-Eppendorf, Hamburg, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
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Xie PX, Li YG, Alsheikh-Ali AA, AlMahmeed W, Shehab A, Sulaiman K, Asaad N, Guo LJ, Liu SW, Zubaid M, Lip GYH. Symptom Status, Clinical Subtypes, and Prognosis in Patients With Atrial Fibrillation from the Middle East Region (from the Gulf-SAFE Registry). Am J Cardiol 2022; 169:57-63. [PMID: 35063269 DOI: 10.1016/j.amjcard.2021.12.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 12/20/2021] [Accepted: 12/21/2021] [Indexed: 11/18/2022]
Abstract
Atrial fibrillation (AF) is often asymptomatic. The prognosis of asymptomatic AF is at least similar or worse than symptomatic AF, but there are no such data from Middle East patients with AF. The Gulf-SAFE (Gulf Survey of Atrial Fibrillation Events) registry is a multicenter prospective survey of patients presenting with AF to participate medical institutions in 6 countries in the Gulf region. We investigated the prognostic outcomes of patients with asymptomatic AF in relation to clinical subtypes. A total of 2043 patients with AF were included; 541 were identified as having asymptomatic AF (26.5%) who tended to be older, with higher prevalences of hypertension, heart failure, coronary artery disease, diabetes, stroke, renal dysfunction, chronic obstructive pulmonary disease, and had higher Congestive heart failure, Hypertension, Age ≥75, Stroke (2 points), Congestive heart failure, Hypertension, Age ≥75 (2 points), Diabetes, Stroke (2 points), Vascular disease, Age 65-74, Sex category (CHA2DS2-VASc), and Hypertension, Age ≥65, Stroke, Bleeding history, liable INR, Elderly, Drug or alcohol use (HAS-BLED) scores (all p <0.05). After multivariable adjustment, asymptomatic AF was associated with higher risks of stroke/systematic embolism (SE) (adjusted odds ratio [aOR] 2.18, 95% confidence interval [CI] 1.10 to 4.34), all-cause mortality (aOR 2.85, 95% CI 1.90 to 4.28), and the composite outcome of stroke/SE, bleeding, and all-cause mortality (aOR 1.74, 95% CI 1.26 to 2.41). Patients with asymptomatic AF had fewer admissions for AF (aOR 0.53, 95% CI 0.32 to 0.83) and heart failure (aOR 0.58, 95% CI 0.38 to 0.86). The increased risk of stroke/SE in asymptomatic AF was more prominent among paroxysmal AF subtype (p for interaction = 0.028). In conclusion, in the Gulf-SAFE registry, patients with asymptomatic AF represent a nonbenign entity with worse outcomes compared with symptomatic AF. In paroxysmal AF, the higher risks of events were more prominent. The absence of "warning signs" and lack of timely admission in asymptomatic AF may be major reasons for the unfavorable prognosis.
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Affiliation(s)
- Peng-Xin Xie
- Department of Cardiology, Peking University Third Hospital, Beijing, China
| | - Yan-Guang Li
- Department of Cardiology, Peking University Third Hospital, Beijing, China; Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Alawi A Alsheikh-Ali
- College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, United Arab Emirates
| | - Wael AlMahmeed
- Heart and Vascular Institute, Cleveland Clinic, Abu Dhabi, United Arab Emirates
| | - Abdullah Shehab
- Internal Medicine Department, College of Medicine and Health Sciences (CMHS), UAE University, Al Ain, United Arab Emirates
| | | | - Nidal Asaad
- Cardiology Department, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Li-Jun Guo
- Department of Cardiology, Peking University Third Hospital, Beijing, China
| | - Shu-Wang Liu
- Department of Cardiology, Peking University Third Hospital, Beijing, China
| | - Mohammad Zubaid
- Department of Medicine, Faculty of Medicine, Kuwait University, Kuwait City, Kuwait
| | - Gregory Y H Lip
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom; Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom.
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5
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Siegbahn A, Lindbäck J, Hijazi Z, Åberg M, Alexander JH, Eikelboom JW, Lopes RD, Pol T, Oldgren J, Granger CB, Yusuf S, Wallentin L. Multiplex protein screening of biomarkers associated with major bleeding in patients with atrial fibrillation treated with oral anticoagulation. J Thromb Haemost 2021; 19:2726-2737. [PMID: 34390530 DOI: 10.1111/jth.15498] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 07/27/2021] [Accepted: 08/12/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND Oral anticoagulants (OAC) in patients with atrial fibrillation (AF) prevent thromboembolic events, but are associated with significant risk of bleeding. OBJECTIVES To explore associations between a wide range of biomarkers and bleeding risk in patients with AF on OAC. METHOD Biomarkers were analyzed in a random sample of 4200 patients, 204 cases with major bleedings, from ARISTOTLE. The replication cohort included 344 cases with major bleeding and 1024 random controls from RE-LY. Plasma samples obtained at randomization were analyzed by the Olink Proximity Extension Assay cardiovascular and inflammation panels and conventional immunoassays. The associations between biomarker levels and major bleeding over 1 to 3 years of follow-up were evaluated by random survival forest/Boruta analyses and Cox regression analyses to assess linear associations and hazard ratios for identified biomarkers. RESULTS Out of 268 proteins, nine biomarkers were independently associated with bleeding in both cohorts. In the replication cohort the linear hazard ratios (95% confidence intervals) per interquartile range were for these biomarkers: TNF-R1 1.748 (1.456, 2.098), GDF-15 1.653 (1.377, 1.985), EphB4 1.575 (1.320, 1.880), suPAR 1.548 (1.294, 1.851), OPN 1.476 (1.240, 1.757), OPG 1.397 (1.156, 1.688), TNF-R2 1.360 (1.144,1.616), cTnT-hs 1.232 (1.067, 1.423), and TRAIL-R2 1.202 (1.069, 1.351). CONCLUSIONS In patients with AF on OAC, GDF-15, cTnT-hs, and seven novel biomarkers were independently associated with major bleedings and reflect pathophysiologic processes of inflammation, apoptosis, oxidative stress, vascular calcification, coagulation, and fibrinolysis. Investigations of the utility of these markers to refine risk stratification and guide the management of patients at high risk of bleeding are warranted.
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Affiliation(s)
- Agneta Siegbahn
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
- Department of Medical Sciences, Clinical Chemistry and Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - Johan Lindbäck
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Ziad Hijazi
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
| | - Mikael Åberg
- Department of Medical Sciences, Clinical Chemistry and Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - John H Alexander
- Duke Clinical Research Institute, Duke Health, Durham, North Carolina, USA
| | | | - Renato D Lopes
- Duke Clinical Research Institute, Duke Health, Durham, North Carolina, USA
| | - Tymon Pol
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
| | - Jonas Oldgren
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
| | | | - Salim Yusuf
- Population Health Research Institute, Hamilton, Ontario, Canada
| | - Lars Wallentin
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
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Kaplan AD, Joca HC, Boyman L, Greiser M. Calcium Signaling Silencing in Atrial Fibrillation: Implications for Atrial Sodium Homeostasis. Int J Mol Sci 2021; 22:10513. [PMID: 34638854 PMCID: PMC8508839 DOI: 10.3390/ijms221910513] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 09/14/2021] [Accepted: 09/14/2021] [Indexed: 12/19/2022] Open
Abstract
Atrial fibrillation (AF) is the most common type of cardiac arrhythmia, affecting more than 33 million people worldwide. Despite important advances in therapy, AF's incidence remains high, and treatment often results in recurrence of the arrhythmia. A better understanding of the cellular and molecular changes that (1) trigger AF and (2) occur after the onset of AF will help to identify novel therapeutic targets. Over the past 20 years, a large body of research has shown that intracellular Ca2+ handling is dramatically altered in AF. While some of these changes are arrhythmogenic, other changes counteract cellular arrhythmogenic mechanisms (Calcium Signaling Silencing). The intracellular Na+ concentration ([Na+])i is a key regulator of intracellular Ca2+ handling in cardiac myocytes. Despite its importance in the regulation of intracellular Ca2+ handling, little is known about [Na+]i, its regulation, and how it might be changed in AF. Previous work suggests that there might be increases in the late component of the atrial Na+ current (INa,L) in AF, suggesting that [Na+]i levels might be high in AF. Indeed, a pharmacological blockade of INa,L has been suggested as a treatment for AF. Here, we review calcium signaling silencing and changes in intracellular Na+ homeostasis during AF. We summarize the proposed arrhythmogenic mechanisms associated with increases in INa,L during AF and discuss the evidence from clinical trials that have tested the pharmacological INa,L blocker ranolazine in the treatment of AF.
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Affiliation(s)
- Aaron D. Kaplan
- Center for Biomedical Engineering and Technology, Department of Physiology, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (A.D.K.); (H.C.J.); (L.B.)
- Division of Cardiovascular Medicine, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Humberto C. Joca
- Center for Biomedical Engineering and Technology, Department of Physiology, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (A.D.K.); (H.C.J.); (L.B.)
| | - Liron Boyman
- Center for Biomedical Engineering and Technology, Department of Physiology, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (A.D.K.); (H.C.J.); (L.B.)
| | - Maura Greiser
- Center for Biomedical Engineering and Technology, Department of Physiology, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (A.D.K.); (H.C.J.); (L.B.)
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7
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Sánchez de la Nava AM, Atienza F, Bermejo J, Fernández-Avilés F. Artificial intelligence for a personalized diagnosis and treatment of atrial fibrillation. Am J Physiol Heart Circ Physiol 2021; 320:H1337-H1347. [PMID: 33513086 DOI: 10.1152/ajpheart.00764.2020] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Although atrial fibrillation (AF) is the most common cardiac arrhythmia, its early identification, diagnosis, and treatment is still challenging. Due to its heterogeneous mechanisms and risk factors, targeting an individualized treatment of AF demands a large amount of patient data to identify specific patterns. Artificial intelligence (AI) algorithms are particularly well suited for treating high-dimensional data, predicting outcomes, and eventually, optimizing strategies for patient management. The analysis of large patient samples combining different sources of information such as blood biomarkers, electrical signals, and medical images opens a new paradigm for improving diagnostic algorithms. In this review, we summarize suitable AI techniques for this purpose. In particular, we describe potential applications for understanding the structural and functional bases of the disease, as well as for improving early noninvasive diagnosis, developing more efficient therapies, and predicting long-term clinical outcomes of patients with AF.
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Affiliation(s)
- Ana María Sánchez de la Nava
- Department of Cardiology, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Hospital General Universitario Gregorio Marañón, Madrid, Spain.,CIBERCV, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid, Spain.,Universitat Politècnica de València, València, Spain
| | - Felipe Atienza
- Department of Cardiology, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Hospital General Universitario Gregorio Marañón, Madrid, Spain.,CIBERCV, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid, Spain.,Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Javier Bermejo
- Department of Cardiology, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Hospital General Universitario Gregorio Marañón, Madrid, Spain.,CIBERCV, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid, Spain.,Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Francisco Fernández-Avilés
- Department of Cardiology, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Hospital General Universitario Gregorio Marañón, Madrid, Spain.,CIBERCV, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid, Spain.,Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
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8
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Hijazi Z, Wallentin L, Lindbäck J, Alexander JH, Connolly SJ, Eikelboom JW, Ezekowitz MD, Granger CB, Lopes RD, Pol T, Yusuf S, Oldgren J, Siegbahn A. Screening of Multiple Biomarkers Associated With Ischemic Stroke in Atrial Fibrillation. J Am Heart Assoc 2020; 9:e018984. [PMID: 33292046 PMCID: PMC7955358 DOI: 10.1161/jaha.120.018984] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Background To explore the pathophysiological features of ischemic stroke in patients with atrial fibrillation (AF), we evaluated the association between 268 plasma proteins and subsequent ischemic stroke in 2 large AF cohorts receiving oral anticoagulation. Methods and Results A case-cohort sample of patients with AF from the ARISTOTLE (Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation) trial, including 282 cases with ischemic stroke or systemic embolism and a random sample of 4124 without these events, during 1.9 years of follow-up was used for identification. Validation was provided by a similar case-cohort sample of patients with AF from the RE-LY (Randomized Evaluation of Long-Term Anticoagulation Therapy) trial, including 149 cases with ischemic stroke/systemic embolism and a random sample of 1062 without these events. In plasma obtained before randomization, 268 unique biomarkers were measured with OLINK proximity extension assay panels (CVD II, CVD III, and Inflammation) and conventional immunoassays. The association between biomarkers and outcomes was evaluated by random survival forest and adjusted Cox regression. According to random survival forest or Cox regression analyses, the biomarkers most strongly and consistently associated with ischemic stroke/systemic embolism were matrix metalloproteinase-9, NT-proBNP (N-terminal pro-B-type natriuretic peptide), osteopontin, sortilin, soluble suppression of tumorigenesis 2, and trefoil factor-3. The corresponding hazard ratios (95% CIs) for an interquartile difference were as follows: 1.18 (1.00-1.38), 1.55 (1.28-1.88), 1.28 (1.07-1.53), 1.19 (1.02-1.39), 1.23 (1.05-1.45), and 1.19 (0.97-1.45), respectively. Conclusions In patients with AF, of 268 unique biomarkers, the 6 biomarkers most strongly associated with subsequent ischemic stroke/systemic embolism represent fibrosis/remodeling (matrix metalloproteinase-9 and soluble suppression of tumorigenesis 2), cardiac dysfunction (NT-proBNP), vascular calcification (osteopontin), metabolism (sortilin), and mucosal integrity/ischemia (trefoil factor-3). Registration URL: https://www.clinicaltrials.gov. Unique Identifiers: NCT00412984 and NCT00262600.
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Affiliation(s)
- Ziad Hijazi
- Department of Medical Sciences Cardiology Uppsala University Uppsala Sweden.,Uppsala Clinical Research Center Uppsala University Uppsala Sweden
| | - Lars Wallentin
- Department of Medical Sciences Cardiology Uppsala University Uppsala Sweden.,Uppsala Clinical Research Center Uppsala University Uppsala Sweden
| | - Johan Lindbäck
- Uppsala Clinical Research Center Uppsala University Uppsala Sweden
| | | | | | | | - Michael D Ezekowitz
- Thomas Jefferson University Philadelphia PA.,Cardiovascular Medicine Lankenau Institute for Medical Research Wynnewood PA
| | | | | | - Tymon Pol
- Department of Medical Sciences Cardiology Uppsala University Uppsala Sweden
| | - Salim Yusuf
- Population Health Research Institute Hamilton ON Canada
| | - Jonas Oldgren
- Department of Medical Sciences Cardiology Uppsala University Uppsala Sweden.,Uppsala Clinical Research Center Uppsala University Uppsala Sweden
| | - Agneta Siegbahn
- Uppsala Clinical Research Center Uppsala University Uppsala Sweden.,Department of Medical Sciences Clinical Chemistry and Science for Life Laboratory Uppsala University Uppsala Sweden
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9
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Iroegbu CD, Chen W, Wu X, Cheng L, Zhang H, Wu M, Zhao Y, Liu LM, Yang J. Evaluating the cost-effectiveness of catheter ablation of atrial fibrillation. Cardiovasc Diagn Ther 2020; 10:1200-1215. [PMID: 33224744 DOI: 10.21037/cdt-20-574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background The pursuit of a clearer understanding of the pathogenesis of atrial fibrillation (AFib) and the development of new technology has resulted in a surge of interest in the surgical ablation for AFib. Here, we report our 8-year experience in the surgical treatment and management of AFib alongside, evaluating the cost-effectiveness in southern Mainland China over a 1-year follow-up. Methods Data of 3,068 patients from March 2011 through June 2019 was retrospectively extracted from The Provincial National Cardiac Database of Xiangya Second Hospital. The activities considered (and costs calculated) were outpatient consultations, hospital admissions, and drug treatment. Quality of life (QoL) questionnaires were also carried out to assess whether concomitant AFib correction procedures increase risk in patients, or improve patient's QoL. Results A total of 3,068 patients completed the questionnaires at a minimum of one time-point during the follow-up. The total cost was combined to obtain incremental costs per quality-adjusted life-years (QALYs). The total costs of the AFib catheter ablation group were remarkably higher compared to surgery as usual group. The incremental cost-effectiveness ratio was $76,513,227 (¥542,287,667) per QALY, with an acceptability line graph for cost at 43%. Conclusions AFib is an extraordinarily costly and worrisome public health problem. Precision medicine is vital as it provides a platform for the clinical translation of targeted interventions that are designed to help treat and prevent AFib. Thus, to improve the QoL expectancy outcome(s), both therapeutic and surgical interventions should be aimed at addressing the underlying heart disease rather than restoring sinus rhythm.
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Affiliation(s)
- Chukwuemeka Daniel Iroegbu
- Department of Cardiovascular Surgery, Second Xiangya Hospital, Central South University, Changsha, China
| | - Wangping Chen
- Department of Cardiovascular Surgery, Second Xiangya Hospital, Central South University, Changsha, China
| | - Xun Wu
- Department of Cardiovascular Surgery, Second Xiangya Hospital, Central South University, Changsha, China
| | - Luo Cheng
- Department of Cardiovascular Surgery, Second Xiangya Hospital, Central South University, Changsha, China
| | - Hao Zhang
- Department of Cardiovascular Surgery, Second Xiangya Hospital, Central South University, Changsha, China
| | - Ming Wu
- Department of Cardiovascular Surgery, Second Xiangya Hospital, Central South University, Changsha, China
| | - Yuan Zhao
- Department of Cardiovascular Surgery, Second Xiangya Hospital, Central South University, Changsha, China
| | - Li Ming Liu
- Department of Cardiovascular Surgery, Second Xiangya Hospital, Central South University, Changsha, China
| | - Jinfu Yang
- Department of Cardiovascular Surgery, Second Xiangya Hospital, Central South University, Changsha, China
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10
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Verberne HJ. Atrial 18F-FDG uptake is related to permanent atrial fibrillation: Will substrate-based patient selection improve outcome? J Nucl Cardiol 2020; 27:1517-1520. [PMID: 30357582 DOI: 10.1007/s12350-018-01480-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 09/25/2018] [Indexed: 01/19/2023]
Affiliation(s)
- Hein J Verberne
- Department of Radiology and Nuclear Medicine, F2-238, Amsterdam UMC, Location AMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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11
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Arai S, Kawamura M, Gokan T, Yoshikawa K, Ogawa K, Ochi A, Munetsugu Y, Ito H, Shinke T. Relationship between device-detected subclinical atrial fibrillation and heart failure in patients with cardiac resynchronization therapy defibrillator. Clin Cardiol 2020; 43:1517-1523. [PMID: 32989791 PMCID: PMC7724202 DOI: 10.1002/clc.23471] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 09/17/2020] [Accepted: 09/18/2020] [Indexed: 12/26/2022] Open
Abstract
Background Atrial fibrillation (AF) is a leading preventable cause of heart failure (HF) for which early detection and treatment is critical. Subclinical‐AF is likely to go untreated in the routine care of patients with cardiac resynchronization therapy defibrillator (CRT‐D). Hypothesis The hypothesis of our study is that subclinical‐AF is associated with HF hospitalization and increasing an inappropriate therapy. Methods We investigated 153 patients with an ejection fraction less than 35%. We divided into three groups, subclinical‐AF (n = 30), clinical‐AF (n = 45) and no‐AF (n = 78). We compared the baseline characteristics, HF hospitalization, and device therapy among three groups. The follow‐up period was 50 months after classification of the groups. Results The average age was 66 ± 15 years and the average ejection fraction was 26 ± 8%. Inappropriate therapy and biventricular pacing were significantly different between subclinical‐AF and other groups (inappropriate therapy: subclinical‐AF 13% vs clinical‐AF 8.9% vs no‐AF 7.7%: P = .04, biventricular pacing: subclinical‐AF 81% vs clinical‐AF 85% vs no‐AF 94%, P = .001). Using Kaplan‐Meier method, subclinical‐AF group had a significantly higher HF hospitalization rate as compared with other groups. (subclinical‐AF 70% vs clinical‐AF 49% vs no‐AF 38%, log‐rank: P = .03). In multivariable analysis, subclinical‐AF was a predictor of HF hospitalization. Conclusions Subclinical‐AF after CRT‐D implantation was associated with a significantly increased risk of HF hospitalization. The loss of the biventricular pacing and increasing an inappropriate therapy might affect the risk of HF hospitalization.
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Affiliation(s)
- Shuhei Arai
- Division of Cardiology, Showa University School of Medicine, Tokyo, Japan
| | - Mitsuharu Kawamura
- Division of Cardiology, Showa University School of Medicine, Tokyo, Japan
| | - Toshihiko Gokan
- Division of Cardiology, Showa University School of Medicine, Tokyo, Japan
| | - Kosuke Yoshikawa
- Division of Cardiology, Showa University School of Medicine, Tokyo, Japan
| | - Ko Ogawa
- Division of Cardiology, Showa University School of Medicine, Tokyo, Japan
| | - Akinori Ochi
- Division of Cardiology, Showa University School of Medicine, Tokyo, Japan
| | - Yumi Munetsugu
- Division of Cardiology, Showa University School of Medicine, Tokyo, Japan
| | - Hiroyuki Ito
- Division of Cardiology, Showa University School of Medicine, Tokyo, Japan
| | - Toshiro Shinke
- Division of Cardiology, Showa University School of Medicine, Tokyo, Japan
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12
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Abstract
While AF most often occurs in the setting of atrial disease, current assessment and treatment of patients with AF does not focus on the extent of the atrial myopathy that serves as the substrate for this arrhythmia. Atrial myopathy, in particular atrial fibrosis, may initiate a vicious cycle in which atrial myopathy leads to AF, which in turn leads to a worsening myopathy. Various techniques, including ECG, plasma biomarkers, electroanatomical voltage mapping, echocardiography, and cardiac MRI, can help to identify and quantify aspects of the atrial myopathy. Current therapies, such as catheter ablation, do not directly address the underlying atrial myopathy. There is emerging research showing that by targeting this myopathy we can help decrease the occurrence and burden of AF.
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Affiliation(s)
- Harold Rivner
- Cardiovascular Division, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, US
| | - Raul D Mitrani
- Cardiovascular Division, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, US
| | - Jeffrey J Goldberger
- Cardiovascular Division, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, US
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13
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Ang YS, Rajamani S, Haldar SM, Hüser J. A New Therapeutic Framework for Atrial Fibrillation Drug Development. Circ Res 2020; 127:184-201. [DOI: 10.1161/circresaha.120.316576] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Atrial fibrillation (AF) is a highly prevalent cardiac arrhythmia and cause of significant morbidity and mortality. Its increasing prevalence in aging societies constitutes a growing challenge to global healthcare systems. Despite substantial unmet needs in AF prevention and treatment, drug developments hitherto have been challenging, and the current pharmaceutical pipeline is nearly empty. In this review, we argue that current drugs for AF are inadequate because of an oversimplified system for patient classification and the development of drugs that do not interdict underlying disease mechanisms. We posit that an improved understanding of AF molecular pathophysiology related to the continuous identification of novel disease-modifying drug targets and an increased appreciation of patient heterogeneity provide a new framework to personalize AF drug development. Together with recent innovations in diagnostics, remote rhythm monitoring, and big data capabilities, we anticipate that adoption of a new framework for patient subsegmentation based on pathophysiological, genetic, and molecular subsets will improve success rates of clinical trials and advance drugs that reduce the individual patient and public health burden of AF.
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Affiliation(s)
- Yen-Sin Ang
- From Amgen Research, Cardiometabolic Disorders, South San Francisco, CA (Y.-S.A., S.R., S.M.H.)
| | - Sridharan Rajamani
- From Amgen Research, Cardiometabolic Disorders, South San Francisco, CA (Y.-S.A., S.R., S.M.H.)
| | - Saptarsi M. Haldar
- From Amgen Research, Cardiometabolic Disorders, South San Francisco, CA (Y.-S.A., S.R., S.M.H.)
- Gladstone Institutes, San Francisco, CA (S.M.H.)
- Department of Medicine, Cardiology Division, UCSF School of Medicine, San Francisco, CA (S.M.H.)
| | - Jörg Hüser
- Bayer AG, Pharma-RD-PCR TA Cardiovascular Disease, Wuppertal, Germany (J.H.)
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14
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Lee HG, Shim J, Choi JI, Kim YH, Oh YW, Hwang SH. Use of Cardiac Computed Tomography and Magnetic Resonance Imaging in Case Management of Atrial Fibrillation with Catheter Ablation. Korean J Radiol 2020; 20:695-708. [PMID: 30993921 PMCID: PMC6470091 DOI: 10.3348/kjr.2018.0774] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 01/21/2019] [Indexed: 12/11/2022] Open
Abstract
Atrial fibrillation (AF) is the most common arrhythmia associated with the risk of morbidity and mortality in clinical patients. AF is considered as an arrhythmia type that develops and progresses through close connection with cardiac structural arrhythmogenic substrates. Since the introduction of catheter ablation-mediated electrical isolation of arrhythmogenic substrates, cardiac imaging indicates improved treatment outcome and prognosis with appropriate candidate selection, ablation catheter guidance, and post-ablation follow-up. Currently, cardiac computed tomography (CCT) and cardiovascular magnetic resonance (CMR) imaging are essential in the case management of AF at both pre-and post-procedural stages of catheter ablation. In this review, we discuss the roles and technical considerations of CCT and CMR imaging in the management of patients with AF undergoing catheter ablation.
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Affiliation(s)
- Hee Gone Lee
- Department of Radiology, Korea University Anam Hospital, Seoul, Korea
| | - Jaemin Shim
- Division of Cardiology, Department of Internal Medicine, Korea University Anam Hospital, Seoul, Korea
| | - Jong Il Choi
- Division of Cardiology, Department of Internal Medicine, Korea University Anam Hospital, Seoul, Korea
| | - Young Hoon Kim
- Division of Cardiology, Department of Internal Medicine, Korea University Anam Hospital, Seoul, Korea
| | - Yu Whan Oh
- Department of Radiology, Korea University Anam Hospital, Seoul, Korea
| | - Sung Ho Hwang
- Department of Radiology, Korea University Anam Hospital, Seoul, Korea.
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15
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Li T, Qian Y. Precise Drug Sequential Therapy Can Improve the Cardioversion Rate of Atrial Fibrillation with Valvular Disease after Radiofrequency Ablation. Methods Mol Biol 2020; 2204:145-159. [PMID: 32710322 DOI: 10.1007/978-1-0716-0904-0_13] [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] [Indexed: 06/11/2023]
Abstract
OBJECTIVE Based on pathogenesis of atrial fibrillation (AF), investigate the effects of precision drugs continuous therapy on AF cardioversion rate after radiofrequency catheter ablation. METHODS We included 1334 patients who underwent mitral valve replacement with bipolar radiofrequency ablation due to mitral valve disease with AF during June 2011 to July 2017. The data of clinical and related laboratory examinations at discharge and follow-up were recorded. All patients were treated with or without angiotensin-converting enzyme inhibitor (ACEI) and angiotensin II-receptor blocker (ARB) drugs according to their conditions and doctor's willingness. The heart rhythm was evaluated after treatment and follow-up of 6 months. RESULTS All 1162 cases were followed up, including 825 cases in mitral stenosis (MS) group, 337 cases in mitral regurgitation (MR) group. In MS group, left atrial diameter(LAD) and left ventricular diameter(LVD) of the patients taking ACEI and ARB were significantly lower (P < 0.05), and they can increase AF cardioversion rate from 79.1% of the control group to 83.7% and 82.8%, respectively (P = 0.03 and 0.04). In MR group, the patients with ACEI compared with control group, there were no significant differences in LAD, LVD, right atrial diameter (RAD), right ventricular diameter (RVD), left ventricular ejection fraction(LVEF), and left ventricular fractional shortening(LVFS) (P > 0.05); but ARB group, LAD, LVD decreased significantly (P < 0.05). And ACEI can increase AF cardioversion rate from 76.1% in the control group to 77.2% (P = 0.62), ARB to 81.6% (P = 0.02). CONCLUSION It does improve AF cardioversion rate after radiofrequency catheter ablation that the precise anti-structural remodeling drugs continuous therapy was adopted based on the pathogenesis of AF.
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Affiliation(s)
- Tao Li
- Department of Cardiovascular Surgery, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Yongjun Qian
- Department of Cardiovascular Surgery, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China.
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16
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Willems S, Meyer C, de Bono J, Brandes A, Eckardt L, Elvan A, van Gelder I, Goette A, Gulizia M, Haegeli L, Heidbuchel H, Haeusler KG, Kautzner J, Mont L, Ng GA, Szumowski L, Themistoclakis S, Wegscheider K, Kirchhof P. Cabins, castles, and constant hearts: rhythm control therapy in patients with atrial fibrillation. Eur Heart J 2019; 40:3793-3799c. [PMID: 31755940 PMCID: PMC6898884 DOI: 10.1093/eurheartj/ehz782] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Revised: 03/01/2019] [Accepted: 11/18/2019] [Indexed: 11/14/2022] Open
Abstract
Recent innovations have the potential to improve rhythm control therapy in patients with atrial fibrillation (AF). Controlled trials provide new evidence on the effectiveness and safety of rhythm control therapy, particularly in patients with AF and heart failure. This review summarizes evidence supporting the use of rhythm control therapy in patients with AF for different outcomes, discusses implications for indications, and highlights remaining clinical gaps in evidence. Rhythm control therapy improves symptoms and quality of life in patients with symptomatic AF and can be safely delivered in elderly patients with comorbidities (mean age 70 years, 3-7% complications at 1 year). Atrial fibrillation ablation maintains sinus rhythm more effectively than antiarrhythmic drug therapy, but recurrent AF remains common, highlighting the need for better patient selection (precision medicine). Antiarrhythmic drugs remain effective after AF ablation, underpinning the synergistic mechanisms of action of AF ablation and antiarrhythmic drugs. Atrial fibrillation ablation appears to improve left ventricular function in a subset of patients with AF and heart failure. Data on the prognostic effect of rhythm control therapy are heterogeneous without a clear signal for either benefit or harm. Rhythm control therapy has acceptable safety and improves quality of life in patients with symptomatic AF, including in elderly populations with stroke risk factors. There is a clinical need to better stratify patients for rhythm control therapy. Further studies are needed to determine whether rhythm control therapy, and particularly AF ablation, improves left ventricular function and reduces AF-related complications.
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Affiliation(s)
- Stephan Willems
- AFNET, Münster, Germany
- Department of Cardiology, Asklepios Kliniken St Georg, Hamburg, Germany
- Semmelweis University, Budapest, Hungary
| | - Christian Meyer
- Department of Cardiology, Electrophysiology, University Heart Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Joseph de Bono
- Institute of Cardiovascular Sciences, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, IBR 136, Wolfson Drive, Birmingham, UK
| | - Axel Brandes
- Department of Clinical Research, University of Southern Denmark, and Odense University Hospital, Odense, Denmark
| | - Lars Eckardt
- AFNET, Münster, Germany
- Department of Cardiology II—Electrophysiology, University Hospital Münster, Münster, Germany
| | - Arif Elvan
- Isala Diagram B.V. SMO Zwolle, Zwolle, Netherlands
| | - Isabelle van Gelder
- University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Andreas Goette
- AFNET, Münster, Germany
- St. Vincenz Hospital Paderborn, Cardiology and Intensive Care Medicine, Paderborn, Germany
| | | | - Laurent Haegeli
- Universitätsspital Zürich, Zürich, Switzerland
- Medical University Department, Kantonsspital Aarau, Aarau, Switzerland
| | | | | | - Josef Kautzner
- Institute for Clinical and Experimental Medicine (IKEM), Prague, Czech Republic
| | - Lluis Mont
- Hospital Clinic Barcelona, Barcelona, Spain
| | - G Andre Ng
- National Institute for Health Research Leicester Biomedical Research Centre, University of Leicester, Glenfield General Hospital, Leicester, UK
| | | | - Sakis Themistoclakis
- Unit of Electrophysiology and Cardiac Pacing, Ospedale Dell'Angelo, Venice, Italy
| | - Karl Wegscheider
- AFNET, Münster, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Paulus Kirchhof
- AFNET, Münster, Germany
- Institute of Cardiovascular Sciences, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, IBR 136, Wolfson Drive, Birmingham, UK
- Sandwell and West Birmingham NHS Trust, Birmingham, UK
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17
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Kao D, Purohit S, Jhund P. Therapeutic futility and phenotypic heterogeneity in heart failure with preserved ejection fraction: what is the role of bionic learning? Eur J Heart Fail 2019; 22:159-161. [PMID: 31749260 DOI: 10.1002/ejhf.1658] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- David Kao
- University of Colorado School of Medicine, Aurora, CO, USA
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18
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Poggesi A, Barbato C, Galmozzi F, Camilleri E, Cesari F, Chiti S, Diciotti S, Galora S, Giusti B, Gori AM, Marzi C, Melone A, Mistri D, Pescini F, Pracucci G, Rinnoci V, Sarti C, Fainardi E, Marcucci R, Salvadori E. Role of Biological Markers for Cerebral Bleeding Risk STRATification in Patients with Atrial Fibrillation on Oral Anticoagulants for Primary or Secondary Prevention of Ischemic Stroke (Strat-AF Study): Study Design and Methodology. MEDICINA (KAUNAS, LITHUANIA) 2019; 55:E626. [PMID: 31548494 PMCID: PMC6843419 DOI: 10.3390/medicina55100626] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 09/09/2019] [Accepted: 09/19/2019] [Indexed: 01/31/2023]
Abstract
Background and Objectives: In anticoagulated atrial fibrillation (AF) patients, the validity of models recommended for the stratification of the risk ratio between benefits and hemorrhage risk is limited. Cerebral small vessel disease (SVD) represents the pathologic substrate for primary intracerebral hemorrhage and ischemic stroke. We hypothesize that biological markers-both circulating and imaging-based-and their possible interaction, might improve the prediction of bleeding risk in AF patients under treatment with any type of oral anticoagulant. Materials and Methods: The Strat-AF study is an observational, prospective, single-center hospital-based study enrolling patients with AF, aged 65 years or older, and with no contraindications to magnetic resonance imaging (MRI), referring to Center of Thrombosis outpatient clinic of our University Hospital for the management of oral anticoagulation therapy. Recruited patients are evaluated by means of a comprehensive protocol, with clinical, cerebral MRI, and circulating biomarkers assessment at baseline and after 18 months. The main outcome is SVD progression-particularly microbleeds-as a selective surrogate marker of hemorrhagic complication. Stroke occurrence (ischemic or hemorrhagic) and the progression of functional, cognitive, and motor status will be evaluated as secondary outcomes. Circulating biomarkers may further improve predictive potentials. Results: Starting from September 2017, 194 patients (mean age 78.1 ± 6.7, range 65-97; 61% males) were enrolled. The type of AF was paroxysmal in 93 patients (48%), and persistent or permanent in the remaining patients. Concerning the type of oral anticoagulant, 57 patients (29%) were on vitamin K antagonists, and 137 (71%) were on direct oral anticoagulants. Follow-up clinical evaluation and brain MRI are ongoing. Conclusions: The Strat-AF study may be an essential step towards the exploration of the role of a combined clinical biomarker or multiple biomarker models in predicting stroke risk in AF, and might sustain the incorporation of such new markers in the existing stroke prediction schemes by the demonstration of a greater incremental value in predicting stroke risk and improvement in clinical outcomes in a cost-effective fashion.
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Affiliation(s)
- Anna Poggesi
- Stroke Unit, Careggi University Hospital, 50134 Florence, Italy.
- NEUROFARBA Department, Neuroscience Section, University of Florence, 50134 Florence, Italy.
- IRCCS Don Carlo Gnocchi, 50143 Florence, Italy.
| | - Carmen Barbato
- NEUROFARBA Department, Neuroscience Section, University of Florence, 50134 Florence, Italy.
| | - Francesco Galmozzi
- NEUROFARBA Department, Neuroscience Section, University of Florence, 50134 Florence, Italy.
| | - Eleonora Camilleri
- Department of Experimental and Clinical Medicine, University of Florence, 50134 Florence, Italy.
| | - Francesca Cesari
- Central Laboratory, Careggi University Hospital, 50134 Florence, Italy.
| | - Stefano Chiti
- Department Health Professions, U.O.c Research and Development, 50134 Careggi University Hospital, 50134 Florence, Italy.
| | - Stefano Diciotti
- Department of Electrical, Electronic, and Information Engineering "Guglielmo Marconi", University of Bologna, 40136 Bologna, Italy.
| | - Silvia Galora
- Department of Experimental and Clinical Medicine, University of Florence, 50134 Florence, Italy.
| | - Betti Giusti
- Department of Experimental and Clinical Medicine, University of Florence, 50134 Florence, Italy.
| | - Anna Maria Gori
- Department of Experimental and Clinical Medicine, University of Florence, 50134 Florence, Italy.
| | - Chiara Marzi
- Department of Electrical, Electronic, and Information Engineering "Guglielmo Marconi", University of Bologna, 40136 Bologna, Italy.
| | - Anna Melone
- NEUROFARBA Department, Neuroscience Section, University of Florence, 50134 Florence, Italy.
| | - Damiano Mistri
- NEUROFARBA Department, Neuroscience Section, University of Florence, 50134 Florence, Italy.
| | | | - Giovanni Pracucci
- NEUROFARBA Department, Neuroscience Section, University of Florence, 50134 Florence, Italy.
| | - Valentina Rinnoci
- Stroke Unit, Careggi University Hospital, 50134 Florence, Italy.
- NEUROFARBA Department, Neuroscience Section, University of Florence, 50134 Florence, Italy.
- IRCCS Don Carlo Gnocchi, 50143 Florence, Italy.
| | - Cristina Sarti
- Stroke Unit, Careggi University Hospital, 50134 Florence, Italy.
- NEUROFARBA Department, Neuroscience Section, University of Florence, 50134 Florence, Italy.
| | - Enrico Fainardi
- Neuroradiology Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Careggi University Hospital, 50134 Florence, Italy.
| | - Rossella Marcucci
- Department of Experimental and Clinical Medicine, University of Florence, 50134 Florence, Italy.
| | - Emilia Salvadori
- Stroke Unit, Careggi University Hospital, 50134 Florence, Italy.
- NEUROFARBA Department, Neuroscience Section, University of Florence, 50134 Florence, Italy.
- IRCCS Don Carlo Gnocchi, 50143 Florence, Italy.
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19
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Cruz D, Pinto R, Freitas-Silva M, Nunes JP, Medeiros R. GWAS contribution to atrial fibrillation and atrial fibrillation-related stroke: pathophysiological implications. Pharmacogenomics 2019; 20:765-780. [PMID: 31368859 DOI: 10.2217/pgs-2019-0054] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Atrial fibrillation (AF) and stroke are included in a group of complex traits that have been approached regarding of their study by susceptibility genetic determinants. Since 2007, several genome-wide association studies (GWAS) aiming to identify genetic variants modulating AF risk have been conducted. Thus, 11 GWAS have identified 26 SNPs (p < 5 × 10-2), of which 19 reached genome-wide significance (p < 5 × 10-8). From those variants, seven were also associated with cardioembolic stroke and three reached genome-wide significance in stroke GWAS. These associations may shed a light on putative shared etiologic mechanisms between AF and cardioembolic stroke. Additionally, some of these identified variants have been incorporated in genetic risk scores in order to elucidate new approaches of stroke prediction, prevention and treatment.
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Affiliation(s)
- Diana Cruz
- Molecular Oncology & Viral Pathology Group-Research Center, Portuguese Institute of Oncology, Edifício Laboratórios. 4° piso, Rua Dr António Bernardino de Almeida, 4200-4072 Porto, Portugal.,FMUP, Faculty of Medicine, Porto University, Alameda Prof Hernâni Monteiro, 4200-319 Porto, Portugal
| | - Ricardo Pinto
- Molecular Oncology & Viral Pathology Group-Research Center, Portuguese Institute of Oncology, Edifício Laboratórios. 4° piso, Rua Dr António Bernardino de Almeida, 4200-4072 Porto, Portugal
| | - Margarida Freitas-Silva
- FMUP, Faculty of Medicine, Porto University, Alameda Prof Hernâni Monteiro, 4200-319 Porto, Portugal.,Department of Medicine, Centro Hospitalar São João, Porto, Portugal
| | - José Pedro Nunes
- FMUP, Faculty of Medicine, Porto University, Alameda Prof Hernâni Monteiro, 4200-319 Porto, Portugal.,Department of Medicine, Centro Hospitalar São João, Porto, Portugal
| | - Rui Medeiros
- Molecular Oncology & Viral Pathology Group-Research Center, Portuguese Institute of Oncology, Edifício Laboratórios. 4° piso, Rua Dr António Bernardino de Almeida, 4200-4072 Porto, Portugal.,FMUP, Faculty of Medicine, Porto University, Alameda Prof Hernâni Monteiro, 4200-319 Porto, Portugal.,Research Department, Portuguese League Against Cancer (NRNorte), Estrada Interior da Circunvalação, 6657, 4200-172 Porto, Portugal.,CEBIMED, Faculty of Health Sciences, Fernando Pessoa University, Praça 9 de Abril, 349, 4249-004 Porto, Portugal
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20
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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: 179] [Impact Index Per Article: 35.8] [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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21
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Roh E, Chung HS, Lee JS, Kim JA, Lee YB, Hong SH, Kim NH, Yoo HJ, Seo JA, Kim SG, Kim NH, Baik SH, Choi KM. Total cholesterol variability and risk of atrial fibrillation: A nationwide population-based cohort study. PLoS One 2019; 14:e0215687. [PMID: 31017966 PMCID: PMC6481829 DOI: 10.1371/journal.pone.0215687] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 04/05/2019] [Indexed: 12/24/2022] Open
Abstract
Background Long-term variability of cardiometabolic risk factors have been suggested as the risk factors for cardiovascular disease and mortality. However, the effect of long-term variability of total cholesterol (TC) on incident atrial fibrillation (AF) has not been examined. Methods and findings We explored whether visit-to-visit TC variability are associated with the risk of incident AF in 160,165 Korean adults, using the population-based Korean National Health Insurance Service–Health Screening Cohort (NHIS-HEALS) database, over a median duration of 8.4 years. TC variability was measured as coefficients of variance (TC-CV), standard deviation (TC-SD), and variability independent of the mean (TC-VIM). Kaplan–Meier analysis demonstrated a decreased disease-free probability in the highest quartile group of TC variability compared to that in the other groups. In the multivariate Cox proportional hazard analysis, the risk of AF increased significantly in the highest quartile group of TC variability. After multivariate adjustment for confounding variables including mean TC levels, the hazard ratio for incident AF was 1.15 (95% confidence interval 1.05–1.25; P = 0.0035) when comparing the highest with the lowest TC variability quartile (TC-CV). These relationships were consistent with TC variability defined using TC-SD or TC-VIM. Subgroup analyses, including age, sex, body mass index, and cardiometabolic disorders, showed similar results. Conclusions The present study is the first to demonstrate that high TC variability was associated with an increased risk of AF.
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Affiliation(s)
- Eun Roh
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Hye Soo Chung
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Hallym University College of Medicine, Seoul, Korea
| | - Ji Sung Lee
- Clinical Research Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung A. Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - You-Bin Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - So-hyeon Hong
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Nam Hoon Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Hye Jin Yoo
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Ji A. Seo
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Sin Gon Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Nan Hee Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Sei Hyun Baik
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Kyung Mook Choi
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
- * E-mail:
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22
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Cha MJ, Cho Y, Oh IY, Choi EK, Oh S. Validation of Conventional Thromboembolic Risk Factors in a Korean Atrial Fibrillation Population - Suggestion for a Novel Scoring System, CHA 2DS 2-VAK. Circ J 2018; 82:2970-2975. [PMID: 30282848 DOI: 10.1253/circj.cj-18-0218] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND There is little evidence that focuses on the ethnic variability of clinical risk factors for thromboembolism (TE) in atrial fibrillation (AF). We aimed to investigate the effect of each traditional risk factor in the Korean AF population. Methods and Results: Medical records of 12,876 consecutive patients (aged >18 years) newly diagnosed and followed up with non-valvular AF from 2000 to 2013 were reviewed. TE events, including ischemic stroke and systemic embolism, were investigated for risk factor validation. Among the total of 12,876 patients, 1,390 (10.8%) had TE events. In univariate/multivariate analysis adjusting for clinical factors and antithrombotic medications, traditional risk factors included in the CHA2DS2-VASc scheme showed statistical significance, except for female sex, which was not a predictor of events. Additionally, chronic kidney disease (CKD; hazard ratio 1.62, P<0.001) was shown to be an independent predictor of TE events. Based on the analysis, we developed a novel stratification system, CHA2DS2-VAK, omitting the female sex category and adding CKD. The new scoring system showed greater discrimination in event rates between score 0 and 1 patients. CONCLUSIONS Female sex was not associated with TE events in a Korean non-valvular AF population. The novel CHA2DS2-VAK scoring system, with substitution of CKD for female sex, might be more appropriate for the Korean population.
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Affiliation(s)
- Myung-Jin Cha
- Department of Internal Medicine, Seoul National University Hospital
| | - Youngjin Cho
- Department of Internal Medicine, Seoul National University Bundang Hospital
| | - Il-Young Oh
- Department of Internal Medicine, Seoul National University Bundang Hospital
| | - Eue-Keun Choi
- Department of Internal Medicine, Seoul National University Hospital
| | - Seil Oh
- Department of Internal Medicine, Seoul National University Hospital
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23
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Gorenek B, Pelliccia A, Benjamin EJ, Boriani G, Crijns HJ, Fogel RI, Van Gelder IC, Halle M, Kudaiberdieva G, Lane DA, Larsen TB, Lip GYH, Løchen ML, Marín F, Niebauer J, Sanders P, Tokgozoglu L, Vos MA, Van Wagoner DR, Fauchier L, Savelieva I, Goette A, Agewall S, Chiang CE, Figueiredo M, Stiles M, Dickfeld T, Patton K, Piepoli M, Corra U, Marques-Vidal PM, Faggiano P, Schmid JP, Abreu A. European Heart Rhythm Association (EHRA)/European Association of Cardiovascular Prevention and Rehabilitation (EACPR) position paper on how to prevent atrial fibrillation endorsed by the Heart Rhythm Society (HRS) and Asia Pacific Heart Rhythm Society (APHRS). Europace 2018; 19:190-225. [PMID: 28175283 DOI: 10.1093/europace/euw242] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
| | | | | | | | - Harry J Crijns
- Maastricht University Medical Centre, Maastricht, The Netherlands
| | | | | | - Martin Halle
- Prevention and Sports Medicine, Technical University Munich, München, Germany
| | | | | | | | | | - Maja-Lisa Løchen
- University of Birmingham, Birmingham, UK.,Aalborg University Hospital, Aalborg, Denmark
| | | | - Josef Niebauer
- Paracelsus Medical University Salzburg, Salzburg, Austria
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Ugo Corra
- Irccs Rehabilitation Medical Center, Veruno, Italy
| | | | | | | | - Ana Abreu
- Hospital de Santa Marta, Lisboa, Portugal
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24
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[Catheter ablation of persistent atrial fibrillation : Possibilities of dipole density mapping]. Herzschrittmacherther Elektrophysiol 2018; 29:278-283. [PMID: 30076445 DOI: 10.1007/s00399-018-0581-z] [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: 07/06/2018] [Accepted: 07/07/2018] [Indexed: 10/28/2022]
Abstract
Voltage-based methods currently form the diagnostic and therapeutic basis of clinical cardiac electrophysiology. These include both noncontact-based approaches (e.g., body surface electrocardiogram) and established, contact-based 3D mapping systems. At the physiological level, voltage is the measure of an electric field that includes both the local and the sum of the surrounding activation sources. As a result, details of complex rhythm patterns like those observed in atrial fibrillation may be obscured. Dipole density mapping represents an alternative approach to detect and visualize the electrical activity of the heart. It records the local activity on the inner surface of a chamber with high spatial and temporal resolution without requiring contact. This could help to further improve our understanding of the mechanisms and therapeutic possibilities. Herein, we review current knowledge of this procedure, potential uses, and clinical experience to date.
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25
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Kim D, Yang PS, Jang E, Yu HT, Kim TH, Uhm JS, Kim JY, Pak HN, Lee MH, Joung B, Lip GYH. 10-year nationwide trends of the incidence, prevalence, and adverse outcomes of non-valvular atrial fibrillation nationwide health insurance data covering the entire Korean population. Am Heart J 2018; 202:20-26. [PMID: 29802976 DOI: 10.1016/j.ahj.2018.04.017] [Citation(s) in RCA: 104] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 04/16/2018] [Indexed: 01/19/2023]
Abstract
BACKGROUND Most data on the clinical epidemiology of atrial fibrillation (AF) are reported from Western populations, and data for Asians are limited. We aimed to investigate the 10-year trends of the prevalence and incidence of non-valvular AF and provide prevalence projections till 2060 in Korea. We also investigated the annual risks of adverse outcomes among patients with AF. METHODS Using the Korean National Health Insurance Service database involving the entire Korean population, a total of 679,416 adults with newly diagnosed AF were identified from 2006 to 2015. The incidence and prevalence of AF and risk of adverse outcomes following AF onset were assessed. RESULTS The prevalence of AF progressively increased by 2.10-fold from 0.73% in 2006 to 1.53% in 2015. The trend of its incidence was flat with a 10-year overall incidence of 1.77 per 1,000 person-years. The prevalence of AF is expected to reach 5.81% (2,290,591 patients with AF) in 2060. For a decade, the risk of all-cause mortality following AF declined by 30% (adjusted hazard ratio [HR]: 0.70, 95% confidence interval [CI]: 0.68-0.72), heart failure by 52% (adjusted HR: 0.48, 95% CI: 0.44-0.51), and ischemic stroke by 9% (adjusted HR: 0.91, 95% CI: 0.88-0.93). CONCLUSIONS The burden of AF among Asian patients is increasing. Although the overall risks of cardiovascular events and death following AF onset have decreased over a decade, the event rates are still high. Optimized management of any associated comorbidities should be part of the holistic management approach for patients with AF.
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Heidbuchel H, Dagres N, Antz M, Kuck KH, Lazure P, Murray S, Carrera C, Hindricks G, Vahanian A. Major knowledge gaps and system barriers to guideline implementation among European physicians treating patients with atrial fibrillation: a European Society of Cardiology international educational needs assessment. Europace 2018. [DOI: 10.1093/europace/euy039] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Affiliation(s)
- Hein Heidbuchel
- Department of Cardiology, Antwerp University Hospital, Wilrijkstraat 10, Edegem, Belgium
| | - Nikolaos Dagres
- Heart Center Leipzig, Leipzig Heart Institute, Leipzig, Germany
| | | | | | | | | | - Céline Carrera
- European Society of Cardiology, Sophia Antipolis, France
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Abstract
BACKGROUND Inflammation markers have been associated with cardiovascular diseases including atrial fibrillation. This arrhythmia is the most frequent, with an incidence of 38/1000 person-years. PURPOSE OF REVIEW The aims of this study are to discuss the association between inflammation, atherosclerosis and atrial fibrillation and its clinical implications. Atherosclerosis is a chronic inflammatory disease and inflammation is a triggering factor of atherosclerotic plaque rupture. In addition to coronary artery disease, clinical conditions identified as risk factors for atrial fibrillation (AF) are also associated with the inflammatory state such as obesity, diabetes mellitus, hypertension, heart failure, metabolic syndrome and sedentary lifestyle. Biomarkers of inflammation, oxidative stress, coagulation, and myocardial necrosis have been identified in patients with atrial fibrillation and these traditional risk factors. Some markers of inflammation were identified as predictors of recurrence of this arrhythmia, subsequent myocardial infarction, stroke by embolism, and death. Thus, approaches to manipulate the inflammatory pathways may be therapeutic interventions, benefiting patients with AF and increased inflammatory markers.
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Affiliation(s)
- Rose Mary Ferreira Lisboa da Silva
- Department of Internal Medicine, Faculty of Medicine, Federal University of Minas Gerais, Avenue Alfredo Balena, 190, room 246, Centro, 30130-100, Belo Horizonte, MG, Brazil.
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28
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Verma A, Ha AC, Kirchhof P, Hindricks G, Healey JS, Hill MD, Sharma M, Wyse DG, Champagne J, Essebag V, Wells G, Gupta D, Heidbuchel H, Sanders P, Birnie DH. The Optimal Anti-Coagulation for Enhanced-Risk Patients Post-Catheter Ablation for Atrial Fibrillation (OCEAN) trial. Am Heart J 2018; 197:124-132. [PMID: 29447772 DOI: 10.1016/j.ahj.2017.12.007] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 12/05/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND The optimal long-term antithrombotic regimen for patients after successful catheter-based atrial fibrillation (AF) ablation is not well defined. Presently, practice variation exists, and the benefits of oral anticoagulation over antiplatelet therapy across the entire spectrum of stroke risk profile remain undefined in the postablation population. To date, there are no randomized trials to inform clinicians on this therapeutic question. OBJECTIVE The objective was to assess whether rivaroxaban is superior to acetylsalicylic acid (ASA) in reducing the risk of clinically overt stroke, systemic embolism, or covert stroke among patients without apparent recurrent atrial arrhythmias for at least 1 year after their most recent AF ablation procedure. METHODS/DESIGN A prospective, multicenter, open-label, randomized trial with blinded assessment of outcomes is under way (NCT02168829). Atrial fibrillation patients with at least 1 stroke risk factor (as defined by the CHA2DS2-VASc score) and without known atrial arrhythmia recurrences for at least 12 months after ablation are randomized to rivaroxaban 15 mg or ASA 75-160 mg daily. The primary outcome is a composite of clinically overt stroke, systemic embolism, and covert stroke based on brain magnetic resonance imaging. Key secondary outcomes include major bleeding outcomes, intracranial hemorrhage, transient ischemic attack, neuropsychological testing, quality of life, and an economic analysis. Subjects will be followed for 3 years. The estimated overall sample size is 1,572 subjects (786 per arm). DISCUSSION The OCEAN trial is a multicenter randomized controlled trial evaluating 2 antithrombotic treatment strategies for patients with risk factors for stroke after apparently successful AF ablation. We hypothesize that rivaroxaban will reduce the occurrence of clinically overt stroke, systemic embolism, and covert stroke when compared with ASA alone.
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29
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Attanasio P, Qaiyumi D, Röhle R, Wutzler A, Safak E, Muntean B, Boldt LH, Pieske B, Haverkamp W, Huemer M. Coronary sinus signal amplitude predicts left atrial scarring. Acta Cardiol 2017; 73:1-6. [PMID: 29272990 DOI: 10.1080/00015385.2017.1420438] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 12/11/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Left atrial scarring is recognised as a critical component in the maintenance of atrial fibrillation and is associated with the failure of interventional treatment. Diminished bipolar voltage (LV) has been proposed as a useful tool for left atrial scar quantification. We hypothesised that, due to its anatomic location, signals on the coronary sinus catheter might be used to predict the amount of left atrial low voltage. METHODS AND RESULTS A total of 124 patients (42% women, average age 66 ± 9 years) were included. Forty-one with paroxysmal and 83 with persistent atrial fibrillation. Left atrial low-voltage (<0.5 mV, measured during sinus rhythm) area size and distribution varied considerably among the included patients (mean: 34.9%; maximum: 94.6%; minimum: 0.4%). Spearman correlation revealed a strong negative correlation between bipolar voltage of the signals on the coronary sinus catheter and the amount of left atrial scarring (R = -0.778, p < .0001). The optimal CS voltage cut off for prediction of left atrial low-voltage size of ≥50% was 1.9 mV with an area-under-the receiver-operating-characteristic (ROC) curve of 0.982, a sensitivity of 97% and a specificity of 98%. CONCLUSIONS There is a strong negative correlation between the size of left atrial low-voltage areas (LVA) and coronary sinus signal amplitude. With increasing left atrial LVA size, CS signal amplitudes decrease, and vice versa. On the basis of these findings, average CS signal amplitudes of ≤1.9 mV can be used as a predictor for a left atrial low-voltage size of ≥50%.
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Affiliation(s)
- Philipp Attanasio
- a Department of Internal Medicine and Cardiology , Charité University Medicine , Berlin , Germany
| | - Daniel Qaiyumi
- a Department of Internal Medicine and Cardiology , Charité University Medicine , Berlin , Germany
| | - Robert Röhle
- b Coordinating Center for Clinical Studies , Charité University Medicine , Berlin , Germany
| | - Alexander Wutzler
- c Cardiovascular Center , St. Josef Hospital, University Hospital of the Ruhr University Bochum , Bochum , Germany
| | - Erdal Safak
- d Department of Internal Medicine and Cardiology , Vivantes Klinikum am Urban Berlin , Berlin , Germany
| | - Bogdan Muntean
- e Department of Internal Medicine and Cardiology , Jüdisches Krankenhaus Berlin , Berlin , Germany
| | - Leif-Hendrik Boldt
- a Department of Internal Medicine and Cardiology , Charité University Medicine , Berlin , Germany
| | - Burkert Pieske
- a Department of Internal Medicine and Cardiology , Charité University Medicine , Berlin , Germany
- f Department of Internal Medicine and Cardiology , German Heart Center Berlin , Berlin , Germany
| | - Wilhelm Haverkamp
- a Department of Internal Medicine and Cardiology , Charité University Medicine , Berlin , Germany
| | - Martin Huemer
- a Department of Internal Medicine and Cardiology , Charité University Medicine , Berlin , Germany
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Montbleau KE, King D, Henault L, Magnani JW. Health literacy, health-related quality of life, and atrial fbrillation. COGENT MEDICINE 2017; 4:1412121. [PMID: 29276719 PMCID: PMC5737959 DOI: 10.1080/2331205x.2017.1412121] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Atrial fbrillation (AF) is a chronic heart rhythm disorder associated with significant adverse outcomes. Health-related quality of life (HRQoL) is an established metric of health status in individuals with AF, and health literacy is highly relevant to how individuals experience HRQoL. We conducted a pilot investigation to examine the association of health literacy and health related quality of life (HRQoL) in a limited-sized cohort of individuals with AF, all of whom had AF and were ≥60 years old. We used the Short-Test of Functional Health Literacy in Adults to categorize participants by health literacy status. We used the SF-36 to examine HRQoL in eight subscales and two composite scores, and related health literacy to HRQoL. In our cohort of 40 participants with AF (45% female, age 77.9 ± 8.0 years), 62.5% had inadequate health literacy. However, we did not identify a significant association between health literacy and HRQoL. We expect our limited-sized sample is a chief limitation for why we did not see an association between health literacy and HRQoL in this convenience cohort. Further studies examining health literacy and its impact on patient-centered outcomes in AF are essential.
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Affiliation(s)
| | - Deandre King
- Boston University School of Medicine, Boston, MA, USA
| | - Lori Henault
- Department of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Jared W Magnani
- Department of Medicine, Division of Cardiology, Heart and Vascular Institute, University of Pittsburgh, UPMC Presbyterian Hospital, Suite 5-B, 200 Lothrop Street, Pittsburgh, PA 15213, USA
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Jiang H, Wang W, Wang C, Xie X, Hou Y. Association of pre-ablation level of potential blood markers with atrial fibrillation recurrence after catheter ablation: a meta-analysis. Europace 2017; 19:392-400. [PMID: 27386883 DOI: 10.1093/europace/euw088] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Accepted: 03/09/2016] [Indexed: 11/13/2022] Open
Abstract
Aims The meta-analysis was aimed to search for candidate blood markers whose pre-ablation level was associated with atrial fibrillation (AF) recurrence after radiofrequency catheter ablation (RFCA). Methods and results A systematic literature search of PubMed, EMBASE, Springer Link, Web of Science, Wiley-Cochrane library, and supplemented with Google scholar search engine was performed. Thirty-six studies covering 11 blood markers were qualified for this meta-analysis. Compared with the nonrecurrence group, the recurrence group had increased pre-ablation level of atrial natriuretic peptide (ANP), brain natriuretic peptide (BNP), N-terminal pro-brain natriuretic peptide (NT-pro-BNP), interleukin-6 (IL-6), C-reactive protein, low density lipoprotein (LDL), and tissue inhibitor of metal loproteinase-2 (TIMP-2) [standardized mean difference (95% confidence interval): 0.37 (0.13-0.61), 0.77 (0.40-1.14), 1.25 (0.64-1.87), 0.37 (0.21-0.52), 0.35 (0.10-0.60), 0.24 (0.07-0.42), 0.17 (0.00-0.34), respectively], while no statistical difference of pre-ablation level of white blood cell, total cholesterol, triglyceride, and transforming growth factor-β1 was found. Subgroup analysis demonstrated that ANP was associated with AF recurrence in participants who had no concomitant structural heart diseases (SHD); however, not in participants who had SHD, C-reactive protein was associated with AF recurrence in Asian studies, whereas not in European studies. Conclusion Increased pre-ablation level of ANP, BNP, NT-pro-BNP, IL-6, C-reactive protein, LDL, and TIMP-2 was associated with greater risk of AF recurrence after RFCA.
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Affiliation(s)
- Hui Jiang
- Department of Clinical Medicine, School of Medicine, Shandong University, Jinan, Shandong Province, China.,Department of Cardiology, Shandong Provincial Qianfoshan Hospital, Shandong University, No. 16766 Jingshi Road, Jinan, Shandong Province 250014, China
| | - Weizong Wang
- Department of Clinical Medicine, School of Medicine, Shandong University, Jinan, Shandong Province, China.,Department of Cardiology, Shandong Provincial Qianfoshan Hospital, Shandong University, No. 16766 Jingshi Road, Jinan, Shandong Province 250014, China
| | - Cong Wang
- Department of Cardiology, Shandong Provincial Qianfoshan Hospital, Shandong University, No. 16766 Jingshi Road, Jinan, Shandong Province 250014, China
| | - Xinxing Xie
- Department of Cardiology, Shandong Provincial Qianfoshan Hospital, Shandong University, No. 16766 Jingshi Road, Jinan, Shandong Province 250014, China
| | - Yinglong Hou
- Department of Cardiology, Shandong Provincial Qianfoshan Hospital, Shandong University, No. 16766 Jingshi Road, Jinan, Shandong Province 250014, China
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Kirchhof P. The future of atrial fibrillation management: integrated care and stratified therapy. Lancet 2017; 390:1873-1887. [PMID: 28460828 DOI: 10.1016/s0140-6736(17)31072-3] [Citation(s) in RCA: 101] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 02/20/2017] [Accepted: 03/10/2017] [Indexed: 02/06/2023]
Abstract
Atrial fibrillation is one of the major cardiovascular health problems: it is a common, chronic condition, affecting 2-3% of the population in Europe and the USA and requiring 1-3% of health-care expenditure as a result of stroke, sudden death, heart failure, unplanned hospital admissions, and other complications. Early diagnosis of atrial fibrillation, ideally before the first complication occurs, remains a challenge, as shown by patients who are only diagnosed with the condition when admitted to hospital for acute cardiac decompensation or stroke. Once diagnosed, atrial fibrillation requires chronic, multidimensional management in five domains (acute management, treatment of underlying and concomitant cardiovascular conditions, stroke prevention therapy, rate control, and rhythm control). The consistent provision of these treatment options to all patients with atrial fibrillation is difficult, despite recent improvements in organisation of care, knowledge about atrial fibrillation, and treatment options. Integrated care models that provide patient-centred care in, or close to, the patient's community while maintaining access to all specialist treatment options, emerge as the best approach to achieve consistent delivery of these chronic treatments to all patients with atrial fibrillation. Ongoing research efforts will establish when to initiate oral anticoagulation in patients with device-detected atrial high-rate episodes, quantify the prognostic effect of early and comprehensive rhythm control therapy, including atrial fibrillation ablation, and delineate optimum methods to reduce bleeding complications in patients treated with anticoagulation. Additionally, research efforts are needed to define different types of atrial fibrillation on the basis of the main causes of atrial fibrillation to pave the way for the clinical development of stratified atrial fibrillation therapy.
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Affiliation(s)
- Paulus Kirchhof
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK; Sandwell and West Birmingham Hospitals NHS Trust and University Hospitals Birmingham NHS Foundation NHS Trust, Birmingham, UK; Atrial Fibrillation NETwork, Münster, Germany.
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Darkner S, Goetze JP, Chen X, Henningsen K, Pehrson S, Svendsen JH. Natriuretic Propeptides as Markers of Atrial Fibrillation Burden and Recurrence (from the AMIO-CAT Trial). Am J Cardiol 2017; 120:1309-1315. [PMID: 28865890 DOI: 10.1016/j.amjcard.2017.07.018] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Revised: 06/18/2017] [Accepted: 07/06/2017] [Indexed: 10/19/2022]
Abstract
Natriuretic peptides are established plasma markers of systolic heart failure, but their usefulness for the evaluation of atrial fibrillation (AF) is unknown. We examined mid-regional pro-atrial natriuretic peptide (MR-proANP) and N-terminal pro-brain natriuretic peptide (NT-proBNP) in patients undergoing ablation for AF. A subpopulation of 102 patients (median age 60 [52;65], 82% male) from the AMIO-CAT trial (Recurrence of arrhythmia following short-term oral AMIOdarone after CATheter ablation for atrial fibrillation: a double-blind, randomized, placebo-controlled study) undergoing ablation for paroxysmal (n = 55) or persistent (n = 47) AF was studied. MR-proANP and NT-proBNP were measured before ablation and at 1, 3, and 6 months' follow-up. Three-day Holter monitoring was performed before ablation, and 6 to 8 weeks and 6 months after ablation. Plasma MR-proANP and NT-proBNP concentrations were higher during AF than during sinus rhythm before ablation (188 pmol/L [131;260] vs 94 pmol/L [64;125], p <0.001; 78 pmol/L [43;121] vs 10.3 pmol/L [5.9;121], p <0.001) and at 1, 3, and 6 months' follow-up. Categories of AF burden on 3-day Holter monitoring (0%, 0% to 99%, and 99% to 100%) were associated with plasma concentrations of both MR-proANP (94 pmol/L [55;127] vs 117 pmol/L [88;185] vs 192 pmol/L [127;261], p <0.001) and NT-proBNP (10 pmol/L [5.9;22] vs 22 pmol/L [8.9;53] vs 81 pmol/L [45;116], p <0.001). In a multivariate regression analysis, however, there was no significant association between baseline propeptide concentrations and recurrence of AF at 6 months' follow-up. In conclusion, AF was associated with higher plasma concentrations of MR-proANP and NT-proBNP than sinus rhythm. Moreover, AF burden was associated with subsequent concentrations of both MR-proANP and NT-proBNP. The results suggest that natriuretic propeptide measurement reflects functional cardiac dysfunction during AF, and that AF burden should be included in biochemical assessment of left ventricular dysfunction.
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Botto GL, Padeletti L, Covino G, Pieragnoli P, Liccardo M, Mariconti B, Favale S, Molon G, De Filippo P, Bolognese L, Landolina M, Raciti G, Boriani G. Electrical treatment of atrial arrhythmias in heart failure patients implanted with a dual defibrillator CRT device. Results from the TRADE-HF study. Int J Cardiol 2017; 236:181-186. [PMID: 28131706 DOI: 10.1016/j.ijcard.2017.01.101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Revised: 01/05/2017] [Accepted: 01/16/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND Ventricular and atrial arrhythmias commonly occur in heart failure patients and are a significant source of symptoms, morbidity and mortality. Some specific generators referred to as dual defibrillators, Dual CRT-Ds, have the ability to treat atrial and ventricular arrhythmias. TRADE-HF is a prospective two-arm randomized study aimed at assessing the benefits of complete automatic management of atrial arrhythmias in patients implanted with a dual CRT-D. METHODS Primary objective of the TRADE-HF study was to document reduction of unplanned hospital admission for cardiac reasons or death for cardiovascular causes or progression to permanent AF, by comparing fully-automatic device driven therapy for atrial tachycardia or fibrillation (AT/AF) to an in-hospital approach for treatment of symptomatic AT/AF. Randomized Patients were followed every 6months for 3years to assess the primary objective. RESULTS Four-hundred-twenty patients have been enrolled in the study. At the end of the study 30 subjects died for cardiovascular causes, 60 had at least one hospitalization for cardiovascular causes and 14 developed permanent AF. Eighty-seven patients experienced a composite event. Hazard Ratio for device-managed automatic therapy arm compared to traditional was 0.987 (95% CI: 0.684-1.503; p=0.951). The primary endpoint analysis resulted in no difference between the device managed and in-hospital treatment arm. CONCLUSION The TRADE-HF study failed to demonstrate a reduction in the composite of unplanned hospitalizations for cardiovascular causes or death for cardiovascular causes or progression to permanent AF using automatic atrial therapy compared to a traditional approach including hospitalization for symptomatic episodes and/or in-hospital treatment of AT/AF.
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Affiliation(s)
| | - Luigi Padeletti
- Cardiology Dept., Careggi Hospital, University of Firenze, Firenze, Italy
| | | | - Paolo Pieragnoli
- Cardiology Dept., Careggi Hospital, University of Firenze, Firenze, Italy
| | - Mattia Liccardo
- Cardiology Dept., S. Maria delle Grazie Hospital, Pozzuoli, Italy
| | - Barbara Mariconti
- Cardiology Dept., Sant'Anna Hopsital, S. Fermo Della Battaglia, Italy
| | - Stefano Favale
- Cardiology Dept., Policlinico Consorziale Hospital, University of Bari, Bari, Italy
| | - Giulio Molon
- Cardiology Dept., Sacro Cuore Hospital, Negrar, Italy
| | | | | | - Maurizio Landolina
- Cardiology Dept., S. Matteo Hospital, Pavia, Italy and Ospedale Maggiore, Crema, Italy
| | | | - Giuseppe Boriani
- Cardiology Dept., DIMES Department, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy and Cardiology Division, Department of Diagnostics, Clinical and Public Health Medicine. University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
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Greiser M. Calcium signalling silencing in atrial fibrillation. J Physiol 2017; 595:4009-4017. [PMID: 28332202 DOI: 10.1113/jp273045] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 01/05/2017] [Indexed: 01/19/2023] Open
Abstract
Subcellular calcium signalling silencing is a novel and distinct cellular and molecular adaptive response to rapid cardiac activation. Calcium signalling silencing develops during short-term sustained rapid atrial activation as seen clinically during paroxysmal atrial fibrillation (AF). It is the first 'anti-arrhythmic' adaptive response in the setting of AF and appears to counteract the maladaptive changes that lead to intracellular Ca2+ signalling instability and Ca2+ -based arrhythmogenicity. Calcium signalling silencing results in a failed propagation of the [Ca2+ ]i signal to the myocyte centre both in patients with AF and in a rabbit model. This adaptive mechanism leads to a substantial reduction in the expression levels of calcium release channels (ryanodine receptors, RyR2) in the sarcoplasmic reticulum, and the frequency of Ca2+ sparks and arrhythmogenic Ca2+ waves remains low. Less Ca2+ release per [Ca2+ ]i transient, increased fast Ca2+ buffering strength, shortened action potentials and reduced L-type Ca2+ current contribute to a substantial reduction of intracellular [Na+ ]. These features of Ca2+ signalling silencing are distinct and in contrast to the changes attributed to Ca2+ -based arrhythmogenicity. Some features of Ca2+ signalling silencing prevail in human AF suggesting that the Ca2+ signalling 'phenotype' in AF is a sum of Ca2+ stabilizing (Ca2+ signalling silencing) and Ca2+ destabilizing (arrhythmogenic unstable Ca2+ signalling) factors. Calcium signalling silencing is a part of the mechanisms that contribute to the natural progression of AF and may limit the role of Ca2+ -based arrhythmogenicity after the onset of AF.
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Affiliation(s)
- Maura Greiser
- Center for Biomedical Engineering and Technology and Department of Physiology, University of Maryland School of Medicine, Baltimore, MD, USA
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Zakeri R, Van Wagoner DR, Calkins H, Wong T, Ross HM, Heist EK, Meyer TE, Kowey PR, Mentz RJ, Cleland JG, Pitt B, Zannad F, Linde C. The burden of proof: The current state of atrial fibrillation prevention and treatment trials. Heart Rhythm 2017; 14:763-782. [PMID: 28161513 PMCID: PMC5403606 DOI: 10.1016/j.hrthm.2017.01.032] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Indexed: 12/19/2022]
Abstract
Atrial fibrillation (AF) is an age-related arrhythmia of enormous socioeconomic significance. In recent years, our understanding of the basic mechanisms that initiate and perpetuate AF has evolved rapidly, catheter ablation of AF has progressed from concept to reality, and recent studies suggest lifestyle modification may help prevent AF recurrence. Emerging developments in genetics, imaging, and informatics also present new opportunities for personalized care. However, considerable challenges remain. These include a paucity of studies examining AF prevention, modest efficacy of existing antiarrhythmic therapies, diverse ablation technologies and practice, and limited evidence to guide management of high-risk patients with multiple comorbidities. Studies examining the long-term effects of AF catheter ablation on morbidity and mortality outcomes are not yet completed. In many ways, further progress in the field is heavily contingent on the feasibility, capacity, and efficiency of clinical trials to incorporate the rapidly evolving knowledge base and to provide substantive evidence for novel AF therapeutic strategies. This review outlines the current state of AF prevention and treatment trials, including the foreseeable challenges, as discussed by a unique forum of clinical trialists, scientists, and regulatory representatives in a session endorsed by the Heart Rhythm Society at the 12th Global CardioVascular Clinical Trialists Forum in Washington, DC, December 3-5, 2015.
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Affiliation(s)
- Rosita Zakeri
- Royal Brompton & Harefield NHS Trust, London, United Kingdom.
| | | | | | - Tom Wong
- Royal Brompton & Harefield NHS Trust, London, United Kingdom
| | | | - E Kevin Heist
- Massachusetts General Hospital, Boston, Massachusetts
| | | | - Peter R Kowey
- Lankenau Heart Institute and Jefferson Medical College, Wynnewood, Pennsylvania
| | - Robert J Mentz
- Duke Clinical Research Institute, Durham, North Carolina
| | - John G Cleland
- Royal Brompton & Harefield NHS Trust, London, United Kingdom
| | | | - Faiez Zannad
- INSERM, Centre d'Investigations Cliniques Plurithématique 1433, INSERM U1116, Université de Lorraine, CHRU de Nancy, F-CRIN INI-CRCT, France
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Vosko MR, Bocksrucker C, Drwiła R, Dulíček P, Hauer T, Mutzenbach J, Schlimp CJ, Špinler D, Wolf T, Zugwitz D. Real-life experience with the specific reversal agent idarucizumab for the management of emergency situations in dabigatran-treated patients: a series of 11 cases. J Thromb Thrombolysis 2017; 43:306-317. [PMID: 28210988 PMCID: PMC5337234 DOI: 10.1007/s11239-017-1476-2] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Non-vitamin K antagonist oral anticoagulants (NOACs) have a favorable benefit-risk profile compared with vitamin K antagonists. However, the lack of specific reversal agents has made the management of some patients receiving long-term treatment with NOACs problematic in emergency situations such as major bleeding events or urgent procedures. Idarucizumab, a fully humanized Fab antibody fragment that binds specifically and with high affinity to dabigatran, was recently approved for use in adult patients treated with dabigatran when rapid reversal of its anticoagulant effect is required. Clinical experience with idarucizumab is currently limited. We report 11 real-life clinical cases in which idarucizumab was used after multidisciplinary consultation in a variety of emergency situations including severe postoperative bleeding, emergency high-bleeding-risk surgery (hip/spine surgery and neurosurgery), invasive diagnostic testing (lumbar puncture), intracranial bleeding (pre-pontine subarachnoid hemorrhage and lobar intracerebral hemorrhage) and thrombolysis with recombinant tissue plasminogen activator for acute ischemic stroke. This case series illustrates the role of idarucizumab in improving patient safety in rare emergency situations requiring rapid reversal of the anticoagulant effect of dabigatran, while highlighting the importance of information and education about the availability and appropriate use of this recently approved specific reversal agent.
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Affiliation(s)
- Milan R Vosko
- Department of Neurology 2, Kepler Universitätsklinikum, Med Campus III, Krankenhausstr. 9, 4020, Linz, Austria.
| | | | - Rafał Drwiła
- Department of Anesthesiology and Intensive Care, John Paul II Hospital, Medical College of Jagiellonian University, Krakow, Poland
| | - Petr Dulíček
- Fourth Department of Internal Medicine, Hematology, Hradec Králové Faculty of Medicine, Hradec Králové University Hospital, Hradec Králové, Czech Republic
| | - Tomas Hauer
- Department of Internal Medicine, České Budějovice Regional Hospital, and Faculty of Health and Science, University of South Bohemia, České Budějovice, Czech Republic
| | - Johannes Mutzenbach
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria
| | - Christoph J Schlimp
- Department of Anesthesiology and Intensive Care, AUVA Trauma Hospital, Klagenfurt, Austria
| | - David Špinler
- Department of Internal Medicine, Ústí nad Orlicí Hospital, Ústí nad Labem, Czech Republic
- Department of Cardiology, Pardubice Regional Hospital, Pardubice, Czech Republic
| | - Thomas Wolf
- Department of Neurology, Wiener Neustadt Regional Hospital, Wiener Neustadt, Austria
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Hobbelt AH, Siland JE, Geelhoed B, Van Der Harst P, Hillege HL, Van Gelder IC, Rienstra M. Clinical, biomarker, and genetic predictors of specific types of atrial fibrillation in a community-based cohort: data of the PREVEND study. Europace 2017; 19:226-232. [PMID: 28175276 PMCID: PMC5834149 DOI: 10.1093/europace/euw016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Accepted: 01/18/2016] [Indexed: 11/14/2022] Open
Abstract
Aims Atrial fibrillation (AF) may present variously in time, and AF may progress from self-terminating to non-self-terminating AF, and is associated with impaired prognosis. However, predictors of AF types are largely unexplored. We investigate the clinical, biomarker, and genetic predictors of development of specific types of AF in a community-based cohort. Methods We included 8042 individuals (319 with incident AF) of the PREVEND study. Types of AF were compared, and multivariate multinomial regression analysis determined associations with specific types of AF. Results Mean age was 48.5 ± 12.4 years and 50% were men. The types of incident AF were ascertained based on electrocardiograms; 103(32%) were classified as AF without 2-year recurrence, 158(50%) as self-terminating AF, and 58(18%) as non-self-terminating AF. With multivariate multinomial logistic regression analysis, advancing age (P< 0.001 for all three types) was associated with all AF types, male sex was associated with AF without 2-year recurrence and self-terminating AF (P= 0.031 and P= 0.008, respectively). Increasing body mass index and MR-proANP were associated with both self-terminating (P= 0.009 and P< 0.001) and non-self-terminating AF (P= 0.003 and P< 0.001). The only predictor associated with solely self-terminating AF is prescribed anti-hypertensive treatment (P= 0.019). The following predictors were associated with non-self-terminating AF; lower heart rate (P= 0.018), lipid-lowering treatment prescribed (P= 0.009), and eGFR <60 mL/min/1.73 m2 (P= 0.006). Three known AF-genetic variants (rs6666258, rs6817105, and rs10821415) were associated with self-terminating AF. Conclusions We found clinical, biomarker and genetic predictors of specific types of incident AF in a community-based cohort. The genetic background seems to play a more important role than modifiable risk factors in self-terminating AF.
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Affiliation(s)
- Anne H. Hobbelt
- Department of Cardiology, University of Groningen, University Medical Center Groningen, PO Box 30.001, 9700 RB Groningen, The Netherlands
| | - Joylene E. Siland
- Department of Cardiology, University of Groningen, University Medical Center Groningen, PO Box 30.001, 9700 RB Groningen, The Netherlands
| | - Bastiaan Geelhoed
- Department of Cardiology, University of Groningen, University Medical Center Groningen, PO Box 30.001, 9700 RB Groningen, The Netherlands
| | - Pim Van Der Harst
- Department of Cardiology, University of Groningen, University Medical Center Groningen, PO Box 30.001, 9700 RB Groningen, The Netherlands
| | - Hans L. Hillege
- Department of Cardiology, University of Groningen, University Medical Center Groningen, PO Box 30.001, 9700 RB Groningen, The Netherlands
| | - Isabelle C. Van Gelder
- Department of Cardiology, University of Groningen, University Medical Center Groningen, PO Box 30.001, 9700 RB Groningen, The Netherlands
| | - Michiel Rienstra
- Department of Cardiology, University of Groningen, University Medical Center Groningen, PO Box 30.001, 9700 RB Groningen, The Netherlands
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Gorenek B, Pelliccia A, Benjamin EJ, Boriani G, Crijns HJ, Fogel RI, Van Gelder IC, Halle M, Kudaiberdieva G, Lane DA, Bjerregaard Larsen T, Lip GYH, Løchen ML, Marin F, Niebauer J, Sanders P, Tokgozoglu L, Vos MA, Van Wagoner DR, Fauchier L, Savelieva I, Goette A, Agewall S, Chiang CE, Figueiredo M, Stiles M, Dickfeld T, Patton K, Piepoli M, Corra U, Manuel Marques-Vidal P, Faggiano P, Schmid JP, Abreu A. European Heart Rhythm Association (EHRA)/European Association of Cardiovascular Prevention and Rehabilitation (EACPR) position paper on how to prevent atrial fibrillation endorsed by the Heart Rhythm Society (HRS) and Asia Pacific Heart Rhythm Society (APHRS). Eur J Prev Cardiol 2017; 24:4-40. [PMID: 27815538 PMCID: PMC5427484 DOI: 10.1177/2047487316676037] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
| | | | | | | | - Harry J Crijns
- Maastricht University Medical Centre, Maastricht, The Netherlands
| | | | | | - Martin Halle
- Prevention and Sports Medicine, Technical University Munich, München, Germany
| | | | | | | | | | - Maja-Lisa Løchen
- UiT The Arctic University of Norway, Tromso, Norway
- Mary MacKillop Institute for Health Research, Centre for Research Excellence to Reduce Inequality in Heart Disease, Australian Catholic University, Melbourne, Australia
| | | | - Josef Niebauer
- Paracelsus Medical University Salzburg, Salzburg, Austria
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Ugo Corra
- Irccs Rehabilitation Medical Center, Veruno, Italy
| | | | | | | | - Ana Abreu
- Hospital de Santa Marta, Lisboa, Portugal
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Rienstra M, Geelhoed B, Yin X, Siland JE, Vermond RA, Mulder BA, Van Der Harst P, Hillege HL, Benjamin EJ, Van Gelder IC. Cluster Individuals Based on Phenotype and Determine the Risk for Atrial Fibrillation in the PREVEND and Framingham Heart Study Populations. PLoS One 2016; 11:e0165828. [PMID: 27832125 PMCID: PMC5104331 DOI: 10.1371/journal.pone.0165828] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 10/04/2016] [Indexed: 12/11/2022] Open
Abstract
Background Risk prediction of atrial fibrillation (AF) is of importance to improve the early diagnosis and treatment of AF. Latent class analysis takes into account the possible existence of classes of individuals each with shared risk factors, and maybe a better method of incorporating the phenotypic heterogeneity underlying AF. Methods and findings Two prospective community-based cohort studies from Netherlands and United States were used. Prevention of Renal and Vascular End-stage Disease (PREVEND) study, started in 1997, and the Framingham Heart Study (FHS) Offspring cohort started in 1971, both with 10-years follow-up. The main objective was to determine the risk of AF using a latent class analysis, and compare the discrimination and reclassification performance with traditional regression analysis. Mean age in PREVEND was 49±13 years, 49.8% were men. During follow-up, 250(3%) individuals developed AF. We built a latent class model based on 18 risk factors. A model with 7 distinct classes (ranging from 341 to 1517 individuals) gave the optimum tradeoff between a high statistical model-likelihood and a low number of model parameters. All classes had a specific profile. The incidence of AF varied; class 1 0.0%, class 2 0.3%, class 3 7.5%, class 4 0.2%, class 5 1.3%, class 6 4.2%, class 7 21.7% (p<0.001). The discrimination (C-statistic 0.830 vs. 0.842, delta-C -0.013, p = 0.22) and reclassification (IDI -0.028, p<0.001, NRI -0.090, p = 0.049, and category-less-NRI -0.049, p = 0.495) performance of both models was comparable. The results were successfully replicated in a sample of the FHS study (n = 3162; mean age 58±9 years, 46.3% men). Conclusions Latent class analysis to build an AF risk model is feasible. Despite the heterogeneity in number and severity of risk factors between individuals at risk for AF, latent class analysis produces distinguishable groups.
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Affiliation(s)
- Michiel Rienstra
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- * E-mail:
| | - Bastiaan Geelhoed
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Xiaoyan Yin
- National Heart Lung and Blood Institute's and Boston University's Framingham Heart Study, Framingham, Massachusetts, United States of America
| | - Joylene E. Siland
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Rob A. Vermond
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Bart A. Mulder
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Pim Van Der Harst
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Hans L. Hillege
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Emelia J. Benjamin
- National Heart Lung and Blood Institute's and Boston University's Framingham Heart Study, Framingham, Massachusetts, United States of America
- Section of Cardiovascular Medicine, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, United States of America
- Section of Preventive Medicine, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, United States of America
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Isabelle C. Van Gelder
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, Castella M, Diener HC, Heidbuchel H, Hendriks J, Hindricks G, Manolis AS, Oldgren J, Popescu BA, Schotten U, Van Putte B, Vardas P. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016; 37:2893-2962. [PMID: 27567408 DOI: 10.1093/eurheartj/ehw210] [Citation(s) in RCA: 4722] [Impact Index Per Article: 590.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
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Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, Castella M, Diener HC, Heidbuchel H, Hendriks J, Hindricks G, Manolis AS, Oldgren J, Popescu BA, Schotten U, Van Putte B, Vardas P, Agewall S, Camm J, Baron Esquivias G, Budts W, Carerj S, Casselman F, Coca A, De Caterina R, Deftereos S, Dobrev D, Ferro JM, Filippatos G, Fitzsimons D, Gorenek B, Guenoun M, Hohnloser SH, Kolh P, Lip GYH, Manolis A, McMurray J, Ponikowski P, Rosenhek R, Ruschitzka F, Savelieva I, Sharma S, Suwalski P, Tamargo JL, Taylor CJ, Van Gelder IC, Voors AA, Windecker S, Zamorano JL, Zeppenfeld K. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur J Cardiothorac Surg 2016; 50:e1-e88. [DOI: 10.1093/ejcts/ezw313] [Citation(s) in RCA: 602] [Impact Index Per Article: 75.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
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Oldgren J, Hijazi Z, Lindbäck J, Alexander JH, Connolly SJ, Eikelboom JW, Ezekowitz MD, Granger CB, Hylek EM, Lopes RD, Siegbahn A, Yusuf S, Wallentin L. Performance and Validation of a Novel Biomarker-Based Stroke Risk Score for Atrial Fibrillation. Circulation 2016; 134:1697-1707. [PMID: 27569438 DOI: 10.1161/circulationaha.116.022802] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 07/29/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Atrial fibrillation is associated with increased but variable risk of stroke. Our aim was to validate the recently developed biomarker-based ABC (age, biomarkers [high-sensitivity troponin and N-terminal fragment B-type natriuretic peptide], and clinical history of prior stroke/transient ischemic attack)-stroke risk score and compare its performance with the CHA2DS2VASc and ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation) risk scores. METHODS The ABC-stroke score includes age, biomarkers (N-terminal fragment B-type natriuretic peptide and high-sensitivity cardiac troponin), and clinical history (prior stroke). This validation was based on 8356 patients, 16 137 person-years of follow-up, and 219 adjudicated stroke or systemic embolic events in anticoagulated patients with atrial fibrillation in the RE-LY study (Randomized Evaluation of Long-Term Anticoagulation Therapy). Levels of N-terminal fragment B-type natriuretic peptide, high-sensitivity cardiac troponin T (hs-cTnT), and high-sensitivity cardiac troponin I (hs-cTnI) were determined in plasma samples obtained at study entry. RESULTS The ABC-stroke score was well calibrated with 0.76 stroke/systemic embolic events per 100 person-years in the predefined low (<1%/y) risk group, 1.48 in the medium (1%-2%/y) risk group, and 2.60 in the high (>2%/y) risk group for the ABC-stroke score with hs-cTnT. Hazard ratios for stroke/systemic embolic events were 1.95 for medium- versus low-risk groups, and 3.44 for high- versus low-risk groups. ABC-stroke score achieved C indices of 0.65 with both hs-cTnT and hs-cTnI, in comparison with 0.60 for CHA2DS2VASc (P=0.004 for hs-cTnT and P=0.022 hs-cTnI) and 0.61 for ATRIA scores (P=0.005 hs-cTnT and P=0.034 for hs-cTnI). CONCLUSIONS The biomarker-based ABC-stroke score was well calibrated and consistently performed better than both the CHA2DS2VASc and ATRIA stroke scores. The ABC score should be considered an improved decision support tool in the care of patients with atrial fibrillation. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifiers: ARISTOTLE, NCT00412984; RE-LY, NCT00262600.
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Affiliation(s)
- Jonas Oldgren
- From Department of Medical Sciences, Cardiology, Uppsala University, Sweden (J.O., Z.H., L.W.); Uppsala Clinical Research Center, Uppsala University, Sweden (J.O., Z.H., J.L., A.S., L.W.); Duke Clinical Research Institute, Duke Medicine, Durham, NC (J.H.A., C.B.G., R.D.L.); Population Health Research Institute, Hamilton, Canada (S.J.C., J.W.E., S.Y.); Thomas Jefferson Medical College and the Heart Center, Wynnewood, PA (M.D.E.); Boston University Medical Center, MA (E.M.H.); and Department of Medical Sciences, Clinical Chemistry, Uppsala University, Sweden (A.S.).
| | - Ziad Hijazi
- From Department of Medical Sciences, Cardiology, Uppsala University, Sweden (J.O., Z.H., L.W.); Uppsala Clinical Research Center, Uppsala University, Sweden (J.O., Z.H., J.L., A.S., L.W.); Duke Clinical Research Institute, Duke Medicine, Durham, NC (J.H.A., C.B.G., R.D.L.); Population Health Research Institute, Hamilton, Canada (S.J.C., J.W.E., S.Y.); Thomas Jefferson Medical College and the Heart Center, Wynnewood, PA (M.D.E.); Boston University Medical Center, MA (E.M.H.); and Department of Medical Sciences, Clinical Chemistry, Uppsala University, Sweden (A.S.)
| | - Johan Lindbäck
- From Department of Medical Sciences, Cardiology, Uppsala University, Sweden (J.O., Z.H., L.W.); Uppsala Clinical Research Center, Uppsala University, Sweden (J.O., Z.H., J.L., A.S., L.W.); Duke Clinical Research Institute, Duke Medicine, Durham, NC (J.H.A., C.B.G., R.D.L.); Population Health Research Institute, Hamilton, Canada (S.J.C., J.W.E., S.Y.); Thomas Jefferson Medical College and the Heart Center, Wynnewood, PA (M.D.E.); Boston University Medical Center, MA (E.M.H.); and Department of Medical Sciences, Clinical Chemistry, Uppsala University, Sweden (A.S.)
| | - John H Alexander
- From Department of Medical Sciences, Cardiology, Uppsala University, Sweden (J.O., Z.H., L.W.); Uppsala Clinical Research Center, Uppsala University, Sweden (J.O., Z.H., J.L., A.S., L.W.); Duke Clinical Research Institute, Duke Medicine, Durham, NC (J.H.A., C.B.G., R.D.L.); Population Health Research Institute, Hamilton, Canada (S.J.C., J.W.E., S.Y.); Thomas Jefferson Medical College and the Heart Center, Wynnewood, PA (M.D.E.); Boston University Medical Center, MA (E.M.H.); and Department of Medical Sciences, Clinical Chemistry, Uppsala University, Sweden (A.S.)
| | - Stuart J Connolly
- From Department of Medical Sciences, Cardiology, Uppsala University, Sweden (J.O., Z.H., L.W.); Uppsala Clinical Research Center, Uppsala University, Sweden (J.O., Z.H., J.L., A.S., L.W.); Duke Clinical Research Institute, Duke Medicine, Durham, NC (J.H.A., C.B.G., R.D.L.); Population Health Research Institute, Hamilton, Canada (S.J.C., J.W.E., S.Y.); Thomas Jefferson Medical College and the Heart Center, Wynnewood, PA (M.D.E.); Boston University Medical Center, MA (E.M.H.); and Department of Medical Sciences, Clinical Chemistry, Uppsala University, Sweden (A.S.)
| | - John W Eikelboom
- From Department of Medical Sciences, Cardiology, Uppsala University, Sweden (J.O., Z.H., L.W.); Uppsala Clinical Research Center, Uppsala University, Sweden (J.O., Z.H., J.L., A.S., L.W.); Duke Clinical Research Institute, Duke Medicine, Durham, NC (J.H.A., C.B.G., R.D.L.); Population Health Research Institute, Hamilton, Canada (S.J.C., J.W.E., S.Y.); Thomas Jefferson Medical College and the Heart Center, Wynnewood, PA (M.D.E.); Boston University Medical Center, MA (E.M.H.); and Department of Medical Sciences, Clinical Chemistry, Uppsala University, Sweden (A.S.)
| | - Michael D Ezekowitz
- From Department of Medical Sciences, Cardiology, Uppsala University, Sweden (J.O., Z.H., L.W.); Uppsala Clinical Research Center, Uppsala University, Sweden (J.O., Z.H., J.L., A.S., L.W.); Duke Clinical Research Institute, Duke Medicine, Durham, NC (J.H.A., C.B.G., R.D.L.); Population Health Research Institute, Hamilton, Canada (S.J.C., J.W.E., S.Y.); Thomas Jefferson Medical College and the Heart Center, Wynnewood, PA (M.D.E.); Boston University Medical Center, MA (E.M.H.); and Department of Medical Sciences, Clinical Chemistry, Uppsala University, Sweden (A.S.)
| | - Christopher B Granger
- From Department of Medical Sciences, Cardiology, Uppsala University, Sweden (J.O., Z.H., L.W.); Uppsala Clinical Research Center, Uppsala University, Sweden (J.O., Z.H., J.L., A.S., L.W.); Duke Clinical Research Institute, Duke Medicine, Durham, NC (J.H.A., C.B.G., R.D.L.); Population Health Research Institute, Hamilton, Canada (S.J.C., J.W.E., S.Y.); Thomas Jefferson Medical College and the Heart Center, Wynnewood, PA (M.D.E.); Boston University Medical Center, MA (E.M.H.); and Department of Medical Sciences, Clinical Chemistry, Uppsala University, Sweden (A.S.)
| | - Elaine M Hylek
- From Department of Medical Sciences, Cardiology, Uppsala University, Sweden (J.O., Z.H., L.W.); Uppsala Clinical Research Center, Uppsala University, Sweden (J.O., Z.H., J.L., A.S., L.W.); Duke Clinical Research Institute, Duke Medicine, Durham, NC (J.H.A., C.B.G., R.D.L.); Population Health Research Institute, Hamilton, Canada (S.J.C., J.W.E., S.Y.); Thomas Jefferson Medical College and the Heart Center, Wynnewood, PA (M.D.E.); Boston University Medical Center, MA (E.M.H.); and Department of Medical Sciences, Clinical Chemistry, Uppsala University, Sweden (A.S.)
| | - Renato D Lopes
- From Department of Medical Sciences, Cardiology, Uppsala University, Sweden (J.O., Z.H., L.W.); Uppsala Clinical Research Center, Uppsala University, Sweden (J.O., Z.H., J.L., A.S., L.W.); Duke Clinical Research Institute, Duke Medicine, Durham, NC (J.H.A., C.B.G., R.D.L.); Population Health Research Institute, Hamilton, Canada (S.J.C., J.W.E., S.Y.); Thomas Jefferson Medical College and the Heart Center, Wynnewood, PA (M.D.E.); Boston University Medical Center, MA (E.M.H.); and Department of Medical Sciences, Clinical Chemistry, Uppsala University, Sweden (A.S.)
| | - Agneta Siegbahn
- From Department of Medical Sciences, Cardiology, Uppsala University, Sweden (J.O., Z.H., L.W.); Uppsala Clinical Research Center, Uppsala University, Sweden (J.O., Z.H., J.L., A.S., L.W.); Duke Clinical Research Institute, Duke Medicine, Durham, NC (J.H.A., C.B.G., R.D.L.); Population Health Research Institute, Hamilton, Canada (S.J.C., J.W.E., S.Y.); Thomas Jefferson Medical College and the Heart Center, Wynnewood, PA (M.D.E.); Boston University Medical Center, MA (E.M.H.); and Department of Medical Sciences, Clinical Chemistry, Uppsala University, Sweden (A.S.)
| | - Salim Yusuf
- From Department of Medical Sciences, Cardiology, Uppsala University, Sweden (J.O., Z.H., L.W.); Uppsala Clinical Research Center, Uppsala University, Sweden (J.O., Z.H., J.L., A.S., L.W.); Duke Clinical Research Institute, Duke Medicine, Durham, NC (J.H.A., C.B.G., R.D.L.); Population Health Research Institute, Hamilton, Canada (S.J.C., J.W.E., S.Y.); Thomas Jefferson Medical College and the Heart Center, Wynnewood, PA (M.D.E.); Boston University Medical Center, MA (E.M.H.); and Department of Medical Sciences, Clinical Chemistry, Uppsala University, Sweden (A.S.)
| | - Lars Wallentin
- From Department of Medical Sciences, Cardiology, Uppsala University, Sweden (J.O., Z.H., L.W.); Uppsala Clinical Research Center, Uppsala University, Sweden (J.O., Z.H., J.L., A.S., L.W.); Duke Clinical Research Institute, Duke Medicine, Durham, NC (J.H.A., C.B.G., R.D.L.); Population Health Research Institute, Hamilton, Canada (S.J.C., J.W.E., S.Y.); Thomas Jefferson Medical College and the Heart Center, Wynnewood, PA (M.D.E.); Boston University Medical Center, MA (E.M.H.); and Department of Medical Sciences, Clinical Chemistry, Uppsala University, Sweden (A.S.)
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Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, Castella M, Diener HC, Heidbuchel H, Hendriks J, Hindricks G, Manolis AS, Oldgren J, Popescu BA, Schotten U, Van Putte B, Vardas P, Agewall S, Camm J, Baron Esquivias G, Budts W, Carerj S, Casselman F, Coca A, De Caterina R, Deftereos S, Dobrev D, Ferro JM, Filippatos G, Fitzsimons D, Gorenek B, Guenoun M, Hohnloser SH, Kolh P, Lip GYH, Manolis A, McMurray J, Ponikowski P, Rosenhek R, Ruschitzka F, Savelieva I, Sharma S, Suwalski P, Tamargo JL, Taylor CJ, Van Gelder IC, Voors AA, Windecker S, Zamorano JL, Zeppenfeld K. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Europace 2016; 18:1609-1678. [PMID: 27567465 DOI: 10.1093/europace/euw295] [Citation(s) in RCA: 1318] [Impact Index Per Article: 164.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Stefan Agewall
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - John Camm
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Gonzalo Baron Esquivias
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Werner Budts
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Scipione Carerj
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Filip Casselman
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Antonio Coca
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Raffaele De Caterina
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Spiridon Deftereos
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Dobromir Dobrev
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - José M Ferro
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Gerasimos Filippatos
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Donna Fitzsimons
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Bulent Gorenek
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Maxine Guenoun
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Stefan H Hohnloser
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Philippe Kolh
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Gregory Y H Lip
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Athanasios Manolis
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - John McMurray
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Piotr Ponikowski
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Raphael Rosenhek
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Frank Ruschitzka
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Irina Savelieva
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Sanjay Sharma
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Piotr Suwalski
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Juan Luis Tamargo
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Clare J Taylor
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Isabelle C Van Gelder
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Adriaan A Voors
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Stephan Windecker
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Jose Luis Zamorano
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Katja Zeppenfeld
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
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Abstract
Atrial fibrillation (AF) is an extremely prevalent arrhythmia that presents a wide range of therapeutic challenges. AF usually begins in a self-terminating paroxysmal form (pAF). With time, the AF pattern often evolves to become persistent (nonterminating within 7 days). Important differences exist between pAF and persistent AF in terms of clinical features, in particular the responsiveness to antiarrhythmic drugs and ablation therapy. AF mechanisms have been extensively reviewed, but few or no Reviews focus specifically on the pathophysiology of pAF. Accordingly, in this Review, we examine the available data on the electrophysiological basis for pAF occurrence and maintenance, as well as the molecular mechanisms forming the underlying substrate. We first consider the mechanistic insights that have been obtained from clinical studies in the electrophysiology laboratory, noninvasive observations, and genetic studies. We then discuss the information about underlying molecular mechanisms that has been obtained from experimental studies on animal models and patient samples. Finally, we discuss the data available from animal models with spontaneous AF presentation, their relationship to clinical findings, and their relevance to understanding the mechanisms underlying pAF. Our analysis then turns to potential factors governing cases of progression from pAF to persistent AF and the clinical implications of the basic mechanisms we review. We conclude by identifying and discussing questions that we consider particularly important to address through future research in this area.
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Kim EJ, Yin X, Fontes JD, Magnani JW, Lubitz SA, McManus DD, Seshadri S, Vasan RS, Ellinor PT, Larson MG, Benjamin EJ, Rienstra M. Atrial fibrillation without comorbidities: Prevalence, incidence and prognosis (from the Framingham Heart Study). Am Heart J 2016; 177:138-44. [PMID: 27297859 DOI: 10.1016/j.ahj.2016.03.023] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Accepted: 03/29/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND The epidemiology of atrial fibrillation (AF) without comorbidities, known as 'lone AF', is uncertain. Although it has been considered a benign condition, we hypothesized that it confers a worse prognosis compared with a matched sample without AF. METHODS We described the proportion of AF without comorbidities (clinical, subclinical cardiovascular disease and triggers) among the entire AF sample in Framingham Heart Study (FHS). We compared AF without comorbidities with typical AF, and age-, sex- and cohort-matched individuals without AF, using Cox proportional hazards analysis in relation to combined cardiovascular events (stroke, heart failure, myocardial infarction), and mortality. RESULTS Of 10,311 FHS participants, 1,961 were diagnosed with incident AF, among which 173 individuals had AF without comorbidities (47% women, mean age 71±12 years). AF without comorbidities had a prevalence of 1.7% of the entire cohort, and an annual incidence of 0.5 per 1000 person-years. During a median follow-up of 9.7 years after initial AF, 137 individuals with AF without comorbidities (79.2%) died and 141 individuals developed cardiovascular events (81.5%). AF without comorbidities had significantly lower mortality (HR 0.67, 95%CI 0.55-0.81, P < .001) and total cardiovascular events (HR 0.66, 95% CI 0.55-0.80, P < .001) compared with typical AF. However, mortality (HR1.43, 95% CI 1.18-1.75, P < .001) and risk of total cardiovascular events (HR 1.73, 95% CI 1.39-2.16, P < .001) were higher than age-, sex-, and cohort-matched individuals without AF. CONCLUSIONS The risk of cardiovascular outcomes and mortality among individuals with AF without comorbidities is lower than typical AF, but is significantly elevated compared with matched individuals without AF.
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Affiliation(s)
- Eun-Jeong Kim
- Department of Medicine, Section of General Internal Medicine, Massachusetts General Hospital, Boston, MA
| | - Xiaoyan Yin
- National Heart Lung and Blood Institute's and Boston University's Framingham Heart Study, Framingham, MA
| | - João D Fontes
- National Heart Lung and Blood Institute's and Boston University's Framingham Heart Study, Framingham, MA
| | - Jared W Magnani
- National Heart Lung and Blood Institute's and Boston University's Framingham Heart Study, Framingham, MA; Section of Cardiovascular Medicine, Department of Medicine, Boston University School of Medicine, MA
| | - Steve A Lubitz
- Cardiovascular Research Center and Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, MA; Program in Medical and Population Genetics, The Broad Institute of Harvard and MIT, Cambridge, MA
| | - David D McManus
- Departments of Medicine and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| | - Sudha Seshadri
- National Heart Lung and Blood Institute's and Boston University's Framingham Heart Study, Framingham, MA; Departments of Neurology, Boston University School of Medicine, Boston, MA
| | - Ramachandran S Vasan
- National Heart Lung and Blood Institute's and Boston University's Framingham Heart Study, Framingham, MA; Section of Cardiovascular Medicine, Department of Medicine, Boston University School of Medicine, MA; Section of Preventive Medicine, Department of Medicine, Boston University School of Medicine, MA
| | - Patrick T Ellinor
- Cardiovascular Research Center and Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, MA; Program in Medical and Population Genetics, The Broad Institute of Harvard and MIT, Cambridge, MA
| | - Martin G Larson
- National Heart Lung and Blood Institute's and Boston University's Framingham Heart Study, Framingham, MA; Department of Mathematics and Statistics, Boston University, MA; Department of Biostatistics, Boston University School of Public Health, MA
| | - Emelia J Benjamin
- National Heart Lung and Blood Institute's and Boston University's Framingham Heart Study, Framingham, MA; Section of Cardiovascular Medicine, Department of Medicine, Boston University School of Medicine, MA; Section of Preventive Medicine, Department of Medicine, Boston University School of Medicine, MA; Department of Epidemiology, Boston University School of Public Health, Boston, MA
| | - Michiel Rienstra
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
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Hijazi Z, Oldgren J, Lindbäck J, Alexander JH, Connolly SJ, Eikelboom JW, Ezekowitz MD, Held C, Hylek EM, Lopes RD, Siegbahn A, Yusuf S, Granger CB, Wallentin L. The novel biomarker-based ABC (age, biomarkers, clinical history)-bleeding risk score for patients with atrial fibrillation: a derivation and validation study. Lancet 2016; 387:2302-2311. [PMID: 27056738 DOI: 10.1016/s0140-6736(16)00741-8] [Citation(s) in RCA: 334] [Impact Index Per Article: 41.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND The benefit of oral anticoagulation in atrial fibrillation is based on a balance between reduction in ischaemic stroke and increase in major bleeding. We aimed to develop and validate a new biomarker-based risk score to improve the prognostication of major bleeding in patients with atrial fibrillation. METHODS We developed and internally validated a new biomarker-based risk score for major bleeding in 14,537 patients with atrial fibrillation randomised to apixaban versus warfarin in the ARISTOTLE trial and externally validated it in 8468 patients with atrial fibrillation randomised to dabigatran versus warfarin in the RE-LY trial. Plasma samples for determination of candidate biomarker concentrations were obtained at randomisation. Major bleeding events were centrally adjudicated. The predictive values of biomarkers and clinical variables were assessed with Cox regression models. The most important variables were included in the score with weights proportional to the model coefficients. The ARISTOTLE and RE-LY trials are registered with ClinicalTrials.gov, numbers NCT00412984 and NCT00262600, respectively. FINDINGS The most important predictors for major bleeding were the concentrations of the biomarkers growth differentiation factor-15 (GDF-15), high-sensitivity cardiac troponin T (cTnT-hs) and haemoglobin, age, and previous bleeding. The ABC-bleeding score (age, biomarkers [GDF-15, cTnT-hs, and haemoglobin], and clinical history [previous bleeding]) score yielded a higher c-index than the conventional HAS-BLED and the newer ORBIT scores for major bleeding in both the derivation cohort (0·68 [95% CI 0·66-0·70] vs 0·61 [0·59-0·63] vs 0·65 [0·62-0·67], respectively; ABC-bleeding vs HAS-BLED p<0·0001 and ABC-bleeding vs ORBIT p=0·0008). ABC-bleeding score also yielded a higher c-index score in the the external validation cohort (0·71 [95% CI 0·68-0·73] vs 0·62 [0·59-0·64] for HAS-BLED vs 0·68 [0·65-0·70] for ORBIT; ABC-bleeding vs HAS-BLED p<0·0001 and ABC-bleeding vs ORBIT p=0·0016). A modified ABC-bleeding score using alternative biomarkers (haematocrit, cTnI-hs, cystatin C, or creatinine clearance) also outperformed the HAS-BLED and ORBIT scores. INTERPRETATION The ABC-bleeding score, using age, history of bleeding, and three biomarkers (haemoglobin, cTn-hs, and GDF-15 or cystatin C/CKD-EPI) was internally and externally validated and calibrated in large cohorts of patients with atrial fibrillation receiving anticoagulation therapy. The ABC-bleeding score performed better than HAS-BLED and ORBIT scores and should be useful as decision support on anticoagulation treatment in patients with atrial fibrillation. FUNDING BMS, Pfizer, Boehringer Ingelheim, Roche Diagnostics.
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Affiliation(s)
- Ziad Hijazi
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden; Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden.
| | - Jonas Oldgren
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden; Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Johan Lindbäck
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - John H Alexander
- Duke Clinical Research Institute, Duke Medicine, Durham, NC, USA
| | | | | | | | - Claes Held
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden; Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | | | - Renato D Lopes
- Duke Clinical Research Institute, Duke Medicine, Durham, NC, USA
| | - Agneta Siegbahn
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden; Department of Medical Sciences, Clinical Chemistry, Uppsala University, Uppsala, Sweden
| | - Salim Yusuf
- Population Health Research Institute, Hamilton, ON, Canada
| | | | - Lars Wallentin
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden; Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
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48
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Atrial fibrillation burden and atrial fibrillation type: Clinical significance and impact on the risk of stroke and decision making for long-term anticoagulation. Vascul Pharmacol 2016; 83:26-35. [PMID: 27196706 DOI: 10.1016/j.vph.2016.03.006] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Revised: 03/04/2016] [Accepted: 03/24/2016] [Indexed: 12/20/2022]
Abstract
Atrial fibrillation (AF) is a common arrhythmia increasing the risk of morbidity and adverse outcomes (stroke, heart failure, death). AF is found in 1-2% of the general population, with increasing prevalence with aging. Its exact epidemiological profile is incomplete and underestimated, because 10-40% of AF patients (particularly the elderly) can be asymptomatic ("clinically silent or subclinical AF"), with occasional electrocardiographic diagnosis. The research interest on silent AF has increased by the evidence that its outcome is no less severe, in terms of risks of stroke and death, than that for symptomatic patients. Data collected from more than 18,000 patients indicate that cardiac implantable electrical devices (CIEDs) are validated tools for detecting silent AF and measuring the time spent in AF, defined as "AF burden." A maximum daily AF burden of ≥5-6min, but particularly ≥1h, is associated with a significant increase in the risk of stroke, and may be clinically relevant to improve current risk stratification based on risk scores and for "personalizing" prescription of oral anticoagulants. An in-depth study of the temporal relationship between AF and ischemic stroke showed that data from CIEDs reveal a complex scenario, by which AF is certainly a risk factor for cardioembolic stroke, with a cause-effect relationship related to atrial thrombi, but can also be a simple "marker of risk," with a noncausal association with stroke. In such cases, stroke is possibly related to atheroemboli from the aorta, the carotid arteries, or other sources.
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Schotten U, Dobrev D, Platonov PG, Kottkamp H, Hindricks G. Current controversies in determining the main mechanisms of atrial fibrillation. J Intern Med 2016; 279:428-38. [PMID: 26991914 DOI: 10.1111/joim.12492] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Despite considerable basic research into the mechanisms of atrial fibrillation (AF), not much progress has been made in the prognosis of patients with AF. With the exception of anticoagulant therapy, current treatments for AF still do not improve major cardiovascular outcomes. This may be due partly to the diverse aetiology of AF with increasingly more factors found to contribute to the arrhythmia. In addition, a strong increase has been seen in the technological complexity of the methods used to quantify the main pathophysiological alterations underlying the initiation and progression of AF. Because of the lack of standardization of the technological approaches currently used, the perception of basic mechanisms of AF varies widely in the scientific community. Areas of debate include the role of Ca(2+) -handling alterations associated with AF, the contribution and noninvasive assessment of the degree of atrial fibrosis, and the best techniques to identify electrophysiological drivers of AF. In this review, we will summarize the state of the art of these controversial topics and describe the diverse approaches to investigating and the scientific opinions on leading AF mechanisms. Finally, we will highlight the need for transparency in scientific reporting and standardization of terminology, assumptions, algorithms and experimental conditions used for the development of better AF therapies.
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Affiliation(s)
- U Schotten
- Cardiovascular Research Institute Maastricht, Maastricht Centre of Systems Biology, Maastricht University, Maastricht, The Netherlands
| | - D Dobrev
- Institute of Pharmacology, West German Heart and Vascular Center, School of Medicine, University Duisburg-Essen, Essen, Germany
| | - P G Platonov
- Center for Integrative Electrocardiology at Lund University (CIEL), Arrhythmia Clinic, Skåne University Hospital, Lund, Sweden
| | - H Kottkamp
- Department of Rhythmology, Klinik Hirslanden, Zürich, Switzerland
| | - G Hindricks
- Department of Cardiac Electrophysiology, Heart Center, University of Leipzig, Leipzig, Germany
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Camm AJ, Savelieva I, Potpara T, Hindriks G, Pison L, Blömstrom-Lundqvist C. The changing circumstance of atrial fibrillation - progress towards precision medicine. J Intern Med 2016; 279:412-27. [PMID: 27029018 DOI: 10.1111/joim.12478] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The prevalence of atrial fibrillation (AF) in the general population is between 1% and 2% in the developed world and is higher in men than in women. The arrhythmia occurs much more commonly in the elderly, and the estimated lifetime risk of developing AF is one in four for men and women aged 40 years and above. Projected data from multiple population-based studies in the USA and Europe predict a two- to threefold increase in the number of AF patients by 2060. The high lifetime risk of AF and increased longevity underscore the important public health burden posed by this arrhythmia worldwide. AF has multiple aetiologies and a broad variety of presentations. The primary pathologies underlying or promoting the occurrence of AF vary more than for any other cardiac arrhythmia, ranging from autonomic imbalance to organic heart disease and metabolic disorders, such as diabetes mellitus, metabolic syndrome, hyperthyroidism and kidney disease, and lifestyle factors such as smoking, alcohol consumption and participation in endurance sports. Biomarkers are increasingly being investigated and, together with clinical and genetic factors, will eventually lead to a clinically valuable detailed classification of AF which will also incorporate pathophysiological determinants and mechanisms of the arrhythmia. In turn, this will allow the development and application of precision medicine to this troublesome arrhythmia.
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Affiliation(s)
- A J Camm
- St. George's University of London, London, UK
| | - I Savelieva
- St. George's University of London, London, UK
| | - T Potpara
- Cardiology Clinic, School of Medicine, Clinical Centre of Serbia, University of Belgrade, Belgrade, Serbia
| | - G Hindriks
- Department of Electrophysiology, Herzzentrum Leipzig GmbH, Leipzig, Germany
| | - L Pison
- Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute, Maastricht, The Netherlands
| | - C Blömstrom-Lundqvist
- Department of Cardiology, Institution of Medical Science, Uppsala University, Uppsala, Sweden
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