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Ferguson C, Shaikh F, Allida SM, Hendriks J, Gallagher C, Bajorek BV, Donkor A, Inglis SC. Clinical service organisation for adults with atrial fibrillation. Cochrane Database Syst Rev 2024; 7:CD013408. [PMID: 39072702 PMCID: PMC11285297 DOI: 10.1002/14651858.cd013408.pub2] [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] [Indexed: 07/30/2024]
Abstract
BACKGROUND Atrial fibrillation (AF) is an increasingly prevalent heart rhythm condition in adults. It is considered a common cardiovascular condition with complex clinical management. The increasing prevalence and complexity in management underpin the need to adapt and innovate in the delivery of care for people living with AF. There is a need to systematically examine the optimal way in which clinical services are organised to deliver evidence-based care for people with AF. Recommended approaches include collaborative, organised multidisciplinary, and virtual (or eHealth/mHealth) models of care. OBJECTIVES To assess the effects of clinical service organisation for AF versus usual care for people with all types of AF. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and CINAHL to October 2022. We also searched ClinicalTrials.gov and the WHO ICTRP to April 2023. We applied no restrictions on date, publication status, or language. SELECTION CRITERIA We included randomised controlled trials (RCTs), published as full texts and as abstract only, involving adults (≥ 18 years) with a diagnosis of any type of AF. We included RCTs comparing organised clinical service, disease-specific management interventions (including e-health models of care) for people with AF that were multicomponent and multidisciplinary in nature to usual care. DATA COLLECTION AND ANALYSIS Three review authors independently selected studies, assessed risk of bias, and extracted data from the included studies. We calculated risk ratio (RR) for dichotomous data and mean difference (MD) or standardised mean difference (SMD) for continuous data with 95% confidence intervals (CIs) using random-effects analyses. We then calculated the number needed to treat for an additional beneficial outcome (NNTB) using the RR. We performed sensitivity analyses by only including studies with a low risk of selection and attrition bias. We assessed heterogeneity using the I² statistic and the certainty of the evidence according to GRADE. The primary outcomes were all-cause mortality and all-cause hospitalisation. The secondary outcomes were cardiovascular mortality, cardiovascular hospitalisation, AF-related emergency department visits, thromboembolic complications, minor cerebrovascular bleeding events, major cerebrovascular bleeding events, all bleeding events, AF-related quality of life, AF symptom burden, cost of intervention, and length of hospital stay. MAIN RESULTS We included 8 studies (8205 participants) of collaborative, multidisciplinary care, or virtual care for people with AF. The average age of participants ranged from 60 to 73 years. The studies were conducted in China, the Netherlands, and Australia. The included studies involved either a nurse-led multidisciplinary approach (n = 4) or management using mHealth (n = 2) compared to usual care. Only six out of the eight included studies could be included in the meta-analysis (for all-cause mortality and all-cause hospitalisation, cardiovascular mortality, cardiovascular hospitalisation, thromboembolic complications, and major bleeding), as quality of life was not assessed using a validated outcome measure specific for AF. We assessed the overall risk of bias as high, as all studies had at least one domain at unclear or high risk of bias rating for performance bias (blinding) in particular. Organised AF clinical services probably result in a large reduction in all-cause mortality (RR 0.64, 95% CI 0.46 to 0.89; 5 studies, 4664 participants; moderate certainty evidence; 6-year NNTB 37) compared to usual care. However, organised AF clinical services probably make little to no difference to all-cause hospitalisation (RR 0.94, 95% CI 0.88 to 1.02; 2 studies, 1340 participants; moderate certainty evidence; 2-year NNTB 101) and may not reduce cardiovascular mortality (RR 0.64, 95% CI 0.35 to 1.19; 5 studies, 4564 participants; low certainty evidence; 6-year NNTB 86) compared to usual care. Organised AF clinical services reduce cardiovascular hospitalisation (RR 0.83, 95% CI 0.71 to 0.96; 3 studies, 3641 participants; high certainty evidence; 6-year NNTB 28) compared to usual care. Organised AF clinical services may have little to no effect on thromboembolic complications such as stroke (RR 1.14, 95% CI 0.74 to 1.77; 5 studies, 4653 participants; low certainty evidence; 6-year NNTB 588) and major cerebrovascular bleeding events (RR 1.25, 95% CI 0.79 to 1.97; 3 studies, 2964 participants; low certainty evidence; 6-year NNTB 556). None of the studies reported minor cerebrovascular events. AUTHORS' CONCLUSIONS Moderate certainty evidence shows that organisation of clinical services for AF likely results in a large reduction in all-cause mortality, but probably makes little to no difference to all-cause hospitalisation compared to usual care. Organised AF clinical services may not reduce cardiovascular mortality, but do reduce cardiovascular hospitalisation compared to usual care. However, organised AF clinical services may make little to no difference to thromboembolic complications and major cerebrovascular events. None of the studies reported minor cerebrovascular events. Due to the limited number of studies, more research is required to compare different models of care organisation, including utilisation of mHealth. Appropriately powered trials are needed to confirm these findings and robustly examine the effect on inconclusive outcomes. The findings of this review underscore the importance of the co-ordination of care underpinned by collaborative multidisciplinary approaches and augmented by virtual care.
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Affiliation(s)
- Caleb Ferguson
- Centre for Chronic & Complex Care Research, Western Sydney Local Health District, Sydney, Australia
- School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, Australia
| | - Fahad Shaikh
- Centre for Chronic & Complex Care Research, Western Sydney Local Health District, Sydney, Australia
- School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, Australia
| | - Sabine M Allida
- Centre for Chronic & Complex Care Research, Western Sydney Local Health District, Sydney, Australia
- School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, Australia
| | - Jeroen Hendriks
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
- Centre for Heart Rhythm Disorders, University of Adelaide, South Australian Health and Medical Research Institute and Royal Adelaide Hospital, Adelaide, Australia
| | - Celine Gallagher
- Centre for Heart Rhythm Disorders, University of Adelaide, South Australian Health and Medical Research Institute and Royal Adelaide Hospital, Adelaide, Australia
| | - Beata V Bajorek
- Heart and Brain Program, Hunter Medical Research Institute, Newcastle, Australia
- College of Health, Medicine, and Wellbeing, University of Newcastle, Newcastle, Australia
- Department of Pharmacy, Hunter New England Local Health District, Newcastle, Australia
| | - Andrew Donkor
- IMPACCT, Faculty of Health, University of Technology Sydney, Sydney, Australia
| | - Sally C Inglis
- IMPACCT, Faculty of Health, University of Technology Sydney, Sydney, Australia
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Reinsch N, Füting A, Hartl S, Höwel D, Rausch E, Lin Y, Kasparian K, Neven K. Pulmonary vein isolation using pulsed field ablation vs. high-power short-duration radiofrequency ablation in paroxysmal atrial fibrillation: efficacy, safety, and long-term follow-up (PRIORI study). Europace 2024; 26:euae194. [PMID: 38996227 PMCID: PMC11267227 DOI: 10.1093/europace/euae194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Accepted: 07/05/2024] [Indexed: 07/14/2024] Open
Abstract
AIMS Pulsed field ablation (PFA) is a novel, non-thermal, cardiac tissue-selective ablation modality. To date, radiofrequency (RF)-guided high-power short-duration (HPSD) ablation represents the gold standard besides cryo-ablation for pulmonary vein isolation (PVI). This single-centre, retrospective study investigated the efficacy of PFA-PVI vs. HPSD-RF PVI in terms of single-procedure arrhythmia-free outcome and safety in a real-world setting. METHODS AND RESULTS Consecutive, paroxysmal atrial fibrillation (AF) patients who underwent PVI using PFA or HPSD-RF were enrolled. In group PFA, PVI was performed using a pentaspline PFA catheter. The ablation procedure in group HPSD-RF was performed with RF energy (45 W, ablation index). A total of 410 patients (group PFA, 201; group HPSD-RF, 209) were included. There was no difference between both groups regarding age, gender, and CHA2DS2-VASc score. The procedure time was significantly shorter in group PFA [61 (44-103) vs. 125 (105-143) min; P < 0.001]; fluoroscopy time and dose area product were significantly higher in group PFA [16 (13-20) vs. 4 (2-5) min; P < 0.01 and 412 (270-739) vs. 129 (58-265) μGym2; P < 0.01]. The overall complication rates were 2.9% in group PFA and 6.2% in group HPSD (P = 0.158). There was one fatal stroke in the PFA group. The 1-year Kaplan-Meier estimated freedom from any atrial tachyarrhythmia was 85% with PFA and 79% with HPSD-RF (log-rank P = 0.160). In 56 repeat ablation procedures, the PV reconnection rate was 30% after PFA and 38% after HPSD-RF (P = 0.372). CONCLUSION Both PFA and HPSD-RF were highly efficient and effective in achieving PVI in paroxysmal AF patients. The arrhythmia-free survival is comparable. The PV reconnection rate was not different.
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Affiliation(s)
- Nico Reinsch
- Department of Electrophysiology, Alfried Krupp Krankenhaus, Alfried-Krupp-Straße 21, 45131 Essen, Germany
- Department of Medicine, Witten/Herdecke University, Alfred-Herrhausen-Straße 50, 58448 Witten, Germany
| | - Anna Füting
- Department of Electrophysiology, Alfried Krupp Krankenhaus, Alfried-Krupp-Straße 21, 45131 Essen, Germany
- Department of Medicine, Witten/Herdecke University, Alfred-Herrhausen-Straße 50, 58448 Witten, Germany
| | - Stefan Hartl
- Department of Electrophysiology, Alfried Krupp Krankenhaus, Alfried-Krupp-Straße 21, 45131 Essen, Germany
- Department of Medicine, Witten/Herdecke University, Alfred-Herrhausen-Straße 50, 58448 Witten, Germany
| | - Dennis Höwel
- Department of Medicine, Witten/Herdecke University, Alfred-Herrhausen-Straße 50, 58448 Witten, Germany
- Department of Cardiology, St. Marienhospital Vechta, Vechta, Germany
| | - Eva Rausch
- Department of Electrophysiology, Alfried Krupp Krankenhaus, Alfried-Krupp-Straße 21, 45131 Essen, Germany
- Department of Medicine, Witten/Herdecke University, Alfred-Herrhausen-Straße 50, 58448 Witten, Germany
| | - Yali Lin
- Department of Electrophysiology, Alfried Krupp Krankenhaus, Alfried-Krupp-Straße 21, 45131 Essen, Germany
- Department of Medicine, Witten/Herdecke University, Alfred-Herrhausen-Straße 50, 58448 Witten, Germany
| | - Karampet Kasparian
- Department of Medicine, Witten/Herdecke University, Alfred-Herrhausen-Straße 50, 58448 Witten, Germany
- Department of Oncology, Gastroenterology and Hematology, Alfried Krupp Krankenhaus, Essen, Germany
| | - Kars Neven
- Department of Electrophysiology, Alfried Krupp Krankenhaus, Alfried-Krupp-Straße 21, 45131 Essen, Germany
- Department of Medicine, Witten/Herdecke University, Alfred-Herrhausen-Straße 50, 58448 Witten, Germany
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Carmo P, Mesquita D, Cabanelas N, Marinheiro AR, Nunes S, Chambel D, Moscoso Costa F, Sanfins V, Parreira L. Quality indicators in atrial fibrillation ablation (RIQAFA). A national registry from the Portuguese Association of Arrhythmology, Pacing and Electrophysiology (APAPE). Rev Port Cardiol 2024; 43:241-254. [PMID: 38122898 DOI: 10.1016/j.repc.2023.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 05/30/2023] [Accepted: 08/01/2023] [Indexed: 12/23/2023] Open
Abstract
INTRODUCTION AND OBJECTIVES Atrial fibrillation (AF) is the most common sustained arrhythmia, with significant burden for patients. Catheter ablation is safe and superior for symptom improvement. The purpose of this work was to assess how clinical practice compares with current scientific evidence and quality indicators for AF ablation. METHODS The Portuguese Association of Arrhythmology, Pacing and Electrophysiology conducted a prospective registry among Portuguese centers to assess clinical practice regarding management of patients referred for ablation and the methodology used in the procedures and related outcomes. RESULTS A total of 337 patients were referred for ablation, 102 (37.91%) female, age 65 (56-70.8) years. The median CHADS2-VaSC2 thromboembolic risk score was 2 (1-3), and 308 (92.49%) were on anticoagulants. AF was mainly paroxysmal (224, 66.97%) and symptomatic (mEHRA score 3; 2-3). Before ablation most patients (273, 81.49%) underwent cardiac computed tomography and only 24 (7.36%) procedures were performed with uninterrupted anticoagulation. For ablation, Carto® (194; 59.15%) and Ensite® (55; 16.77%) were mainly used, and the preferential strategy was pulmonary vein isolation (316; 94.61%). Acute complications occurred in five (1.49%) patients, while most had symptom improvement at one month (200; 86.21%), sustained at one year. There were 40 (12.6%) relapses within 30 days and 19 (26.39%) at one year. CONCLUSIONS In a population of patients with AF referred for ablation in Portuguese centers, patient management is provided according to the best scientific evidence and there is a high standard of practice with respect to the quality of AF ablation practice.
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Affiliation(s)
- Pedro Carmo
- Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental E.P.E., Carnaxide, Portugal; Hospital da Luz, Lisboa, Portugal
| | - Dinis Mesquita
- Hospital de São Bernardo, Centro Hospitalar de Setúbal E.P.E., Setúbal, Portugal.
| | - Nuno Cabanelas
- Hospital Prof. Doutor Fernando Fonseca E.P.E., Amadora, Portugal
| | - Ana Rita Marinheiro
- Hospital de São Bernardo, Centro Hospitalar de Setúbal E.P.E., Setúbal, Portugal
| | | | - Duarte Chambel
- Hospital de São Bernardo, Centro Hospitalar de Setúbal E.P.E., Setúbal, Portugal
| | - Francisco Moscoso Costa
- Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental E.P.E., Carnaxide, Portugal; National Centre for Data Collection in Cardiology (CNDC), Portugal
| | | | - Leonor Parreira
- Hospital da Luz, Lisboa, Portugal; Hospital de São Bernardo, Centro Hospitalar de Setúbal E.P.E., Setúbal, Portugal
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Nilsen L, Sharashova E, Løchen ML, Danaei G, Wilsgaard T. Hypothetical interventions and risk of atrial fibrillation by sex and education: application of the parametric g-formula in the Tromsø Study. Eur J Prev Cardiol 2023; 30:1791-1800. [PMID: 37467047 DOI: 10.1093/eurjpc/zwad240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 07/03/2023] [Accepted: 07/17/2023] [Indexed: 07/21/2023]
Abstract
AIMS To use the parametric g-formula to estimate the long-term risk of atrial fibrillation (AF) by sex and education under hypothetical interventions on six modifiable risk factors. METHODS AND RESULTS We estimated the risk reduction under hypothetical risk reduction strategies for smoking, physical activity, alcohol intake, body mass index, systolic, and diastolic blood pressure in 14 923 women and men (baseline mean age 45.8 years in women and 47.8 years in men) from the population-based Tromsø Study with a maximum of 22 years of follow-up (1994-2016). The estimated risk of AF under no intervention was 6.15% in women and 13.0% in men. This cumulative risk was reduced by 41% (95% confidence interval 17%, 61%) in women and 14% (-7%, 30%) in men under joint interventions on all risk factors. The most effective intervention was lowering body mass index to ≤ 25 kg/m2, leading to a 16% (4%, 25%) lower risk in women and a 14% (6%, 23%) lower risk in men. We found significant sex-differences in the relative risk reduction by sufficient physical activity, leading to a 7% (-4%, 18%) lower risk in women and an 8% (-2%, -13%) increased risk in men. We found no association between the level of education and differences in risk reduction by any of the interventions. CONCLUSION The population burden of AF could be reduced by modifying lifestyle risk factors. Namely, these modifications could have prevented 41% of AF cases in women and 14% of AF cases in men in the municipality of Tromsø, Norway during a maximum 22-year follow-up period.
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Affiliation(s)
- Linn Nilsen
- Department of Community Medicine, UiT The Arctic University of Norway, PO Box 6050 Langnes, N-9037 Tromsø, Norway
| | - Ekaterina Sharashova
- Department of Community Medicine, UiT The Arctic University of Norway, PO Box 6050 Langnes, N-9037 Tromsø, Norway
| | - Maja-Lisa Løchen
- Department of Community Medicine, UiT The Arctic University of Norway, PO Box 6050 Langnes, N-9037 Tromsø, Norway
| | - Goodarz Danaei
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA
- Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Tom Wilsgaard
- Department of Community Medicine, UiT The Arctic University of Norway, PO Box 6050 Langnes, N-9037 Tromsø, Norway
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Association Between Coffee Consumption and Incident Atrial Fibrillation (from the Multi-Ethnic Study of Atherosclerosis [MESA]). Am J Cardiol 2023; 186:5-10. [PMID: 36334435 DOI: 10.1016/j.amjcard.2022.10.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 10/04/2022] [Accepted: 10/13/2022] [Indexed: 11/06/2022]
Abstract
This study aimed to elucidate a potential dose-dependent relation between coffee intake and atrial fibrillation (AF) incidence in a multi-ethnic setting. Previous studies were comprised mainly of White populations, and an exploration of dose dependency is limited. To address these gaps, we analyzed the Multi-Ethnic Study of Atherosclerosis data, a prospective cohort study. In the primary analysis, we crudely divided patients into 3 groups: nonconsumers, 1 to 3 cups/month, and ≥1 cup/week. For the secondary analysis, we stratified the cohort into 9 groups of gradual increments for coffee consumption. A multivariable cox proportional hazards regression model was adjusted for 6 potential confounders: age, gender, smoking, hypertension, diabetes mellitus, and alcohol. Subjects who drank ≥1 cup of coffee/week had a higher incidence of AF (adjusted hazard ratio 1.40, p = 0.015) than nonconsumers. Furthermore, in the secondary analysis, there was an overall trend, albeit not consistent, of increasing adjusted hazard ratio with progressively increasing doses of coffee in the following groups: 1 to 3 cups/month, 2 to 4 cups/week, 2 to 3 cups/day and ≥6 cups/day. Notably, AF incidence was highest (9.8%) for the group consuming the most coffee, that is, ≥6 cups/day (p = 0.02). Stratification by race/ethnicity suggested the results may be driven by White and Hispanic rather than Black or Chinese-American subgroups. In conclusion, the findings suggest an association between coffee consumption and incident AF in contrast to most previous studies.
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Holmlund L, Hellström Ängerud K, Hörnsten Å, Valham F, Olsson K. Experiences of living with symptomatic atrial fibrillation. Nurs Open 2022; 10:1821-1829. [PMID: 36309946 PMCID: PMC9912440 DOI: 10.1002/nop2.1442] [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: 10/27/2021] [Revised: 08/23/2022] [Accepted: 10/07/2022] [Indexed: 11/07/2022] Open
Abstract
AIM To explore the experiences of living with symptomatic atrial fibrillation. DESIGN This study, with a descriptive qualitative design, was performed using semi-structured individual interviews. METHOD Six women and nine men with symptomatic atrial fibrillation were included. The transcribed interviews were analysed using qualitative content analysis. The COREQ checklist was followed. RESULTS The analysis resulted in a main theme, namely balancing life and included the themes striving for illness control, becoming a receiver or an active partner in care and dealing with changed self-image. The participants strived to understand their illness, prevent attacks and manage anxiety. Some of the participants were not involved in decision-making, were uninformed about self-care measures, reported a lack of continuity in care and felt that the doctors focused on information about the medical part of care.
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Affiliation(s)
| | | | | | - Fredrik Valham
- Department of Public Health and Clinical MedicineUmeå UniversityUmeåSweden
| | - Karin Olsson
- Department of Public Health and Clinical MedicineUmeå UniversityUmeåSweden
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7
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Park CS, Choi EK, Lee SR, Ahn HJ, Kwon S, Kim S, Sohn SH, Choi JW, Hwang HY, Oh S. Catheter ablation and thoracoscopic ablation in long persistent atrial fibrillation with large left atrium. Front Cardiovasc Med 2022; 9:881831. [PMID: 36211574 PMCID: PMC9537550 DOI: 10.3389/fcvm.2022.881831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 08/30/2022] [Indexed: 12/03/2022] Open
Abstract
Background Pulmonary vein antrum isolation (PVAI) is the cornerstone of atrial fibrillation (AF) ablation, but the clinical outcomes of PVAI are unsatisfactory in patients with persistent AF and a large left atrium (LA). Objectives We investigated the clinical outcomes following radiofrequency ablation (RFCA), cryoballoon ablation (CBA), and thoracoscopic maze in patients with persistent AF and a large LA. Methods We included patients with consecutive persistent AF who had a large LA (LA diameter >50 mm) and underwent RFCA, CBA, or thoracoscopic maze surgery. In the RFCA group, additional linear ablation was performed at the physician’s discretion. The endpoint was 12 months without recurrence of an atrial arrhythmia, including AF, atrial flutter, and atrial tachycardia, following a 90-day blanking period. Results We recruited 89 persistent AF patients with a large LA who underwent RFCA (n = 32), CBA (n = 38), or the thoracoscopic maze procedure (n = 19). During the 12-month follow-up, 48 (53.9%) cases of AF recurrence were observed. There was no prognostic difference between groups (50.0% in RFCA vs. 52.6% in CBA vs. 63.2% in thoracoscopic maze, all P > 0.05). Early recurrence during the blanking period was a significant predictor of late recurrence for RFCA and CBA, but not for the thoracoscopic maze. Conclusion In persistent AF patients with a large LA, we did not find a prognostic difference RFCA, CBA, or a thoracoscopic maze procedure in recurrence of atrial arrhythmia. Early recurrence predicted late recurrence in catheter ablation, but not in thoracoscopic maze.
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Affiliation(s)
- Chan Soon Park
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Eue-Keun Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
- *Correspondence: Eue-Keun Choi,
| | - So-Ryoung Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Hyo-Jeong Ahn
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Soonil Kwon
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Sunhwa Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Suk Ho Sohn
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul, South Korea
| | - Jae Woong Choi
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul, South Korea
- Department of Thoracic and Cardiovascular Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Ho Young Hwang
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul, South Korea
- Department of Thoracic and Cardiovascular Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Seil Oh
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
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8
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Woo BFY, Tam WWS, Rangpa T, Liau WF, Nathania J, Lim TW. A Nurse-Led Integrated Chronic Care E-Enhanced Atrial Fibrillation (NICE-AF) Clinic in the Community: A Preliminary Evaluation. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19084467. [PMID: 35457336 PMCID: PMC9026946 DOI: 10.3390/ijerph19084467] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 03/31/2022] [Accepted: 04/06/2022] [Indexed: 02/01/2023]
Abstract
The current physician-centric model of care is not sustainable for the rising tide of atrial fibrillation. The integrated model of care has been recommended for managing atrial fibrillation. This study aims to provide a preliminary evaluation of the effectiveness of a Nurse-led Integrated Chronic care E-enhanced Atrial Fibrillation (NICE-AF) clinic in the community. The NICE-AF clinic was led by an advanced practice nurse (APN) who collaborated with a family physician. The clinic embodied integrated care and shifted from hospital-based, physician-centric care. Regular patient education, supplemented by a specially curated webpage, fast-tracked appointments for hospital-based specialised investigations, and teleconsultation with a hospital-based cardiologist were the highlights of the clinic. Forty-three participants were included in the six-month preliminary evaluation. No significant differences were observed in cardiovascular hospitalisations (p-value = 0.102) and stroke incidence (p-value = 1.00) after attending the NICE-AF clinic. However, significant improvements were noted for AF-specific QoL (p = 0.001), AF knowledge (p < 0.001), medication adherence (p = 0.008), patient satisfaction (p = 0.020), and depression (p = 0004). The preliminary evaluation of the NICE-AF clinic demonstrated the clinical utility of this new model of integrated care in providing safe and effective community-based AF care. Although a full evaluation is pending, the preliminary results highlighted its promising potential to be expanded into a permanent, larger-scale service.
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Affiliation(s)
- Brigitte Fong Yeong Woo
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore;
- Correspondence: ; Tel.: +65-6601-6812
| | - Wilson Wai San Tam
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore;
| | - Taiju Rangpa
- Bukit Batok—Medical, National University Polyclinics, National University Health System, Singapore 659164, Singapore;
| | - Wei Fong Liau
- Bukit Batok—Nursing, National University Polyclinics, National University Health System, Singapore 659164, Singapore;
| | - Jennifer Nathania
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore;
| | - Toon Wei Lim
- Department of Cardiology, National University Heart Centre, National University Health System, Singapore 119228, Singapore;
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9
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Pensa AV, Baman JR, Puckelwartz MJ, Wilcox JE. Genetically Based Atrial Fibrillation: Current Considerations for Diagnosis and Management. J Cardiovasc Electrophysiol 2022; 33:1944-1953. [PMID: 35262243 DOI: 10.1111/jce.15446] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Revised: 03/01/2022] [Accepted: 03/04/2022] [Indexed: 11/30/2022]
Abstract
Atrial fibrillation (AF) is the most common atrial arrhythmia and is subcategorized into numerous clinical phenotypes. Given its heterogeneity, investigations into the genetic mechanisms underlying AF have been pursued in recent decades, with predominant analyses focusing on early onset or lone AF. Linkage analyses, genome wide association studies (GWAS), and single gene analyses have led to the identification of rare and common genetic variants associated with AF risk. Significant overlap with genetic variants implicated in dilated cardiomyopathy syndromes, including truncating variants of the sarcomere protein titin, have been identified through these analyses, in addition to other genes associated with cardiac structure and function. Despite this, widespread utilization of genetic testing in AF remains hindered by the unclear impact of genetic risk identification on clinical outcomes and the high prevalence of variants of unknown significance (VUS). However, genetic testing is a reasonable option for patients with early onset AF and in those with significant family history of arrhythmia. While many knowledge gaps remain, emerging data support genotyping to inform selection of AF therapeutics. In this review we highlight the current understanding of the complex genetic basis of AF and explore the overlap of AF with inherited cardiomyopathy syndromes. We propose a set of criteria for clinical genetic testing in AF patients and outline future steps for the integration of genetics into AF care. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Anthony V Pensa
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jayson R Baman
- Department of Medicine, Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Megan J Puckelwartz
- Department of Pharmacology, Center for Genetic Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jane E Wilcox
- Department of Medicine, Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL
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10
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Ngo L, Ali A, Ganesan A, Woodman R, Krumholz HM, Adams R, Ranasinghe I. Institutional Variation in 30‐Day Complications Following Catheter Ablation of Atrial Fibrillation. J Am Heart Assoc 2022; 11:e022009. [PMID: 35156395 PMCID: PMC9245833 DOI: 10.1161/jaha.121.022009] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background Complications are a measure of procedural quality, yet variation in complication rates following catheter ablation of atrial fibrillation (AF) among hospitals has not been systematically examined. We examined institutional variation in the risk‐standardized 30‐day complication rates (RSCRs) following AF ablation which may suggest variation in care quality. Methods and Results This cohort study included all patients >18 years old undergoing AF ablations from 2012 to 2017 in Australia and New Zealand. The primary outcome was procedure‐related complications occurring during the hospital stay and within 30 days of hospital discharge. We estimated the hospital‐specific risk‐standardized complication rates using a hierarchical generalized linear model. A total of 25 237 patients (mean age, 62.5±11.4 years; 30.2% women; median length of stay 1 day [interquartile range, 1–2 days]) were included. Overall, a complication occurred in 1400 (5.55%) patients (4.34% in hospital, 1.46% following discharge, and 0.25% experienced both). Bleeding (3.31%), pericardial effusion (0.74%), and infection (0.44%) were the most common complications while stroke/transient ischemic attack (0.24%), cardiorespiratory failure and shock (0.19%), and death (0.08%) occurred less frequently. Among 46 hospitals that performed ≥25 ablations during the study period, the crude complication rate varied from 0.00% to 21.43% (median, 5.74%). After adjustment for differences in patient and procedural characteristics, the median risk‐standardized complication rate was 5.50% (range, 2.89%–10.31%), with 10 hospitals being significantly different from the national average. Conclusions Procedure‐related complications occur in 5.55% of patients undergoing AF ablations, although the risk of complications varies 3‐fold among hospitals, which suggests potential disparities in care quality and the need for efforts to standardize AF ablation practices among hospitals.
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Affiliation(s)
- Linh Ngo
- School of Clinical Medicine The University of Queensland Australia
- Department of Cardiology The Prince Charles Hospital Queensland Australia
- Cardiovascular CentreE Hospital Hanoi Vietnam
| | - Anna Ali
- Discipline of Medicine Faculty of Health and Medical Sciences The University of Adelaide South Australia Australia
| | - Anand Ganesan
- Department of Cardiovascular Medicine Flinders Medical Centre South Australia Australia
- College of Medicine and Public Health Flinders University South Australia Australia
| | - Richard Woodman
- Flinders Centre for Epidemiology and Biostatistics College of Medicine and Public Health Flinders University South Australia Australia
| | - Harlan M. Krumholz
- Section of Cardiovascular Medicine Department of Medicine Yale School of Medicine New Haven CT
- Center for Outcomes Research and Evaluation Yale New Haven Hospital New Haven CT
- Department of Health Policy and Management Yale School of Public Health New Haven CT
| | - Robert Adams
- Discipline of Medicine Faculty of Health and Medical Sciences The University of Adelaide South Australia Australia
- College of Medicine and Public Health Flinders University South Australia Australia
- Respiratory and Sleep Services Southern Adelaide Local Health Network South Australia Australia
| | - Isuru Ranasinghe
- School of Clinical Medicine The University of Queensland Australia
- Department of Cardiology The Prince Charles Hospital Queensland Australia
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11
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Abstract
Atrial fibrillation (AF) is one of the main cardiac arrhythmias associated with higher risk of cardiovascular morbidity and mortality. AF can cause adverse symptoms and reduced quality of life. One of the strategies for the management of AF is rate control, which can modulate ventricle rate, alleviate adverse associated symptoms and improve the quality of life. As primary management of AF through rate control or rhythm is a topic under debate, the purpose of this review is to explore the rationale for the rate control approach in managing AF by considering the guidelines, recommendations and determinants for the choice of rate control drugs, including beta blockers, digoxin and non- dihydropyridine calcium channel blockers for patients with AF and other comorbidities and atrioventricular nodal ablation and pacing. Despite the limitations of rate control treatment, which may not be effective in preventing disease progression or in reducing symptoms in highly symptomatic patients, it is widely used for almost all patients with atrial fibrillation. Although rate control is one of the first line management of all patient with atrial fibrillation, several issues remain debateable.
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Affiliation(s)
- Muath Alobaida
- Department of Basic Sciences, Prince Sultan bin Abdulaziz College for Emergency Medical Services, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Abdullah Alrumayh
- Department of Basic Sciences, Prince Sultan bin Abdulaziz College for Emergency Medical Services, King Saud University, Riyadh, Kingdom of Saudi Arabia
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12
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Rosca CI, Kundnani NR, Tudor A, Rosca MS, Nicoras VA, Otiman G, Ciurariu E, Ionescu A, Stelian M, Sharma A, Borza C, Lighezan DF. Benefits of prescribing low-dose digoxin in atrial fibrillation. Int J Immunopathol Pharmacol 2021; 35:20587384211051955. [PMID: 34724841 PMCID: PMC8573519 DOI: 10.1177/20587384211051955] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
INTRODUCTION The role of digoxin (cardiac glycoside) in controlling the heart rate (HR) for the treatment of atrial fibrillation (AF) patients has not been explored in depth. METHODS To contribute to the limited data, our team conducted retrospective analysis of the clinical records of 1444 AF patients. We divided the AF patients into two groups, wherein group 1 patients were treated with beta-blockers (BB), low-dose digoxin, and an anticoagulant (vitamin K antagonist/factor-IIa inhibitor/factor-Xa inhibitor), and group 2 patients were treated with just BB and an anticoagulant. Our objectives were to compare the impact of combination therapy of BB and digoxin on the resting HR in patients with permanent AF and the patients' quality of life (QOL) at periodic intervals. RESULTS The findings of our study showed a better control of the resting HR rate (<110bpm) and an improved QOL among the group 1 patients when compared with group 2 patients. CONCLUSION Our findings are indicative of the favorable clinical outcomes that resulted from the addition of a low-dose of digoxin to the AF treatment regimen. However, larger studies/trials elucidating the outcomes of AF patients treated with the dual rate control therapy are required, to clarify the role of digoxin, guide the choice of agents, and standardize the AF treatment protocol.
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Affiliation(s)
- Ciprian Ilie Rosca
- Advanced Research Center for Cardiovascular Pathology and Haemostaseology, Department of Internal Medicine I - Medical Semiology I, 162271"Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania.,Family Physician Clinic, Civil Medical Society Dr Rosca, Teremia Mare, Timis, Romania.,Department of Internal Medicine, Municipal Emergency University Hospital, Timisoara, Romania
| | - Nilima Rajpal Kundnani
- Family Physician Clinic, Civil Medical Society Dr Rosca, Teremia Mare, Timis, Romania.,Department of Functional Sciences, Physiology, Centre of Immuno-Physiology and Biotechnologies (CIFBIOTEH), "162271Victor Babeș" University of Medicine and Pharmacy, Timisoara, Romania
| | - Anca Tudor
- Department of Functional Science, Discipline of Informatics and medical biostatistics, 162271"Victor Babes" University of Medicine and Pharmacy Timisoara, Timisoara, Romania
| | - Maria-Silvia Rosca
- Family Physician Clinic, Civil Medical Society Dr Rosca, Teremia Mare, Timis, Romania
| | - Violeta-Ariana Nicoras
- Department of Internal Medicine, Municipal Emergency University Hospital, Timisoara, Romania
| | - Gabriela Otiman
- Department of Cardiology-Ambulatory internal medicine, 162271"Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania
| | - Elena Ciurariu
- Department of Functional Sciences, Physiology, Centre of Immuno-Physiology and Biotechnologies (CIFBIOTEH), "162271Victor Babeș" University of Medicine and Pharmacy, Timisoara, Romania
| | - Alin Ionescu
- Department of Family Medicine, 162271"Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania
| | - Morariu Stelian
- Department of Occupational Medicine, 473223Vasile Goldis University of Arad Faculty of Medicine, Arad, Romania
| | - Abhinav Sharma
- Family Physician Clinic, Civil Medical Society Dr Rosca, Teremia Mare, Timis, Romania.,Department of Cardio-vascular Rehabilitation, 162271"Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania
| | - Claudia Borza
- Department of Functional Science, Discipline of Physiopathology, Centre for cognitive research in neuro-psychiatric pathologies NEUROPSY-COG, 162271"Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania
| | - Daniel Florin Lighezan
- Advanced Research Center for Cardiovascular Pathology and Haemostaseology, Department of Internal Medicine I - Medical Semiology I, 162271"Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania.,Department of Internal Medicine, Municipal Emergency University Hospital, Timisoara, Romania
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13
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Buchbender M, Schlee N, Kesting MR, Grimm J, Fehlhofer J, Rau A. A prospective comparative study to assess the risk of postoperative bleeding after dental surgery while on medication with direct oral anticoagulants, antiplatelet agents, or vitamin K antagonists. BMC Oral Health 2021; 21:504. [PMID: 34620135 PMCID: PMC8499467 DOI: 10.1186/s12903-021-01868-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 09/21/2021] [Indexed: 12/03/2022] Open
Abstract
Background The aim of this prospective study was to investigate the occurrence and severity of postoperative bleeding following dentoalveolar surgery in patients with uninterrupted anticoagulation therapy (AT). Methods Patients receiving AT (vitamin k antagonist (VK), direct oral anticoagulants (DOAC) or antiplatelet therapy (APT) and in need of surgical intervention classified as A, B or C (single or serial tooth extraction, osteotomy, or implant placement) were studied between 2019 and 2021. A healthy, non-anticoagulated cohort (CG) served as a control group. The main outcomes measured were the frequency of postoperative bleeding, the classification of the severity of postoperative bleeding (1a, 1b, 1c, 2, 3), and the correlation with the AT surgical intervention classification. Results In total, 195 patients were included in the study, with 95 patients in the AT group and 100 in the CG. Postoperative bleeding was significant in the AT group vs. the CG (p = 0.000), with a significant correlation with surgical intervention class C (p = 0.013) and the severity class of bleeding 1a (p = 0.044). There was no significant correlation with procedures of type A, B or C for the other postoperative bleeding gradations (1b, 1c, 2 and 3). There was a statistically significant difference in the occurrence of postoperative bleeding events between the DOAC/APT group and the VK group (p = 0.036), but there were no significant differences regarding the other AT agents. Conclusion The continuation of anticoagulation therapy for surgical interventions also seems reasonable for high-risk interventions. Although significantly more postoperative bleeding occurs, the severity of bleeding is low. The perioperative management of anticoagulated patients requires well-coordinated interdisciplinary teamwork and detailed instruction of patients. Clinical trial registration The study is registered (29.03.2021) at the German clinical trial registry (DRKS00024889).
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Affiliation(s)
- Mayte Buchbender
- Department of Oral and Maxillofacial Surgery, Friedrich-Alexander-University Erlangen-Nuremberg, Glückstrasse 11, 91054, Erlangen, Germany.
| | - Nicola Schlee
- Department of Oral and Maxillofacial Surgery, Friedrich-Alexander-University Erlangen-Nuremberg, Glückstrasse 11, 91054, Erlangen, Germany
| | - Marco R Kesting
- Department of Oral and Maxillofacial Surgery, Friedrich-Alexander-University Erlangen-Nuremberg, Glückstrasse 11, 91054, Erlangen, Germany
| | - Jannik Grimm
- Department of Oral and Maxillofacial Surgery, Friedrich-Alexander-University Erlangen-Nuremberg, Glückstrasse 11, 91054, Erlangen, Germany
| | - Jakob Fehlhofer
- Department of Oral and Maxillofacial Surgery, Friedrich-Alexander-University Erlangen-Nuremberg, Glückstrasse 11, 91054, Erlangen, Germany
| | - Andrea Rau
- Department of Oral and Maxillofacial Surgery, Universitätsmedizin Greifswald, Greifswald, Germany
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14
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Benjamin EJ, Al‐Khatib SM, Desvigne‐Nickens P, Alonso A, Djoussé L, Forman DE, Gillis AM, Hendriks JML, Hills MT, Kirchhof P, Link MS, Marcus GM, Mehra R, Murray KT, Parkash R, Piña IL, Redline S, Rienstra M, Sanders P, Somers VK, Van Wagoner DR, Wang PJ, Cooper LS, Go AS. Research Priorities in the Secondary Prevention of Atrial Fibrillation: A National Heart, Lung, and Blood Institute Virtual Workshop Report. J Am Heart Assoc 2021; 10:e021566. [PMID: 34351783 PMCID: PMC8475065 DOI: 10.1161/jaha.121.021566] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 04/28/2021] [Indexed: 12/24/2022]
Abstract
There has been sustained focus on the secondary prevention of coronary heart disease and heart failure; yet, apart from stroke prevention, the evidence base for the secondary prevention of atrial fibrillation (AF) recurrence, AF progression, and AF-related complications is modest. Although there are multiple observational studies, there are few large, robust, randomized trials providing definitive effective approaches for the secondary prevention of AF. Given the increasing incidence and prevalence of AF nationally and internationally, the AF field needs transformative research and a commitment to evidenced-based secondary prevention strategies. We report on a National Heart, Lung, and Blood Institute virtual workshop directed at identifying knowledge gaps and research opportunities in the secondary prevention of AF. Once AF has been detected, lifestyle changes and novel models of care delivery may contribute to the prevention of AF recurrence, AF progression, and AF-related complications. Although benefits seen in small subgroups, cohort studies, and selected randomized trials are impressive, the widespread effectiveness of AF secondary prevention strategies remains unknown, calling for development of scalable interventions suitable for diverse populations and for identification of subpopulations who may particularly benefit from intensive management. We identified critical research questions for 6 topics relevant to the secondary prevention of AF: (1) weight loss; (2) alcohol intake, smoking cessation, and diet; (3) cardiac rehabilitation; (4) approaches to sleep disorders; (5) integrated, team-based care; and (6) nonanticoagulant pharmacotherapy. Our goal is to stimulate innovative research that will accelerate the generation of the evidence to effectively pursue the secondary prevention of AF.
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Affiliation(s)
- Emelia J. Benjamin
- Cardiovascular MedicineDepartment of MedicineBoston University School of MedicineBostonMA
- Department of EpidemiologyBoston University School of Public HealthBostonMA
| | - Sana M. Al‐Khatib
- Division of Cardiology and Duke Clinical Research InstituteDuke University Medical CenterDurhamNC
| | - Patrice Desvigne‐Nickens
- Division of Cardiovascular SciencesNational Heart, Lung, and Blood InstituteNational Institutes of HealthBethesdaMD
| | - Alvaro Alonso
- Department of EpidemiologyRollins School of Public HealthEmory UniversityAtlantaGA
| | - Luc Djoussé
- Division of AgingDepartment of MedicineBrigham and Women’s Hospital and Harvard Medical SchoolBostonMA
| | - Daniel E. Forman
- Divisions of Geriatrics and CardiologyUniversity of Pittsburgh Medical CenterAging InstituteUniversity of PittsburghVA Pittsburgh Healthcare SystemPittsburghPA
| | - Anne M. Gillis
- Libin Cardiovascular Institute of AlbertaUniversity of CalgaryAlbertaCanada
| | - Jeroen M. L. Hendriks
- Centre for Heart Rhythm DisordersUniversity of Adelaide, and Royal Adelaide HospitalAdelaideAustralia
- Caring Futures InstituteCollege of Nursing and Health SciencesFlinders UniversityAdelaideAustralia
| | | | - Paulus Kirchhof
- Department of CardiologyUniversity Heart and Vascular Center UKE HamburgHamburgGermany
- Institute of Cardiovascular ScienceUniversity of BirminghamUnited Kingdom
- German Center for Cardiovascular Research, Partner Site Hamburg/Kiel/LübeckBerlinGermany
- AFNETMünsterGermany
| | - Mark S. Link
- Division of CardiologyDepartment of MedicineUT Southwestern Medical CenterDallasTX
| | - Gregory M. Marcus
- Division of CardiologyUniversity of California, San FranciscoSan FranciscoCA
| | - Reena Mehra
- Sleep Disorders CenterNeurologic InstituteRespiratory InstituteHeart and Vascular Institute, and Molecular Cardiology Department of the Lerner Research InstituteCleveland ClinicClevelandOH
| | | | - Ratika Parkash
- Division of CardiologyQEII Health Sciences Center/Dalhousie UniversityHalifaxNova ScotiaCanada
| | - Ileana L. Piña
- Wayne State UniversityDetroitMI
- Central Michigan UniversityMt PleasantMI
- FDAOPEQCenter for Devices and Radiological HealthSilver SpringMD
| | - Susan Redline
- Department of MedicineBrigham and Women’s HospitalBostonMA
| | - Michiel Rienstra
- Department of CardiologyUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
| | - Prashanthan Sanders
- Centre for Heart Rhythm DisordersUniversity of Adelaide, and Royal Adelaide HospitalAdelaideAustralia
| | | | | | - Paul J. Wang
- Stanford University School of MedicinePalo AltoCA
| | - Lawton S. Cooper
- Division of Cardiovascular SciencesNational Heart, Lung, and Blood InstituteNational Institutes of HealthBethesdaMD
| | - Alan S. Go
- Division of ResearchKaiser Permanente Northern CaliforniaOaklandCA
- Department of Health System ScienceKaiser Permanente Bernard J. Tyson School of MedicinePasadenaCA
- Departments of Epidemiology, Biostatistics and MedicineUniversity of California, San FranciscoSan FranciscoCA
- Departments of MedicineHealth Research and PolicyStanford UniversityStanfordCA
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15
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Fabritz L, Crijns HJGM, Guasch E, Goette A, Häusler KG, Kotecha D, Lewalter T, Meyer C, Potpara TS, Rienstra M, Schnabel RB, Willems S, Breithardt G, Camm AJ, Chan A, Chua W, de Melis M, Dimopoulou C, Dobrev D, Easter C, Eckardt L, Haase D, Hatem S, Healey JS, Heijman J, Hohnloser SH, Huebner T, Ilyas BS, Isaacs A, Kutschka I, Leclercq C, Lip GYH, Marinelli EA, Merino JL, Mont L, Nabauer M, Oldgren J, Pürerfellner H, Ravens U, Savelieva I, Sinner MF, Sitch A, Smolnik R, Steffel J, Stein K, Stoll M, Svennberg E, Thomas D, Van Gelder IC, Vardar B, Wakili R, Wieloch M, Zeemering S, Ziegler PD, Heidbuchel H, Hindricks G, Schotten U, Kirchhof P. Dynamic risk assessment to improve quality of care in patients with atrial fibrillation: the 7th AFNET/EHRA Consensus Conference. Europace 2021; 23:329-344. [PMID: 33555020 DOI: 10.1093/europace/euaa279] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 11/28/2020] [Indexed: 01/07/2023] Open
Abstract
AIMS The risk of developing atrial fibrillation (AF) and its complications continues to increase, despite good progress in preventing AF-related strokes. METHODS AND RESULTS This article summarizes the outcomes of the 7th Consensus Conference of the Atrial Fibrillation NETwork (AFNET) and the European Heart Rhythm Association (EHRA) held in Lisbon in March 2019. Sixty-five international AF specialists met to present new data and find consensus on pressing issues in AF prevention, management and future research to improve care for patients with AF and prevent AF-related complications. This article is the main outcome of an interactive, iterative discussion between breakout specialist groups and the meeting plenary. AF patients have dynamic risk profiles requiring repeated assessment and risk-based therapy stratification to optimize quality of care. Interrogation of deeply phenotyped datasets with outcomes will lead to a better understanding of the cardiac and systemic effects of AF, interacting with comorbidities and predisposing factors, enabling stratified therapy. New proposals include an algorithm for the acute management of patients with AF and heart failure, a call for a refined, data-driven assessment of stroke risk, suggestions for anticoagulation use in special populations, and a call for rhythm control therapy selection based on risk of AF recurrence. CONCLUSION The remaining morbidity and mortality in patients with AF needs better characterization. Likely drivers of the remaining AF-related problems are AF burden, potentially treatable by rhythm control therapy, and concomitant conditions, potentially treatable by treating these conditions. Identifying the drivers of AF-related complications holds promise for stratified therapy.
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Affiliation(s)
- Larissa Fabritz
- Institute of Cardiovascular Sciences, University of Birmingham, UK.,Department of Cardiology, University Hospital Birmingham, UK
| | - Harry J G M Crijns
- School for Cardiovascular Diseases, Maastricht University Medical Centre, the Netherlands
| | - Eduard Guasch
- Hospital Clinic, IDIBAPS, CIBERCV, University of Barcelona, Spain
| | - Andreas Goette
- Medical Clinic II, St. Vincenz Krankenhaus, Paderborn, Germany.,Atrial Fibrillation NETwork (AFNET), Münster, Germany
| | | | - Dipak Kotecha
- Institute of Cardiovascular Sciences, University of Birmingham, UK
| | - Thorsten Lewalter
- Atrial Fibrillation NETwork (AFNET), Münster, Germany.,Internistisches Klinikum München Süd, Germany
| | - Christian Meyer
- University Heart Center, University Hospital Hamburg-Eppendorf, Germany
| | - Tatjana S Potpara
- School of Medicine, University of Belgrade, Clinical Centre of Serbia, Serbia
| | | | - Renate B Schnabel
- Atrial Fibrillation NETwork (AFNET), Münster, Germany.,University Heart Center, University Hospital Hamburg-Eppendorf, Germany
| | - Stephan Willems
- Atrial Fibrillation NETwork (AFNET), Münster, Germany.,Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
| | - Guenter Breithardt
- Atrial Fibrillation NETwork (AFNET), Münster, Germany.,Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany.,Department of Cardiovascular Medicine, University Hospital Münster, Germany
| | - A John Camm
- St George's Hospital Medical School, University of London, UK
| | | | - Winnie Chua
- Institute of Cardiovascular Sciences, University of Birmingham, UK
| | | | | | - Dobromir Dobrev
- Department of Cardiology, University Hospital Essen, Germany
| | - Christina Easter
- Institute of Cardiovascular Sciences, University of Birmingham, UK
| | - Lars Eckardt
- Atrial Fibrillation NETwork (AFNET), Münster, Germany.,Department of Cardiovascular Medicine, University Hospital Münster, Germany
| | - Doreen Haase
- Atrial Fibrillation NETwork (AFNET), Münster, Germany
| | - Stephane Hatem
- Department of Cardiology, Sorbonne Universités, Faculté de médecine UPMC, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Paris, France
| | - Jeff S Healey
- Population Health Research Institute Hamilton, Canada
| | - Jordi Heijman
- Department of Cardiology, University Hospital Birmingham, UK
| | | | | | | | - Aaron Isaacs
- School for Cardiovascular Diseases, Maastricht University Medical Centre, the Netherlands
| | - Ingo Kutschka
- Atrial Fibrillation NETwork (AFNET), Münster, Germany.,Klinik für Thorax-, Herz- und Gefäßchirurgie, University Hospital Göttingen, Germany
| | | | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, UK
| | | | - Jose L Merino
- Arrhythmia & Robotic EP Unit, La Paz University Hospital, Spain
| | - Lluís Mont
- Hospital Clinic, Universitat de Barcelona, Barcelona, Catalonia, Spain
| | - Michael Nabauer
- Atrial Fibrillation NETwork (AFNET), Münster, Germany.,Medizinische Klinik und Poliklinik I, University Hospital Munich, Germany
| | - Jonas Oldgren
- Department of Medical Sciences, Uppsala Clinical Research Center, Uppsala University, Sweden
| | - Helmut Pürerfellner
- Department für Rhythmologie und Elektrophysiologie, Ordensklinikum Linz, Austria
| | - Ursula Ravens
- Atrial Fibrillation NETwork (AFNET), Münster, Germany.,Institut für Experimentelle Kardiovaskuläre Medizin, Universitätsherzzentrum Freiburg, Bad Krozingen, Germany
| | | | - Moritz F Sinner
- Medizinische Klinik und Poliklinik I, University Hospital Munich, Germany
| | - Alice Sitch
- Institute of Cardiovascular Sciences, University of Birmingham, UK
| | | | | | | | - Monika Stoll
- School for Cardiovascular Diseases, Maastricht University Medical Centre, the Netherlands
| | - Emma Svennberg
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Karolinska Institutet, Danderyd's Hospital Stockholm, Sweden
| | - Dierk Thomas
- Atrial Fibrillation NETwork (AFNET), Münster, Germany.,Department of Internal Medicine III-Cardiology, Angiology and Pneumonology, Medical University Hospital Heidelberg, Germany
| | - Isabelle C Van Gelder
- Department of Cardiology, University Medical Center Groningen, University of Groningen, the Netherlands
| | | | - Reza Wakili
- Atrial Fibrillation NETwork (AFNET), Münster, Germany.,Department of Cardiology, University Hospital Essen, Germany
| | | | - Stef Zeemering
- Department of Cardiology, University Medical Center Groningen, University of Groningen, the Netherlands
| | | | - Hein Heidbuchel
- Department of Cardiology, Antwerp University, University Hospital, Belgium
| | - Gerhard Hindricks
- Department of Electrophysiology, Heart Center Leipzig, University of Leipzig, Germany
| | - Ulrich Schotten
- School for Cardiovascular Diseases, Maastricht University Medical Centre, the Netherlands.,Atrial Fibrillation NETwork (AFNET), Münster, Germany.,Department of Cardiology, University Medical Center Groningen, University of Groningen, the Netherlands
| | - Paulus Kirchhof
- Institute of Cardiovascular Sciences, University of Birmingham, UK.,Atrial Fibrillation NETwork (AFNET), Münster, Germany.,University Heart Center, University Hospital Hamburg-Eppendorf, Germany
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16
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Olsson K, Hörnsten Å, Hellström Ängerud K. Treated with preventive anticoagulation therapy in atrial fibrillation: The patients' perspective. Nurs Open 2021; 9:2657-2664. [PMID: 34132062 PMCID: PMC9584489 DOI: 10.1002/nop2.964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 04/24/2021] [Accepted: 05/28/2021] [Indexed: 11/11/2022] Open
Abstract
AIM The aim of this study was to explore patients' experiences of preventive anticoagulation therapy in atrial fibrillation. DESIGN This was a descriptive qualitative study based on interviews. METHODS Individual interviews with 15 patients, 6 women and 9 men, treated with preventive oral anticoagulant due to atrial fibrillation, were conducted. The interviews were analysed with qualitative content analysis. RESULTS Based on the analysis, the theme Managing a necessary evil emerged. The theme comprised the three categories: Coping with anxiety and changes in daily life, Having confidence in care and Being a partner or only a receiver of treatment. Patients described it like being faced with a situation where a treatment perceived as vital was weighed against undesirable consequences and risks. Patients trusted caregivers and had confidence in care, but there was a risk of being a receiver of care instead of becoming a partner.
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Affiliation(s)
- Karin Olsson
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Åsa Hörnsten
- Department of Nursing, Umeå University, Umeå, Sweden
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17
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Numminen A, Penttilä T, Arola O, Inkovaara J, Oksala N, Mäkynen H, Hernesniemi J. Treatment success and its predictors as well as the complications of catheter ablation for atrial fibrillation in a high-volume centre. J Interv Card Electrophysiol 2021; 63:357-367. [PMID: 34060008 PMCID: PMC8983498 DOI: 10.1007/s10840-021-01011-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 05/12/2021] [Indexed: 11/29/2022]
Abstract
Purpose Catheter ablation for atrial fibrillation (AF) is a standard procedure for maintaining sinus rhythm. The aim of this study was to evaluate treatment success and its predictors and to provide quality control data on complications and redo operations in a centre with an initially a low but currently high annual volume. Methods Data on patients (n = 1,253) treated with catheter ablation for AF in Tays Heart Hospital between January 2010 and May 2018 was evaluated (n = 1178 ablation-naïve patients and n = 1514 AF ablations). Comprehensive data on patient characteristics, treatment results, redo operations and complications were collected. Treatment success (maintenance of sinus rhythm at 1 year) was evaluated among patients residing within the hospital district (45% of the entire study population). Results Treatment success was observed in approximately 62.9% of the ablation-naïve patients. Preoperative predictors of treatment success were paroxysmal AF type, previous use of antiarrhythmic drugs, left atrium diameter and age. The experience at the centre did not associate with the 1-year outcome. A relapse during the first 3-month blanking period was associated with a nine-fold risk of failure at 1 year (unadjusted OR 9.1, 95% CI 5.5–15.1, p < 0.001). The major complication rate was 4.5% (68/1514) with no deaths. Ten percent of the patients needed a redo procedure within the first year. Conclusions Patient-related factors are the most significant predictors of treatment success. A relapse during a 3-month blanking period is associated with a very high risk of failure at 1 year.
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Affiliation(s)
- Anna Numminen
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.
| | - Tero Penttilä
- Tays Heart Hospital, Tampere University Hospital, Tampere, Finland
| | - Olli Arola
- Tays Heart Hospital, Tampere University Hospital, Tampere, Finland
| | - Jaakko Inkovaara
- Tays Heart Hospital, Tampere University Hospital, Tampere, Finland
| | - Niku Oksala
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Vascular Centre, Tampere University Hospital, Tampere, Finland
| | - Heikki Mäkynen
- Tays Heart Hospital, Tampere University Hospital, Tampere, Finland
| | - Jussi Hernesniemi
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Tays Heart Hospital, Tampere University Hospital, Tampere, Finland
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18
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Ritchie LA, Lip GYH, Lane DA. Optimization of atrial fibrillation care: management strategies and quality measures. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2021; 7:121-133. [PMID: 32761177 DOI: 10.1093/ehjqcco/qcaa063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 07/22/2020] [Accepted: 07/29/2020] [Indexed: 12/14/2022]
Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia and a leading cause of mortality and morbidity. Optimal management of AF is paramount to improve quality of life and reduce the impact on health and social care services. Owing to its strong associations with other cardiovascular and non-cardiovascular comorbidities, a holistic management approach to AF care is advocated but this is yet to be clearly defined by international clinical guidelines. This ambiguity has prompted us to review the available clinical evidence on different management strategies to optimize AF care in the context of performance and quality measures, which can be used to objectively assess standards of care.
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Affiliation(s)
- Leona A Ritchie
- Liverpool Centre for Cardiovascular Sciences, University of Liverpool and Liverpool Heart and Chest Hospital, William Henry Duncan Building, 6 West Derby Street, Liverpool L7 8TX, UK.,Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Sciences, University of Liverpool and Liverpool Heart and Chest Hospital, William Henry Duncan Building, 6 West Derby Street, Liverpool L7 8TX, UK.,Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Sciences, University of Liverpool and Liverpool Heart and Chest Hospital, William Henry Duncan Building, 6 West Derby Street, Liverpool L7 8TX, UK.,Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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19
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Abstract
Incidence and prevalence of atrial fibrillation (AF) and chronic kidney disease are increasing, and the two conditions commonly coexist. Renal impairment further increases the risk of ischemic stroke and systemic thromboembolism in patients with AF but also paradoxically predisposes to bleeding. Renal function should be monitored closely in patients with AF requiring oral anticoagulation therapy, particularly those receiving direct oral anticoagulants. Vitamin K antagonists can be used as part of a dose-adjusted anticoagulation regimen in patients with mild to moderate renal dysfunction. Dialysis-dependent patients taking vitamin K antagonists are at increased risk of sustaining major hemorrhage.
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Affiliation(s)
- Maria Stefil
- Department of Cardiology, Royal Liverpool Hospital, Prescot Street, Liverpool, L7 8XP, UK; Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool L14 3PE, UK
| | - Katarzyna Nabrdalik
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool L14 3PE, UK; Department of Internal Medicine, Diabetology and Nephrology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool L14 3PE, UK; Department of Internal Medicine, Diabetology and Nephrology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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20
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Wilton SB, Kaul P, Islam S, Atzema CL, Cruz J, MacFarlane K, McKelvie R, Poon S, Lambert L, Rush K, Deyell M, Wyse DG, Cox JL, Skanes A, Sandhu RK. Surveillance for Outcomes Selected as Atrial Fibrillation Quality Indicators in Canada: 10-Year Trends in Stroke, Major Bleeding, and Heart Failure. CJC Open 2021; 3:609-618. [PMID: 34036258 PMCID: PMC8134946 DOI: 10.1016/j.cjco.2021.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 01/04/2021] [Indexed: 11/29/2022] Open
Abstract
Background Whether advances in identification and management of atrial fibrillation and atrial flutter (collectively, AF) have led to improved outcomes is unclear. We sought to study trends in clinical outcomes selected as quality indicators for nonvalvular AF in Canada. Methods We identified hospitalized patients with a first diagnosis of nonvalvular AF between April 2006 and March 2015, in all of Canada except Quebec. We assessed trends in 1-year incidence of stroke/systemic embolism (SSE), major bleeding, and initial heart failure (HF) hospitalization. Results The cohort included 466,476 patients. The median age was 77 years (interquartile range, 68-84 years), 46% were female, and 68% had a Congestive Heart Failure, Hypertension, Age (≥75 years), Diabetes, Stroke/Transient Ischemic Attack, Vascular Disease, Age (65-74 years), Sex (Female) (CHA2DS2-VASc) score > 3. Within 1 year of discharge, 3.5% were hospitalized for stroke or SSE, 1.6% for major bleeding, and 8.6% for new HF. Over the study period, the crude rate of SSE declined from 3.6% to 3.3% (P = 0.002), whereas the rates of hospitalization for new HF and for major bleeding did not significantly change. After adjustment for CHA2DS2-VASc score, the yearly rates of incident SSE (risk ratio, 0.99; 95% confidence interval [CI], 0.98-0.99; P = 0.002) and HF (risk ratio, 0.99; 95% CI, 0.99-1.00; P = 0.001) declined ≤ 1% absolute, whereas major bleeding remained unchanged (risk ratio, 1.00; 95% CI, 0.99-1.00; P = 0.28). Conclusions Among hospitalized patients with nonvalvular AF in Canada, the rate of SSE and new HF decreased modestly over a 10-year period, with no significant change in major bleeding. Efforts to study process-based quality indicators, with increased focus on HF prevention, are needed.
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Affiliation(s)
- Stephen B Wilton
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Padma Kaul
- Department of Medicine, Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - Sunjidatul Islam
- Department of Medicine, Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - Clare L Atzema
- Department of Emergency Services, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Jennifer Cruz
- Cardiac Arrhythmia Service, St Michael's Hospital, Toronto, Ontario, Canada
| | | | - Robert McKelvie
- Division of Cardiology, Western University, London, Ontario, Canada
| | - Stephanie Poon
- Division of Cardiology, Sunnybrook Hospital, Toronto, Ontario, Canada
| | - Laurie Lambert
- Institut national d'excellence en santé et en services sociaux, Montreal, Quebec, Canada
| | - Kathy Rush
- Faculty of Health and Social Development, School of Nursing, University of British Columbia, Kelowna, British Columbia, Canada.,Departments of Medicine and of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Marc Deyell
- Department of Medicine, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - D George Wyse
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Jafna L Cox
- Departments of Medicine and of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Allan Skanes
- Department of Medicine, London Heart Institute, University of Western Ontario, London, Ontario, Canada
| | - Roopinder K Sandhu
- Department of Medicine, Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
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21
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Jawad-Ul-Qamar M, Chua W, Purmah Y, Nawaz M, Varma C, Davis R, Maher A, Fabritz L, Kirchhof P. Detection of unknown atrial fibrillation by prolonged ECG monitoring in an all-comer patient cohort and association with clinical and Holter variables. Open Heart 2020; 7:openhrt-2019-001151. [PMID: 32371464 PMCID: PMC7223355 DOI: 10.1136/openhrt-2019-001151] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 02/12/2020] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES Prolonged ECG monitoring is clinically useful to detect unknown atrial fibrillation (AF) in stroke survivors. The diagnostic yield of prolonged ECG monitoring in other patient populations is less well characterised. We therefore studied the diagnostic yield of prolonged Holter ECG monitoring for AF in an unselected patient cohort referred from primary care or seen in a teaching hospital. METHODS We analysed consecutive 7-day ECG recordings in unselected patients referred from different medical specialities and assessed AF detection rates by indication, age and comorbidities. RESULTS Seven-day Holter ECGs (median monitoring 127.5 hours, IQR 116 to 152) were recorded in 476 patients (mean age 54.6 (SD 17.0) years, 55.9% female) without previously known AF, requested to evaluate palpitations (n=241), syncope (n=99), stroke or transient ischaemic attack (n=75), dizziness (n=29) or episodic chest pain (n=32). AF was newly detected in 42/476 (8.8%) patients. Oral anticoagulation was initiated in 40/42 (95.2%) patients with newly detected AF. Multivariate logistic regression, adjusted for age, sex and monitoring duration found four clinical parameters to be associated with newly detected AF: hypertension OR=2.54, (1.08 to 8.61) (adjusted OR (95% CI)), p=0.034; previous stroke or TIA OR=4.14 (1.81 to 13.01), p=0.001; left-sided valvular heart disease OR=5.07 (2.48 to 18.70), p<0.001 and palpitations OR=2.86, (1.33 to 10.44), p=0.015. CONCLUSIONS Open multispeciality access to prolonged ECG monitoring, for example, as part of integrated, cross-sector AF care, can accelerate diagnosis of AF and increase adequate use of oral anticoagulation, especially in older and symptomatic patients with comorbidities.
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Affiliation(s)
- Muhammad Jawad-Ul-Qamar
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK.,Department of Cardiology, Sandwell and West Birmingham Hospitals NHS Trust, West Bromwich, UK
| | - Winnie Chua
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Yanish Purmah
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK.,Department of Cardiology, Sandwell and West Birmingham Hospitals NHS Trust, West Bromwich, UK
| | - Mohammad Nawaz
- Department of Cardiology, Sandwell and West Birmingham Hospitals NHS Trust, West Bromwich, UK
| | - Chetan Varma
- Department of Cardiology, Sandwell and West Birmingham Hospitals NHS Trust, West Bromwich, UK
| | - Russell Davis
- Department of Cardiology, Sandwell and West Birmingham Hospitals NHS Trust, West Bromwich, UK
| | - Abdul Maher
- Department of Cardiology, Sandwell and West Birmingham Hospitals NHS Trust, West Bromwich, UK
| | - Larissa Fabritz
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK.,Department of Cardiology, Sandwell and West Birmingham Hospitals NHS Trust, West Bromwich, UK
| | - Paulus Kirchhof
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK .,Department of Cardiology, Sandwell and West Birmingham Hospitals NHS Trust, West Bromwich, UK.,University Heart and Vascular Center UKE Hamburg, Hamburg, Germany
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22
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Waalen J, Edwards AM, Sanyal A, Zambon RA, Ariniello L, Ebner GS, Baca-Motes K, Carter C, Felicione E, Sarich T, Topol EJ, Steinhubl SR. Healthcare resource utilization following ECG sensor patch screening for atrial fibrillation. Heart Rhythm O2 2020; 1:351-358. [PMID: 34113893 PMCID: PMC8183948 DOI: 10.1016/j.hroo.2020.09.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Screening for asymptomatic, undiagnosed atrial fibrillation (AF) has the potential to allow earlier treatment, possibly resulting in prevention of strokes, but also to increase medical resource utilization. OBJECTIVE To compare healthcare utilization rates during the year following initiation of screening among participants screened for AF by electrocardiogram (ECG) sensor patch compared with a matched observational control group. METHODS A total of 1718 participants recruited from a health care plan based on age and comorbidities who were screened with an ECG patch (actively monitored group) as part of a prospective, pragmatic research trial were matched by age, sex, and CHA2DS2-VASc score with 3371 members from the same health plan (observational control group). Healthcare utilization, including visits, prescriptions, procedures, and diagnoses, during the 1 year following screening was compared between the groups using health plan claims data. RESULTS Overall, the actively monitored group had significantly higher rates of cardiology visits (adjusted incidence rate ratio [aIRR] [95% confidence interval (CI)]: 1.43 [1.27, 1.60]), no difference in primary care provider visits (aIRR [95% CI]: 1.0 [0.95, 1.05]), but lower rates of emergency department (ED) visits and hospitalizations (aIRR [95% CI]: 0.80 [0.69, 0.92]) compared with controls. Among those with newly diagnosed AF, the reduction in ED visits and hospitalizations was even greater (aIRR [95% CI]: 0.27 [0.17, 0.43]). CONCLUSION AF screening in an asymptomatic, moderate-risk population with an ECG patch was associated with an increase in cardiology outpatient visits but also significantly lower rates of ED visits and hospitalizations over the 1 year following screening.
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Affiliation(s)
- Jill Waalen
- Scripps Research Translational Institute, La Jolla, California
| | | | | | | | | | - Gail S. Ebner
- Scripps Research Translational Institute, La Jolla, California
| | | | | | | | - Troy Sarich
- Johnson & Johnson, New Brunswick, New Jersey
| | - Eric J. Topol
- Scripps Research Translational Institute, La Jolla, California
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23
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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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24
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Schmidt C, Benda S, Kraft P, Wiedmann F, Pleger S, Büscher A, Thomas D, Wachter R, Schmid C, Eils R, Katus HA, Kallenberger SM. Prospective multicentric validation of a novel prediction model for paroxysmal atrial fibrillation. Clin Res Cardiol 2020; 110:868-876. [PMID: 33211156 PMCID: PMC8166666 DOI: 10.1007/s00392-020-01773-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Accepted: 10/27/2020] [Indexed: 12/25/2022]
Abstract
Background The early recognition of paroxysmal atrial fibrillation (pAF) is a major clinical challenge for preventing thromboembolic events. In this prospective and multicentric study we evaluated prediction scores for the presence of pAF, calculated from non-invasive medical history and echocardiographic parameters, in patients with unknown AF status. Methods The 12-parameter score with parameters age, LA diameter, aortic root diameter, LV,ESD, TDI Aʹ, heart frequency, sleep apnea, hyperlipidemia, type II diabetes, smoker, ß-blocker, catheter ablation, and the 4-parameter score with parameters age, LA diameter, aortic root diameter and TDI A’ were tested. Presence of pAF was verified by continuous electrocardiogram (ECG) monitoring for up to 21 days in 305 patients. Results The 12-parameter score correctly predicted pAF in all 34 patients, in which pAF was newly detected by ECG monitoring. The 12- and 4-parameter scores showed sensitivities of 100% and 82% (95%-CI 65%, 93%), specificities of 75% (95%-CI 70%, 80%) and 67% (95%-CI 61%, 73%), and areas under the receiver operating characteristic (ROC) curves of 0.84 (95%-CI 0.80, 0.88) and 0.81 (95%-CI 0.74, 0.87). Furthermore, properties of AF episodes and durations of ECG monitoring necessary to detect pAF were analysed. Conclusions The prediction scores adequately detected pAF using variables readily available during routine cardiac assessment and echocardiography. The model scores, denoted as ECHO-AF scores, represent simple, highly sensitive and non-invasive tools for detecting pAF that can be easily implemented in the clinical practice and might serve as screening test to initiate further diagnostic investigations for validating the presence of pAF. Graphic abstract Prospective validation of a novel prediction model for paroxysmal atrial fibrillation based on echocardiography and medical history parameters by long-term Holter ECG
![]() Electronic supplementary material The online version of this article (10.1007/s00392-020-01773-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Constanze Schmidt
- Department of Cardiology, University Hospital Heidelberg, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany. .,DZHK (German Center for Cardiovascular Research), Partner Site Heidelberg/Mannheim, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.
| | - Sebastian Benda
- Department of Cardiology, University Hospital Heidelberg, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Heidelberg/Mannheim, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Patricia Kraft
- Kardiologen Am Brückenkopf, Cardiology Practice, Brückenkopfstraße 1/2, 69120, Heidelberg, Germany
| | - Felix Wiedmann
- Department of Cardiology, University Hospital Heidelberg, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Heidelberg/Mannheim, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Sven Pleger
- Department of Cardiology, University Hospital Heidelberg, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.,Kardiologen Am Brückenkopf, Cardiology Practice, Brückenkopfstraße 1/2, 69120, Heidelberg, Germany
| | - Antonius Büscher
- Department of Cardiology, University Hospital Heidelberg, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Heidelberg/Mannheim, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Dierk Thomas
- Department of Cardiology, University Hospital Heidelberg, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Heidelberg/Mannheim, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Rolf Wachter
- Clinic and Policlinic for Cardiology, University Hospital Leipzig, Liebigstraße 18, 04103, Leipzig, Germany.,Clinic for Cardiology and Pneumology, University Medicine Göttingen, 37099, Göttingen, Germany
| | - Christian Schmid
- Department of Internal Medicine, GPR Klinikum Rüsselsheim, August-Bebel-Straße 59, 65428, Rüsselsheim am Main, Germany
| | - Roland Eils
- Digital Health Center, Berlin Institute of Health (BIH) and Charité, Anna-Louisa-Karsch-Straße 2, 10178, Berlin, Germany.,Division of Theoretical Bioinformatics, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 267, 69120, Heidelberg, Germany
| | - Hugo A Katus
- Department of Cardiology, University Hospital Heidelberg, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Heidelberg/Mannheim, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Stefan M Kallenberger
- Digital Health Center, Berlin Institute of Health (BIH) and Charité, Anna-Louisa-Karsch-Straße 2, 10178, Berlin, Germany.,Division of Theoretical Bioinformatics, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 267, 69120, Heidelberg, Germany
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25
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Popova EP, Puzin SS, Bogova OT, Puzin SN, Sychev DA, Fisenko VP. Effect of Amiodarone, Sotalol and Bisoprolol on Heart Rate Variability in Patients with Atrial Fibrillation. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2020. [DOI: 10.20996/1819-6446-2020-10-07] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Aim. To study the effect of class III antiarrhythmic drugs (amiodarone and sotalol), and the β-blocker bisoprolol on the spectral parameters of heart rate variability in patients with different forms of atrial fibrillation (AF).Material and methods. Spectral analysis of heart rate variability of 5-minute electrocardiography intervals was used. The study included patients with newly diagnosed AF and having a duration of the disease from 6 months to 8 years. Arterial hypertension, coronary artery disease, myocardial infarction (in history), conduction disorders and type 2 diabetes mellitus were diagnosed as comorbidities. The following parameters were calculated: the total power (TP) of the spectrum, the power of very low frequencies (VLF), low frequencies (LF) and high frequencies (HF).Results. In the group of patients with newly diagnosed AF without concomitant diseases after administration of amiodarone, VLF prevails in the spectrum structure, which indicates a significant role of humoral factors in the regulation of heart rate. The power of LF, reflecting the activity of the sympathetic nervous system, prevails over HF power after administration of amiodarone. In patients with newly diagnosed AF, having concomitant diseases, sympathetic influences prevail over parasympathetic ones by 3.6 times after administration of amiodarone. In the group of patients who have reduced the number of comorbidities, the LF/HF decreases and is only 1.66 after administration of amiodarone. The decrease in the number of negative factors is also accompanied by an increase in the influence of the vagus nerve on the activity of the heart. In the study of the effects of sotalol, the LF/HF in this group was twice lower in the group of patients with long-term AF. In patients receiving bisoprolol as antiarrhythmic therapy, the proportion of LF in the group of patients with newly diagnosed AF is 2 times lower, and the proportion of HF is twice higher than in the group of patients with long-term AF.Conclusion. The effect of antiarrhythmic drugs on the spectral parameters of heart rate variability depends on the duration AF. The presence of concomitant diseases of the cardiovascular system can significantly change the effect of antiarrhythmic drugs on the spectral parameters of heart rate variability and is accompanied by an increase in sympathetic activity. In patients with newly diagnosed AF, amiodarone and sotalol cause a similar effect – the predominance of sympathetic influence; when using bisoprolol, the predominant influence belongs to the vagus nerve. In patients with long-term AF, the opposite effect of drugs is observed: the use of amiodarone is accompanied by a more pronounced influence of the vagus nerve, and bisoprolol – the predominance of sympathetic influence. When using sotalol, sympathetic influences also prevail, more pronounced in patients with newly diagnosed AF.
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Affiliation(s)
- E. P. Popova
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - S. S. Puzin
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - O. T. Bogova
- Russian Medical Academy of Continuous Professional Education
| | - S. N. Puzin
- I.M. Sechenov First Moscow State Medical University (Sechenov University);
Russian Medical Academy of Continuous Professional Education;
Federal Research Clinical Center for Resuscitation and Rehabilitation
| | - D. A. Sychev
- Russian Medical Academy of Continuous Professional Education
| | - V. P. Fisenko
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
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26
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Reinsch N, Füting A, Buchholz J, Ruprecht U, Holzendorf V, Buschmeier F, Kälsch H, Neven K. One-year outcome and durability of pulmonary vein isolation after prospective use of ablation index for catheter ablation in patients with persistent atrial fibrillation. J Interv Card Electrophysiol 2020; 62:143-151. [PMID: 32989651 DOI: 10.1007/s10840-020-00880-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Accepted: 09/16/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Radiofrequency (RF) catheter ablation for persistent atrial fibrillation (peAF) is associated with less favorable outcomes than for paroxysmal AF (PAF). Recent studies have shown improved clinical outcomes with use of ablation index (AI) targets for pulmonary vein isolation (PVI) in PAF. AI is a novel ablation quality marker that incorporates contact force (CF), time, and power in a weighted formula. This is a single-arm registry to investigate the 1-year efficacy of AF ablation guided by the AI in patients with peAF, and further to evaluate pulmonary vein reconduction at repeat electrophysiology study in case of recurrent AF. METHODS In total, 55 consecutive patients (69 ± 10 years, 55% male, median time since first AF diagnosis: 31 months (Q1-Q3: 10-70)) with peAF underwent AIguided PVI using a CF surround-flow catheter. AI targets were 600 for anterior and 450 for roof/posterior/inferior antral segments. Patients were monitored for atrial tachyarrhythmia recurrence using 5-day Holter-ECG recordings at 3, 6, and 12 months. RESULTS The median procedure time was 173 min (Q1-Q3: 152-204). The median fluoroscopy time was 4 min (Q1-Q3: 3-6) and the median fluoroscopy dose was 2.64 Gy/cm2 (Q1-Q3: 1.04-3.99). The median ablation time was 57 min (Q1-Q3: 47-63). At 12 months, 42% of the patients were in sinus rhythm. AF recurrence was seen in 58% of patients. No major complications occurred. CONCLUSIONS RF ablation using AI in peAF is a feasible and safe technique. At 1 year, AI-guided ablation was associated with AF recurrence in 58% of the patients.
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Affiliation(s)
- Nico Reinsch
- Department of Electrophysiology, Alfried Krupp Krankenhaus, Alfried-Krupp-Straße 21, 45131, Essen, Germany. .,University Witten/Herdecke, Witten, Germany.
| | - Anna Füting
- Department of Electrophysiology, Alfried Krupp Krankenhaus, Alfried-Krupp-Straße 21, 45131, Essen, Germany
| | - Jochen Buchholz
- Department of Electrophysiology, Alfried Krupp Krankenhaus, Alfried-Krupp-Straße 21, 45131, Essen, Germany
| | - Ute Ruprecht
- Department of Electrophysiology, Alfried Krupp Krankenhaus, Alfried-Krupp-Straße 21, 45131, Essen, Germany.,University Witten/Herdecke, Witten, Germany
| | - Volker Holzendorf
- Clinical Trial Centre Leipzig - Coordination Centre for Clinical Trials (ZKS Leipzig - KKS), University Leipzig, Leipzig, Germany
| | - Felix Buschmeier
- Department of Electrophysiology, Alfried Krupp Krankenhaus, Alfried-Krupp-Straße 21, 45131, Essen, Germany
| | - Hagen Kälsch
- University Witten/Herdecke, Witten, Germany.,Department of Cardiology, Alfried Krupp Krankenhaus, Essen, Germany
| | - Kars Neven
- Department of Electrophysiology, Alfried Krupp Krankenhaus, Alfried-Krupp-Straße 21, 45131, Essen, Germany.,University Witten/Herdecke, Witten, Germany
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Jones J, Stanbury M, Haynes S, Bunting KV, Lobban T, Camm AJ, Calvert MJ, Kotecha D. Importance and Assessment of Quality of Life in Symptomatic Permanent Atrial Fibrillation: Patient Focus Groups from the RATE-AF Trial. Cardiology 2020; 145:666-675. [PMID: 32862174 DOI: 10.1159/000511048] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 08/19/2020] [Indexed: 11/19/2022]
Abstract
AIMS To establish the extent and impact of symptoms in patients with atrial fibrillation (AF), the importance of different aspects of quality of life (QoL), and how we should assess wellbeing. METHODS Focus groups of patients with symptomatic permanent AF in a trial of heart rate control; the RATE-AF trial randomised 160 patients aged ≥60 years with permanent AF and at least NYHA class II dyspnoea to either digoxin or beta-blockers. Patient and public representatives led the focus groups and performed all data acquisition and analysis, using thematic approaches to interpret patient views about QoL and its measurement. RESULTS Substantial impairment of health-related QoL was noted in 160 trial patients, with impact on all domains apart from mental health. Eight women and 11 men aged 61-87 years participated in the focus groups. Common themes were a lack of information from healthcare professionals about AF, a lack of focus on QoL in consultations, and a sense of frustration, isolation, and reduced confidence. There was marked variability in symptoms in individual patients, with some describing severe impact on activities of daily living, and profound interaction with comorbidities such as arthritis. Day-to-day variation in QoL and difficulty in attributing symptom burden to AF or other comorbidities led to challenges in questionnaire completion. Consensus was reached that collecting both general and AF-specific QoL would be useful in routine practice, along with participation in peer support, which was empowering for the patients. CONCLUSIONS The impact of comorbidities is poorly appreciated in the context of AF, with considerable variability in QoL that requires both generic and AF-specific assessment. Improvement in QoL should direct the appraisal, and reappraisal, of treatment decisions for patients with permanent AF.
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Affiliation(s)
- Jacqueline Jones
- Patient and Public Involvement Team, RATE-AF trial, Birmingham, United Kingdom
| | - Mary Stanbury
- Patient and Public Involvement Team, RATE-AF trial, Birmingham, United Kingdom
| | - Sandra Haynes
- Patient and Public Involvement Team, RATE-AF trial, Birmingham, United Kingdom
| | - Karina V Bunting
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom.,University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Trudie Lobban
- Arrhythmia Alliance and Atrial Fibrillation Association, Chipping Norton, United Kingdom
| | - A John Camm
- St. George's University of London, London, United Kingdom
| | - Melanie J Calvert
- Institute of Applied Health Research & National Institute for Health Research Biomedical Research Centre, University of Birmingham, Birmingham, United Kingdom.,Centre for Patient Reported Outcomes Research, University of Birmingham, Birmingham, United Kingdom.,Birmingham Health Partners Centre for Regulatory Science and Innovation, University of Birmingham, Birmingham, United Kingdom
| | - Dipak Kotecha
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom, .,University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom, .,Centre for Patient Reported Outcomes Research, University of Birmingham, Birmingham, United Kingdom,
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28
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Dretzke J, Chuchu N, Agarwal R, Herd C, Chua W, Fabritz L, Bayliss S, Kotecha D, Deeks JJ, Kirchhof P, Takwoingi Y. Predicting recurrent atrial fibrillation after catheter ablation: a systematic review of prognostic models. Europace 2020; 22:748-760. [PMID: 32227238 PMCID: PMC7203634 DOI: 10.1093/europace/euaa041] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 02/05/2020] [Indexed: 12/22/2022] Open
Abstract
AIMS We assessed the performance of modelsf (risk scores) for predicting recurrence of atrial fibrillation (AF) in patients who have undergone catheter ablation. METHODS AND RESULTS Systematic searches of bibliographic databases were conducted (November 2018). Studies were eligible for inclusion if they reported the development, validation, or impact assessment of a model for predicting AF recurrence after ablation. Model performance (discrimination and calibration) measures were extracted. The Prediction Study Risk of Bias Assessment Tool (PROBAST) was used to assess risk of bias. Meta-analysis was not feasible due to clinical and methodological differences between studies, but c-statistics were presented in forest plots. Thirty-three studies developing or validating 13 models were included; eight studies compared two or more models. Common model variables were left atrial parameters, type of AF, and age. Model discriminatory ability was highly variable and no model had consistently poor or good performance. Most studies did not assess model calibration. The main risk of bias concern was the lack of internal validation which may have resulted in overly optimistic and/or biased model performance estimates. No model impact studies were identified. CONCLUSION Our systematic review suggests that clinical risk prediction of AF after ablation has potential, but there remains a need for robust evaluation of risk factors and development of risk scores.
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Affiliation(s)
- Janine Dretzke
- Institute of Applied Health Research, University of Birmingham, Birmingham B15 2TT, UK
| | - Naomi Chuchu
- Institute of Applied Health Research, University of Birmingham, Birmingham B15 2TT, UK
| | - Ridhi Agarwal
- Institute of Applied Health Research, University of Birmingham, Birmingham B15 2TT, UK
| | - Clare Herd
- Institute of Applied Health Research, University of Birmingham, Birmingham B15 2TT, UK
| | - Winnie Chua
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - Larissa Fabritz
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham B15 2TT, UK
- University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, UK
| | - Susan Bayliss
- Institute of Applied Health Research, University of Birmingham, Birmingham B15 2TT, UK
| | - Dipak Kotecha
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham B15 2TT, UK
- University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, UK
| | - Jonathan J Deeks
- Institute of Applied Health Research, University of Birmingham, Birmingham B15 2TT, UK
| | - Paulus Kirchhof
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham B15 2TT, UK
- University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, UK
- Sandwell and West Birmingham Hospitals NHS Trust, Birmingham B18 7QH, UK
| | - Yemisi Takwoingi
- Institute of Applied Health Research, University of Birmingham, Birmingham B15 2TT, UK
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Jatau Abubakar I, Wimmer BC, Bereznicki LR, Dwan C, Black JA, M. Bezabhe W, M. Peterson G. Development and Validation of an Atrial Fibrillation Knowledge Assessment Tool (AFKAT). INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E1721. [PMID: 32155724 PMCID: PMC7084596 DOI: 10.3390/ijerph17051721] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 02/25/2020] [Accepted: 03/03/2020] [Indexed: 01/18/2023]
Abstract
Assessing and improving public knowledge of atrial fibrillation (AF) could increase its detection rate and the subsequent use of stroke prevention therapies. However, there is no validated AF knowledge assessment tool applicable to the general population, including those at risk of AF. Therefore, we aimed to develop and validate such a tool. The tool was developed from a literature review and discussion with subject matter experts. Content validity was ensured by a ten-member panel of experts comprising cardiologists and pharmacists. An online validation survey was conducted and reported based on the Checklist for Reporting Results of Internet E-Surveys (CHERRIES). The survey evaluated the tool performance by construct validity, internal consistency reliability, item discrimination, difficulty index and ease of readability. The survey participants included 14 general medical specialists, 20 fourth-year and 33 second-year undergraduate pharmacy students, and 122 members of the general public. The tool had satisfactory content validity, with a scale content validity index of 0.8. The mean percentage knowledge scores for general medical specialists and fourth-year pharmacy students were higher than second-year pharmacy students, followed by the general public (92.9%, 87.6%, 68.5% and 53.4%, respectively; p-value < 0.001), supporting construct validity. The tool had good internal consistency reliability (Cronbach's alpha = 0.91). The item-total correlation was in the preferred range of 0.23 to 0.71. The Atrial Fibrillation Knowledge Assessment Tool is a valid instrument and can be used to investigate AF knowledge of the general population.
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Affiliation(s)
- Ibrahim Jatau Abubakar
- School of Pharmacy and Pharmacology, College of Health and Medicine, University of Tasmania, Private Bag 26, Hobart, TAS 7001, Australia; (B.C.W.); (L.R.B.); (C.D.); (W.M.B.); (G.M.P.)
| | - Barbara C. Wimmer
- School of Pharmacy and Pharmacology, College of Health and Medicine, University of Tasmania, Private Bag 26, Hobart, TAS 7001, Australia; (B.C.W.); (L.R.B.); (C.D.); (W.M.B.); (G.M.P.)
| | - Luke R. Bereznicki
- School of Pharmacy and Pharmacology, College of Health and Medicine, University of Tasmania, Private Bag 26, Hobart, TAS 7001, Australia; (B.C.W.); (L.R.B.); (C.D.); (W.M.B.); (G.M.P.)
| | - Corinna Dwan
- School of Pharmacy and Pharmacology, College of Health and Medicine, University of Tasmania, Private Bag 26, Hobart, TAS 7001, Australia; (B.C.W.); (L.R.B.); (C.D.); (W.M.B.); (G.M.P.)
| | | | - Woldesellassie M. Bezabhe
- School of Pharmacy and Pharmacology, College of Health and Medicine, University of Tasmania, Private Bag 26, Hobart, TAS 7001, Australia; (B.C.W.); (L.R.B.); (C.D.); (W.M.B.); (G.M.P.)
| | - Gregory M. Peterson
- School of Pharmacy and Pharmacology, College of Health and Medicine, University of Tasmania, Private Bag 26, Hobart, TAS 7001, Australia; (B.C.W.); (L.R.B.); (C.D.); (W.M.B.); (G.M.P.)
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30
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Chang JC. Stroke Classification: Critical Role of Unusually Large von Willebrand Factor Multimers and Tissue Factor on Clinical Phenotypes Based on Novel "Two-Path Unifying Theory" of Hemostasis. Clin Appl Thromb Hemost 2020; 26:1076029620913634. [PMID: 32584600 PMCID: PMC7427029 DOI: 10.1177/1076029620913634] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 02/19/2020] [Accepted: 02/20/2020] [Indexed: 12/17/2022] Open
Abstract
Stroke is a hemostatic disease associated with thrombosis/hemorrhage caused by intracranial vascular injury with spectrum of clinical phenotypes and variable prognostic outcomes. The genesis of different phenotypes of stroke is poorly understood due to our incomplete understanding of hemostasis and thrombosis. These shortcomings have handicapped properly recognizing each specific stroke syndrome and contributed to controversy in selecting therapeutic agents. Treatment recommendation for stroke syndromes has been exclusively derived from the result of laborious and expensive clinical trials. According to newly proposed "two-path unifying theory" of in vivo hemostasis, intracranial vascular injury would yield several unique stroke syndromes triggered by 3 distinctly different thrombogenetic mechanisms depending upon level of intracranial intravascular injury and character of formed blood clots. Five major phenotypes of stroke occur via thrombogenetic paths: (1) transient ischemic attack due to focal endothelial damage limited to endothelial cells (ECs), (2) acute ischemic stroke due to localized ECs and subendothelial tissue (SET) damage extending up to the outer vascular wall, (3) thrombo-hemorrhagic stroke due to localized vascular damage involving ECs and SET and extending beyond SET to extravascular tissue, (4) acute hemorrhagic stroke due to major localized intracranial hemorrhage/hematoma into the brain tissue or space between the coverings of the brain associated with vascular anomaly or obtuse trauma, and (5) encephalopathic stroke due to disseminated endotheliopathy leading to microthrombosis within the brain. New classification of stroke phenotypes would assist in selecting rational therapeutic regimen for each stroke syndrome and designing clinical trials to improve clinical outcome.
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Affiliation(s)
- Jae C. Chang
- Department of Medicine, University of California Irvine School of Medicine, Irvine, CA, USA
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31
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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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32
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Yiu AWP, Lee VW, Ng KK, Bajorek BV. Patient Feedback on a Warfarin Action Plan Used in a Local Australian Physician Practice Setting. Ther Innov Regul Sci 2019:2168479019865900. [PMID: 31426683 DOI: 10.1177/2168479019865900] [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: 02/28/2024]
Abstract
BACKGROUND Warfarin is a high-risk medicine, and older persons (those aged 65 years and older)1,2 who take this therapy need medicines information about it that is at a level which is both understandable and comprehensive to improve their knowledge about the risks and benefits of warfarin therapy.3,4 Therefore, the primary objective of this study was to report patient feedback on a Warfarin Action Plan (WAP) (leaflet) and identify patients' preferences regarding its content and format. The secondary objective was to canvass in-depth feedback regarding the participants' information needs and current information-seeking practices with respect to warfarin therapy. METHOD In an Australian General Practice medical centre setting, a qualitative study comprising 34 individual interviews was conducted. Emergent themes were elicited via a qualitative analysis using manual inductive coding. RESULTS The majority of participants gave very positive feedback on the WAP leaflet, stating that it was a useful and concise resource. In canvasing this feedback, 4 themes emerged: (1) the need for information about warfarin therapy, (2) reliance on doctors and/or pharmacists for information, (3) the need for information to normalize their daily life, and (4) patients and carers acting on the new information. CONCLUSION The WAP is a simple and well-received tool that meets the knowledge and education needs about warfarin therapy for older people and their carers.
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Affiliation(s)
- Angela W P Yiu
- 1 University Technology of Sydney, Sydney, New South Wales, Australia
- 2 Department of Pharmacy, Westmead Hospital, Westmead, New South Wales, Australia
| | - Vincent W Lee
- 3 Department of Renal Medicine, University of Sydney, Sydney, New South Wales, Australia
- 4 Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Kingsley K Ng
- 2 Department of Pharmacy, Westmead Hospital, Westmead, New South Wales, Australia
| | - Beata V Bajorek
- 1 University Technology of Sydney, Sydney, New South Wales, Australia
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Berge T, Brynildsen J, Larssen HKN, Onarheim S, Jenssen GR, Ihle-Hansen H, Christophersen IE, Myrstad M, Røsjø H, Smith P, Tveit A. Systematic screening for atrial fibrillation in a 65-year-old population with risk factors for stroke: data from the Akershus Cardiac Examination 1950 study. Europace 2019; 20:f299-f305. [PMID: 29095966 DOI: 10.1093/europace/eux293] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 08/25/2017] [Indexed: 11/12/2022] Open
Abstract
Aims To investigate the yield of screening for atrial fibrillation (AF) in a cohort of 65-year-old individuals from the general population with additional risk factors for stroke. Methods and results We invited participants with additional risk factors for stroke (CHA2DS2-VASc score ≥2 for men or ≥ 3 for women) without previously known AF from a population-based study in Norway to participate in a 2-week screening for AF. Screening was performed by one-lead 'thumb electrocardiography (ECG)' recordings of 30 s twice daily or when the participants experienced symptoms. In total, 1742 (47.0%) participants of the Akershus Cardiac Examination (ACE) 1950 study had at least one additional risk factor for stroke. Of these, 123 cases reported a history of AF and 101 (5.8%) cases were ECG validated. Eight [0.5%, 95% confidence interval (CI) 0.2-0.9] new AF cases were diagnosed by 12-lead ECG at baseline, and 10 additional participants were diagnosed with AF before screening commenced. We invited all 1601 participants who met the inclusion criteria for screening, of which 1510 (94.3%) participants were included (44% women and 56% men). The screening revealed AF in 13 (0.9%, 95% CI 0.5-1.5) participants. The total prevalence of ECG-validated AF after screening among the 65-year-olds with risk factors for stroke was 7.6% (95% CI 6.4-8.9), in men 10.0% (95% CI 8.2-12.0), and in women 4.3% (95% CI 3.0-6.1) (P < 0.001). Conclusion In a group of 1510 well-characterized 65-year-olds with risk factors for stroke, 2-week intermittent ECG screening identified undiagnosed AF in 0.9%. The total prevalence of AF was 7.6%.
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Affiliation(s)
- Trygve Berge
- Department of Medical Research, Bærum Hospital, Vestre Viken Hospital Trust, N-3004 Drammen, Norway.,Center for Heart Failure Research, Institute of Clinical Medicine, University of Oslo, N-0407 Oslo, Norway
| | - Jon Brynildsen
- Center for Heart Failure Research, Institute of Clinical Medicine, University of Oslo, N-0407 Oslo, Norway.,Division of Medicine, Akershus University Hospital, N-1478 Lørenskog, Norway
| | | | - Sophia Onarheim
- Department of Medical Research, Bærum Hospital, Vestre Viken Hospital Trust, N-3004 Drammen, Norway
| | - Gaute R Jenssen
- Department of Medical Research, Bærum Hospital, Vestre Viken Hospital Trust, N-3004 Drammen, Norway.,Center for Heart Failure Research, Institute of Clinical Medicine, University of Oslo, N-0407 Oslo, Norway
| | - Haakon Ihle-Hansen
- Department of Medical Research, Bærum Hospital, Vestre Viken Hospital Trust, N-3004 Drammen, Norway.,Center for Heart Failure Research, Institute of Clinical Medicine, University of Oslo, N-0407 Oslo, Norway
| | - Ingrid E Christophersen
- Department of Medical Research, Bærum Hospital, Vestre Viken Hospital Trust, N-3004 Drammen, Norway
| | - Marius Myrstad
- Department of Medical Research, Bærum Hospital, Vestre Viken Hospital Trust, N-3004 Drammen, Norway
| | - Helge Røsjø
- Center for Heart Failure Research, Institute of Clinical Medicine, University of Oslo, N-0407 Oslo, Norway.,Division of Medicine, Akershus University Hospital, N-1478 Lørenskog, Norway
| | - Pål Smith
- Center for Heart Failure Research, Institute of Clinical Medicine, University of Oslo, N-0407 Oslo, Norway.,Division of Medicine, Akershus University Hospital, N-1478 Lørenskog, Norway
| | - Arnljot Tveit
- Department of Medical Research, Bærum Hospital, Vestre Viken Hospital Trust, N-3004 Drammen, Norway.,Center for Heart Failure Research, Institute of Clinical Medicine, University of Oslo, N-0407 Oslo, Norway
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Dobrev D. Atrial Ca2+/calmodulin-dependent protein kinase II: A druggable master switch of atrial fibrillation-associated atrial remodeling? Heart Rhythm 2019; 16:1089-1090. [DOI: 10.1016/j.hrthm.2019.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Indexed: 01/23/2023]
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35
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Orchard J, Lowres N, Neubeck L, Freedman B. Atrial fibrillation: is there enough evidence to recommend opportunistic or systematic screening? Int J Epidemiol 2019; 47:1372-1378. [PMID: 29931278 DOI: 10.1093/ije/dyy111] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 05/25/2018] [Indexed: 11/14/2022] Open
Affiliation(s)
- Jessica Orchard
- Sydney Medical School and Charles Perkins Centre, University of Sydney, Sydney, NSW, Australia
| | - Nicole Lowres
- Sydney Medical School and Charles Perkins Centre, University of Sydney, Sydney, NSW, Australia.,Heart Research Institute, University of Sydney, Sydney, NSW, Australia
| | - Lis Neubeck
- School of Health and Social Care, Edinburgh Napier University, Edinburgh, UK
| | - Ben Freedman
- Sydney Medical School and Charles Perkins Centre, University of Sydney, Sydney, NSW, Australia.,Heart Research Institute, University of Sydney, Sydney, NSW, Australia
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36
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Heijman J, Dobrev D. Inhibition of Small-Conductance Ca 2+-Activated K + Channels: The Long-Awaited Breakthrough for Antiarrhythmic Drug Therapy of Atrial Fibrillation? Circ Arrhythm Electrophysiol 2019; 10:CIRCEP.117.005776. [PMID: 29018167 DOI: 10.1161/circep.117.005776] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Jordi Heijman
- From the Department of Cardiology, Cardiovascular Research Institute Maastricht, Faculty of Health, Medicine, and Life Sciences, Maastricht University, The Netherlands (J.H.); and Institute of Pharmacology, West German Heart and Vascular Center, School of Medicine, University Duisburg-Essen, Germany (D.D.)
| | - Dobromir Dobrev
- From the Department of Cardiology, Cardiovascular Research Institute Maastricht, Faculty of Health, Medicine, and Life Sciences, Maastricht University, The Netherlands (J.H.); and Institute of Pharmacology, West German Heart and Vascular Center, School of Medicine, University Duisburg-Essen, Germany (D.D.).
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37
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Rush KL, Burton L, Schaab K, Lukey A. The impact of nurse-led atrial fibrillation clinics on patient and healthcare outcomes: a systematic mixed studies review. Eur J Cardiovasc Nurs 2019; 18:526-533. [DOI: 10.1177/1474515119845198] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Atrial fibrillation, the most common arrhythmia worldwide, continues to increase as the population ages. Patients with atrial fibrillation, particularly those newly diagnosed or who have multiple comorbidities, have high healthcare utilisation rates. Nurse-led atrial fibrillation clinics have developed to improve care and guidance for atrial fibrillation patients, with the potential to reduce hospital presentations and healthcare utilisation. Atrial fibrillation clinics that provide specialised and patient-centred care have improved patient symptom management, quality of life and reduced healthcare utilisation and costs. Aims: The aim of this study was to provide the first synthesis of evidence for the impact of nurse-led atrial fibrillation clinics on patient, healthcare utilisation, and quality of care outcomes. Methods: This systematic mixed studies review examined citations from three databases: Medline, CINAHL and Embase, using the search terms ‘atrial fibrillation’ and ‘clinic’, and related concepts. Seventeen moderate to high quality articles were selected. Results: Overall, atrial fibrillation clinics were more cost effective, had shorter wait times and reduced hospitalisation and emergency department visits. Symptoms and sinus rhythm restoration were comparable in the nurse-led compared to physician-led cardioversion clinics. Findings related to patient knowledge and patient satisfaction were mixed, while mortality rates were lower, and patient medication adherence was higher in nurse-led atrial fibrillation compared to usual care. Quality of life and guideline adherence was increased in patients receiving nurse-led atrial fibrillation care compared to usual care. Conclusion: Nurse-led clinics improved healthcare, patient and quality care outcomes. Future research might examine the role of technology in delivery of nurse-led clinics in rural/remote areas as well as patient experiences with nurse-led clinics.
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Affiliation(s)
- Kathy L Rush
- Faculty of Health and Social Development, University of British Columbia, Canada
| | - Lindsay Burton
- School of Nursing, University of British Columbia, Canada
| | - Kira Schaab
- University of Medicine and Health Sciences, St Kitts
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Fender AC, Wakili R, Dobrev D. Straight to the heart: Pleiotropic antiarrhythmic actions of oral anticoagulants. Pharmacol Res 2019; 145:104257. [PMID: 31054953 DOI: 10.1016/j.phrs.2019.104257] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 04/30/2019] [Accepted: 05/01/2019] [Indexed: 02/06/2023]
Abstract
Mechanistic understanding of atrial fibrillation (AF) pathophysiology and the complex bidirectional relationship with thromboembolic risk remains limited. Oral anticoagulation is a mainstay of AF management. An emerging concept is that anticoagulants may themselves have potential pleiotropic disease-modifying effects. We here review the available evidence for hemostasis-independent actions of the oral anticoagulants on electrical and structural remodeling, and the inflammatory component of the vulnerable substrate.
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Affiliation(s)
- Anke C Fender
- Institute of Pharmacology, West-German Heart and Vascular Center, Faculty of Medicine, University Duisburg-Essen, Germany.
| | - Reza Wakili
- Clinic for Cardiology and Angiology, West-German Heart and Vascular Center, Faculty of Medicine, University Duisburg-Essen, Germany
| | - Dobromir Dobrev
- Institute of Pharmacology, West-German Heart and Vascular Center, Faculty of Medicine, University Duisburg-Essen, Germany
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39
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Bode K. Transfemoral vascular access in electrophysiology: should we exclusively rely on ultrasound guidance? Europace 2019; 21:361-362. [PMID: 30010748 DOI: 10.1093/europace/euy167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Kerstin Bode
- Department of Electrophysiology, Heart Centre Leipzig, University of Leipzig, Struempellstrasse 39, Leipzig, Germany
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40
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Wutzler A, Krogias C, Grau A, Veltkamp R, Heuschmann PU, Haeusler KG. Stroke prevention in patients with acute ischemic stroke and atrial fibrillation in Germany - a cross sectional survey. BMC Neurol 2019; 19:25. [PMID: 30755168 PMCID: PMC6371606 DOI: 10.1186/s12883-019-1249-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Accepted: 01/31/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Atrial fibrillation (AF) is present in 15-20% of patients with acute ischemic stroke. Oral anticoagulation reduces the risk of AF-related recurrent stroke but clinical guideline recommendations are rather vague regarding its use in the acute phase of stroke. We aimed to assess the current clinical practice of medical stroke prevention in AF patients during the acute phase of ischemic stroke. METHODS In April 2017, a standardized anonymous questionnaire was sent to clinical leads of all 298 certified stroke units in Germany. RESULTS Overall, 154 stroke unit leads participated (response rate 52%). Anticoagulation in the acute phase of stroke is considered feasible in more than 90% of AF patients with ischemic stroke. Clinicians assume that about two thirds of all AF patients (range 20-100%) are discharged on oral anticoagulation. According to local preferences, acetylsalicylic acid is given orally in the majority of patients with delayed initiation of oral anticoagulation. A non-vitamin K-dependent oral anticoagulant (NOAC) is more often prescribed than a vitamin K-dependent oral anticoagulant (VKA). VKA is more often chosen in patients with previous VKA intake than in VKA naive patients. In the minority of patients, stroke unit leads discuss the prescription of a specific oral anticoagulant with the treating general practitioner. Adherence to medical stroke prevention after hospital discharge is not assessed on a regular basis in any patient by the majority of participating stroke centers. CONCLUSIONS Early secondary stroke prevention in AF patients in German stroke units is based on OAC use but prescription modalities vary in clinical practice.
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Affiliation(s)
- Alexander Wutzler
- Cardiovascular Center, St. Josef Hospital, University Hospital of the Ruhr-University Bochum, Bochum, Germany
| | - Christos Krogias
- Department of Neurology, St. Josef Hospital, University Hospital of the Ruhr-University Bochum, Bochum, Germany
| | - Anna Grau
- Institute of Clinical Epidemiology and Biometry, University Würzburg, Würzburg, Germany
| | - Roland Veltkamp
- Department of Stroke Medicine, Department of Neurology, Alfried Krupp Krankenhaus, Essen, Germany & Department of Neurology, Imperial College London UK, University Hospital Heidelberg, Heidelberg, Germany
| | - Peter U Heuschmann
- Institute of Clinical Epidemiology and Biometry, University Würzburg, Würzburg, Germany.,Comprehensive Heart Failure Center, University of Würzburg & Clinical Trial Centre Würzburg, University Hospital Würzburg, Würzburg, Germany
| | - Karl Georg Haeusler
- Department of Neurology, University Hospital Würzburg, Josef-Schneider-Str. 11, 97080, Würzburg, Germany.
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41
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Dillon-Murphy D, Marlevi D, Ruijsink B, Qureshi A, Chubb H, Kerfoot E, O'Neill M, Nordsletten D, Aslanidi O, de Vecchi A. Modeling Left Atrial Flow, Energy, Blood Heating Distribution in Response to Catheter Ablation Therapy. Front Physiol 2019; 9:1757. [PMID: 30618785 PMCID: PMC6302108 DOI: 10.3389/fphys.2018.01757] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 11/20/2018] [Indexed: 11/16/2022] Open
Abstract
Introduction: Atrial fibrillation (AF) is a widespread cardiac arrhythmia that commonly affects the left atrium (LA), causing it to quiver instead of contracting effectively. This behavior is triggered by abnormal electrical impulses at a specific site in the atrial wall. Catheter ablation (CA) treatment consists of isolating this driver site by burning the surrounding tissue to restore sinus rhythm (SR). However, evidence suggests that CA can concur to the formation of blood clots by promoting coagulation near the heat source and in regions with low flow velocity and blood stagnation. Methods: A patient-specific modeling workflow was created and applied to simulate thermal-fluid dynamics in two patients pre- and post-CA. Each model was personalized based on pre- and post-CA imaging datasets. The wall motion and anatomy were derived from SSFP Cine MRI data, while the trans-valvular flow was based on Doppler ultrasound data. The temperature distribution in the blood was modeled using a modified Pennes bioheat equation implemented in a finite-element based Navier-Stokes solver. Blood particles were also classified based on their residence time in the LA using a particle-tracking algorithm. Results: SR simulations showed multiple short-lived vortices with an average blood velocity of 0.2-0.22 m/s. In contrast, AF patients presented a slower vortex and stagnant flow in the LA appendage, with the average blood velocity reduced to 0.08–0.14 m/s. Restoration of SR also increased the blood kinetic energy and the viscous dissipation due to the presence of multiple vortices. Particle tracking showed a dramatic decrease in the percentage of blood remaining in the LA for longer than one cycle after CA (65.9 vs. 43.3% in patient A and 62.2 vs. 54.8% in patient B). Maximum temperatures of 76° and 58°C were observed when CA was performed near the appendage and in a pulmonary vein, respectively. Conclusion: This computational study presents novel models to elucidate relations between catheter temperature, patient-specific atrial anatomy and blood velocity, and predict how they change from SR to AF. The models can quantify blood flow in critical regions, including residence times and temperature distribution for different catheter positions, providing a basis for quantifying stroke risks.
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Affiliation(s)
- Desmond Dillon-Murphy
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - David Marlevi
- School of Engineering Sciences in Chemistry, Biotechnology and Health, KTH Royal Institute of Technology, Stockholm, Sweden
| | - Bram Ruijsink
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Ahmed Qureshi
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Henry Chubb
- Department of Cardiothoracic Surgery, Stanford University, Palo Alto, CA, United States
| | - Eric Kerfoot
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Mark O'Neill
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - David Nordsletten
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Oleg Aslanidi
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Adelaide de Vecchi
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
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Sepehri Shamloo A, Arya A, Dagres N, Hindricks G. Sleep Disorders and Atrial Fibrillation: Current Situation and Future Directions. Galen Med J 2018; 7:e1416. [PMID: 34466452 PMCID: PMC8343595 DOI: 10.22086/gmj.v0i0.1416] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 10/17/2018] [Accepted: 10/29/2018] [Indexed: 11/30/2022] Open
Abstract
Atrial fibrillation (AF) is a growing health problem worldwide. In recent years, there has been a rising interest in the relationship between sleep disorders and AF. Several studies have reported higher prevalence and incidence rates of AF in patients with obstructive sleep apnea-hypopnea syndrome (OSAHS). However, some believe that OSAHS is not a risk factor for AF; but AF, by itself, is regarded as one of the possible triggers for OSAHS. In this study, the related literature investigating the association between OSAHS and AF was reviewed, and then the possible mechanisms of this interplay were discussed. To conclude, recommendations for further research in this field were presented to researchers and some points were highlighted for physicians.
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Affiliation(s)
- Alireza Sepehri Shamloo
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
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Sepehri Shamloo A, Arya A, Dagres N, Hindricks G. Exercise and Atrial Fibrillation: Some Good News and Some Bad News. Galen Med J 2018; 7:e1401. [PMID: 34466451 PMCID: PMC8343702 DOI: 10.22086/gmj.v0i0.1401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 10/14/2018] [Accepted: 10/26/2018] [Indexed: 11/30/2022] Open
Abstract
Atrial fibrillation (AF) is considered as the most common sustained arrhythmia in adults, whose incidence rate is on the rise due to the increase in the mean age of the global population. In recent years, many efforts have been made to identify effective factors in the incidence of AF to prevent them and thereby reduce the consequences of AF. Physical activity is one of the topics that attracted much attention in the last two decades. According to some findings, extreme and prolonged exercise itself can be considered as a risk factor for the onset of AF; however, other studies have shown that exercise can be regarded a protective factor against AF in the general population. The present study reviews the findings of studies on the relationship between AF and exercise and discusses possible mechanisms for this relationship. Additionally, we present some recommendations for researchers and physicians about exercise management in association with AF prevention.
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Affiliation(s)
| | - Arash Arya
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig
| | - Nikolaos Dagres
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig
| | - Gerhard Hindricks
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig
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Mairesse GH, Moran P, Van Gelder IC, Elsner C, Rosenqvist M, Mant J, Banerjee A, Gorenek B, Brachmann J, Varma N, Glotz de Lima G, Kalman J, Claes N, Lobban T, Lane D, Lip GYH, Boriani G. Screening for atrial fibrillation: a European Heart Rhythm Association (EHRA) consensus document endorsed by the Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulación Cardíaca y Electrofisiología (SOLAECE). Europace 2018; 19:1589-1623. [PMID: 29048522 DOI: 10.1093/europace/eux177] [Citation(s) in RCA: 182] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 05/06/2017] [Indexed: 01/21/2023] Open
Affiliation(s)
- Georges H Mairesse
- Department of Cardiology, Cliniques du Sud-Luxembourg, 137 rue des déportés, B6700 Arlon, Belgium
| | - Patrick Moran
- Health Information and Quality Authority, George's Lane, Dublin 7, D07 E98Y, Ireland
| | - Isabelle C Van Gelder
- University of Groningen, University Medical Center Groningen, Hanzeplein 1, Groningen, 9713 GZ, The Netherlands
| | - Christian Elsner
- University Clinic Of Schleswig Holstein, Maria Goeppert Strasse 7a-b, Luebeck, 23538, Germany
| | | | - Jonathan Mant
- Primary Care Unit, University of Cambridge, Strangeways Research Laboratory, Wort's Causeway, Cambridge, CB1 8RN, United Kingdom
| | - Amitava Banerjee
- University College London, Farr Institute of Health Informatics Research, 222 Euston Road, London, West Midlands NW1 2DA, United Kingdom
| | - Bulent Gorenek
- Eskisehir Osmangazi University, ESOGÜ Meselik Yerleskesi, 26480 ESKISEHIR, Turkey
| | - Johannes Brachmann
- Klinikum Coburg, Chefarzt der II. Medizinischen Klinik, Ketschendorfer Str. 33, Coburg, DE-96450, Germany
| | - Niraj Varma
- Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, Ohio 44195, USA
| | - Gustavo Glotz de Lima
- Instituto de Cardiologia do RS / FUC, Eletrofisiologia Dept., Av. Princesa Isabel 370, Porto Alegre, 90620-001, Brazil
| | - Jonathan Kalman
- The Royal Melbourne Hospital, Melbourne Heart Center, Royal Parade Suite 1, Parkville, Victoria, 3050, Australia
| | - Neree Claes
- University of Hasselt, Patient Safety in General Practice and Hospitals, Diepenbeek, Belgium, Antwerp Management School, Clinical Leadership, Antwerp, Belgium
| | - Trudie Lobban
- Arrhythmia Alliance & AF Association, Unit 6B, Essex House, Cromwell Business Park, Chipping Norton, Oxfordshire OX7 5SR, UK
| | - Deirdre Lane
- Institute of Cardiovascular Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, United Kingdom; and Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Fredrik Bajers Vej 5, 9100 Aalborg, Denmark
| | - Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, United Kingdom; and Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Fredrik Bajers Vej 5, 9100 Aalborg, Denmark
| | - Giuseppe Boriani
- Cardiology Division, Department of Diagnostics, Clinical and Public Health Medicine, University of Modena and Reggio Emilia, Policlinico di Modena, Largo del Pozzo, 71, 41125 Modena, Italy
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Fredriksson T, Frykman V, Friberg L, Al-Khalili F, Engdahl J, Svennberg E. Usefulness of Short-Lasting Episodes of Supraventricular Arrhythmia (Micro-Atrial Fibrillation) as a Risk Factor for Atrial Fibrillation. Am J Cardiol 2018; 122:1179-1184. [PMID: 30064858 DOI: 10.1016/j.amjcard.2018.06.030] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 06/06/2018] [Accepted: 06/11/2018] [Indexed: 02/02/2023]
Abstract
According to the present European Society of Cardiology's guidelines for atrial fibrillation (AF), the definition of AF contains a 30-second time criterion, based on consensus. The aim of this cohort study is to evaluate whether very short-lasting episodes of AF, micro-AF, are risk factors for developing AF and to compare AF detection between continuous and intermittent ECG recordings applied in parallel. All participants, n = 102, were identified from the STROKESTOP study, a Swedish mass-screening study for AF. Participants were divided into 2 groups depending on results in the STROKESTOP study: a micro-AF group (with abrupt onset episodes of ≥4 consecutive supraventricular beats, irregular rate-to-rate intervals, absence of regular p waves, lasting for <30 seconds), n = 54, and a control group, n = 48. After a follow-up period participants who were clinically free of AF were invited to undergo repeat AF screening during a 2-week period, using continuous ECG recording and 30 seconds intermittent recordings simultaneously. After 2.3years of follow-up, significantly more participants in the micro-AF group had developed AF, 27 of 54 (50%), compared with the control group, 5 of 48 (10%), p < 0.001. Among the 94 participants not already diagnosed with AF who underwent AF-screening, 25 of 25 (100%) AF cases were detected with help of continuous monitoring whereas 10 of 25 (40%) AF cases were found with intermittent ECGs. In conclusion, micro-AF seems to be an important risk factor for the development of AF in an elderly population. The detection of AF was significantly higher using 2 weeks of continuous ECG monitoring compared with intermittent 30-second ECG recordings twice daily for 2 weeks.
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46
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Colman MA, Saxena P, Kettlewell S, Workman AJ. Description of the Human Atrial Action Potential Derived From a Single, Congruent Data Source: Novel Computational Models for Integrated Experimental-Numerical Study of Atrial Arrhythmia Mechanisms. Front Physiol 2018; 9:1211. [PMID: 30245635 PMCID: PMC6137999 DOI: 10.3389/fphys.2018.01211] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 08/13/2018] [Indexed: 11/13/2022] Open
Abstract
Introduction: The development of improved diagnosis, management, and treatment strategies for human atrial fibrillation (AF) is a significant and important challenge in order to improve quality of life for millions and reduce the substantial social-economic costs of the condition. As a complex condition demonstrating high variability and relation to other cardiac conditions, the study of AF requires approaches from multiple disciplines including single-cell experimental electrophysiology and computational modeling. Models of human atrial cells are less well parameterized than those of the human ventricle or other mammal species, largely due to the inherent challenges in patch clamping human atrial cells. Such challenges include, frequently, unphysiologically depolarized resting potentials and thus injection of a compensatory hyperpolarizing current, as well as detecting certain ion currents which may be disrupted by the cell isolation process. The aim of this study was to develop a laboratory specific model of human atrial electrophysiology which reproduces exactly the conditions of isolated-cell experiments, including testing of multiple experimental interventions. Methods: Formulations for the primary ion currents characterized by isolated-cell experiments in the Workman laboratory were fit directly to voltage-clamp data; the fast sodium-current was parameterized based on experiments relating resting membrane potential to maximal action potential upstroke velocity; compensatory hyperpolarizing current was included as a constant applied current. These formulations were integrated with three independent human atrial cell models to provide a family of novel models. Extrapolated intact-cell models were developed through removal of the hyperpolarizing current and introduction of terminal repolarization potassium currents. Results: The isolated-cell models quantitatively reproduced experimentally measured properties of excitation in both control and pharmacological and dynamic-clamp interventions. Comparison of isolated and intact-cell models highlighted the importance of reproducing this cellular environment when comparing experimental and simulation data. Conclusion: We have developed a laboratory specific model of the human atrial cell which directly reproduces the experimental isolated-cell conditions and captures human atrial excitation properties. The model may be particularly useful for directly relating model to experiment, and offers a complementary tool to the available set of human atrial cell models with specific advantages resulting from the congruent input data source.
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Affiliation(s)
- Michael A Colman
- Leeds Computational Physiology Lab, School of Biomedical Sciences, University of Leeds, Leeds, United Kingdom
| | - Priyanka Saxena
- Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Sarah Kettlewell
- Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Antony J Workman
- Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom
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47
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Kirchhof P, Haeusler KG, Blank B, De Bono J, Callans D, Elvan A, Fetsch T, Van Gelder IC, Gentlesk P, Grimaldi M, Hansen J, Hindricks G, Al-Khalidi HR, Massaro T, Mont L, Nielsen JC, Nölker G, Piccini JP, De Potter T, Scherr D, Schotten U, Themistoclakis S, Todd D, Vijgen J, Di Biase L. Apixaban in patients at risk of stroke undergoing atrial fibrillation ablation. Eur Heart J 2018; 39:2942-2955. [PMID: 29579168 PMCID: PMC6110196 DOI: 10.1093/eurheartj/ehy176] [Citation(s) in RCA: 165] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 03/09/2018] [Accepted: 03/14/2018] [Indexed: 02/02/2023] Open
Abstract
Aims It is recommended to perform atrial fibrillation ablation with continuous anticoagulation. Continuous apixaban has not been tested. Methods and results We compared continuous apixaban (5 mg b.i.d.) to vitamin K antagonists (VKA, international normalized ratio 2-3) in atrial fibrillation patients at risk of stroke a prospective, open, multi-centre study with blinded outcome assessment. Primary outcome was a composite of death, stroke, or bleeding (Bleeding Academic Research Consortium 2-5). A high-resolution brain magnetic resonance imaging (MRI) sub-study quantified acute brain lesions. Cognitive function was assessed by Montreal Cognitive Assessment (MoCA) at baseline and at end of follow-up. Overall, 674 patients (median age 64 years, 33% female, 42% non-paroxysmal atrial fibrillation, 49 sites) were randomized; 633 received study drug and underwent ablation; 335 undertook MRI (25 sites, 323 analysable scans). The primary outcome was observed in 22/318 patients randomized to apixaban, and in 23/315 randomized to VKA {difference -0.38% [90% confidence interval (CI) -4.0%, 3.3%], non-inferiority P = 0.0002 at the pre-specified absolute margin of 0.075}, including 2 (0.3%) deaths, 2 (0.3%) strokes, and 24 (3.8%) ISTH major bleeds. Acute small brain lesions were found in a similar number of patients in each arm [apixaban 44/162 (27.2%); VKA 40/161 (24.8%); P = 0.64]. Cognitive function increased at the end of follow-up (median 1 MoCA unit; P = 0.005) without differences between study groups. Conclusions Continuous apixaban is safe and effective in patients undergoing atrial fibrillation ablation at risk of stroke with respect to bleeding, stroke, and cognitive function. Further research is needed to reduce ablation-related acute brain lesions.
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Affiliation(s)
- Paulus Kirchhof
- Institute of Cardiovascular Sciences, University of Birmingham, and SWBH and UHB NHS Trusts, IBR 136, Wolfson Drive, Birmingham, UK
- SWBH NHS Trust, Birmingham, UK
- University Hospitals Birmingham, Birmingham, UK
- Atrial Fibrillation NETwork Association (AFNET), Germany, Münster
| | - Karl Georg Haeusler
- Atrial Fibrillation NETwork Association (AFNET), Germany, Münster
- Center for Stroke Research Berlin & Department of Neurology, Charité – Universitätsmedizin Berlin, Germany
| | - Benjamin Blank
- Atrial Fibrillation NETwork Association (AFNET), Germany, Münster
| | - Joseph De Bono
- Institute of Cardiovascular Sciences, University of Birmingham, and SWBH and UHB NHS Trusts, IBR 136, Wolfson Drive, Birmingham, UK
- University Hospitals Birmingham, Birmingham, UK
| | | | - Arif Elvan
- Isala Heart Center Zwolle, Zwolle, The Netherlands
| | | | - Isabelle C Van Gelder
- University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | | | - Massimo Grimaldi
- Ospedale Generale Regionale F. Miulli, Acquaviva delle Fonti, Italy
| | | | | | - Hussein R Al-Khalidi
- Department of Biostatistics & Bioinformatics, Duke University School of Medicine, USA
| | - Tyler Massaro
- Duke Clinical Research Institute (DCRI), Durham, NC, USA
| | - Lluis Mont
- Hospital Clinic Barcelona, University of Barcelona, Barcelona, Spain
| | | | - Georg Nölker
- Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Jonathan P Piccini
- Duke Clinical Research Institute (DCRI), Durham, NC, USA
- Division of Cardiology Duke University Medical Center, Duke University, Durham, NC, USA
| | | | - Daniel Scherr
- Department of Cardiology, Medical University Graz, Austria
| | - Ulrich Schotten
- Atrial Fibrillation NETwork Association (AFNET), Germany, Münster
- Department of Physiology, University Maastricht, Maastricht, Netherlands
| | | | - Derick Todd
- Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Johan Vijgen
- Jessa Ziekenhuis, Campus Virga Jesse, Hasselt, Belgium
| | - Luigi Di Biase
- Albert Einstein College of Medicine, at Montefiore Hospital, New York, USA
- Texas Cardiac Arrhythmia Institute at St. David’s Medical Center, Austin, TX, USA
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Ferguson C, Hickman LD, Phillips J, Newton PJ, Inglis SC, Lam L, Bajorek BV. An mHealth intervention to improve nurses’ atrial fibrillation and anticoagulation knowledge and practice: the EVICOAG study. Eur J Cardiovasc Nurs 2018; 18:7-15. [DOI: 10.1177/1474515118793051] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: There is a need to improve cardiovascular nurses’ knowledge and practices related to stroke prevention, atrial fibrillation and anticoagulation therapy. Aims: The aim of this study was to evaluate the efficacy of EVICOAG – a novel mHealth, smartphone-based, spaced-learning intervention on nurses’ knowledge of atrial fibrillation and anticoagulation. Methods: Nurses employed in four clinical specialties (neuroscience, stroke, rehabilitation, cardiology) across three hospitals were invited to participate. In this quasi-experimental study, 12 case-based atrial fibrillation and anticoagulation learning scenarios (hosted by an mHealth platform) were delivered to participants’ smartphones over a 6-week period (July–December 2016) using a spaced timing algorithm. Electronic surveys to assess awareness and knowledge were administered pre (T1) and post (T2) intervention. Results: From 74 participants recruited to T1, 40 completed T2. There was a 54% mean improvement in knowledge levels post-intervention. The largest improvement was achieved in domains related to medication interaction and stroke and bleeding risk assessment. Post-intervention, those who completed T2 were significantly more likely to use CHA2DS2-VASc (2.5% vs. 37.5%) and HAS-BLED (2.5% vs. 35%) tools to assess stroke and bleeding risk, respectively ( P<0.01). Conclusion: The EVICOAG intervention improved nurses’ knowledge of atrial fibrillation and anticoagulation, and influenced their uptake and use of stroke and bleeding risk assessment tools in clinical practice. Future research should focus on whether a similar intervention might improve patient-centred outcomes such as patients’ knowledge of their condition and therapies, medication adherence, time in the therapeutic range and quality of life.
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Affiliation(s)
- Caleb Ferguson
- Western Sydney Nursing and Midwifery Research Centre, Western Sydney University, Australia
| | | | - Jane Phillips
- Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT), University of Technology Sydney, Australia
| | - Phillip J Newton
- Western Sydney Nursing and Midwifery Research Centre, Western Sydney University, Australia
| | - Sally C Inglis
- Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT), University of Technology Sydney, Australia
| | - Lawrence Lam
- Faculty of Health, University of Technology Sydney, Australia
- Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT), University of Technology Sydney, Australia
- Discipline of Pharmacy, University of Technology Sydney, Australia
- President’s Office, Tung Wah College, Hong Kong
| | - Beata V Bajorek
- Discipline of Pharmacy, University of Technology Sydney, Australia
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Turakhia MP, Blankestijn PJ, Carrero JJ, Clase CM, Deo R, Herzog CA, Kasner SE, Passman RS, Pecoits-Filho R, Reinecke H, Shroff GR, Zareba W, Cheung M, Wheeler DC, Winkelmayer WC, Wanner C. Chronic kidney disease and arrhythmias: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Eur Heart J 2018; 39:2314-2325. [PMID: 29522134 PMCID: PMC6012907 DOI: 10.1093/eurheartj/ehy060] [Citation(s) in RCA: 167] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 12/18/2017] [Accepted: 01/27/2018] [Indexed: 12/15/2022] Open
MESH Headings
- Arrhythmias, Cardiac/epidemiology
- Arrhythmias, Cardiac/therapy
- Atrial Fibrillation/complications
- Atrial Fibrillation/drug therapy
- Atrial Fibrillation/epidemiology
- Death, Sudden, Cardiac/prevention & control
- Defibrillators, Implantable
- Humans
- Hyperkalemia/epidemiology
- Hyperkalemia/metabolism
- Hypokalemia/epidemiology
- Hypokalemia/metabolism
- Inflammation
- Kidney Failure, Chronic/epidemiology
- Kidney Failure, Chronic/metabolism
- Kidney Failure, Chronic/therapy
- Oxidative Stress
- Potassium/metabolism
- Renal Dialysis
- Renal Insufficiency, Chronic/epidemiology
- Renal Insufficiency, Chronic/metabolism
- Renal Insufficiency, Chronic/therapy
- Risk Factors
- Stroke/etiology
- Stroke/prevention & control
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Affiliation(s)
- Mintu P Turakhia
- Stanford University School of Medicine, Veterans Affairs Palo Alto Health Care System, Miranda Ave, Palo Alto, CA, USA
| | - Peter J Blankestijn
- Department of Nephrology, room F03.220, University Medical Center, Utrecht, The Netherlands
| | - Juan-Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Nobels väg 12A, Stockholm, Sweden
| | - Catherine M Clase
- Department of Medicine and Department of Health Research Methods, Evidence, and Impact, McMaster University, St. Joseph’s Healthcare, Marian Wing, 3rd Floor, M333, 50 Charlton Ave. E, Hamilton, Ontario, Canada
| | - Rajat Deo
- Section of Electrophysiology, Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, 3400 Spruce Street, 9 Founders Cardiology, Philadelphia, PA, USA
| | - Charles A Herzog
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis, Minnesota and Chronic Disease Research Group, Minneapolis Medical Research Foundation, 914 S. 8th Street, S4.100, Minneapolis, MN, USA
| | - Scott E Kasner
- Department of Neurology, 3W Gates Bldg. Hospital of the University of Pennsylvania, 3400 Spruce St., Philadelphia, PA, USA
| | - Rod S Passman
- Northwestern University Feinberg School of Medicine and the Bluhm Cardiovascular Institute, 201 E. Huron St. Chicago, IL, USA
| | - Roberto Pecoits-Filho
- School of Medicine, Pontificia Universidade Catolica do Paraná, Rua Imaculada Conceição Curitiba PR, Brazil
| | - Holger Reinecke
- Department für Kardiologie und Angiologie Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude A1, Muenster, Germany
| | - Gautam R Shroff
- Division of Cardiology, Hennepin County Medical Center, 701 Park Avenue, Minneapolis, MN, USA
| | - Wojciech Zareba
- Heart Research Follow-up Program, Cardiology Division, University of Rochester Medical Center, Saunders Research Building, 265 Crittenden Blvd. CU, Rochester, NY, USA
| | | | - David C Wheeler
- Centre for Nephrology, University College London, Rowland Hill Street, London, UK
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, One Baylor Plaza, ABBR R705, MS: 395, Houston, TX, USA
| | - Christoph Wanner
- Division of Nephrology, Department of Medicine, University Hospital of Würzburg, Oberduerrbacherstr. 6 Würzburg, Germany
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50
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Van Gelder IC, Hobbelt AH, Brügemann J, Rienstra M. Time to implement fitness and reduction of fatness in atrial fibrillation therapy. Europace 2018; 19:513-514. [PMID: 28431072 DOI: 10.1093/europace/euw287] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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