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Vargas CE, Bhatnagar M, Ahmed H, Flynn MG, Alexander T. Atrial Fibrillation: Rate Versus Rhythm Control. HCA HEALTHCARE JOURNAL OF MEDICINE 2023; 4:329-339. [PMID: 37969851 PMCID: PMC10635694 DOI: 10.36518/2689-0216.1564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2023]
Abstract
Description Atrial fibrillation (AF) remains the most common arrhythmia worldwide and is expected to affect approximately 12 million individuals in the United States alone by 2030. Thromboembolic events remain a feared complication of AF and should be treated and risk-stratified utilizing the CHA2DS2-VASc scoring system. Other complications of AF span a wide spectrum from impaired quality of life (QoL) to an increase in all-cause mortality. Rate control strategies consist of controlling the ventricular rate and have been shown to be a safe and effective strategy for asymptomatic AF patients. In patients who are plagued with symptoms leading to impaired QoL or a decrease in exercise capacity, rhythm control with antiarrhythmic drugs or catheter ablation may be suitable options. Mortality benefits when comparing rate versus rhythm control remain equivocal when comparing multiple studies over the past decade.
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Affiliation(s)
| | | | - Haris Ahmed
- HCA Houston Healthcare Kingwood, Kingwood, TX
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Calvert P, Kollias G, Pürerfellner H, Narasimhan C, Osorio J, Lip GYH, Gupta D. Silent cerebral lesions following catheter ablation for atrial fibrillation: a state-of-the-art review. Europace 2023; 25:euad151. [PMID: 37306314 PMCID: PMC10259069 DOI: 10.1093/europace/euad151] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 04/25/2023] [Indexed: 06/13/2023] Open
Abstract
Atrial fibrillation is associated with neurocognitive comorbidities such as stroke and dementia. Evidence suggests that rhythm control-especially if implemented early-may reduce the risk of cognitive decline. Catheter ablation is highly efficacious for restoring sinus rhythm in the setting of atrial fibrillation; however, ablation within the left atrium has been shown to result in MRI-detected silent cerebral lesions. In this state-of-the-art review article, we discuss the balance of risk between left atrial ablation and rhythm control. We highlight suggestions to lower the risk, as well as the evidence behind newer forms of ablation such as very high power short duration radiofrequency ablation and pulsed field ablation.
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Affiliation(s)
- Peter Calvert
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Cardiology, Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool L14 3PE, UK
| | | | | | - Calambur Narasimhan
- Department of Cardiac Electrophysiology, AIG Hospitals, 1-66/AIG/2 to 5, Mindspace Road, Gachibowli Hyderabad, Telangana 500032, India
| | - Jose Osorio
- Grandview Medical Center, Arrhythmia Institute at Grandview, 3686 Grandview Parkway Suite 720, Birmingham, AL 35243, USA
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Cardiology, Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool L14 3PE, UK
- Danish Centre for Clinical Health Services Research, Aalborg University, Aalborg, Denmark
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Cardiology, Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool L14 3PE, UK
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Bodagh N, Kotadia I, Gharaviri A, Zelaya F, Birns J, Bhalla A, Sommerville P, Niederer S, O’Neill M, Williams SE. The Impact of Atrial Fibrillation Treatment Strategies on Cognitive Function. J Clin Med 2023; 12:3050. [PMID: 37176490 PMCID: PMC10179566 DOI: 10.3390/jcm12093050] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 04/12/2023] [Accepted: 04/17/2023] [Indexed: 05/15/2023] Open
Abstract
There is increasing evidence to suggest that atrial fibrillation is associated with a heightened risk of dementia. The mechanism of interaction is unclear. Atrial fibrillation-induced cerebral infarcts, hypoperfusion, systemic inflammation, and anticoagulant therapy-induced cerebral microbleeds, have been proposed to explain the link between these conditions. An understanding of the pathogenesis of atrial fibrillation-associated cognitive decline may enable the development of treatment strategies targeted towards the prevention of dementia in atrial fibrillation patients. The aim of this review is to explore the impact that existing atrial fibrillation treatment strategies may have on cognition and the putative mechanisms linking the two conditions. This review examines how components of the 'Atrial Fibrillation Better Care pathway' (stroke risk reduction, rhythm control, rate control, and risk factor management) may influence the trajectory of atrial fibrillation-associated cognitive decline. The requirements for further prospective studies to understand the mechanistic link between atrial fibrillation and dementia and to develop treatment strategies targeted towards the prevention of atrial fibrillation-associated cognitive decline, are highlighted.
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Affiliation(s)
- Neil Bodagh
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London SE1 7EH, UK
| | - Irum Kotadia
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London SE1 7EH, UK
| | - Ali Gharaviri
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4TJ, UK
| | - Fernando Zelaya
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London SE1 7EH, UK
| | - Jonathan Birns
- St Thomas’ Hospital, Guys and St Thomas’ NHS Foundation Trust, London SE1 7EH, UK
| | - Ajay Bhalla
- St Thomas’ Hospital, Guys and St Thomas’ NHS Foundation Trust, London SE1 7EH, UK
| | - Peter Sommerville
- St Thomas’ Hospital, Guys and St Thomas’ NHS Foundation Trust, London SE1 7EH, UK
| | - Steven Niederer
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London SE1 7EH, UK
| | - Mark O’Neill
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London SE1 7EH, UK
- St Thomas’ Hospital, Guys and St Thomas’ NHS Foundation Trust, London SE1 7EH, UK
| | - Steven E. Williams
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London SE1 7EH, UK
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4TJ, UK
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Bodagh N, Yap R, Kotadia I, Sim I, Bhalla A, Somerville P, O'Neill M, Williams SE. Impact of catheter ablation versus medical therapy on cognitive function in atrial fibrillation: a systematic review. J Interv Card Electrophysiol 2022; 65:271-286. [PMID: 35380337 PMCID: PMC9550702 DOI: 10.1007/s10840-022-01196-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 03/21/2022] [Indexed: 12/22/2022]
Abstract
PURPOSE Atrial fibrillation is associated with an increased risk of cognitive impairment. It is unclear whether the restoration of sinus rhythm with catheter ablation may modify this risk. We conducted a systematic review of studies comparing cognitive outcomes following catheter ablation with medical therapy (rate and/or rhythm control) in atrial fibrillation. METHODS Searches were performed on the following databases from their inception to 17 October 2021: PubMed, OVID Medline, Embase and Cochrane Library. The inclusion criteria comprised studies comparing catheter ablation against medical therapy (rate and/or rhythm control in conjunction with anticoagulation where appropriate) which included cognitive assessment and/or a diagnosis of dementia as an outcome. RESULTS A total of 599 records were screened. Ten studies including 15,886 patients treated with catheter ablation and 42,684 patients treated with medical therapy were included. Studies which compared the impact of catheter ablation versus medical therapy on quantitative assessments of cognitive function yielded conflicting results. In studies, examining new onset dementia during follow-up, catheter ablation was associated with a lower risk of subsequent dementia diagnosis compared to medical therapy (hazard ratio: 0.60 (95% confidence interval 0.42-0.88, p < 0.05)). CONCLUSION The accumulating evidence linking atrial fibrillation with cognitive impairment warrants the design of atrial fibrillation treatment strategies aimed at minimising cognitive decline. However, the impact of catheter ablation and atrial fibrillation medical therapy on cognitive decline is currently uncertain. Future studies investigating atrial fibrillation treatment strategies should include cognitive outcomes as important clinical endpoints.
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Affiliation(s)
- Neil Bodagh
- King's College London, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK.
| | - Reuben Yap
- Princess Royal University Hospital, Orpington, UK
| | - Irum Kotadia
- King's College London, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
- Guys and St. Thomas' NHS Foundation Trust, London, UK
| | - Iain Sim
- King's College London, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
| | - Ajay Bhalla
- Guys and St. Thomas' NHS Foundation Trust, London, UK
| | | | - Mark O'Neill
- King's College London, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
- Guys and St. Thomas' NHS Foundation Trust, London, UK
| | - Steven E Williams
- King's College London, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
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Chen P, Chen Z, Pan D, Miao L, Shi Y, Guo M, Du J. Catheter ablation and cognitive function in atrial fibrillation: A systematic review and meta-analysis. Front Neurol 2022; 13:934512. [PMID: 36158973 PMCID: PMC9492882 DOI: 10.3389/fneur.2022.934512] [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: 05/02/2022] [Accepted: 07/29/2022] [Indexed: 11/17/2022] Open
Abstract
Background Atrial fibrillation (AF) is a risk factor for cognitive dysfunction. Although catheter ablation (CA) is one of the main treatments for AF, whether it can improve cognitive function in patients with AF remains unclear. We conducted a systematic review and meta-analysis to evaluate the cognitive outcome post-CA procedure. Methods Two investigators independently searched the PubMed, EMBASE, Web of Science, CNKI, WanFang, and VIP databases from inception to September 2021 for all the potentially eligible studies. The outcomes of interest included dementia or cognitive disorder through scoring or recognized classification criteria. Heterogeneity was determined by using Cochrane's Q test and calculating the I2. A random-effects model was used to incorporate the potential effects of heterogeneity. The Newcastle-Ottawa Scale (NOS) was used to assess the methodological quality of each included study, and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) method was adopted to evaluate the quality of evidence. Result Thirteen studies including 40,868 patients were included, among which 12,086 patients received AF ablation. Meta-analysis indicated that patients with AF ablation had a lower risk of dementia incidence in comparison to patients with AF without ablation [hazard ratio (HR): 0.60, 95% CI: 0.43 to 0.84, p = 0.003 I2 = 40%]. Significant differences were observed in the incidence of new-onset dementia [risk ratio (RR): 0.43, 95% CI: 0.28 to 0.65, p < 0.0001 I2 = 84%]; the changes in the Montreal Cognitive Assessment (MoCA) score [weighted mean difference (WMD): 1.00, 95% CI: 0.36 to 1.64, p < 0.005 I2 = 0%] and Mini-Mental State Examination (MMSE) score (WMD: 0.98, 95% CI: 0.69 to 1.26, p < 0.00001 I2 = 0%]. However, in subgroup analysis, we did not observe significant changes in MoCA score at < 3 months (WMD: 1.20, 95% CI: −0.19 to 2.58, p = 0.09 I2 = 50%) and changes in cognitive function scores between the radiofrequency group and cryoballoon group [standard mean difference (SMD): 0.39, 95% CI: −0.47 to 1.24, p = 0.38 I2 = 87%]. The NOS indicated that included studies were moderate to high quality, while the quality of evidence assessed by GRADE was low in 2 and very low in 2. Conclusion We analyzed the related cognitive outcomes after AF ablation. In the overall population, AF ablation had a positive trend for improving cognitive function at >3 months post-procedure. However, AF ablation might not be related to the improvement of cognitive function at < 3 months. Systematic review registration https://www.crd.york.ac.uk/PROSPERO/, identifier: CRD42021285198.
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Affiliation(s)
- Pengfei Chen
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Zhuhong Chen
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Cardiovascular Diseases Center, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Deng Pan
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Graduate School of Beijing University of Traditional Chinese Medicine, Beijing, China
| | - Lina Miao
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Graduate School of Beijing University of Traditional Chinese Medicine, Beijing, China
| | - Yujiao Shi
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Ming Guo
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Cardiovascular Diseases Center, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- *Correspondence: Ming Guo
| | - Jianpeng Du
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Cardiovascular Diseases Center, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Jianpeng Du
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Saglietto A, Ballatore A, Xhakupi H, De Ferrari GM, Anselmino M. Association of Catheter Ablation and Reduced Incidence of Dementia among Patients with Atrial Fibrillation during Long-Term Follow-Up: A Systematic Review and Meta-Analysis of Observational Studies. J Cardiovasc Dev Dis 2022; 9:jcdd9050140. [PMID: 35621851 PMCID: PMC9143892 DOI: 10.3390/jcdd9050140] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 04/27/2022] [Accepted: 04/28/2022] [Indexed: 12/10/2022] Open
Abstract
Background: Atrial fibrillation (AF) is independently associated with the onset of cognitive decline/dementia. AF catheter ablation (AFCA) is the most effective treatment strategy in terms of sinus rhythm maintenance, but its effects on dementia prevention remain under investigation. The aim of the present study was to perform a systematic review and meta-analysis of the presently available studies exploring the effect of AFCA on dementia occurrence. Methods: PubMed/MEDLINE databases were screened for articles through 14 March 2022 reporting adjusted time-to-event outcome data comparing AFCA and non-AFCA cohorts in terms of de novo dementia occurrence. A random effect meta-analysis was performed to estimate the meta-analytic hazard ratio (HR) of dementia occurrence in AFCA vs. non-AFCA cohorts, as well as the meta-analytic incidence rate of dementia in the non-AFCA cohort. Based on the aforementioned estimates, the number needed to treat (NNT), projected at median follow-up, was derived. Results: Four observational studies were included in the analysis, encompassing 40,146 patients (11,312 in the AFCA cohort; 28,834 in the non-AFCA cohort). AFCA conferred a significant protection to the development of dementia with an overall HR of 0.52 (95% CI 0.35–0.76). The incidence rate of dementia in the non-AFCA group was 1.12 events per 100 person-year (95% CI 0.47–2.67). The derived NNT projected to the median follow-up (4.5 years) was 41. Conclusion: AFCA is associated with a nearly 50% reduction in dementia occurrence during a median 4.5-year follow-up. Future randomized clinical trials are needed to reinforce these findings.
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Noutsias M, Hauptmann M, Völler H. Pointing a FINGER at the contribution of lifestyle to cardiovascular events and dementia. Eur Heart J 2022; 43:2062-2064. [PMID: 35417548 DOI: 10.1093/eurheartj/ehac186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Michel Noutsias
- Department of Internal Medicine A (Division of Cardiology, Angiology, Nephrology and Intensive Medical Care), University Hospital of the Brandenburg Medical School Theodor Fontane (MHB), Campus Ruppiner Kliniken, Fehrbelliner Strasse 38, D-16816 Neuruppin, Germany.,Faculty of Medicine, Martin-Luther-University Halle-Wittenberg, Magdeburger Strasse 6, D-06112 Halle (Saale), Germany
| | - Michael Hauptmann
- Institute of Biostatistics and Registry Research, Brandenburg Medical School Theodor Fontane (MHB), Fehrbelliner Strasse 38, D-16816 Neuruppin, Germany
| | - Heinz Völler
- Department of Rehabilitation Medicine, Faculty of Health Sciences, University of Potsdam, Am Neuen Palais 10, D-14469 Potsdam, Germany
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