Electrical cardioversion for persistent atrial fibrillation or atrial flutter in clinical practice: predictors of long-term outcome

Left atrial volume index: A predictor of atrial fibrillation recurrence following direct current cardioversion - A systematic review and meta-analysis

This systematic review and meta-analysis was conducted to determine the clinical relevance of echocardiographically measured left atrial (LA) size to predict the recurrence of atrial fibrillation (AF) after direct current cardioversion (DCCV). A search was performed on Medline (Ovid), Embase (Elsevier), Cochrane Central Register of Controlled Trials (CENTRAL) in Cochrane Library, Wiley and Web of Science (Clarivate) to identify relevant studies. Amongst the initial 4066 citations identified, 31 fulfilled the criteria for inclusion in the data analysis incorporating 2725 patients with a mean follow-up period of 6.5 months. The weighted mean left atrial volume index (LAVI) was 40.56 ml/m2 (95 %CI:37.24-43.88) in the sinus rhythm (SR) maintenance group versus 48.69 ml/m2 (95 % CI: 44.42-52.97) in the AF recurrence group with P value of < 0.001, left atrial diameter (LAD) was 42.06 mm (95 %CI: 41.08-43.05) in the SR maintenance group versus 45.13 mm (95 %CI: 44.09-46.16) in the AF recurrence group, P value < 0.001. Effect size analysis of LAVI showed that each unit increase in LAVI resulted in an increase in the risk of AF recurrence by 6 % (95 % CI: 3 %-10 %). Age and AF duration were also statistically significant between the two groups however comorbidities, use of beta blockers or amiodarone were not significantly different. This meta-analysis shows that AF duration, LAVI, LAD and age predict the risk of recurrence of atrial fibrillation post electrical cardioversion with LAVI being the most clinically relevant echocardiographic feature.

Biomarkers of Atrial Fibrillation Recurrence in Patients with Paroxysmal or Persistent Atrial Fibrillation Following External Direct Current Electrical Cardioversion

Atrial fibrillation (AF) is associated with atrial remodeling, cardiac dysfunction, and poor clinical outcomes. External direct current electrical cardioversion is a well-developed urgent treatment strategy for patients presenting with recent-onset AF. However, there is a lack of accurate predictive serum biomarkers to identify the risks of AF relapse after electrical cardioversion. We reviewed the currently available data and interpreted the findings of several studies revealing biomarkers for crucial elements in the pathogenesis of AF and affecting cardiac remodeling, fibrosis, inflammation, endothelial dysfunction, oxidative stress, adipose tissue dysfunction, myopathy, and mitochondrial dysfunction. Although there is ample strong evidence that elevated levels of numerous biomarkers (such as natriuretic peptides, C-reactive protein, galectin-3, soluble suppressor tumorigenicity-2, fibroblast growth factor-23, turn-over collagen biomarkers, growth differential factor-15) are associated with AF occurrence, the data obtained in clinical studies seem to be controversial in terms of their predictive ability for post-cardioversion outcomes. Novel circulating biomarkers are needed to elucidate the modality of this approach compared with conventional predictive tools. Conclusions: Biomarker-based strategies for predicting events after AF treatment require extensive investigation in the future, especially in the presence of different gender and variable comorbidity profiles. Perhaps, a multiple biomarker approach exerts more utilization for patients with different forms of AF than single biomarker use.

Atrial Natriuretic Peptides as a Bridge between Atrial Fibrillation, Heart Failure, and Amyloidosis of the Atria

ANP is mainly synthesized by the atria, and upon excretion, it serves two primary purposes: vasodilation and increasing the renal excretion of sodium and water. The understanding of ANP's role in cardiac systems has improved considerably in recent decades. This review focuses on several studies demonstrating the importance of analyzing the regulations between the endocrine and mechanical function of the heart and emphasizes the effect of ANP, as the primary hormone of the atria, on atrial fibrillation (AF) and related diseases. The review first discusses the available data on the diagnostic and therapeutic applications of ANP and then explains effect of ANP on heart failure (HF) and atrial fibrillation (AF) and vice versa, where tracking ANP levels could lead to understanding the pathophysiological mechanisms operating in these diseases. Second, it focuses on conventional treatments for AF, such as cardioversion and catheter ablation, and their effects on cardiac endocrine and mechanical function. Finally, it provides a point of view about the delayed recovery of cardiac mechanical and endocrine function after cardioversion, which can contribute to the occurrence of acute heart failure, and the potential impact of restoration of the sinus rhythm by extensive ablation or surgery in losing ANP-producing sites. Overall, ANP plays a key role in heart failure through its effects on vasodilation and natriuresis, leading to a decrease in the activity of the renin-angiotensin-aldosterone system, but it is crucial to understand the intimate role of ANP in HF and AF to improve their diagnosis and personalizing the patients' treatment.

Personalizing configuration for atrial fibrillation external electrical cardioversion to improve first shock efficacy

BACKGROUND

Despite the common use of biphasic electrical cardioversion (ECV) to convert atrial fibrillation (AF), we lack definite recommendations on electrode configuration.

METHODS

We adopted a quasi-experimental design enrolling all candidates to ECV for AF. In the first stage, two units were involved, one using antero-apical pads (AAP) and the second antero-posterior adhesive patches (APP). These data enabled the creation of a decision algorithm to personalize the ECV approach, which was subsequently validated during the second stage.

RESULTS

A total of 492 patients were enrolled overall. In the first stage, APP and AAP presented similar conversion rates (87.4 vs. 86.9% at first attempt of a step-up protocol, P = 0.661). While body surface area (BSA) ≤2.12 m2 was an independent predictor in the overall population, the two components (height and weight) acted differently in the two configurations: being height ≤1.73 m2 a significant cut-off value in the AAP subgroup, and weight <83 kg in the APP subgroup. Considering these cut-offs, we developed a decision algorithm for electrode configuration. In the second stage, algorithm validation confirmed an improvement in the first shock efficacy with respect to the results of the first stage (93.2 vs. 87.2%, P = 0.025), with a significant reduction in shock impedance (70.8 ± 15.3 vs. 81.8 ± 15.6, P < 0.001).

CONCLUSION

Patients with high BSA require high energy shocks for sinus rhythm restoration with ECV. Weight seems to affect more APP configuration, while height seems to impact more for the AAP. These findings have the potential to optimize ECV in clinical practice.

Effect of electrical cardioversion on 1-year outcomes in patients with early recurrence after catheter ablation for atrial fibrillation

Background

Atrial fibrillation (AF) recurrence is common in the 3‐month blanking‐period after catheter ablation, during which electrical cardioversion (ECV) is usually performed to restore sinus rhythm. Whether ECV can affect the clinical outcome of post‐ablation AF patients is inconsistent, however. We aimed to explore the 1‐year effect of ECV on AF recurrence and rehospitalization in patients experienced recurrence within 3‐month after AF catheter ablation.

Methods

Patients who experienced recurrence within 3‐month after AF catheter ablation procedure were enrolled from the China Atrial Fibrillation Registry (China‐AF). A 1:3 Propensity score matching (PSM) method was applying to adjust the confounders between patients who had been treated by ECV or not. Logistic regression models were conducted to evaluate the association of ECV with 1‐year AF recurrence and rehospitalization.

Results

In this study, 2961 patients experienced AF recurrence within 3‐month after the procedure, and 282 of them underwent successful ECV, 2155 patients did not undergo ECV. One‐year AF recurrence rates were 56.4% in ECV group versus 65.4% in non‐ECV group (p = .003), and were 55.9% versus 65.9%, respectively, after PSM (adjusted odds ratio [OR] 0.66; 95% confidence interval (CI): 0.49–0.88, p = .005). However, the difference of 1‐year rehospitalization rates between two groups were not statistically significant before (ECV group: 23.7% vs. non‐ECV group: 22.3%, p = .595) and after PSM (ECV group: 24.4% vs. non‐ECV group: 21.6%, adjusted OR1.14; 95% CI 0.81–1.62, p = .451).

Conclusions

Successful ECV was associated with lower rate of one‐year recurrence in patients with early recurrent AF after catheter ablation.

Procedural sedation for direct current cardioversion: a feasibility study between two management strategies in the emergency department

BACKGROUND

A cardiologist-only approach to procedural sedation with midazolam in the setting of elective cardioversion (DCC) for AF has already been proven as safe as sedation with propofol and anaesthesiologist assistance. No data exist regarding the safety of such a strategy during emergency procedures. The aim of this study is to compare the feasibility of sedation with midazolam, administered by a cardiologist, to an anaesthesiologist-assisted protocol with propofol in emergency DCC.

METHODS

Single centre, prospective, open blinded, randomized study including all consecutive patients admitted to the Emergency Department requiring urgent or emergency DCC. Patients were randomized in a 1:1 fashion to either propofol or midazolam treatment arm. Patients in the midazolam group were managed by the cardiologist only, while patients treated with propofol group underwent DCC with anaesthesiologist assistance.

RESULTS

Sixty-nine patients were enrolled and split into two groups. Eighteen patients (26.1%) experienced peri-procedural adverse events (bradycardia, severe hypotension and severe hypoxia), which were similar between the two groups and all successfully managed by the cardiologist. No deaths, stroke or need for invasive ventilation were registered. Patients treated with propofol experienced a greater decrease in systolic and diastolic blood pressure when compared with those treated with midazolam. As the procedure was shorter when midazolam was used, the median cost of urgent/emergency DCC with midazolam was estimated to be 129.0 € (1st-3rd quartiles 114.6-151.6) and 195.6 € (1st-3rd quartiles 147.3-726.7) with propofol (p < .001).

CONCLUSIONS

Procedural sedation with midazolam given by the cardiologist alone was feasible, well-tolerated and cost-effective in emergency DCC.

Predictors of left atrial appendage stunning after electrical cardioversion in patients with atrial fibrillation

The transient left atrial appendage (LAA) dysfunction after electrical cardioversion (CV), which is called as LAA-stunning, was found to be an important etiology of thrombus formation. The aim of the present study was to investigate the risk factors of LAA-stunning. This study included 134 patients who underwent catheter ablation for non-paroxysmal, non-valvular, and symptomatic atrial fibrillation (AF). Internal-CV was performed, and LAA emptying fraction (LAA-EF) was assessed using LAA-angiogram before and just after CV. LAA-stunning (defined as 10% reduction of LAA-EF after CV) was observed in 45/134 patients (34%). Patients in LAA-stunning group had longer duration of AF prior to CV, higher brain natriuretic peptide (BNP), higher prevalence of patients taking calcium blocker, larger left atrial (LA) diameter, elevated E wave, and larger LA volume than those in non LAA-stunning group. Multivariate analysis showed that longer duration of AF prior to CV (p = 0.015, OR 1.033 for 1 month extend, 95% CI 1.006-1.073) and elevated BNP (p = 0.038, OR 1.041 for each 10 pg/mL increase, 95% CI 1.001-1.009) were associated with LAA-stunning. In addition, all patients were divided into four groups based on the combination between duration of AF prior to CV and BNP; group 1 (low BNP/short-lasting AF), group 2 (high BNP/short-lasting AF), group 3 (low BNP/long-lasting AF), and group 4 (high BNP/long-lasting AF). The rate of LAA-stunning was the highest in the group 4 (55.6%). Elevated BNP and long duration of AF were associated with LAA stunning after electrical cardioversion.

A review of factors associated with maintenance of sinus rhythm after elective electrical cardioversion for atrial fibrillation

Atrial fibrillation is the most common heart-rhythm disorder, affecting about 1.5% to 2% of the population with an increased risk of mortality and morbidity due to stroke, thromboembolism, and heart failure. If the conversion back to sinus rhythm does not happen spontaneously, pharmacological or electrical cardioversion (ECV) is the next available treatment options for some patients. However, the long-term success following ECV is variable. This review describes the factors that are associated with maintenance of sinus rhythm following ECV and proposes a clinical strategy based on the available evidence.

Does antiarrhythmic drugs premedication improve electrical cardioversion success in persistent atrial fibrillation?

AIMS

Aim of this study is to evaluate the impact of antiarrhythmic drugs (AADs) administration for at least one month before ECV on the acute and long term success rate of the procedure.

METHODS

1313 consecutive persistent AF patients were enrolled in 3 different centers (Turin, Asti and Avellino): 692 patients received AADs before and after ECV (group A), 621 patients were treated only after the procedure, at discharge (group B). Primary end point was the restoration and maintenance of sinus rhythm acutely and at a long-term follow up.

RESULTS

Acute ECV success was higher in group A compared with group B (99% vs. 88%, p=0.0001) and a fewer number of shock attempts were administered (1.15±0.42 vs. 1.27±0.53 p<0.0001). Moreover group A maintained SR more often than group B at one month (99% vs. 89%, log-rank p<0.0001), at one year (55% vs. 48% log-rank p=0.01) and at the end of follow up (mean 2.7±2.1years, 45% vs. 29%, log-rank p<0.0001). At multivariate analysis AADs premedication was the strongest independent predictor of acute and long-term ECV success (respectively p<0.0001 OR 10.71 CI 5.10-22.50 and p=0.004, OR 1.50 CI 1.14-1.97). At sensitivity analysis no differences were found between ADDs in terms of acute success improvement (p=0.605), number of shock attempts (p=0.853) and long term SR maintenance (log-rank p=0.480).

CONCLUSIONS

AADs administration for at least 4weeks before the ECV in persistent AF increases significantly the acute success rate and this result was maintained over a long-term follow-up.

Atrial fibrillation in women: treatment

Sex-specific differences in the epidemiology, pathophysiology, presentation, prognosis, and treatment of atrial fibrillation (AF) are increasingly recognized. Women with AF generally experience worse symptoms, poorer quality of life, and have higher risk of stroke and death than men with AF. Effective treatment of the arrhythmia in women is critical to reduce the rate of adverse events. We review the current evidence on sex-specific differences in the utilization and outcomes of treatments for AF, including rate-control and rhythm-control strategies, and stroke-prevention therapy. In addition, we provide a critical evaluation of potential disparities and biases in health-care use that might be associated with differences in the outcomes between women and men. We underscore current knowledge gaps that need to be addressed in future studies to improve the management of AF in women. In particular, we suggest several strategies to produce high-quality evidence from randomized clinical trials for women with AF.

Long-Term Predictors of Thromboembolic Events in Nonvalvular Atrial Fibrillation Patients Undergoing Electrical Cardioversion

BACKGROUND

Patients with nonvalvular atrial fibrillation (AF) who undergo electrical cardioversion (ECV) tend to be younger and have less comorbidity. Long-term anticoagulation after ECV should be based on thromboembolic risk. We sought to study the long-term incidence of thromboembolic events (TE), factors related to TE and compare the predictive value of the CHADS2and CHA2DS2-VASc scores in this particular population.

METHODS AND RESULTS

From January 2008 to June 2012, 571 ECV were performed in 406 consecutive patients with nonvalvular AF. Risk factors for TE and factors related to anticoagulation therapy after ECV were registered. During a follow-up of approximately 2 years, the annual incidence of TE was 1.9%. Factors associated with TE were: poor quality anticoagulation control (hazard ratio [HR]: 2.91; 95% confidence interval [CI]: 1.10-7.80; P=0.03), cessation of anticoagulation after ECV (HR: 8.80; 95% CI: 3.11-25.10; P<0.001), age ≥65 years (HR: 13.65; 95% CI: 1.74-107.16; P=0.01), CHADS2score (HR: 1.59; 95% CI: 1.10-2.29; P=0.01) and CHA2DS2-VASc score (HR: 1.67; 95% CI: 1.30-2.22; P<0.001). Both risk scores predicted TE [c-statistic for CHADS2: 0.68 (95% CI: 0.62-0.74; P=0.005), for CHA2DS2-VASc: 0.75 (95% CI: 0.70-0.80; P<0.001)]. Based on c-statistics, the predictive accuracy of CHA2DS2-VASc was superior (difference between areas: 0.064±0.031; P=0.0403).

CONCLUSIONS

Important determinants of long-term occurrence of TE after ECV were related to anticoagulant therapy (poor quality anticoagulation and cessation of this therapy over follow-up). The CHA2DS2-VASc score successfully predicts TE after ECV, having better predictive accuracy than the CHADS2score. (Circ J 2016; 80: 605-612).

Cardiotrophin-1: A new predictor of atrial fibrillation relapses after successful cardioversion

We aimed to investigate whether or not cardiotrophin-1 (CT-1) can be used as a predictor of sinus rhythm constancy in patients with atrial fibrillation (AF) converted to sinus rhythm. Thirty two patients with AF (48-78 years), without any structural heart disease were enrolled for the study. The control group consisted of 32, age and gender matched healthy persons. Measurements of CT-1 were made after transthoracic and transesophageal echocardiography prior to cardioversion (CV). Relapses of AF were investigated by monthly electrocardiograms (ECGs) and ambulatory ECGs at 1st, 3rd, and 6th month. At the end of 6th month, measurements of CT-1 were repeated. At the beginning patients with AF had increased CT-1 levels when compared to controls (0.94 ± 0.32 pg/mL vs. 0.30 ± 0.12 pg/mL, [p < 0.001]). At the end of follow-up of the 32 patients, 17 (53%) had AF relapse. Age, initial duration of AF, left ventricle diameters, ejection fraction, left atrium appendix flow rates were similar among patients with and without AF relapse. However, basal left atrium diameter (4.24 ± 0.14 cm vs. 4.04 ± 0.22 cm, p = 0.005), pulmonary artery pressure (32.82 ± 5 vs. 28.60 ± 6.23 mmHg, p = 0.004) and CT-1 values (1.08 ± 0.37 vs. 0.82 ± 0.16 pg/mL, p = 0.02) were significantly increased in patients with AF relapse. Furthermore, patients with relapsed AF had higher CT-1 levels at 6th month when compared to those in sinus rhythm (1.00 ± 0.40 vs. 0.71 ± 0.23 pg/mL). We conclude that post-CV, AF relapses are more frequent among patients with increased baseline CT-1 levels, and CT-1 may be a potential predictor of AF relapse.

A South Australian registry of biphasic cardioversions of atrial arrhythmias: efficacy and predictors of success

BACKGROUND

Restoration of sinus rhythm by biphasic cardioversion is an established strategy for patients in atrial arrhythmias. This study aimed to investigate the real-life practice of cardioversions throughout a local hospital to determine frequency and predictors of success and use of high energy (> 200 joules).

METHODS

Prospective analysis of consecutive biphasic cardioversions from 2009-2013. Patient demographics, medical history and cardioversion data were collected.

RESULTS

484 cardioversions from 379 patients were included in the final analysis. The majority (73%) of cardioversions were immediately successful after a single shock; overall success was 88% (1-5 shocks). Exploratory analyses revealed that single-shock success was significantly associated with lighter weight (OR 1.19, 95% CI 1.0-1.4, p<0.05). If a second shock was required, energy escalation was significantly associated with success (OR 3.11, 95% CI 1.43-6.77, p<0.05). Increasing weight was the strongest predictor of receiving high energy (10kg increase OR 1.43, 95% CI 1.13-1.81, p<0.05).

CONCLUSIONS

This prospective analysis reflects the real-life heterogeneous practice of biphasic cardioversions of atrial arrhythmias throughout a local hospital. These findings highlight the importance of first shock energy selection with careful consideration of patient weight. We emphasise the recommendation to escalate energy, highlighting the need for high-energy defibrillators in 'hard-to-cardiovert' patients.

Role of left atrial speckle tracking echocardiography in predicting persistent atrial fibrillation electrical cardioversion success and sinus rhythm maintenance at 6 months

PURPOSE

We assessed the value of left atrium speckle tracking imaging (STI) indices, and clinical and other echocardiographic parameters in persistent atrial fibrillation (AF) patients to predict the efficacy of electrical cardioversion (EC) and sinus rhythm (SR) maintenance at 6 months.

MATERIAL/METHODS

Eighty persistent AF patients planned to receive EC, underwent echocardiography including STI. After 24h, patients with successful EC were examined to predict SR maintenance. After 6 months patients with no AF recurrence in electrocardiogram (ECG) underwent 7-day ECG to exclude silent AF. Every AF>1 min was a recurrence.

RESULTS

SR restored in 61 patients, 19 unsuccessful. Prior use of statins (68.8% vs. 42.1%, p=0.03) was the only factor, determined later by univariate analysis to be a significant EC success predictor (OR=1.09, CL ± 95% 1.001-1.019, p<0.03). Both groups received similar antiarrhythmics and had similar echocardiographic parameters. After 6 months, SR was maintained in 19 patients (31.1%, Group I); AF recurrences were registered in 42 patients (68.8%, Group II). In Group I, only the mitral valve deceleration time (MVDT) 224.18 ± 88.13 vs. 181.6 ± 60.6 in Group II, p=0.04) and the dispersion of time to peak longitudinal strain (dTPLS) (86.0 ± 68.3 vs. 151.8 ± 89.6, p=0.03) differed significantly. The univariate analysis revealed dTPLS as a significant predictor of SR maintenance.

CONCLUSION

High EC efficacy and frequent AF recurrences were observed. The dispersion of time to the maximal longitudinal strain (LS) of left atrial segments facilitated prediction of SR maintenance. The value of 7-day ECG monitoring for detection of arrhythmia after 6 months was limited.

Noninvasive time and frequency predictors of long-standing atrial fibrillation early recurrence after electrical cardioversion

BACKGROUND

Several clinical factors have been studied to predict atrial fibrillation (AF) recurrence after electrical cardioversion (ECV) with limited predictive value.

METHODS

 A method able to predict robustly long-standing AF early recurrence by characterizing noninvasively the electrical atrial activity (AA) with parameters related to its time course and spectral features is presented. To this respect, 63 patients (20 men and 43 women; mean age 73.4 ± 9.0 years; under antiarrhythmic drug treatment with amiodarone) who were referred for ECV of persistent AF were studied. During a 4-week follow-up, AF recurrence was observed in 41 patients (65.1%).

RESULTS

 RR variability and the studied AA spectral features, including dominant atrial frequency (DAF), its first harmonic and their amplitude, provided poor statistical differences between groups. On the contrary, f waves power (fWP) and Sample Entropy (SampEn) of the AA behaved as very good predictors. Patients who relapsed to AF presented lower fWP (0.036 ± 0.019 vs 0.081 ± 0.029 n.u.(2) , P < 0.001) and higher SampEn (0.107 ± 0.022 vs 0.086 ± 0.033, P < 0.01). Furthermore, fWP presented the highest predictive accuracy of 82.5%, whereas SampEn provided a 79.4%. The remaining features revealed accuracies lower than 70%. A stepwise discriminant analysis (SDA) provided a model based on fWP and SampEn with 90.5% of accuracy.

CONCLUSIONS

 The fWP has proved to predict long-standing AF early recurrence after ECV and can be combined with SampEn to improve its diagnostic ability. Furthermore, a thorough analysis of the results allowed outlining possible associations between these two features and the concomitant status of atrial remodeling.

First time and repeat cardioversion of atrial tachyarrhythmias - a comparison of outcomes

INTRODUCTION

Repeat cardioversion may be necessary in over 50% of patients with persistent atrial fibrillation (AF), but identifying responders remains challenging. This study evaluates the long-term success of direct current cardioversion (DCCV) and the clinical and echocardiographical parameters that influence them, in over 1000 sedation-cardioversion procedures undertaken at Eastbourne General Hospital between 1996 and 2006.

METHODS

A total of 770 patients of mean age (SD) 70.1(10.1) underwent 1013 DCCVs (first n = 665, repeat n = 348) for atrial tachyarrhythmias from 1996 to 2006. Time to persistent arrhythmia recurrence was compared between first and multiple DCCV, and the effect of age, gender, presence of heart disease, left atrial size, fractional shortening, arrhythmia duration, anti-arrhythmic drug therapy (AAD) and other concomitant cardiac medication was evaluated using the Kaplan-Meier method and Cox's Proportional-hazards model.

RESULTS

In all, 33% of first and 29% of repeat DCCVs were in sinus rhythm (SR) at 12 months (m). There was no difference in median time to arrhythmia recurrence (SE) between first and multiple procedures: 1.5 +/- 0.1 m (1.3-1.7) and 1.5 +/- 0.0 m (1.4-1.6) respectively, p = 0.45. AAD use was significantly higher, arrhythmia duration shorter and more diabetic patients underwent repeat procedures. Amiodarone, OR 0.56, p = 0.04, sotalol, OR 0.61, p = 0.02 and arrhythmia duration, < 6 m, OR 0.72, p = 0.03 were independent predictors of improved outcome in first procedures only. In patients undergoing first procedures on amiodarone or sotalol, median time to arrhythmia recurrence was longer and 12 m SR rates higher, 6.0 +/- 2.4 m (42%) than those who had a repeat procedure on the same medication, 1.5 +/- 0.1 m (33%), p = 0.06.

CONCLUSIONS

The efficacy of first and subsequent DCCV procedures is similar, achieving a similar proportion of SR maintenance at 1 year. However, the benefits of AAD therapy are the greatest following first time procedures. Concomitant AAD therapy should be considered for all first time procedures for persistent AF.

Clinical predictors of atrial fibrillation recurrence in the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico-Atrial Fibrillation (GISSI-AF) trial

BACKGROUND

Atrial fibrillation (AF) is a common arrhythmia that frequently recurs after restoration of sinus rhythm (SR). Identifying risk factors for recurrence may help define the best strategy for secondary prevention.

METHODS

The GISSI-AF trial enrolled 1,442 patients in SR with at least 2 documented AF episodes in the previous 6 months or after cardioversion in the last 2 weeks. Patients were randomized to valsartan or placebo; all other treatments for AF or underlying heart diseases were allowed. Primary end points were time to first recurrence of AF and proportion of patients with >1 AF episode during 1-year follow-up. We evaluated clinical and electrocardiographic baseline characteristics of all patients to identify independent predictors for AF recurrence using a Cox multivariable model.

RESULTS

Risk factors for AF recurrence were a history of 2 or more AF episodes in the previous 6 months, independent of the modality of SR restoration, spontaneous (HR 1.42, 95% CI 1.14-1.77, P = .002), or by cardioversion (HR 1.19, 95% CI 1.01-1.40, P = .038), and a lower heart rate during SR (HR 0.99, 95% CI 0.99-1.00, P = .052). The risk factors were the same for >1 AF recurrence. Patients treated with amiodarone had a lower risk for both end points (P < .0001 and P = .017), whereas those on diuretics had a greater risk (P = .009 and P = .003).

CONCLUSIONS

In the GISSI-AF study population, AF history had significant prognostic value independent of the modality of SR restoration. Amiodarone and diuretic treatment affected the rate of AF recurrence.

Short-term and long-term success of electrical cardioversion in atrial fibrillation in managed care system

Background

Initial success of electrical cardioversion (ECV) of atrial fibrillation (AF) has been reported in several studies as 50%-90%, of which only 50% patients remain in sinus rhythm (SR) at the end of one year. We conducted this study to see if outcomes of other trials are applicable in managed care setting.

Methods

We conducted a retrospective study in 370 consecutive patients who underwent ECV for AF. They were reviewed for initial outcome of ECV and recurrence of AF after a successful ECV, with and without prophylactic antiarrhythmic drugs.

Results

Initial success of ECV for AF was 65.7%. At one year, 47% remained in SR. AF for ≤ 3 months (p = 0.006) and pretreatment with antiarrhythmic drugs (p = 0.032) resulted in improved success. Predictors of recurrence were patients ≤ 65 years (p = 0.019), paroxysmal atrial fibrillation (PAF) (p = 0.0094) and alcohol consumption (p = 0.0074).

Conclusion

Shorter duration of AF, prophylactic antiarrhythmic drugs and serial ECVs improve outcome of ECV in AF. For younger patients with PAF and alcohol consumption, due to higher recurrence of AF, rate control or ablative therapy may be the preferred strategy.

Contemporary management of atrial fibrillation: update on anticoagulation and invasive management strategies

Atrial fibrillation (AF) is the most common arrhythmia encountered in clinical practice. Its increasing prevalence, particularly among the elderly, renders it one of the most serious current medical epidemics. Several management questions confront the clinician treating a patient with AF: Should the condition be treated? Is the patient at risk of death or serious morbidity as a result of this diagnosis? If treatment is necessary, is rate control or rhythm control superior? Which patients need anticoagulation therapy, and for how long? This review of articles obtained by a search of the PubMed and MEDLINE databases presents the available evidence that can guide the clinician in answering these questions. After discussing the merits of available therapy, including medications aimed at controlling rate, rhythm, or both, we focus on the present status of ablative therapy for AF. Catheter ablation, particularly targeting the pulmonary veins, is being increasingly performed, although the precise indications for this approach and its effectiveness and safety are being actively investigated. We briefly discuss other invasive options that are less frequently used, such as pacemakers, defibrillators, left atrial appendage closure devices, and the surgical maze procedure.