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Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2024; 149:e1-e156. [PMID: 38033089 PMCID: PMC11095842 DOI: 10.1161/cir.0000000000001193] [Citation(s) in RCA: 192] [Impact Index Per Article: 192.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
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Affiliation(s)
| | | | | | | | | | | | - Anita Deswal
- ACC/AHA Joint Committee on Clinical Practice Guidelines liaison
| | | | | | | | | | - Paul L Hess
- ACC/AHA Joint Committee on Performance Measures liaison
| | | | | | | | | | - Kazuhiko Kido
- American College of Clinical Pharmacy representative
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Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2024; 83:109-279. [PMID: 38043043 PMCID: PMC11104284 DOI: 10.1016/j.jacc.2023.08.017] [Citation(s) in RCA: 57] [Impact Index Per Article: 57.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Patients With Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
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Grbović A, Pavlović S, Žugić V. Predictors of Higher Frequency of Atrial Fibrillation in Patients with Cardiac Resynchronization Therapy. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:2178. [PMID: 38138281 PMCID: PMC10745040 DOI: 10.3390/medicina59122178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 11/15/2023] [Accepted: 11/23/2023] [Indexed: 12/24/2023]
Abstract
Background and Objectives: Cardiac resynchronization therapy (CRT) is one of the effective therapeutic options in the treatment of systolic heart failure (HF) with persistent symptoms. This prospective study was designed to determine whether CRT with biventricular pacing would reduce the risk of development of atrial fibrillation (AF) and to identify predictors for AF occurrence. Materials and Methods: The study population consisted of 126 patients, with a mean age of 63.8 ± 9.1 years, who were eligible for CRT with biventricular pacing. Inclusion criteria were left ventricular ejection fraction (LVEF) ≤ 35%, QRS duration ≥ 130 msec, and persistent HF symptoms of New York Heart Association (NYHA) II or III, despite optimal drug therapy. Patients were followed for a period of 24 months and were evaluated through clinical, electrocardiographic, and echocardiographic examination at baseline (prior to CRT implantation), as well as at 6 and 24 months post-implantation. At the end of follow-up, patients were divided into clinical responders and non-responders based on the following criteria: decrease in NYHA class ≥ I, increase in LVEF ≥ 10%, and reduction in QRS duration ≥ 20 msec. Results: At follow-up, CRT was associated with a significant increase in LVEF (20.6 ± 6.9% pre-implantation, 32.9 ± 9.3% 24 months after implantation; p < 0.001), reduction in left ventricular end-diastolic and end-systolic diameters, and decrease in QRS duration (167.6 ± 14.3 msec pre-implantation, 131.7 ± 11.7 msec 24 months after implantation; p < 0.001), while left atrial (LA) diameter was slightly increased (p = 0.070). The frequency of AF occurrence increased after two years of follow-up (52.4% to 56.9%, p < 0.001). Significant predictors of AF occurrence in our study population were response to CRT-AF more frequent in non-responders (B = 8.134; p < 0.001), LA diameter-AF more frequent with larger LA diameter (B = 0.813; p < 0.001), and coronary sinus (CS) lead position-AF more frequent with posterolateral in comparison with lateral CS lead position (B = 5.159; p = 0.005). Conclusions: The results of our study provide new data on AF predictors in patients with HF subjected to CRT. There remains a permanent need for new predictors, which might help in patient selection and improvement in response rate.
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Affiliation(s)
- Aleksandra Grbović
- Dedinje Cardiovascular Institute, Heroja Milana Tepića 1, 11000 Belgrade, Serbia; (S.P.); (V.Ž.)
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de Vere F, Wijesuriya N, Elliott MK, Mehta V, Howell S, Bishop M, Strocchi M, Niederer SA, Rinaldi CA. Managing arrhythmia in cardiac resynchronisation therapy. Front Cardiovasc Med 2023; 10:1211560. [PMID: 37608808 PMCID: PMC10440957 DOI: 10.3389/fcvm.2023.1211560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 06/30/2023] [Indexed: 08/24/2023] Open
Abstract
Arrhythmia is an extremely common finding in patients receiving cardiac resynchronisation therapy (CRT). Despite this, in the majority of randomised trials testing CRT efficacy, patients with a recent history of arrhythmia were excluded. Most of our knowledge into the management of arrhythmia in CRT is therefore based on arrhythmia trials in the heart failure (HF) population, rather than from trials dedicated to the CRT population. However, unique to CRT patients is the aim to reach as close to 100% biventricular pacing (BVP) as possible, with HF outcomes greatly influenced by relatively small changes in pacing percentage. Thus, in comparison to the average HF patient, there is an even greater incentive for controlling arrhythmia, to achieve minimal interference with the effective delivery of BVP. In this review, we examine both atrial and ventricular arrhythmias, addressing their impact on CRT, and discuss the available evidence regarding optimal arrhythmia management in this patient group. We review pharmacological and procedural-based approaches, and lastly explore novel ways of harnessing device data to guide treatment of arrhythmia in CRT.
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Affiliation(s)
- Felicity de Vere
- School of Biomedical Engineering and Imaging Sciences, King’s College, London, United Kingdom
- Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Nadeev Wijesuriya
- School of Biomedical Engineering and Imaging Sciences, King’s College, London, United Kingdom
- Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Mark K. Elliott
- School of Biomedical Engineering and Imaging Sciences, King’s College, London, United Kingdom
- Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Vishal Mehta
- School of Biomedical Engineering and Imaging Sciences, King’s College, London, United Kingdom
- Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Sandra Howell
- School of Biomedical Engineering and Imaging Sciences, King’s College, London, United Kingdom
- Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Martin Bishop
- School of Biomedical Engineering and Imaging Sciences, King’s College, London, United Kingdom
| | - Marina Strocchi
- School of Biomedical Engineering and Imaging Sciences, King’s College, London, United Kingdom
| | - Steven A. Niederer
- School of Biomedical Engineering and Imaging Sciences, King’s College, London, United Kingdom
| | - Christopher A. Rinaldi
- School of Biomedical Engineering and Imaging Sciences, King’s College, London, United Kingdom
- Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
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Yoon M, Oh J, Chun KH, Yu HT, Lee CJ, Kim TH, Pak HN, Lee MH, Joung B, Kang SM. Clinical Implications of Device-Detected Atrial Fibrillation in Cardiac Resynchronization Therapy. Korean Circ J 2023; 53:483-496. [PMID: 37271751 PMCID: PMC10406527 DOI: 10.4070/kcj.2022.0342] [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: 12/06/2022] [Revised: 02/27/2023] [Accepted: 04/04/2023] [Indexed: 06/06/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Atrial fibrillation (AF) is associated with decreased cardiac resynchronization therapy (CRT) benefits compared to sinus rhythm (SR). Effective biventricular (BiV) pacing is a determinant of CRT success, but AF can interfere with adequate BiV pacing and affect clinical outcomes. We investigated the effect of device-detected AF on clinical outcomes and optimal BiV pacing in patients with heart failure (HF) treated with CRT. METHODS We retrospectively analyzed 174 patients who underwent CRT implantation between 2012 and 2019 at a tertiary center. The optimal BiV pacing percentage was defined as ≥98%. Device-detected AF was defined as an atrial high-rate episode ≥180 beats per minute lasting more than 6 minutes during the follow-up period. We stratified the patients without preexisting AF at pre-implantation into device-detected AF and no-AF groups. RESULTS A total of 120 patients did not show preexisting AF at pre-implantation, and 54 had AF. Among these 120 patients, 19 (15.8%) showed device-detected AF during a median follow-up of 25.1 months. The proportion of optimal BiV pacing was significantly lower in the device-detected AF group than in the no-AF group (42.1% vs. 75.2%, p=0.009). The device-detected AF group had a higher incidence of HF hospitalization, cardiovascular death, and all-cause death than the no-AF group. The device-detected AF and previous AF groups showed no significant differences regarding the percentage of BiV pacing and clinical outcomes. CONCLUSIONS For HF patients implanted with CRT, device-detected AF was associated with lower optimal BiV pacing and worse clinical outcomes than no-AF.
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Affiliation(s)
- Minjae Yoon
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea
- Division of Cardiology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jaewon Oh
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Kyeong-Hyeon Chun
- Division of Cardiology, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Hee Tae Yu
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Chan Joo Lee
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Tae-Hoon Kim
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Hui-Nam Pak
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Moon-Hyoung Lee
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Boyoung Joung
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Seok-Min Kang
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea.
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Elliott MK, de Vere F, Mehta VS, Wijesuriya N, Strocchi M, Rajani R, Niederer S, Rinaldi CA. Rate or Rhythm Control in CRT (RHYTHMIC): Study rationale and protocol. Heart Rhythm O2 2022; 3:681-687. [PMID: 36589918 PMCID: PMC9795294 DOI: 10.1016/j.hroo.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Background Atrial fibrillation (AF) has several detrimental effects on heart failure patients treated with cardiac resynchronization therapy (CRT). These include suboptimal biventricular pacing and the loss of atrioventricular (AV) synchrony. AV node ablation improves biventricular pacing and clinical outcomes in large observational studies. However, restoration of sinus rhythm with AF ablation may have additional benefits. Objectives To compare the effects of AV node ablation and AF ablation on echocardiographic and symptomatic outcomes in patients with CRT and suboptimal biventricular pacing. Methods RHYTHMIC is a multicenter prospective randomized controlled trial. Seventy patients will be recruited and randomized to each ablation strategy in a 1:1 ratio. Key inclusion criteria include a previous CRT implant (with atrial lead) for dyssynchronous heart failure, and biventricular pacing <95% secondary to AF. Patients with permanent AF will be excluded. Results Patients will undergo baseline assessment including transthoracic echocardiography (TTE), device check, blood tests, electrocardiogram (ECG), 6-minute walk test, and symptom questionnaire. They will then undergo either AV node ablation or AF ablation according to their allocated group. Follow-up will occur at 1 week (TTE and ECG) and at 6 months (repeat of baseline investigations). The primary endpoint will be change in left ventricular ejection fraction on TTE. Conclusion This is the first randomized controlled trial comparing AV node ablation and AF ablation in patients with CRT. We anticipate it will provide valuable insight into the management of this frequently encountered clinical scenario in a challenging patient cohort.
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Affiliation(s)
- Mark K. Elliott
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
- Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Felicity de Vere
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
- Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Vishal S. Mehta
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
- Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Nadeev Wijesuriya
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
- Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Marina Strocchi
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
| | - Ronak Rajani
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
- Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Steven Niederer
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
| | - Christopher A. Rinaldi
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
- Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
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Țica O, Țica O, Bunting KV, deBono J, Gkoutos GV, Popescu MI, Kotecha D. Post-mortem examination of high mortality in patients with heart failure and atrial fibrillation. BMC Med 2022; 20:331. [PMID: 36195871 PMCID: PMC9533594 DOI: 10.1186/s12916-022-02533-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 08/17/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The prevalence of combined heart failure (HF) and atrial fibrillation (AF) is rising, and these patients suffer from high rates of mortality. This study aims to provide robust data on factors associated with death, uniquely supported by post-mortem examination. METHODS A retrospective cohort study of hospitalized adults with a clinical diagnosis of HF and AF at a tertiary centre in Romania between 2014 and 2017. A standardized post-mortem examination was performed where death occurred within 24 h of admission, when the cause of death was not clear or by physician request. National records were used to collect mortality data, subsequently categorized and analysed as HF-related death, vascular death and non-cardiovascular death using Cox proportional hazards regression. RESULTS A total of 1009 consecutive patients with a mean age of 73 ± 11 years, 47% women, NYHA class 3.0 ± 0.9, left ventricular ejection fraction (LVEF) 40.1 ± 11.0% and 100% anticoagulated were followed up for 1.5 ± 0.9 years. A total of 291 (29%) died, with post-mortems performed on 186 (64%). Baseline factors associated with mortality were dependent on the cause of death. HF-related death in 136 (47%) was associated with higher NYHA class (hazard ratio [HR] 2.45 per one class increase, 95% CI 1.73-3.46; p < 0.001) and lower LVEF (0.95 per 1% increase, 0.93-0.97; p < 0.001). Vascular death occurred in 75 (26%) and was associated with hypertension (HR 2.83, 1.36-5.90; p = 0.005) and higher LVEF (1.08 per 1% increase, 1.05-1.11; p < 0.001). Non-cardiovascular death in 80 (28%) was associated with clinical obesity (HR 2.20, 1.21-4.00; p = 0.010) and higher LVEF (1.10 per 1% increase, 1.06-1.13; p < 0.001). Across all causes, there was no relationship between mortality and AF type (p = 0.77), HF type (p = 0.85) or LVEF (p = 0.58). CONCLUSIONS Supported by post-mortem data, the cause of death in HF and AF patients is heterogeneous, and the relationships with typical markers of mortality are critically dependent on the mode of death. The poor prognosis in this group demands further attention to improve management beyond anticoagulation.
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Affiliation(s)
- Otilia Țica
- Institute of Cardiovascular Sciences, Medical School, University of Birmingham, Vincent Drive, Birmingham, B15 2TT, UK.
- Cardiology Department, Emergency County Clinical Hospital of Oradea, Gheorghe Doja street, No 65, 410165, Oradea, Romania.
| | - Ovidiu Țica
- Pathology Department, Emergency County Clinical Hospital of Oradea, Gheorghe Doja street, no 65, 410165, Oradea, Romania
| | - Karina V Bunting
- Institute of Cardiovascular Sciences, Medical School, University of Birmingham, Vincent Drive, Birmingham, B15 2TT, UK
- Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Birmingham, B15 2GW, UK
| | - Joseph deBono
- Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Birmingham, B15 2GW, UK
| | - Georgios V Gkoutos
- Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Birmingham, B15 2GW, UK
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, B15 2TT, UK
- Health Data Research (HDR)-UK Midlands, Institute of Translational Medicine, B15 2GW, Birmingham, UK
| | - Mircea I Popescu
- Cardiology Department, Emergency County Clinical Hospital of Oradea, Gheorghe Doja street, No 65, 410165, Oradea, Romania
| | - Dipak Kotecha
- Institute of Cardiovascular Sciences, Medical School, University of Birmingham, Vincent Drive, Birmingham, B15 2TT, UK.
- Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Birmingham, B15 2GW, UK.
- Health Data Research (HDR)-UK Midlands, Institute of Translational Medicine, B15 2GW, Birmingham, UK.
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Martins R, António N, Donato H, Oliveiros B. Predictors of echocardiographic response to cardiac resynchronization therapy: A systematic review with Meta-Analysis. IJC HEART & VASCULATURE 2022; 39:100979. [PMID: 35252540 PMCID: PMC8891947 DOI: 10.1016/j.ijcha.2022.100979] [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: 12/26/2021] [Revised: 01/30/2022] [Accepted: 02/20/2022] [Indexed: 11/17/2022]
Abstract
NYHA class II seems to predict response to CRT. We should not delay CRT, trying medical management first, even in mildly symptomatic patients. Atrial fibrillation patients must have the same indication for CRT as those in sinus rhythm.
Background At least 30% of the patients do not respond to cardiac resynchronization therapy (CRT). We performed a systematic review and meta-analysis of real-world studies trying to identify predictors of response to CRT. Methods PubMed, Embase and Cochrane Central Register of Controlled Trials (CENTRAL) were searched for observational prospective studies, referring the evaluation of response to CRT, defined as a decrease in left ventricle end-systolic volume (LVESV) ≥ 15% at 6-month follow-up, via two-dimensional echocardiography. Results A total of 24 studies were included. The meta-analysis showed that female gender (p = 0.018), non-ischemic cardiomyopathy (NICM) (p < 0.001), left bundle branch morphology (LBBB) (p = 0.001), longer QRS (p < 0.001) and New York Heart Association (NYHA) class II (p = 0.014) appear to favor response to CRT. After ROC analysis and logistic regression procedures, female gender (kappa = 0.450; p < 0.001), NICM (kappa = 0.636; p < 0.001), LBBB (kappa = 0.935; p < 0.001), and NYHA class II (kappa = 0.647; p < 0.001) were identified as independent predictors of response to CRT, being LBBB the most reliable one (sensitivity = 97.24%; specificity = 98.86%). Conclusions Female gender, NICM, LBBB and NYHA class II are baseline variables with an apparent capability to independently predict response to CRT, being LBBB the most reliable one.
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Affiliation(s)
- Rodrigo Martins
- Faculdade de Medicina da Universidade de Coimbra, Coimbra, Portugal
| | - Natália António
- Faculdade de Medicina da Universidade de Coimbra, Coimbra, Portugal
- Serviço de Cardiologia, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
- Corresponding author.
| | - Helena Donato
- Faculdade de Medicina da Universidade de Coimbra, Coimbra, Portugal
- Serviço de Documentação, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
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Zhang C, Wang XY, Lou L, Zhang X, Chen LL, Chen YX, Yang J. Pacemaker and Atrioventricular Junction Ablation in Patients With Atrial Fibrillation—A Systematic Review of Systematic Review and Meta-Analysis. Front Cardiovasc Med 2022; 8:587297. [PMID: 35127840 PMCID: PMC8810654 DOI: 10.3389/fcvm.2021.587297] [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: 07/27/2020] [Accepted: 12/20/2021] [Indexed: 11/25/2022] Open
Abstract
Background Cardiac resynchronization therapy (CRT) could be considered for heart failure (HF) patients with atrial fibrillation (AF) unless a potent ventricular capture strategy is conducted. However, the benefit of a pacemaker (PM; as part of CRT) in patients with AF and whether atrioventricular junction (or nodal) ablation (AVAB) can improve the prognosis of these patients compared with those treated medically to support ventricular capture are unclear. Methods and Results Systematic reviews and meta-analyses investigating the roles of PMs and AVAB in patients with AF were obtained in a search of the PubMed, Embase, and Medline databases and then analyzed with respect to the following outcomes: mortality, left ventricular ejection fraction, and clinical findings including the New York Heart Association class, 6-min walk distance (6MWD), quality of life as assessed in a specific questionnaire, and response to CRT. The quality of the included reviews was assessed using the Assessing the Methodological Quality of Systematic Reviews 2 tool, which includes 16 items. This study was finally based on 13 systematic reviews or meta-analyses. The results showed that patients with AF have higher all-cause mortality rates compared with patients with sinus rhythm and that AVAB can reduce all-cause mortality in patients with AF. Although the functional improvement was better in sinus rhythm than in patients with AF, in the latter, AVAB increased the 6MWD and reduced the CRT nonresponse rate in patients with AF. Conclusion Atrial fibrillation is associated with a higher all-cause mortality rate in patients with CRT implantation. AVAB, by increasing the 6MWD and survival, can improve the prognosis of these patients.
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Elliott MK, Mehta VS, Martic D, Sidhu BS, Niederer S, Rinaldi CA. Atrial fibrillation in cardiac resynchronization therapy. Heart Rhythm O2 2021; 2:784-795. [PMID: 34988530 PMCID: PMC8710632 DOI: 10.1016/j.hroo.2021.09.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Patients with atrial fibrillation (AF) were largely excluded from the major clinical trials of cardiac resynchronization therapy (CRT), despite the presence of AF in up to 40% of patients receiving CRT in clinical practice. AF appears to attenuate the response to CRT, by the combination of a reduction in biventricular pacing and the loss of atrioventricular synchrony. In addition, remodeling secondary to CRT may influence the progression of AF. Management options for patients with AF and CRT include rate control, with drugs or atrioventricular node ablation, or rhythm control, with electrical cardioversion and antiarrhythmic therapy, or AF catheter ablation. The evidence for these therapies in patients with CRT is largely limited to observational studies or inferred from randomized studies in the general heart failure population. In this review, we explore the complex interaction between AF, heart failure, and CRT and discuss the evidence for the treatment options in this difficult patient cohort.
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Affiliation(s)
- Mark K. Elliott
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
- Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Vishal S. Mehta
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
- Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Dejana Martic
- Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Baldeep S. Sidhu
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
- Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Steven Niederer
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
| | - Christopher A. Rinaldi
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
- Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
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11
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Ariyaratnam JP, Lau DH, Sanders P, Kalman JM. Atrial Fibrillation and Heart Failure: Epidemiology, Pathophysiology, Prognosis, and Management. Card Electrophysiol Clin 2021; 13:47-62. [PMID: 33516407 DOI: 10.1016/j.ccep.2020.11.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Atrial fibrillation (AF) and heart failure (HF) have similar risk factors, frequently coexist, and potentiate each other in a vicious cycle. Evidence suggests the presence of AF in both HF with reduced ejection fraction (HFrEF) and HF with preserved ejection fraction (HFpEF) increases the risk of all-cause mortality and stroke, particularly when AF is incident. Catheter ablation may be an effective strategy in controlling symptoms and improving quality of life in AF-HFrEF. Strong data guiding management of AF-HFpEF are lacking largely due to its challenging diagnosis. Improving outcomes associated with these coexistent conditions requires further careful investigation.
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Affiliation(s)
- Jonathan P Ariyaratnam
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Dennis H Lau
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Jonathan M Kalman
- Department of Cardiology, Royal Melbourne Hospital, Department of Medicine, University of Melbourne, Melbourne, Australia.
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12
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Wu S, Cai M, Zheng R, Wang S, Jiang L, Xu L, Shi R, Xiao F, Ellenbogen KA, Cha Y, Su L, Huang W. Impact of QRS morphology on response to conduction system pacing after atrioventricular junction ablation. ESC Heart Fail 2021; 8:1195-1203. [PMID: 33395736 PMCID: PMC8006676 DOI: 10.1002/ehf2.13181] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 11/16/2020] [Accepted: 12/08/2020] [Indexed: 01/03/2023] Open
Abstract
Aims His–Purkinje conduction system pacing (HPCSP) utilizing His (HBP) or left bundle branch pacing (LBBP) in patients with atrial fibrillation (AF) and wide QRS duration has not been well studied. We assessed the benefit of left bundle branch block (LBBB) correction during HPCSP in AF patients undergoing atrioventricular junction (AVJ) ablation with LBBB, compared with those with narrow QRS duration. Methods and results This is an observational study in consecutive patients with typical LBBB or narrow QRS duration in whom we attempted HPCSP after AVJ ablation for refractory AF with a left ventricular ejection fraction (LVEF) ≤ 50%. Echocardiographic responses and clinical outcomes were assessed at baseline and during 1 year of follow‐up. A total of 178 patients were enrolled, of which 170 achieved AVJ ablation + permanent HPCSP (age 69.3 ± 10.1 years; LVEF 34.3 ± 7.7%), 133 (78.2%) patients had a narrow QRS duration, and 37 (21.2%) had an LBBB. The QRS duration changed from a baseline of 159.7 ± 16.6 ms to a paced QRS duration of 110.4 ± 12.7 ms in the LBBB cohort and from 95.6 ± 10.4 to 100.8 ± 14.5 ms (both P < 0.001) in the narrow QRS cohort after AVJ ablation and pacing. Compared with the narrow QRS cohort, the LBBB cohort showed a greater absolute increase in LVEF (+22.3% vs. +14.2%, P < 0.001), higher super responder rate (71.4% vs. 49.2%, P = 0.011), and greater New York Heart Association (NYHA) class improvement (−1.9 vs. −1.4, P < 0.001) at 1 year. Conclusion Patients with LBBB have greater improvement in LVEF and NYHA class function than patients with narrow QRS from HPCSP after AVJ ablation.
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Affiliation(s)
- Shengjie Wu
- Department of Cardiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China.,The Key Lab of Cardiovascular Disease of Wenzhou, Wenzhou, 325000, China
| | - Mengxing Cai
- Department of Cardiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China.,The Key Lab of Cardiovascular Disease of Wenzhou, Wenzhou, 325000, China
| | - Rujie Zheng
- Department of Cardiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China.,The Key Lab of Cardiovascular Disease of Wenzhou, Wenzhou, 325000, China
| | - Songjie Wang
- Department of Cardiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China.,The Key Lab of Cardiovascular Disease of Wenzhou, Wenzhou, 325000, China
| | - Limeng Jiang
- Department of Cardiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China.,The Key Lab of Cardiovascular Disease of Wenzhou, Wenzhou, 325000, China
| | - Lei Xu
- Department of Cardiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China.,The Key Lab of Cardiovascular Disease of Wenzhou, Wenzhou, 325000, China
| | - Ruiyu Shi
- Department of Cardiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China.,The Key Lab of Cardiovascular Disease of Wenzhou, Wenzhou, 325000, China
| | - Fangyi Xiao
- Department of Cardiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China.,The Key Lab of Cardiovascular Disease of Wenzhou, Wenzhou, 325000, China
| | - Kenneth A Ellenbogen
- Department of Cardiology, Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Yongmei Cha
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Lan Su
- Department of Cardiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China.,The Key Lab of Cardiovascular Disease of Wenzhou, Wenzhou, 325000, China
| | - Weijian Huang
- Department of Cardiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China.,The Key Lab of Cardiovascular Disease of Wenzhou, Wenzhou, 325000, China
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13
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Firouzbakht T, Mustafa U, Jiwani S, Dominic P. Atrial Fibrillation Management in Heart Failure: Interrupting the Vicious Cycle. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2020. [DOI: 10.1007/s11936-020-00812-2] [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: 10/24/2022]
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14
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Cai M, Hua W, Zhang N, Yang S, Hu Y, Gu M, Niu H, Zhang S. A prognostic nomogram for event-free survival in patients with atrial fibrillation before cardiac resynchronization therapy. BMC Cardiovasc Disord 2020; 20:221. [PMID: 32404049 PMCID: PMC7222436 DOI: 10.1186/s12872-020-01502-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 04/30/2020] [Indexed: 12/20/2022] Open
Abstract
Background Atrial fibrillation (AF), one of the most common comorbidities of heart failure (HF), is associated with worse long-term prognosis in HF patients receiving cardiac resynchronization therapy (CRT). However, there is still no convenient tool to identify CRT candidates with AF who are at high risk of mortality and hospitalization due to HF. Methods We included 152 consecutive patients with AF for CRT in our hospital from January 2009 to July 2019. Multiple imputation was used for missing values. With imputed datasets, a multivariate Cox regression model was performed for variable selection using the backward stepwise method to predict all-cause mortality and HF readmissions. A nomogram and nomogram-based scoring system were constructed from the selected predictors. Then, internal validation and calibration were achieved by the bootstrap method, deriving the corrected concordance index and calibration curves. Sensitivity analysis was also performed to validate our selected predictors. Results Five predictors were incorporated in the nomogram, including N-terminal pro brain natriuretic protein (NT-proBNP) > 1745 pg/mL, history of syncope, previous pulmonary hypertension, moderate or severe tricuspid regurgitation, thyroid-stimulating hormone (TSH) > 4 mIU/L. The concordance index (0.70, 95% CI 0.62–0.77), corrected concordance index (0.67, 95% CI 0.59–0.74) and calibration curve showed optimal discrimination and calibration of the established nomogram. A significant difference in overall event-free survival was recognized by the nomogram-derived scores for patients with high risk (> 50 points), intermediate risk (21–50 points) and low risk (0–20 points) before CRT. Conclusion Our internally validated nomogram may be an applicable tool for the early risk stratification of CRT candidates with AF.
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Affiliation(s)
- Minsi Cai
- Chinese Academy of Medical Sciences & Peking Union Medical College Fuwai Hospital, No. 167, Beilishi Rd, Xicheng District, Beijing, 100037, China
| | - Wei Hua
- Chinese Academy of Medical Sciences & Peking Union Medical College Fuwai Hospital, No. 167, Beilishi Rd, Xicheng District, Beijing, 100037, China.
| | - Nixiao Zhang
- Chinese Academy of Medical Sciences & Peking Union Medical College Fuwai Hospital, No. 167, Beilishi Rd, Xicheng District, Beijing, 100037, China
| | - Shengwen Yang
- Chinese Academy of Medical Sciences & Peking Union Medical College Fuwai Hospital, No. 167, Beilishi Rd, Xicheng District, Beijing, 100037, China
| | - Yiran Hu
- Chinese Academy of Medical Sciences & Peking Union Medical College Fuwai Hospital, No. 167, Beilishi Rd, Xicheng District, Beijing, 100037, China
| | - Min Gu
- Chinese Academy of Medical Sciences & Peking Union Medical College Fuwai Hospital, No. 167, Beilishi Rd, Xicheng District, Beijing, 100037, China
| | - Hongxia Niu
- Chinese Academy of Medical Sciences & Peking Union Medical College Fuwai Hospital, No. 167, Beilishi Rd, Xicheng District, Beijing, 100037, China
| | - Shu Zhang
- Chinese Academy of Medical Sciences & Peking Union Medical College Fuwai Hospital, No. 167, Beilishi Rd, Xicheng District, Beijing, 100037, China
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