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Zuin M, Bertini M, Vitali F, Turakhia M, Boriani G. Heart Failure-Related Death in Subjects With Atrial Fibrillation in the United States, 1999 to 2020. J Am Heart Assoc 2024; 13:e033897. [PMID: 38686875 PMCID: PMC11179935 DOI: 10.1161/jaha.123.033897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 03/15/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND Population-based data on heart failure (HF)-related death in patients with atrial fibrillation (AF) are lacking. We assessed HF-related death in people with AF in the United States over the past 21 years and examined differences by age, sex, race, ethnicity, urbanization, and census region. METHODS AND RESULTS Data were extracted from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research to determine trends in age-adjusted mortality rates per 100 000 people, due to HF-related death among subjects with AF aged ≥15 years. To calculate nationwide annual trends, we assessed the average annual percent change (AAPC) and annual percent change with relative 95% CIs using joinpoint regression. Between 1999 and 2020, 916 685 HF-related deaths (396 205 men and 520 480 women) occurred among US adults having a concomitant AF. The overall age-adjusted mortality rates increased (AAPC: +4.1% [95% CI, 3.8-4.4]; P<0.001), especially after 2011 (annual percent change, +6.8% [95% CI, 6.2-7.4]; P<0.001) in men (AAPC, +4.8% [95% CI, 4.4-5.1]; P<0.001), in White subjects (AAPC: +4.2% [95% CI, 3.9 to 4.6]; P<0.001) and in subjects aged <65 years (AAPC: +7.5% [95% CI, 6.7-8.4]; P<0.001). The higher percentage of deaths were registered in the South (32.8%). During the first year of the COVID-19 pandemic, a significant excess in HF-related deaths among patients with AF aged >65 years was observed. CONCLUSIONS A worrying increase in the HF-related mortality rate among patients with AF has been observed in the United States over the past 2 decades.
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Affiliation(s)
- Marco Zuin
- Cardiology Unit, Department of Translational Medicine Sant'Anna University Hospital, University of Ferrara Ferrara Italy
| | - Matteo Bertini
- Cardiology Unit, Department of Translational Medicine Sant'Anna University Hospital, University of Ferrara Ferrara Italy
| | - Francesco Vitali
- Cardiology Unit, Department of Translational Medicine Sant'Anna University Hospital, University of Ferrara Ferrara Italy
| | - Mintu Turakhia
- Division of Cardiovascular Medicine, The Center for Digital Health Stanford University Stanford CA USA
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences Italy University of Modena and Reggio Emilia, Policlinico di Modena Modena Italy
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2
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Mutagaywa RK, Cramer MJ, Chillo P, Khamis RH, Boniface R, Muhozya A, Barongo A, Byomuganyizi M, Kwesigabo G, Kamuhabwa A, Nyangasa B, Kisenge P, Chamuleau S. Health related quality of life of patients following mechanical valve replacement surgery for rheumatic mitral stenosis in Tanzania. J Cardiothorac Surg 2023; 18:159. [PMID: 37085912 PMCID: PMC10122295 DOI: 10.1186/s13019-023-02235-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 04/02/2023] [Indexed: 04/23/2023] Open
Abstract
BACKGROUND The assessment of outcomes of interventions based on the patient's perspective using patient-reported outcome measures (PROMs) has been increasingly highlighted in clinical practice. However, health related quality of life (HRQoL), one of the common constructs measured by PROMs remain unknown among patients after heart valve replacement (HVR) in Tanzania. OBJECTIVES To assess the HRQoL amongst patients operated on for rheumatic mitral stenosis at Jakaya Kikwete Cardiac Institute (JKCI). METHODS A prospective study of patients operated on due to rheumatic mitral stenosis at JKCI from January 2020 to April 2021 was undertaken. The HRQoL was assessed by using the MacNew questionnaire, addressing three domains (physical, emotional, and social function); the score ranges from 0 to 7. We categorized HRQoL as low (mean score ≤ 4.9), moderate (5-6) and high (> 6). We analysed several sociodemographic and clinical variables for HRQoL. RESULTS Out of 54 patients, there were 34 females and 20 males. Their mean (± SD) age was 37.98 (± 12.58) years. The reliability of translated Kiswahili version of MacNew was good. The mean (± SD) global scores were 3.47 ± 0.59, 4.88 ± 0.71 and 6.14 ± 0.50 preoperatively, at 3 months and 6 months respectively (p-values < 0.001 preoperatively vs. 3 months, preoperatively vs. 6 months and at 3 months vs. 6 months). The median of individual mean difference HRQoL score pre-operatively and at 6 months was 2.67. The preoperative and 6 months mean difference HRQoL scores were higher among patients with vs. without atrial fibrillation (2.95 ± 0.59 vs. 2.45 ± 0.53, p = 0.003) and those on anticoagulants (preoperatively) vs. not on anticoagulants (3.14 ± 0.58 vs. 2.57 ± 0.57, 0.009). The mean difference HRQoL scores were similar for sociodemographic and other clinical parameters, including those with stroke vs. without stroke. CONCLUSION Six months after HVR the overall MacNew HRQoL scores improved markedly. This improvement in HRQoL was regardless of the presence of comorbidities (e.g. stroke and atrial fibrillation) which underscores the importance of considering valvular surgery if they fit the criteria. Clinicians and researchers in low-resource settings should collaborate to promote the utilization of PROMs in the routine care of patients.
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Affiliation(s)
- Reuben K Mutagaywa
- School of Medicine, Department of Internal Medicine, Muhimbili University of Health and Allied Sciences, P.O. BOX 5539, Dar es Salaam, Tanzania.
- Muhimbili Orthopaedic Institute, Dar es Salaam, Tanzania.
- Jakaya Kikwete Cardiac Institute, Dar es Salaam, Tanzania.
- Division of Heart and Lung, Department of Cardiology, University Medical Centre Utrecht, Utrecht, Netherlands.
| | - Maarten J Cramer
- Division of Heart and Lung, Department of Cardiology, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Pilly Chillo
- School of Medicine, Department of Internal Medicine, Muhimbili University of Health and Allied Sciences, P.O. BOX 5539, Dar es Salaam, Tanzania
- Jakaya Kikwete Cardiac Institute, Dar es Salaam, Tanzania
| | - Ramadhan H Khamis
- School of Medicine, Department of Surgery (Cardiothoracic& vascular section), Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | | | - Anjela Muhozya
- Jakaya Kikwete Cardiac Institute, Dar es Salaam, Tanzania
| | - Aileen Barongo
- Department of Paediatrics, Mwananyamala Regional Referral Hospital, Dar es Salaam, Tanzania
| | - Moses Byomuganyizi
- School of Medicine, Department of Surgery (Cardiothoracic& vascular section), Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Gideon Kwesigabo
- School of Public Health, Department of Epidemiology and Biostatistics, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Appolinary Kamuhabwa
- School of Pharmacy, Department of Pharmacology and Clinical Pharmacy and Pharmacology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | | | - Peter Kisenge
- Jakaya Kikwete Cardiac Institute, Dar es Salaam, Tanzania
| | - Steven Chamuleau
- Heart Center, Department of Cardiology and Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centre, Amsterdam, Netherlands
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3
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Gao YF, Chen Y, Wang CJ, Du Y, Ding YH. Atrial fibrillation episode status and incidence of coronary slow flow: A propensity score-matched analysis. Front Cardiovasc Med 2023; 10:1047748. [PMID: 37020520 PMCID: PMC10067859 DOI: 10.3389/fcvm.2023.1047748] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Accepted: 02/27/2023] [Indexed: 04/07/2023] Open
Abstract
Background Previous studies have shown that patients with a history of atrial fibrillation (AF) have a higher risk of developing coronary slow flow (CSF). However, whether AF episode status affects the incidence of CSF has not been confirmed. This study investigated the correlation between AF episode status and the incidence of CSF. Methods We enrolled patients with AF who underwent coronary angiography for symptoms of myocardial ischemia between January 1, 2017, and April 30, 2022, at our institution and classified them according to whether they had an episode of AF in the perioperative period. The outcomes were defined the occurrence of CSF overall and in each of the three coronary arteries. The analysis was repeated after adjusting the baseline information by the propensity score matching method in a 1:1 ratio. Results 214 patients who met the inclusion and exclusion criteria were included in the study (AF episode group: 100 patients, AF non-episode group: 114 patients). Before matching, age, left atrial size, ejection fraction, heart rate, CSF incidence, and mean corrected thrombolysis in myocardial infarction frame counts were higher in patients with intraoperative AF episodes than in patients without episodes. To prevent the dependent variable (CSF incidence) from being confounded by confounding factors, we matched the two groups for age, left atrial size, and ejection fraction. In the logistic regression analysis, the incidence of CSF was significantly higher in the intraoperative AF episode group (P = 0.010, OR = 2.327, 95% CI: 1.226-4.416) than in the non-episode group. Conclusion In patients with AF, AF episode status is significantly correlated with an increased overall incidence of CSF.
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Affiliation(s)
- Ya-fang Gao
- Heart Center, Department of Cardiovascular Medicine, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, China
- Graduate Department, Bengbu Medical College, Bengbu, China
| | - Yan Chen
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Cheng-jian Wang
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Ying Du
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Ya-hui Ding
- Heart Center, Department of Cardiovascular Medicine, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, China
- Correspondence: Ya-hui Ding
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4
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Jarab AS, Al-Qerem WA, Hamam HW, Alzoubi KH, Abu Heshmeh SR, Mukattash TL, Alefishat E. Medication Adherence and Its Associated Factors Among Outpatients with Heart Failure. Patient Prefer Adherence 2023; 17:1209-1220. [PMID: 37187575 PMCID: PMC10178996 DOI: 10.2147/ppa.s410371] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 04/28/2023] [Indexed: 05/17/2023] Open
Abstract
Background Poor adherence to heart failure (HF) medications represents a major barrier to achieve the desired health outcomes in those patients. Objective To assess medication adherence and to explore the factors associated with medication non-adherence among patient with HF in Jordan. Methods The current cross-sectional study was conducted at the outpatient cardiology clinics at two main hospitals in Jordan from August 2021 through April 2022. Variables including socio-demographics, biomedical variables, in addition to disease and medication characteristics were collected using medical records and custom-designed questionnaire. Medication adherence was assessed using the 4-item Morisky Medication Adherence Scale. Multinomial logistic regression analysis was performed to identify the factors that are significantly and independently associated with medication non-adherence. Results Of the 427 participating patients, 92.5% had low to moderate medication adherence. Results of the regression analysis revealed that that patients who had higher education level (OR=3.36; 95% CI 1.08-10.43; P=0.04) and were not suffering from medication-related side effects (OR=4.7; 95% CI 1.91-11.5; P=0.001) had significantly higher odds of being in the moderate adherence group. Patients who were taking statins (OR=16.59; 95% CI 1.79-153.98; P=0.01) or ACEIs/ ARBs (OR=3.95; 95% CI 1.01-15.41; P=0.04) had significantly higher odds of being in the high adherence group. Furthermore, Patients who were not taking anticoagulants had higher odds of being in the moderate (OR=2.77; 95% CI 1.2-6.46; P=0.02) and high (OR=4.11; 95% CI 1.27-13.36; P=0.02) adherence groups when compared to patients who were taking anticoagulants. Conclusion The poor medication adherence in the present study sheds the light on the importance of implementing intervention programs which focus on improving patients' perception about the prescribed medications particularly for patients who have low educational levels, receive an anticoagulant, and do not receive a statin or an ACEI/ ARB.
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Affiliation(s)
- Anan S Jarab
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, 22110, Jordan
- College of Pharmacy, Al Ain University, Abu Dhabi, United Arab Emirates
| | - Walid A Al-Qerem
- Department of Pharmacy, Faculty of Pharmacy, Al-Zaytoonah University of Jordan, Amman, 11733, Jordan
| | - Hanan Walid Hamam
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, 22110, Jordan
| | - Karem H Alzoubi
- Department of Pharmacy Practice and Pharmacotherapeutics, College of Pharmacy, University of Sharjah, Sharjah, United Arab Emirates
- Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Shrouq R Abu Heshmeh
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, 22110, Jordan
| | - Tareq L Mukattash
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, 22110, Jordan
| | - Eman Alefishat
- Department of Pharmacology, College of Medicine and Health Science, Khalifa University of Science and Technology, Abu Dhabi, 127788, United Arab Emirates
- Department Biopharmaceutics and Clinical Pharmacy, Faculty of Pharmacy, University of Jordan, Amman, 11942, Jordan
- Center for Biotechnology, Khalifa University of Science and Technology, Abu Dhabi, 127788, United Arab Emirates
- Correspondence: Eman Alefishat, Department of Pharmacology, College of Medicine and Health Science, Khalifa University of Science and Technology, Abu Dhabi, 127788, United Arab Emirates, Tel +971 5 07293877, Email
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5
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Qammar NW, Šiaučiūnaitė V, Zabiela V, Vainoras A, Ragulskis M. Detection of Atrial Fibrillation Episodes based on 3D Algebraic Relationships between Cardiac Intervals. Diagnostics (Basel) 2022; 12:diagnostics12122919. [PMID: 36552926 PMCID: PMC9776502 DOI: 10.3390/diagnostics12122919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 11/17/2022] [Accepted: 11/18/2022] [Indexed: 11/25/2022] Open
Abstract
In this study, the notion of perfect matrices of Lagrange differences is employed to detect atrial fibrillation episodes based on three ECG parameters (JT interval, QRS interval, RR interval). The case study comprised 8 healthy individuals and 7 unhealthy individuals, and the mean and standard deviation of age was 65.84 ± 1.4 years, height was 1.75 ± 0.12 m, and weight was 79.4 ± 0.9 kg. Initially, it was demonstrated that the sensitivity of algebraic relationships between cardiac intervals increases when the dimension of the perfect matrices of Lagrange differences is extended from two to three. The baseline dataset was established using statistical algorithms for classification by means of the developed decision support system. The classification helps to determine whether the new incoming candidate has indications of atrial fibrillation or not. The application of probability distribution graphs and semi-gauge indicator techniques aided in visualizing the categorization of the new candidates. Though the study's data are limited, this work provides a strong foundation for (1) validating the sensitivity of the perfect matrices of Lagrange differences, (2) establishing a robust baseline dataset for supervised classification, and (3) classifying new incoming candidates within the classification framework. From a clinical standpoint, the developed approach assists in the early detection of atrial fibrillation in an individual.
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Affiliation(s)
- Naseha Wafa Qammar
- Department of Mathematical Modelling, Kaunas University of Technology, LT-51368 Kaunas, Lithuania
| | - Vaiva Šiaučiūnaitė
- Department of Mathematical Modelling, Kaunas University of Technology, LT-51368 Kaunas, Lithuania
| | - Vytautas Zabiela
- Cardiology Institute, The Lithuanian University of Health Sciences, Mickeviciaus g.9, LT-44307 Kaunas, Lithuania
| | - Alfonsas Vainoras
- Cardiology Institute, The Lithuanian University of Health Sciences, Mickeviciaus g.9, LT-44307 Kaunas, Lithuania
- Correspondence:
| | - Minvydas Ragulskis
- Department of Mathematical Modelling, Kaunas University of Technology, LT-51368 Kaunas, Lithuania
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6
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Sanghai SR, Liu W, Wang W, Rongali S, Orkaby AR, Saczynski JS, Rose AJ, Kapoor A, Li W, Yu H, McManus DD. Prevalence of Frailty and Associations with Oral Anticoagulant Prescribing in Atrial Fibrillation. J Gen Intern Med 2022; 37:730-736. [PMID: 33948795 PMCID: PMC8904680 DOI: 10.1007/s11606-021-06834-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 04/14/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Frailty is often cited as a factor influencing oral anticoagulation (OAC) prescription in patients with non-valvular atrial fibrillation (NVAF). We sought to determine the prevalence of frailty and its association with OAC prescription in older veterans with NVAF. METHODS We used ICD-9 codes in Veterans Affairs (VA) records and Medicare claims data to identify patients with NVAF and CHA2DS2VASC ≥2 receiving care between February 2010 and September 2015. We examined rates of OAC prescription, further stratified by direct oral anticoagulant (DOAC) or vitamin K antagonist (VKA). Participants were characterized into 3 categories: non-frail, pre-frail, and frail based on a validated 30-item EHR-derived frailty index. We examined relations between frailty and OAC receipt; and frailty and type of OAC prescribed in regression models adjusted for factors related to OAC prescription. RESULTS Of 308,664 veterans with NVAF and a CHA2DS2VASC score ≥2, 121,839 (39%) were prescribed OAC (73% VKA). The mean age was 77.7 (9.6) years; CHA2DS2VASC and ATRIA scores were 4.6 (1.6) and 5.0 (2.9) respectively. Approximately a third (38%) were frail, another third (32%) were pre-frail, and the remainder were not frail. Veterans prescribed OAC were younger, had higher bleeding risk, and were less likely to be frail than participants not receiving OAC (all p's<0.001). After adjustment for factors associated with OAC use, pre-frail (OR: 0.89, 95% CI: 0.87-0.91) and frail (OR: 0.66, 95% CI: 0.64-0.68) veterans were significantly less likely to be prescribed OAC than non-frail veterans. Of those prescribed OAC, pre-frail (OR:1.27, 95% CI: 1.22-1.31) and frail (OR: 1.75, 95% CI: 1.67-1.83) veterans were significantly more likely than non-frail veterans to be prescribed a DOAC than a VKA. CONCLUSIONS There are high rates of frailty among older veterans with NVAF. Frailty using an EHR-derived index is associated with decreased OAC prescription.
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Affiliation(s)
- Saket R Sanghai
- Division of Cardiac Electrophysiology, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA.
| | - Weisong Liu
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Weijia Wang
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | | | - Ariela R Orkaby
- New England GRECC, VA Boston Health Care System, Boston, MA, USA
- Division of Aging, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jane S Saczynski
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA, USA
| | - Adam J Rose
- Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Alok Kapoor
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Wenjun Li
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Hong Yu
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
- University of Massachusetts, Lowell, MA, USA
- Edith Nourse Rogers Memorial VA Medical Center, Bedford, MA, USA
| | - David D McManus
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
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7
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Ivković B, Opačić D, Džudović B, Crevar M, Gojković-Bukarica L. Antiarrhythmic effects of newly developed propafenone derivatives. ARHIV ZA FARMACIJU 2022. [DOI: 10.5937/arhfarm72-37114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
It is well known that the presence of different chemical groups in drug molecules influences their pharmacological properties. The aim of our study is to investigate whether newly synthesized derivatives of propafenone, with changes in benzyl moiety, have a different effect upon arrhythmia, compared to propafenone. 5OCl-PF and 5OF-PF are derivatives of propafenone with -Cl or -F substituent on the ortho position of the benzyl moiety. For verification of their antiarrhythmic effect, we used an in vivo rat model of aconitine-induced arrhythmia. 5OCl-PF speeded the appearance of supraventricular premature beats (SVPB) and death more than aconitine. All animals treated with 5OCl-PF developed ventricular premature beats in salvos (VPBS), bigeminies (VPBB) and paroxysmal ventricular tachycardia (PVT). 5OF-PF had a negative chronotropic effect and potentiated atrial excitability (more SVPB). It had a positive effect on the occurrence and onset time of supraventricular tachycardia, VPBS, and PVT. Based on the obtained results, it can be concluded that newly synthesized propafenone derivatives have no better antiarrhythmic effect than the parent compound. In the future, our research will be focused on the synthesis of different derivatives and examining their antiarrhythmic effects.
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8
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T Brown M, M Pelling M, Kiani S, M Merchant F, F El-Chami M, R Leon A, Westerman S, Shah A, Wise D, S Lloyd M. Same-Day Versus Next-Day Discharge Strategies for Left Atrial Ablation Procedures: A Parallel, Intra-Institutional Comparison of Safety and Feasibility. J Atr Fibrillation 2021; 13:2466. [PMID: 34950339 DOI: 10.4022/jafib.2466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 12/29/2020] [Accepted: 01/25/2021] [Indexed: 11/10/2022]
Abstract
Background Head-to-head comparative data for the postoperative care of patients undergoing left atrial ablation procedures are lacking. Objective We sought to investigate complication and readmission rates between patients undergoing same-day (SD) or next-day (ND) discharges for ablative procedures in the left atrium, primarily atrial fibrillation (AF). Methods Two electrophysiology centers simultaneously perform left atrial ablations with differing discharge strategies. We identified all patients who underwent left atrial ablation from August 2017 to August 2019 (n = 409) undergoing either SD (n = 210) or ND (n = 199) discharge protocols. We analyzed any clinical events that resulted in procedural abortion, extended hospitalization, or readmission within 72 hours. Results The primary endpoint of complication and readmission rate was similar between SD and ND discharge (14.3% vs 12.6%, p = 0.665). Rates of complications categorized as major (2.4% vs 3.0%, p = 0. 776) and minor (11.9% vs 9.5%, p = 0.524) were also similar.Multivariable regression modeling revealed no significant correlation between discharge strategy and complication/readmission occurrence (OR 1.565 [0.754 - 3.248], p = 0.23), but a positive association of hypertension and procedure duration (OR 3.428 [1.436 - 8.184], p = 0.006) and (OR 1.01 [1 - 1.019], p = 0.046) respectively. Conclusions Left atrial ablation complication and readmission rates were similar between SD and ND discharge practices. Hypertension and procedural duration were associated with increased complication rates irrespective of discharge strategy. These data, which represent the first side-by-side comparison of discharge strategy, suggests same-day discharge is safe and feasible for left atrial ablation procedures.
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9
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Lin PL, Chiou WR, Su MI, Huang CC, Liao FC, Liu LYM, Chuang JY, Chen CY, Tsai CT, Kuo JY, Yang TF, Wu YJ, Lee YH. Exploratory Evaluation of Rhythm Control by Dronedarone in Combination With Low-Dose Rivaroxaban, Warfarin, Antiplatelet, or None of the Antithrombotic Therapy in High-Risk Patients With Non-Permanent Atrial Fibrillation: A Retrospective Cohort Study. Clin Appl Thromb Hemost 2021; 27:10760296211052968. [PMID: 34894780 PMCID: PMC8671665 DOI: 10.1177/10760296211052968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The emerging data supports rhythm control to prevent major adverse cardiac events (MACE) in high-risk patients with atrial fibrillation (AF). Limited data demonstrated rivaroxaban 10 mg combining dronedarone seemed feasible. This study aimed at investigating clinical events in a dronedarone-treated cohort. This exploratory, retrospective chart review was conducted in nonpermanent AF patients receiving dronedarone for ≥ 3 months between 2009/1 and 2016/2. In Taiwan, dronedarone's labeled indication was strict to age ≥ 70 or 65 to 70 years with either hypertension, diabetes, prior stroke, or left atrium >50 mm. We divided all into 4 groups using antithrombotic strategies to evaluate the safety, effectiveness, and MACE endpoints. A total of 689 patients (mean CHA2DS2-VASc score 3.8 ± 1.4) were analyzed: rivaroxaban 10 mg (n = 93, 13.5%), warfarin (n = 89, 12.9%), antiplatelet (n = 331, 48.0%), and none (n = 176, 25.5%). During the follow-up period (mean 946 ± 493.8 days), the rivaroxaban group did not report any stroke or thromboembolism (ishcmeic stroke rate: antiplatelet [0.6%], none [1.1%]; hemorrahgic stroke rate: warfarin [2.2%]; thromboembolism rate: warfarin [2.2%]). There was no significant difference in safety, effectiveness, and MACE endpoints between groups. Also, >104 weeks of dronedarone use was the independent predictor for MACE after adjusting the strategy and other covariates (hazard ratio 0.14 [95% confidence interval 0.04-0.44], P = .001). Our findings warrant concomitant rivaroxaban 10 mg and dronedarone for further investigation. Regardless of antithrombotic strategies, a more extended persistence of dronedarone was associated with fewer MACE.
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Affiliation(s)
- Po-Lin Lin
- 156934Hsinchu MacKay Memorial Hospital, Hsinchu, Taiwan.,210861National Yang Ming Chiao Tung University, Hsinchu, Taiwan
| | - Wei-Ru Chiou
- 117127Taitung MacKay Memorial Hospital, Taitung, Taiwan.,145474MacKay Medical College, New Taipei, Taiwan
| | - Min-I Su
- 117127Taitung MacKay Memorial Hospital, Taitung, Taiwan
| | | | - Feng-Ching Liao
- 145474MacKay Medical College, New Taipei, Taiwan.,36897MacKay Memorial Hospital, Taipei, Taiwan
| | - Lawrence Yu-Min Liu
- 156934Hsinchu MacKay Memorial Hospital, Hsinchu, Taiwan.,145474MacKay Medical College, New Taipei, Taiwan
| | | | - Chun-Yen Chen
- 145474MacKay Medical College, New Taipei, Taiwan.,36897MacKay Memorial Hospital, Taipei, Taiwan
| | - Cheng-Ting Tsai
- 145474MacKay Medical College, New Taipei, Taiwan.,36897MacKay Memorial Hospital, Taipei, Taiwan.,36897MacKay Junior College of Medicine, Nursing, and Management, Taipei, Taiwan
| | - Jen-Yuan Kuo
- 145474MacKay Medical College, New Taipei, Taiwan.,36897MacKay Memorial Hospital, Taipei, Taiwan
| | - Ten-Fang Yang
- 210861National Yang Ming Chiao Tung University, Hsinchu, Taiwan.,Taipei Medical University and Hospital, 63474Taipei, Taiwan
| | - Yih-Jer Wu
- 145474MacKay Medical College, New Taipei, Taiwan.,36897MacKay Memorial Hospital, Taipei, Taiwan
| | - Ying-Hsiang Lee
- 145474MacKay Medical College, New Taipei, Taiwan.,36897MacKay Memorial Hospital, Taipei, Taiwan.,36897MacKay Junior College of Medicine, Nursing, and Management, Taipei, Taiwan
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Ortigosa N, Ayala G, Cano Ó. Variation of P-wave indices in paroxysmal atrial fibrillation patients before and after catheter ablation. Biomed Signal Process Control 2021. [DOI: 10.1016/j.bspc.2021.102500] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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11
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Brown SM, Larsen NK, Thankam FG, Agrawal DK. Fetal cardiomyocyte phenotype, ketone body metabolism, and mitochondrial dysfunction in the pathology of atrial fibrillation. Mol Cell Biochem 2020; 476:1165-1178. [PMID: 33188453 DOI: 10.1007/s11010-020-03980-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 11/06/2020] [Indexed: 10/23/2022]
Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia diagnosed in clinical practice. Even though hypertension, congestive heart failure, pulmonary disease, and coronary artery disease are the potential risk factors for AF, the underlying molecular pathology is largely unknown. The reversion of the mature cardiomyocytes to fetal phenotype, impaired ketone body metabolism, mitochondrial dysfunction, and the cellular effect of reactive oxygen species (ROS) are the major underlying biochemical events associated with the molecular pathology of AF. On this background, the present manuscript sheds light into these biochemical events in regard to the metabolic derangements in cardiomyocyte leading to AF, especially with respect to structural, contractile, and electrophysiological properties. In addition, the article critically reviews the current understanding, potential demerits, and translational strategies in the management of AF.
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Affiliation(s)
- Sean M Brown
- Creighton University School of Medicine, Omaha, NE, 68178, USA
| | | | - Finosh G Thankam
- Department of Translational Research, Western University of Health Sciences, 309 E. Second Street, Pomona, CA, 91766, USA
| | - Devendra K Agrawal
- Department of Translational Research, Western University of Health Sciences, 309 E. Second Street, Pomona, CA, 91766, USA.
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12
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Lévy S, Santini L, Cappato R, Steinbeck G, Capucci A, Saksena S. Clinical classification and the subclinical atrial fibrillation challenge: a position paper of the European Cardiac Arrhythmia Society. J Interv Card Electrophysiol 2020; 59:495-507. [PMID: 33048302 DOI: 10.1007/s10840-020-00859-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 08/26/2020] [Indexed: 12/19/2022]
Abstract
Symptomatic atrial fibrillation (AF) or clinical AF is associated with impaired quality of life, higher risk of stroke, heart failure, and increased mortality. Current clinical classification of AF is based on the duration of AF episodes and the recurrence over time. Appropriate management strategy should follow guidelines of Scientific Societies. The last decades have been marked by the advances in mechanism comprehension, better management of symptomatic AF, particularly regarding stroke prevention with the use of direct oral anticoagulants and a wider use of AF catheter or surgical ablations. The advent of new tools for detection of asymptomatic AF including continuous monitoring with implanted electronic devices and the use of implantable cardiac monitors and recently wearable devices or garments have identified what is called "subclinical AF" encompassing atrial high-rate episodes (AHREs). New concepts such as "AF burden" have resulted in new management challenges. Oral anticoagulation has proven to reduce substantially stroke risk in patients with symptomatic clinical AF but carries the risk of bleeding. Management of detected asymptomatic atrial arrhythmias and their relation to clinical AF and stroke risk is currently under evaluation. Based on a review of recent literature, the validity of current clinical classification has been reassessed and appropriate updates are proposed. Current evidence supporting the inclusion of subclinical AF within current clinical classification is discussed as well as the need for controlled trials which may provide responses to current therapeutic challenges particularly regarding the subsets of asymptomatic AF patients that might benefit from oral anticoagulation.
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Affiliation(s)
- Samuel Lévy
- Marseille School of Medicine, Aix-Marseille University, Marseille, France.
| | - Luca Santini
- Cardiology Division, G. B. Grassi Hospital, Via G. Passeroni 28, Ostia Lido, RM, Italy
| | - Riccardo Cappato
- Arrhythmia and Elecrtrophysiology Center, IRCCS-MultiMedica Group, Via Milanese 300, 20099, Milan, Sesto San Giovanni, Italy
| | | | - Alessandro Capucci
- Department of Cardiology, Università Politecnica delle Marche, Ancona, Italy
| | - Sanjeev Saksena
- Rutgers-Robert Wood Johnson Medical School, Piscataway, NJ, USA
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Martins GL, Duarte RCF, Vieira ÉLM, Rocha NP, Figueiredo EL, Silveira FR, Caiaffa JRS, Lanna RP, Carvalho MDG, Palotás A, Ferreira CN, Reis HJ. Comparison of Inflammatory Mediators in Patients With Atrial Fibrillation Using Warfarin or Rivaroxaban. Front Cardiovasc Med 2020; 7:114. [PMID: 32793635 PMCID: PMC7393940 DOI: 10.3389/fcvm.2020.00114] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 06/02/2020] [Indexed: 01/03/2023] Open
Abstract
Background: Atrial fibrillation (AF) is the most common arrhythmia associated with high risk of venous thromboembolism. Inflammatory mechanisms may be involved in the pathophysiology of AF and in the AF-related thrombogenesis, and patients with AF might benefit from the use of anticoagulants with anti-inflammatory properties. However, the evidence is still scarce, and it points out the need of trials seeking to investigate the levels of inflammatory mediators in patients with AF under different anticoagulant therapies. Therefore, this study was designed to define whether patients with AF treated either with an activated coagulation factor X (FXa) inhibitor (rivaroxaban) or with a vitamin K inhibitor (warfarin) present changes in peripheral levels of inflammatory mediators, mainly cytokines and chemokines. Methods: A total of 127 subjects were included in this study, divided into three groups: patients with non-valvular atrial fibrillation (NVAF) using warfarin (N = 42), patients with NVAF using rivaroxaban (N = 29), and controls (N = 56). Plasma levels of inflammatory mediators were quantified by immunoassays. Results: Patients with AF (both warfarin and rivaroxaban groups) presented increased levels of inflammatory cytokines in comparison with controls. The use of rivaroxaban was associated with decreased levels of inflammatory cytokines in comparison with warfarin. On the other hand, patients with AF using rivaroxaban presented increased levels of the chemokines (MCP-1 in comparison with warfarin users; MIG and IP-10 in comparison with controls). Conclusions: AF is associated with an inflammatory profile that was less pronounced in patients on rivaroxaban in comparison with warfarin users. Further studies are necessary to assess the clinical implications of our results and whether patients with AF would benefit from rivaroxaban anti-inflammatory effects.
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Affiliation(s)
- Gabriela Lopes Martins
- Neurofar Laboratory, Departamento de Farmacologia, ICB, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | | | - Érica Leandro Marciano Vieira
- Neurofar Laboratory, Departamento de Farmacologia, ICB, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Natalia Pessoa Rocha
- Department of Neurology, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | | | | | | | | | - Maria das Graças Carvalho
- Neurofar Laboratory, Departamento de Farmacologia, ICB, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - András Palotás
- Asklepios-Med, Szeged, Hungary
- Kazan Federal University, Kazan, Russia
| | - Cláudia Natália Ferreira
- Neurofar Laboratory, Departamento de Farmacologia, ICB, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Helton José Reis
- Neurofar Laboratory, Departamento de Farmacologia, ICB, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
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Acharya D, Rane S, Bohora S, Kevadiya H. Incidence, clinical, electrophysiological characteristics and outcomes of patients with Wolff-Parkinson-White syndrome and atrial fibrillation. Indian Pacing Electrophysiol J 2020; 20:3-7. [PMID: 31945418 PMCID: PMC6994406 DOI: 10.1016/j.ipej.2019.12.015] [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: 08/29/2019] [Revised: 12/17/2019] [Accepted: 12/21/2019] [Indexed: 10/27/2022] Open
Abstract
AIMS AND OBJECTIVES Atrial fibrillation (AF) with preexcitation can be life threatening. Our study evaluated the incidence, clinical features, electrophysiologic characteristics and outcomes of patients presenting with AF and fast ventricular rates associated with an antegrade conducting accessory pathway. METHODS Hospital data of patients who had undergone electrophysiology study and radiofrequency ablation for AF and Wolff-Parkinson-White (WPW) syndrome was retrospectively evaluated over 10 years and prospective data was further collected over 1 year. Out of 2876 patients undergoing electrophysiology study, 320 patients had manifest preexcitation on ECG. Forty one patients who had presented with AF and fast ventricular rates were included in the study. RESULTS Forty one (12.8%) patients out of 320 patients of WPW syndrome patients presented with AF and fast ventricular rates. Mean age of presentation was 38.5 ± 12.3 yrs. Twenty nine (72.5%) were male. Most common presenting features were palpitations, presyncope and syncope. Twenty eight (71.1%) patients were electrically cardioverted on presentation, of which two patients having narrow complex tachycardia, when given adenosine, developed AF and fast ventricular rates and had to be electrically cardioverted. Intravenous amiodarone converted AF to sinus rhythm in 11 (28.9%) patients. Right postero-septal pathway (33.3%) followed by coronary sinus epicardial pathway (22.9%) were the most commonly located pathways associated with AF. Five (12.2%) patients had multiple pathways. CS diverticulum was seen in 6 (14.7%) patients. Ablation was done during AF in 6 (14.7%) patients. All except one had immediate successful ablation. One patient had a recurrence of preexcitation on follow up and successfully ablated during redo procedure. CONCLUSION AF with WPW syndrome is not uncommon. AF is commonly associated with posteriorly located accessory pathways, CS diverticulum and multiple pathways. Radiofrequency ablation has good outcomes.
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Affiliation(s)
- Debasis Acharya
- U N Mehta Institute of Cardiology and Research Centre, Asarwa, Ahmedabad, India.
| | - Sameer Rane
- U N Mehta Institute of Cardiology and Research Centre, Asarwa, Ahmedabad, India.
| | - Shomu Bohora
- U N Mehta Institute of Cardiology and Research Centre, Asarwa, Ahmedabad, India.
| | - Hiren Kevadiya
- U N Mehta Institute of Cardiology and Research Centre, Asarwa, Ahmedabad, India.
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Zhang Y, Du W, Yang B. Long non-coding RNAs as new regulators of cardiac electrophysiology and arrhythmias: Molecular mechanisms, therapeutic implications and challenges. Pharmacol Ther 2019; 203:107389. [DOI: 10.1016/j.pharmthera.2019.06.011] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 06/27/2019] [Indexed: 12/21/2022]
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Kanametov TN, Shvartz VA, Oltarzhevskaya ND, Bockeria OL. Effect of epicardial application of amiodarone-releasing hydrogel on heart rate in an animal model. Cardiovasc Diagn Ther 2019; 9:328-336. [PMID: 31555537 PMCID: PMC6732076 DOI: 10.21037/cdt.2019.04.01] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 03/26/2019] [Indexed: 11/06/2022]
Abstract
BACKGROUND The purpose of the experiment was to study the safety of local epicardial use of the hydrogel with amiodarone, as well as the influence of its different dosages on the heart rate of mongrel rabbits. METHODS The epicardial application of the hydrogel material with amiodarone was performed in 46 rabbits. Rabbits were divided into 5 groups: Group No. 1-dose of amiodarone in the hydrogel 1 mg, Group No. 2-dose 3 mg; Group No. 3-dose 6 mg; Group No. 4-hydrogel without amiodarone; Group No. 5-amiodarone intravenously, 60 mg. RESULTS The application of hydrogel with amiodarone is not accompanied by a systemic inflammatory reaction. In group No. 2, there was a significant reduction in the heart rate (before surgery: 158±16, after: 130±11, (P<0,001), without any disturbances to the conduction system of the heart functioning. With an increase in amiodarone concentration (Group No. 3), significant atrial and atrioventricular (AV) conduction defects (up to 70%) were noted; when the dosage of amiodarone (Group No. 1) was reduced, there was no influence on the heart rate reduction. The hydrogel without amiodarone has no effect on the conductive system. CONCLUSIONS The method of local epicardial delivery of amiodarone in the form of a hydrogel material is safe. The hydrogel with amiodarone is effective for the heart rate reduction (according to the experiment on animals), compared to the control group and the group with intravenous drug administration. The optimal dosage of amiodarone in the hydrogel is 3 mg.
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Affiliation(s)
- Teymuraz N Kanametov
- Bakulev National Medical Research Center for Cardiovascular Surgery, Moscow, Russia
| | - Vladimir A Shvartz
- Bakulev National Medical Research Center for Cardiovascular Surgery, Moscow, Russia
| | | | - Olga L Bockeria
- Bakulev National Medical Research Center for Cardiovascular Surgery, Moscow, Russia
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Epicardial Application of Hydrogel with Amiodarone for Prevention of Postoperative Atrial Fibrillation in Patients After Coronary Artery Bypass Grafting. J Cardiovasc Transl Res 2019; 13:191-198. [PMID: 31367901 DOI: 10.1007/s12265-019-09905-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Accepted: 07/25/2019] [Indexed: 02/01/2023]
Abstract
The objective of this study was to assess the safety and efficacy of local epicardial application of amiodarone-releasing hydrogel for prevention of postoperative atrial fibrillation (POAF) in patients after coronary artery bypass grafting. Patients were randomized into two groups: with the application of amiodarone-releasing hydrogel and the control group. It included 60 patients (47 males, 13 females) (mean age of 62 ± 8.5). POAF incidence differences were statistically significant between two groups: in the study group, the POAF incidence was 3.3%, while in the control group, the POAF incidence was 37% (p < 0.001). Statistically significant differences were revealed in the PQ interval duration. The risk of POAF incidence was calculated using the Cox regression model: the age and the application of amiodarone-releasing hydrogel application were statistically significant. Hospital length of stay in two groups was also different (р < 0.001). The age and the application of amiodarone-releasing hydrogel were statistically significant for POAF incidence.
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Daci A, Bozalija A, Cavolli R, Alaj R, Beretta G, Krasniqi S. Pharmacotherapy Evaluation and Utilization in Coronary Artery Bypass Grafting Patients in Kosovo during the Period 2016-2017. Open Access Maced J Med Sci 2018; 6:498-505. [PMID: 29610608 PMCID: PMC5874373 DOI: 10.3889/oamjms.2018.132] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 02/15/2018] [Accepted: 02/17/2018] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND: Coronary Artery Bypass Grafting (CABG) is realised in patients with critical or advanced disease of coronary arteries. There are different pharmacotherapeutic approaches which are used as management, treatment and preventive therapy in cardiovascular disease or related comorbidities. Performing a successful surgery, pharmacotherapy, and increase of bypass patency rate remains a serious challenge. AIM: This study aims to analyse the patient characteristics undergoing CABG and evaluation of their drug utilisation rate and daily dosages in the perioperative period. MATERIAL AND METHODS: Data were collected from 102 patients in the period 2016-2017 and detailed therapeutic prescription and dosages, patient characteristics were analysed before the operation, after the operation and visit after operation in the Clinic of Cardiac surgery-University Clinical Center of Kosovo. RESULTS: Our findings had shown that patients provided to have normal biochemical parameters in the clinic before the operation, and were related to cardiovascular diseases and comorbidities and risk factors with mainly elective intervention. The, however, higher utilisation of cardiovascular drugs such as beta blockers, diuretics, anticoagulants, statins and lower calcium blockers, ACEi, ARBs, hydrochlorothiazide, amiodarone were founded. ARBs, beta blockers, statins, nitrates and nadroparin utilisation decreased after operation and visit after the operation, whereas amiodarone only in the visit after the operation. Diuretics are increased after the operation which decreases in the visit after the operation. Regarding the daily dosage, only metoprolol was increased in the visit after operation (P < 0.001) and visit after operation (P < 0.05) whereas losartan and furosemide were increased (P < 0.01) and (P < 0.05) respectively. CONCLUSION: The study showed that beta blockers, statins, aspirin, nitrates (before the operation), furosemide and spironolactone are the most utilised drugs. However, we found low utilisation rate for ACEi, ARBs, clopidogrel, nadroparin, warfarin, xanthines, amiodarone, calcium blockers. Daily dosages were different compared to before CABG only in metoprolol, losartan, and furosemide.
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Affiliation(s)
- Armond Daci
- Department of Pharmacy, Faculty of Medicine, University of Prishtina, Prishtina, Kosovo
| | - Adnan Bozalija
- Department of Pharmacy, Faculty of Medicine, University of Prishtina, Prishtina, Kosovo
| | - Raif Cavolli
- Cardiovascular Surgery Clinic, University Clinical Center of Kosovo, Prishtina, Kosovo
| | - Rame Alaj
- Cardiovascular Surgery Clinic, University Clinical Center of Kosovo, Prishtina, Kosovo
| | - Giangiacomo Beretta
- Department of Pharmaceutical Sciences, Università degli Studi di Milano, Milan, Italy
| | - Shaip Krasniqi
- Department of Pharmacology, Faculty of Medicine, University of Prishtina, Prishtina, Kosovo
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Yoshida Y, Watarai M, Fujii K, Shimizu W, Satomi K, Inden Y, Murakami Y, Murakami M, Iwasa A, Kimura M, Yamada N, Nakagawa T, Nordaby M, Okumura K. Comparison of uninterrupted anticoagulation with dabigatran etexilate or warfarin in the periprocedural period for atrial fibrillation catheter ablation: Results of the Japanese subgroup of the RE-CIRCUIT trial. J Arrhythm 2018; 34:148-157. [PMID: 29657590 PMCID: PMC5891433 DOI: 10.1002/joa3.12024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 11/20/2017] [Indexed: 01/10/2023] Open
Abstract
Background There are limited data on uninterrupted anticoagulation with direct oral anticoagulants during catheter ablation for atrial fibrillation (AF), particularly in Japan. We planned a subgroup analysis of the RE-CIRCUIT study, comparing the use of uninterrupted dabigatran therapy with warfarin therapy during catheter ablation among the Japanese subgroup and with that in the total population. Methods The RE-CIRCUIT study utilized a prospective, randomized, open-label, blinded endpoint design, and the primary endpoint was the incidence of major bleeding events (MBEs). Patients were randomized to uninterrupted dabigatran 150 mg twice daily or warfarin. In this study, we analyzed the results in Japanese patients. Results Of 704 enrolled patients in the study, 112 Japanese patients were randomized to dabigatran (n = 65) or warfarin (n = 47). MBEs were experienced by two patients: one in the dabigatran group (1.6%, cardiac tamponade) and one in the warfarin group (2.2%, groin hematoma) (risk difference vs warfarin -0.6%; 95% CI -5.8, 4.7). Within the Japanese subgroup, there were no thromboembolic events in both groups. Conclusion While not designed to show statistical difference between two treatment groups, our results from the Japanese subgroup supported those from the overall population. Furthermore, this study provided clinical information regarding MBE, especially cardiac tamponade, in Japanese patients.
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Affiliation(s)
- Yukihiko Yoshida
- Department of Cardiology Japanese Red Cross Nagoya Daini Hospital Nagoya Aichi Japan
| | - Masato Watarai
- Department of Cardiology Aichi Prefectural Welfare Federation of Agricultural Co-operative Associations Anjo-kosei Hospital Anjo Aichi Japan
| | - Kenshi Fujii
- Cardiovascular Division Sakurabashi Watanabe Hospital Osaka Japan
| | - Wataru Shimizu
- Department of Cardiovascular Medicine Nippon Medical School Hospital Bunkyo-ku Tokyo Japan
| | - Kazuhiro Satomi
- Department of Cardiology Tokyo Medical University Shinjyuku-ku Tokyo Japan
| | - Yasuya Inden
- Department of Cardiology Nagoya University Hospital Nagoya Aichi Japan
| | - Yoshimasa Murakami
- Division of Cardiology Nagoya City East Medical Center Nagoya Aichi Japan
| | - Masato Murakami
- Department of Cardiology Shonan Kamakura General Hospital Kamakura Kanagawa Japan
| | - Atsushi Iwasa
- Department of Cardiology New Tokyo Hospital Matsudo Chiba Japan
| | - Masaomi Kimura
- Department of Cardiology and Nephrology Hirosaki University Hospital Hirosaki Aomori Japan
| | - Nobuko Yamada
- Nippon Boehringer Ingelheim Co., Ltd. Shinagawa-ku Tokyo Japan
| | | | - Matias Nordaby
- Boehringer Ingelheim Pharma GmbH & Co. K GIngelheim am Rhein Germany
| | - Ken Okumura
- Division of Cardiology Saiseikai Kumamoto Hospital Kumamoto Japan
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Ademi Z, Pasupathi K, Liew D. Clinical and Cost Effectiveness of Apixaban Compared to Aspirin in Patients with Atrial Fibrillation: An Australian Perspective. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2017; 15:363-374. [PMID: 27699648 DOI: 10.1007/s40258-016-0283-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To determine the clinical and cost effectiveness of apixaban compared to aspirin in the prevention of thromboembolic events for patients with atrial fibrillation for whom vitamin K antagonist (VKA) therapy (warfarin) has been considered unsuitable. METHODS A previously published Markov model with yearly cycles was updated. Information from the Apixaban Versus Acetylsalicylic acid to prevent Stroke in Atrial Fibrillation (AVERROES) trial in combination with other population data was used to simulate the costs and effects of apixaban compared to aspirin over 10 years. The model comprised five health states. Costs from an Australian healthcare perspective were estimated from published sources for the year 2015. The main outcome of interest was number needed to treat (NNT), number needed to harm (NNH), the incremental cost-effectiveness ratio (ICER) [cost per quality-adjusted life-year (QALY) gained, and cost per year of life saved (YoLS)]. Costs and benefits were discounted at 5.0 % per annum. RESULTS For each patient followed up over 10 years, NNT to prevent one additional event (thromboembolic event, death) for apixaban compared to aspirin was 4.6 and 11.8, respectively. NNH was 35.9 for non-fatal major bleeding. The model predicted that compared to aspirin, apixaban would lead to 0.33 YoLS (discounted) and 0.29 QALYs gained (discounted), at an incremental cost of AUD$1996 (discounted). This resulted in ICERs of AUD$6011 per YoLS and AUD$6929 per QALY gained. In the sensitivity analyses, ICERs were most sensitive to efficacy measures derived from the AVERROES study, and time frame. CONCLUSION Compared to aspirin, apixaban is likely to be cost effective in preventing thromboembolic disease among VKA unsuitable patients with atrial fibrillation.
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Affiliation(s)
- Zanfina Ademi
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia.
- Institute of Pharmaceutical Medicine (ECPM), University of Basel, Klingelbergstrasse 61, 4056, Basel, Switzerland.
| | | | - Danny Liew
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
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Abstract
Big Data may be useful to identify and perhaps ameliorate health disparities. However, over reliance on the power on Big Data can potentially cause harm. When assessing health disparities, the use of Big Data should be limited to hypothesis generation.
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Schirdewan A, Herm J, Roser M, Landmesser U, Endres M, Koch L, Haeusler KG. Loop Recorder Detected High Rate of Atrial Fibrillation Recurrence after a Single Balloon- or Basket-Based Ablation of Paroxysmal Atrial Fibrillation: Results of the MACPAF Study. Front Cardiovasc Med 2017; 4:4. [PMID: 28243592 PMCID: PMC5303896 DOI: 10.3389/fcvm.2017.00004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Accepted: 01/18/2017] [Indexed: 11/28/2022] Open
Abstract
Purpose Pulmonary vein isolation (PVI) is an established approach to treat symptomatic non-permanent atrial fibrillation (AF). Detecting AF recurrence after PVI is important, if discontinuation of oral anticoagulation after ablation is considered. Methods Patients with symptomatic paroxysmal AF were enrolled in the prospective randomized mesh ablator vs. cryoballoon pulmonary vein (PV) ablation of symptomatic paroxysmal AF study, comparing efficacy and safety of the HD Mesh Ablator® (C.R. Bard, Lowell, MA, USA) and the Arctic Front® (Medtronic, Minneapolis, MN, USA) catheter. Rhythm status post-PVI was closely monitored for 1 year using the implantable loop recorder (ILR) Reveal XT® (Medtronic Minneapolis, MN, USA). Results The study was terminated after the first interim analysis due to the inability of the HD Mesh Ablator® to achieve the predefined primary study endpoint, an exit block of all PVs. After a 90-day blanking period, 23 (62.2%) out of 37 study patients (median 63.0 years; 41% females) had at least one episode of AF. AF recurrence was associated with AF episodes during the blanking period {hazard ratios (HR) 5.10 [95% confidence interval (CI) 1.21–21.4]; p = 0.038}, and a common left-sided PV ostium [HR 4.17 (95%CI 1.48–11.8); p = 0.039] but not with catheter type, age, gender, cardiovascular risk profile, or left atrial volume. There was a trend toward AF recurrence in patients without complete PVI of all PV (p = 0.095). Overall, 337 (59.4%) out of 566 ILR-detected episodes represented AF. Comparing patients with AF recurrence to those without, there was no difference in cognitive performance 6 months post-ablation. Conclusion Using an ILR, in more than 60% of all patients with paroxysmal AF, a recurrence of AF was detected within 12 months after ablation. In patients with a common PV ostium, the first generation balloon-based catheter is obviously less effective. Clinical trials http://Clinicaltrials.gov NCT01061931.
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Affiliation(s)
| | - Juliane Herm
- Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany; Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Mattias Roser
- Department of Cardiology and Pneumology, Charité - Universitätsmedizin Berlin , Berlin , Germany
| | - Ulf Landmesser
- Department of Cardiology and Pneumology, Charité - Universitätsmedizin Berlin , Berlin , Germany
| | - Matthias Endres
- Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany; Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany; German Center for Neurodegenerative Diseases (DZNE), Partner Site, Berlin, Germany; German Center for Cardiovascular Diseases (DZHK), Partner Site, Berlin, Germany
| | - Lydia Koch
- Department of Cardiology, Sana Clinic Lichtenberg , Berlin , Germany
| | - Karl Georg Haeusler
- Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany; Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
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Ortigosa N, Galbis A, Fernández C, Cano Ó. Gabor frames for classification of paroxysmal and persistent atrial fibrillation episodes. Med Eng Phys 2016; 39:31-37. [PMID: 27863910 DOI: 10.1016/j.medengphy.2016.10.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Revised: 10/10/2016] [Accepted: 10/23/2016] [Indexed: 11/26/2022]
Abstract
In this study, we propose a new classification method for early differentiation of paroxysmal and persistent atrial fibrillation episodes, i.e. those which spontaneously or with external intervention will return to sinus rhythm within 7 days of onset from the ones where the arrhythmia is sustained for more than 7 days. Today, clinicians provide patients classification once the course of the arrhythmia has been disclosed. This classification problem is dealt with in this study. We study a sparse representation of surface electrocardiogram signals by means of Gabor frames and afterwards we apply a linear discriminant analysis. Thus, we provide an early discrimination, obtaining promising performances on a heterogeneous cohort of patients in terms of pharmacological treatment and state of progression of the arrhythmia: 95% sensitivity, 82% specificity, 89% accuracy. In this manner, the proposed method can help clinicians to choose the most appropriate treatment using the electrocardiogram, which is a widely available and non-invasive technique. This early differentiation is clinically highly significant in order to choose optimal patients who may undergo catheter ablation with higher success rates.
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Affiliation(s)
- Nuria Ortigosa
- I.U. Matemática Pura y Aplicada, Universitat Politècnica de València, Camino de Vera s/n, 46022 Valencia, Spain.
| | - Antonio Galbis
- Departament d'Anàlisi Matemàtica, Universitat de València, E-46100 Burjassot, Spain.
| | - Carmen Fernández
- Departament d'Anàlisi Matemàtica, Universitat de València, E-46100 Burjassot, Spain.
| | - Óscar Cano
- Instituto de Investigación Sanitaria La Fe, Hospital Universitari i Politècnic La Fe Servicio de Cardiología, Planta 4-Torre F. Av. Fernando Abril Martorell no 106, 46026 Valencia, Spain.
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Steinberg BA, Shrader P, Kim S, Thomas L, Fonarow GC, Ansell J, Kowey PR, Singer DE, Gersh BJ, Mahaffey KW, Peterson ED, Piccini JP. How well does physician risk assessment predict stroke and bleeding in atrial fibrillation? Results from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF). Am Heart J 2016; 181:145-152. [PMID: 27823686 DOI: 10.1016/j.ahj.2016.07.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Accepted: 07/22/2016] [Indexed: 02/01/2023]
Abstract
BACKGROUND Assessments of stroke and bleeding risks are essential to selecting oral anticoagulation in patients with atrial fibrillation (AF). We aimed to assess outcomes according to physician assessed risk, with comparison to empirical risk scores. METHODS This was a prospective, observational study of 9,715 outpatients with AF enrolled in ORBIT-AF, a US national registry. Stroke and bleeding risks were quantified by physician assignment, CHADS2 and CHA2DS2-VASc stroke scores, and ATRIA and HAS-BLED bleeding scores. Outcomes were stroke or systemic embolism and major bleeding during a median follow-up of 28 months. RESULTS Physician-assigned risk was associated with thromboembolic events: low risk (0.71 per 100 patient-years [95% CI 0.56-0.91], n=3,991), intermediate risk (0.98 [95% CI 0.79-1.20], n=4,148), and high risk (1.84 [95% CI 1.43-2.37], n=1,576, P<.0001), and major bleeding: low (3.43 [95% CI 3.07-3.82], n=4,250), intermediate (4.55 [95% CI 4.03-5.15], n=2,702), and high (5.76 [95% CI 4.42-7.50], n=468; P<.0001). Discrimination of stroke risk was similar with CHADS2 (c=0.59, 95% CI 0.57-0.61) vs physician assessment (c=0.58, 95% CI 0.55-0.62). Among patients on oral anticoagulation, bleeding risk discrimination was higher with ATRIA (c=0.63, 95% CI 0.61-0.65) and HAS-BLED (c=0.60, 95% CI 0.59-0.62) than with physician assessment (0.55, 95% CI 0.53-0.57). Physician-assessed risk categories did not add significantly to empirical risk scores, in Cox models for outcomes (Padjusted>.05 for all physician assessments vs Padjusted<.05 for empirical scores). CONCLUSION Physician-assigned risk showed a graded relationship with outcomes, and both physician-based and empirical scores yielded only moderate discrimination. Although empirical scores provided valuable risk stratification information (with or without physician judgment), physician assessment added little to existing scores. These data support the use of empirical scores for stroke and bleeding risk stratification, and the need for novel approaches to risk stratification in this population.
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Wang RX, Lee HC, Li JP, Hodge DO, Cha YM, Friedman PA, Munger TM, Srivathsan K, Pavri BB, Shen WK. Sudden death and its risk factors after atrioventricular junction ablation and pacemaker implantation in patients with atrial fibrillation. Clin Cardiol 2016; 40:18-25. [PMID: 27748530 DOI: 10.1002/clc.22600] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2016] [Revised: 08/25/2016] [Accepted: 08/31/2016] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Although sudden death (SD) is a rare complication after atrioventricular junction (AVJ) ablation and permanent pacemaker implantation, the risk factors leading to this SD remain unknown. The purpose of this study was to investigate SD and its risk factors after ablate-and-pace strategy for rate control in atrial fibrillation (AF) patients during long-term follow-up. HYPOTHESIS METHODS: From January 2005 to December 2009, we enrolled into this study 517 AF patients with AVJ ablation and right ventricular pacemaker implantation. Patients were divided into 2 groups, SD and non-SD. Cox proportional hazards models were used to assess potential risk factors for overall mortality and SD. RESULTS During a mean follow-up of 25.8 ± 18.6 months (range, 3 days to 63.8 months), 53 patients died (15 with SD). Cox proportional hazards models showed that the presence of congestive heart failure, New York Heart Association functional class, chronic renal failure, and nonsustained ventricular tachycardia were risk factors that predicted overall mortality. For SD, the presence of dilated cardiomyopathy and mitral stenosis were associated risk factors. SD was exclusively seen in patients who had narrow QRS complex or right bundle branch block prior to AVJ ablation and pacemaker implantation; SD was not seen in any patient with preexisting complete left bundle branch block. CONCLUSIONS Dilated cardiomyopathy, mitral stenosis, and baseline QRS morphology should be examined as potential risk factors for SD after AVJ ablation and pacemaker implantation.
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Affiliation(s)
- Ru-Xing Wang
- Department of Cardiology, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi 214023, PR China
| | - Hon-Chi Lee
- Division of Cardiovascular Diseases, Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Jia-Ping Li
- Department of Cardiology, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi 214023, PR China
| | - David O Hodge
- Division of Cardiovascular Diseases, Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Yong-Mei Cha
- Division of Cardiovascular Diseases, Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Paul A Friedman
- Division of Cardiovascular Diseases, Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Thomas M Munger
- Division of Cardiovascular Diseases, Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | | | - Behzad B Pavri
- Division of Cardiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Win-Kuang Shen
- Division of Cardiovascular Diseases, Mayo Clinic, Scottsdale, Arizona
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26
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Addison D, Farhad H, Shah RV, Mayrhofer T, Abbasi SA, John RM, Michaud GF, Jerosch-Herold M, Hoffmann U, Stevenson WG, Kwong RY, Neilan TG. Effect of Late Gadolinium Enhancement on the Recovery of Left Ventricular Systolic Function After Pulmonary Vein Isolation. J Am Heart Assoc 2016; 5:e003570. [PMID: 27671316 PMCID: PMC5079022 DOI: 10.1161/jaha.116.003570] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 07/15/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND The factors that predict recovery of left ventricular (LV) systolic dysfunction among patients with atrial fibrillation (AF) are not completely understood. Late gadolinium enhancement (LGE) of the LV has been reported among patients with AF, and we aimed to test whether the presence LGE was associated with subsequent recovery of LV systolic function among patients with AF and LV dysfunction. METHODS AND RESULTS From a registry of 720 consecutive patients undergoing a cardiac magnetic resonance study prior to pulmonary vein isolation (PVI), patients with LV systolic dysfunction (ejection fraction [EF] <50%) were identified. The primary outcome was recovery of LVEF defined as an EF >50%; a secondary outcome was a combined outcome of subsequent heart failure (HF), admission, and death. Of 720 patients, 172 (24%) had an LVEF of <50% prior to PVI. The mean LVEF pre-PVI was 41±6% (median 43%, range 20% to 49%). Forty-three patients (25%) had LGE (25 [58%] ischemic), and the extent of LGE was 7.5±4% (2% to 19%). During follow-up (mean 42 months), 91 patients (53%) had recovery of LVEF, 68 (40%) had early recurrence of AF, 65 (38%) had late AF, 18 (5%) were admitted for HF, and 23 died (13%). Factors associated with nonrecovery of LVEF were older age, history of myocardial infarction, early AF recurrence, late AF recurrence, and LGE. In a multivariable model, the presence of LGE and any recurrence of AF had the strongest association with persistence of LV dysfunction. Additionally, all patients without recurrence of AF and LGE had normalization of LVEF, and recovery of LVEF was associated with reduced HF admissions and death. CONCLUSIONS In patients with AF and LV dysfunction undergoing PVI, the absence of LGE and AF recurrence are predictors of LVEF recovery and LVEF recovery in AF with associated reduction in subsequent death and heart failure.
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Affiliation(s)
- Daniel Addison
- Cardiac MR PET CT Program, Division of Radiology, Massachusetts General Hospital, Boston, MA
| | - Hoshang Farhad
- Non-Invasive Cardiovascular Imaging Program and the Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Ravi V Shah
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Thomas Mayrhofer
- Cardiac MR PET CT Program, Division of Radiology, Massachusetts General Hospital, Boston, MA
| | - Siddique A Abbasi
- Non-Invasive Cardiovascular Imaging Program and the Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Roy M John
- Non-Invasive Cardiovascular Imaging Program and the Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Gregory F Michaud
- Non-Invasive Cardiovascular Imaging Program and the Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Michael Jerosch-Herold
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Udo Hoffmann
- Cardiac MR PET CT Program, Division of Radiology, Massachusetts General Hospital, Boston, MA
| | - William G Stevenson
- Non-Invasive Cardiovascular Imaging Program and the Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Raymond Y Kwong
- Non-Invasive Cardiovascular Imaging Program and the Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Tomas G Neilan
- Cardiac MR PET CT Program, Division of Radiology, Massachusetts General Hospital, Boston, MA Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Chao TF, Liu CJ, Tuan TC, Wang KL, Lin YJ, Chang SL, Lo LW, Hu YF, Chen TJ, Chiang CE, Hsieh MH, Lip GYH, Chen SA. Impact on Outcomes of Changing Treatment Guideline Recommendations for Stroke Prevention in Atrial Fibrillation: A Nationwide Cohort Study. Mayo Clin Proc 2016; 91:567-74. [PMID: 27068667 DOI: 10.1016/j.mayocp.2016.03.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Revised: 02/18/2016] [Accepted: 03/07/2016] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To investigate the impact on outcomes of changing treatment guideline recommendations by comparing the proportion of patients with atrial fibrillation (AF) recommended oral anticoagulants (OACs) under the 2011 and 2014 American College of Cardiology/American Heart Association (ACC/AHA) guidelines. PATIENTS AND METHODS We used the "National Health Insurance Research Database" in Taiwan, which included 354,649 patients with AF from January 1, 1996 through December 31, 2011. Patients with a CHADS2 (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, and prior stroke or transient ischemic attack) score of 2 or more and a CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, prior stroke or transient ischemic attack, vascular disease, age 65-74 years, female sex category) score of 2 or more were considered to have a definitive indication for receiving OACs according to the 2011 and 2014 ACC/AHA guidelines, respectively. RESULTS The percentages of patients with AF recommended OACs increased from 69.3% (n=245,598) under the 2011 guideline to 86.7% (n=307,640) under the new 2014 guidelines, an increment of 17.5% (95% CI, 17.4-17.6). Most women with AF (94.1%) and patients older than 65 years (97.2%) would receive OACs on the basis of the 2014 guidelines. Among patients previously not being recommended OACs in older guidelines, OAC use under the new guidelines was associated with a lower risk of adverse outcomes (ischemic stroke or intracranial hemorrhage or bleeding requiring blood transfusion or mortality) with an adjusted hazard ratio of 0.89 (95% CI, 0.85-0.94). CONCLUSION In this nationwide cohort study, use of the 2014 guidelines led more patients with AF to receive OACs for stroke prevention, and this increased OAC use was associated with better outcomes. Better efforts to implement guidelines would lead to improved outcomes for patients with AF.
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Affiliation(s)
- Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Chia-Jen Liu
- Division of Hematology and Oncology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Public Health and School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Ta-Chuan Tuan
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Kang-Ling Wang
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan; General Clinical Research Center, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Medical Research and Education, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yenn-Jiang Lin
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Shih-Lin Chang
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Li-Wei Lo
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Yu-Feng Hu
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Tzeng-Ji Chen
- Department of Family Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chern-En Chiang
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan; General Clinical Research Center, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Medical Research and Education, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ming-Hsiung Hsieh
- Division of Cardiovascular Medicine, Department of Internal Medicine, Wan-Fang Hospital, and Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
| | - Gregory Y H Lip
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, UK
| | - Shih-Ann Chen
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
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Steinberg BA, Greiner MA, Hammill BG, Curtis LH, Benjamin EJ, Heckbert SR, Piccini JP. Contraindications to anticoagulation therapy and eligibility for novel anticoagulants in older patients with atrial fibrillation. Cardiovasc Ther 2016; 33:177-83. [PMID: 25930214 DOI: 10.1111/1755-5922.12129] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
AIMS Oral anticoagulation therapy prevents stroke and improves survival in patients with atrial fibrillation, but the therapy is underutilized. We sought to identify the prevalence of contraindications for oral anticoagulation and the proportion of patients potentially eligible for different agents. METHODS We identified patients with nonacute atrial fibrillation in a nationally representative 5% sample of 2009 Medicare data. We divided the population into patients ineligible for any oral anticoagulant, patients eligible for warfarin only, and patients eligible for any anticoagulant. We compared patient characteristics and the use of anticoagulation among the subgroups. RESULTS Among 86,671 patients with atrial fibrillation, 1872 (2.2%) were ineligible for anticoagulation because of an absolute contraindication, most frequently a history of intracranial hemorrhage (60%). Patients ineligible for any anticoagulant were the same age as the overall group (mean age, 80.5 vs. 80.4 years). However, they had higher rates of dementia (19% vs. 8.6%) and heart failure (59% vs. 43%) and higher mean CHADS2 scores (3.8 vs. 2.8). Of the remaining 84,799 patients eligible for anticoagulation, 7146 (8.4%) were eligible for warfarin only (most commonly because of mechanical heart valves [66%] and end-stage renal disease [12%]). Sixty-five percent of patients eligible for anticoagulation received warfarin, and the proportion was similar for patients with a relatively high risk of bleeding. CONCLUSIONS Older adults with atrial fibrillation rarely have absolute contraindications to oral anticoagulation therapy. Among patients without contraindications, most appeared to be eligible for any anticoagulant, and relatively high-risk features appeared not to influence warfarin use.
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Affiliation(s)
- Benjamin A Steinberg
- Duke Clinical Research Institute, Durham, North Carolina, USA.,Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | | | | | - Lesley H Curtis
- Duke Clinical Research Institute, Durham, North Carolina, USA.,Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Emelia J Benjamin
- Framingham Heart Study, Framingham, Massachusetts, USA.,Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Susan R Heckbert
- Department of Epidemiology, University of Washington School of Public Health, Seattle, Washington, USA
| | - Jonathan P Piccini
- Duke Clinical Research Institute, Durham, North Carolina, USA.,Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
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Atrial fibrillation in dialysis patients: time to abandon warfarin? Int J Artif Organs 2016; 39:99-105. [PMID: 27079417 DOI: 10.5301/ijao.5000487] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2016] [Indexed: 11/20/2022]
Abstract
Atrial fibrillation (AF) is a frequent clinical complication in dialysis patients, and warfarin therapy represents the most common approach for reducing the risk of stroke in this population. However, current evidence based on observational studies, offer conflicting results, whereas no randomized controlled trials have been carried out so far. Additionally, many clinicians are wary of the possible role of warfarin as vascular calcification inducer and its potential to increase the high risk of bleeding among patients on dialysis. Ideally the most promising therapy would be based on direct inhibitors of factor IIa or Xa; however, at the moment, none of these drugs can be safely prescribed in dialysis patients, because of their potentially dangerous accumulation, and the lack of sufficient experience with apixaban or rivaroxaban, two drugs showing a favorable pharmacokinetic profile in end-stage renal disease. Hence, the use of vitamin K inhibitors is currently the only pharmacological option for stroke prevention in dialysis patients with atrial fibrillation, leaving the clinicians in a management conundrum.This review discusses the trade-offs implicated in warfarin use for this population, the promises of newly developed drugs, the role of dialysis as atrial fibrillation trigger, as well as potential non-pharmacological management options suitable in selected clinical situations.
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30
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Guillem MS, Climent AM, Rodrigo M, Fernández-Avilés F, Atienza F, Berenfeld O. Presence and stability of rotors in atrial fibrillation: evidence and therapeutic implications. Cardiovasc Res 2016; 109:480-92. [PMID: 26786157 PMCID: PMC4777913 DOI: 10.1093/cvr/cvw011] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2015] [Revised: 12/30/2015] [Accepted: 01/15/2016] [Indexed: 01/08/2023] Open
Abstract
Rotor-guided ablation has opened new perspectives into the therapy of atrial fibrillation (AF). Analysis of the spatio-temporal cardiac excitation patterns in the frequency and phase domains has demonstrated the importance of rotors in research models of AF, however, the dynamics and role of rotors in human AF are still controversial. In this review, the current knowledge gained through research models and patient data that support the notion that rotors are key players in AF maintenance is summarized. We report and discuss discrepancies regarding rotor prevalence and stability in various studies, which can be attributed in part to methodological differences among mapping systems. Future research for validation and improvement of current clinical electrophysiology mapping technologies will be crucial for developing mechanistic-based selection and application of the best therapeutic strategy for individual AF patient, being it, pharmaceutical, ablative, or other approach.
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Affiliation(s)
- María S Guillem
- ITACA, Universitat Politèscnica de València, Valencia, Spain
| | - Andreu M Climent
- Hospital General Universitario Gregorio Marañón, Madrid, Spain Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Miguel Rodrigo
- ITACA, Universitat Politèscnica de València, Valencia, Spain
| | - Francisco Fernández-Avilés
- Hospital General Universitario Gregorio Marañón, Madrid, Spain Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain Facultad de Medicina, Universidad Complutense de Madrid, Spain
| | - Felipe Atienza
- Hospital General Universitario Gregorio Marañón, Madrid, Spain Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain Facultad de Medicina, Universidad Complutense de Madrid, Spain
| | - Omer Berenfeld
- Center for Arrhythmia Research, University of Michigan, 2800 Plymouth Road, Ann Arbor, MI 48109, USA
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Iram F, Ali S, Ahmad A, Khan SA, Husain A. A review on dronedarone: Pharmacological, pharmacodynamic and pharmacokinetic profile. JOURNAL OF ACUTE DISEASE 2016. [DOI: 10.1016/j.joad.2015.10.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Lavergne F, Morin L, Armitstead J, Benjafield A, Richards G, Woehrle H. Atrial fibrillation and sleep-disordered breathing. J Thorac Dis 2016; 7:E575-84. [PMID: 26793367 DOI: 10.3978/j.issn.2072-1439.2015.12.57] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Atrial fibrillation (AF) is a common supraventricular arrhythmia that increases in prevalence with increasing age and in the presence of comorbidities such as heart failure (HF). AF increases the risk of a number of serious complications, including stroke and HF. As a result, the rate of hospitalization is high, making AF a costly disease. Treatment strategies for AF are broadly based around rate and rhythm control, either pharmacological or mechanical. There appear to be a number of links between sleep-disordered breathing (SDB) and AF, although further studies are needed to fully understand the physiological mechanisms that link these conditions. Patients with AF and SDB share a number of risk factors and comorbidities, including age, male sex, hypertension, congestive HF and coronary artery disease (CAD), and the prevalence of SDB in AF is higher than in the general population. Prevalence rates of obstructive sleep apnea (OSA) in patients with AF have been reported to range from 21% to just over 80%. The prevalence of central sleep apnea (CSA) in patients with AF is less well defined, but appears to be particularly high in patients who also have HF and a reduced left ventricular ejection fraction (LVEF). The frequency of apneas can be reduced by effective treatment of AF, while co-existing OSA reduces the effectiveness of treatments for AF and there is an increased risk of arrhythmia recurrence in the presence of SDB. Treating OSA with continuous positive airway pressure (CPAP) therapy has shown the potential to decrease the incidence of AF, improve the effectiveness of AF interventions, and decrease the risk of arrhythmia recurrence, although data from large randomized, controlled clinical trials are lacking. Based on available data, inclusion of SDB recognition and management strategies as part of AF management appears to have the potential to reduce the impact of this arrhythmia at both the individual and societal levels, and has been recognized as important in recent guidelines.
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Affiliation(s)
- Florent Lavergne
- 1 ResMed Science Center, Lyon, France ; 2 ResMed Science Center, Sydney, Australia ; 3 ResMed Science Center, San Diego, USA ; 4 ResMed Science Center, Martinsried, Germany ; 5 Sleep and Ventilation Center Blaubeuren, Respiratory Center Ulm, Ulm, Germany
| | - Laurent Morin
- 1 ResMed Science Center, Lyon, France ; 2 ResMed Science Center, Sydney, Australia ; 3 ResMed Science Center, San Diego, USA ; 4 ResMed Science Center, Martinsried, Germany ; 5 Sleep and Ventilation Center Blaubeuren, Respiratory Center Ulm, Ulm, Germany
| | - Jeff Armitstead
- 1 ResMed Science Center, Lyon, France ; 2 ResMed Science Center, Sydney, Australia ; 3 ResMed Science Center, San Diego, USA ; 4 ResMed Science Center, Martinsried, Germany ; 5 Sleep and Ventilation Center Blaubeuren, Respiratory Center Ulm, Ulm, Germany
| | - Adam Benjafield
- 1 ResMed Science Center, Lyon, France ; 2 ResMed Science Center, Sydney, Australia ; 3 ResMed Science Center, San Diego, USA ; 4 ResMed Science Center, Martinsried, Germany ; 5 Sleep and Ventilation Center Blaubeuren, Respiratory Center Ulm, Ulm, Germany
| | - Glenn Richards
- 1 ResMed Science Center, Lyon, France ; 2 ResMed Science Center, Sydney, Australia ; 3 ResMed Science Center, San Diego, USA ; 4 ResMed Science Center, Martinsried, Germany ; 5 Sleep and Ventilation Center Blaubeuren, Respiratory Center Ulm, Ulm, Germany
| | - Holger Woehrle
- 1 ResMed Science Center, Lyon, France ; 2 ResMed Science Center, Sydney, Australia ; 3 ResMed Science Center, San Diego, USA ; 4 ResMed Science Center, Martinsried, Germany ; 5 Sleep and Ventilation Center Blaubeuren, Respiratory Center Ulm, Ulm, Germany
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López-Sendón JL, González-Juanatey JR, Pinto F, Castillo JC, Badimón L, Dalmau R, Torrecilla EG, Mínguez JRL, Maceira AM, Pascual-Figal D, Moya-Prats JLP, Sionis A, Zamorano JL. Quality markers in cardiology: measures of outcomes and clinical practice--a perspective of the Spanish Society of Cardiology and of Thoracic and Cardiovascular Surgery. Eur Heart J 2016; 37:12-23. [PMID: 26491106 PMCID: PMC4692288 DOI: 10.1093/eurheartj/ehv527] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Revised: 08/04/2015] [Accepted: 09/18/2015] [Indexed: 02/06/2023] Open
Affiliation(s)
- José-Luis López-Sendón
- Cardiology/Planta 1, Hospital Universitario La Paz, Paseo de la Casellana 261, Madrid, Spain
| | | | - Fausto Pinto
- Cardiology/Planta 1, Hospital Universitario La Paz, Paseo de la Casellana 261, Madrid, Spain
| | - José Cuenca Castillo
- Cardiology/Planta 1, Hospital Universitario La Paz, Paseo de la Casellana 261, Madrid, Spain
| | - Lina Badimón
- Cardiology/Planta 1, Hospital Universitario La Paz, Paseo de la Casellana 261, Madrid, Spain
| | - Regina Dalmau
- Cardiology/Planta 1, Hospital Universitario La Paz, Paseo de la Casellana 261, Madrid, Spain
| | | | | | - Alicia M Maceira
- Cardiology/Planta 1, Hospital Universitario La Paz, Paseo de la Casellana 261, Madrid, Spain
| | - Domingo Pascual-Figal
- Cardiology/Planta 1, Hospital Universitario La Paz, Paseo de la Casellana 261, Madrid, Spain
| | | | - Alessandro Sionis
- Cardiology/Planta 1, Hospital Universitario La Paz, Paseo de la Casellana 261, Madrid, Spain
| | - José Luis Zamorano
- Cardiology/Planta 1, Hospital Universitario La Paz, Paseo de la Casellana 261, Madrid, Spain
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McKibben RA, Al Rifai M, Mathews LM, Michos ED. Primary Prevention of Atherosclerotic Cardiovascular Disease in Women. CURRENT CARDIOVASCULAR RISK REPORTS 2015; 10. [PMID: 28149430 DOI: 10.1007/s12170-015-0480-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of morbidity and mortality among women. Despite improvements in cardiovascular disease prevention efforts, there remain gaps in cardiovascular disease awareness among women, as well as age and racial disparities in ASCVD outcomes for women. Disparity also exists in the impact the traditional risk factors confer on ASCVD risk between women and men, with smoking and diabetes both resulting in stronger relative risks in women compared to men. Additionally there are risk factors that are unique to women (such as pregnancy-related factors) or that disproportionally affect women (such as auto-immune disease) where preventive efforts should be targeted. Risk assessment and management must also be sex-specific to effectively reduce cardiovascular disease and improve outcomes among women. Evidence supports the use of statin therapy for primary prevention in women at higher ASCVD risk. However, some pause should be given to prescribing aspirin therapy in women without known ASCVD, with most evidence supporting the use of aspirin for women≥65 years not at increased risk for bleeding. This review article will summarize (1) traditional and non-traditional assessments of ASCVD risk and (2) lifestyle and pharmacologic therapies for the primary prevention of ASCVD in women.
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Affiliation(s)
- Rebeccah A McKibben
- Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA 21287
| | - Mahmoud Al Rifai
- Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA 21287
| | - Lena M Mathews
- Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA 21287
| | - Erin D Michos
- Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA 21287
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López-Sendón JL, González-Juanatey JR, Pinto F, Castillo JC, Badimón L, Dalmau R, Torrecilla EG, Mínguez JRL, Maceira AM, Pascual-Figal D, Moya-Prats JLP, Sionis A, Zamorano JL. Quality markers in cardiology: measures of outcomes and clinical practice —a perspective of the Spanish Society of Cardiology and of Thoracic and Cardiovascular Surgery1. CIRUGIA CARDIOVASCULAR 2015. [DOI: 10.1016/j.circv.2015.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Borah BJ, Roger VL, Mills RM, Weston SA, Anderson SS, Chamberlain AM. Association Between Atrial Fibrillation and Costs After Myocardial Infarction: A Community Study. Clin Cardiol 2015; 38:548-54. [PMID: 26418757 DOI: 10.1002/clc.22448] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Revised: 07/24/2015] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND The authors sought to estimate incremental economic impact of atrial fibrillation (AF) and the timing of its onset in myocardial infarction (MI) patients. HYPOTHESIS Concurrent AF and its timing are associated with higher costs in MI patients. METHODS This retrospective cohort study included incident MI patients from Olmsted County, Minnesota, treated between November 1, 2002, and December 31, 2010. We compared inflation-adjusted standardized costs accumulated between incident MI and end of follow-up among 3 groups by AF status and timing: no AF, new-onset AF (within 30 days after index MI), and prior AF. Multivariate adjustment of median costs accounted for right-censoring in costs. RESULTS The final study cohort had 1389 patients, with 989 in no AF, 163 in new-onset AF, and 237 in prior AF categories. Median follow-up times were 3.98, 3.23, and 2.55 years, respectively. Mean age at index was 67 years, with significantly younger patients in the no AF group (64 years vs 76 and 77 years, respectively; P < 0.001). New-onset and prior AF patients had more comorbid conditions (hypertension, heart failure, and chronic obstructive pulmonary disease). After accounting for differences in baseline characteristics, we found adjusted median (95% confidence interval) costs of $73 000 ($69 000-$76 000) for no AF; $85 000 ($81 000-$89 000) for new-onset AF; and $97 000 ($94 000-$100 000) for prior AF. Inpatient costs composed the largest share of total median costs (no AF, 82%; new-onset AF, 84%; prior AF, 83%). CONCLUSIONS Atrial fibrillation frequently coexists with MI and imposes incremental costs, mainly attributable to inpatient care. Timing of AF matters, as prior AF was found to be associated with higher costs than new-onset AF.
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Affiliation(s)
- Bijan J Borah
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Véronique L Roger
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota.,Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Roger M Mills
- Janssen Research and Development LLC (Mills), Johnson & Johnson, Raritan, New Jersey
| | - Susan A Weston
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
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Steinberg BA, Kim S, Thomas L, Fonarow GC, Gersh BJ, Holmqvist F, Hylek E, Kowey PR, Mahaffey KW, Naccarelli G, Reiffel JA, Chang P, Peterson ED, Piccini JP. Increased Heart Rate Is Associated With Higher Mortality in Patients With Atrial Fibrillation (AF): Results From the Outcomes Registry for Better Informed Treatment of AF (ORBIT-AF). J Am Heart Assoc 2015; 4:e002031. [PMID: 26370445 PMCID: PMC4599492 DOI: 10.1161/jaha.115.002031] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Accepted: 07/27/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Most patients with atrial fibrillation (AF) require rate control; however, the optimal target heart rate remains under debate. We aimed to assess rate control and subsequent outcomes among patients with permanent AF. METHODS AND RESULTS We studied 2812 US outpatients with permanent AF in the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation. Resting heart rate was measured longitudinally and used as a time-dependent covariate in multivariable Cox models of all-cause and cause-specific mortality during a median follow-up of 24 months. At baseline, 7.4% (n=207) had resting heart rate <60 beats per minute (bpm), 62% (n=1755) 60 to 79 bpm, 29% (n=817) 80 to 109 bpm, and 1.2% (n=33) ≥110 bpm. Groups did not differ by age, previous cerebrovascular disease, heart failure status, CHA2DS2-VASc scores, renal function, or left ventricular function. There were significant differences in race (P=0.001), sinus node dysfunction (P=0.004), and treatment with calcium-channel blockers (P=0.006) and anticoagulation (P=0.009). In analyses of continuous heart rates, lower heart rate ≤65 bpm was associated with higher all-cause mortality (adjusted hazard ratio [HR], 1.15 per 5-bpm decrease; 95% CI, 1.01 to 1.32; P=0.04). Similarly, increasing heart rate >65 bpm was associated with higher all-cause mortality (adjusted HR, 1.10 per 5-bpm increase; 95% CI, 1.05 to 1.15; P<0.0001). This relationship was consistent across endpoints and in a broader sensitivity analysis of permanent and nonpermanent AF patients. CONCLUSIONS Among patients with permanent AF, there is a J-shaped relationship between heart rate and mortality. These data support current guideline recommendations, and clinical trials are warranted to determine optimal rate control. CLINICAL TRIAL REGISTRATION URL: http://clinicaltrials.gov/. Unique identifier: NCT01165710.
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Affiliation(s)
- Benjamin A Steinberg
- Duke University Medical CenterDurham, NC
- Duke Clinical Research InstituteDurham, NC
| | | | | | | | | | | | | | - Peter R Kowey
- Lankenau Institute for Medical ResearchWynnewood, PA
| | | | | | - James A Reiffel
- Columbia University College of Physicians and SurgeonsNew York, NY
| | - Paul Chang
- Janssen Pharmaceuticals, Inc.Raritan, NJ
| | - Eric D Peterson
- Duke University Medical CenterDurham, NC
- Duke Clinical Research InstituteDurham, NC
| | - Jonathan P Piccini
- Duke University Medical CenterDurham, NC
- Duke Clinical Research InstituteDurham, NC
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Abstract
Atrial fibrillation (AF) is common in the elderly population. Elderly patients with AF are often asymptomatic, may have atypical presentation or may present with heart failure or thromboembolic complications. The optimal management strategy of AF in the elderly population is challenging. We present an overview of AF in elderly patients, in particular addressing the pros and cons of various management strategies, and provide a practical approach within the guidelines.
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Affiliation(s)
- Fayaz A Hakim
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, 13400 E Shea Blvd, Scottsdale, AZ 85259, USA
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Trivedi C, Sadadia M. Colchicine in prevention of atrial fibrillation following cardiac surgery: systematic review and meta-analysis. Indian J Pharmacol 2015; 46:590-5. [PMID: 25538328 PMCID: PMC4264072 DOI: 10.4103/0253-7613.144905] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Revised: 08/07/2014] [Accepted: 10/22/2014] [Indexed: 12/05/2022] Open
Abstract
Objectives: Inflammation is one of the predictors of atrial fibrillation (AF) following surgical or interventional cardiac procedures. Recent evidence suggests that colchicine may represent a new strategy to prevent AF following cardiac procedures. This study aims to assess the antiinflammatory efficacy of colchicine in prevention of early AF event (EAFE). Materials and Methods: We reviewed all available studies that assessed the effectiveness of colchicine therapy on the occurrence of AF in patients undergoing cardiac procedures. Meta-analysis was performed by random effect inverse variance-weighted method by entering AF events and the total population from each study. Results: After thorough review of the databases, we found three studies comparing colchicine and placebo which had EAFE as the outcome. Of 584 patients, 286 patients were on colchicine and 298 on placebo. All the three studies were randomized. After pooled analysis, colchicine was associated with significant reduction in AF events compared to placebo (odds ratio = 0.44 [0.29, 0.66], P < 0.001). There was no statistical heterogeneity between included studies (χ2 = 0.45, P = 0.80, I2 = 0%). Conclusion: Colchicine may prove beneficial in the prevention of AF following cardiac surgery. Further research is warranted.
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Affiliation(s)
- Chintan Trivedi
- St. Davids Medical Center, Suite 408, Austin, Texas 78705, USA
| | - Mihir Sadadia
- Department of Pharmacology, Smt. B K Shah Medical Institute and Research Centre, Piparia, Vadodara, Gujarat, India
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Boriani G, Savelieva I, Dan GA, Deharo JC, Ferro C, Israel CW, Lane DA, La Manna G, Morton J, Mitjans AM, Vos MA, Turakhia MP, Lip GY. Chronic kidney disease in patients with cardiac rhythm disturbances or implantable electrical devices: clinical significance and implications for decision making-a position paper of the European Heart Rhythm Association endorsed by the Heart Rhythm Society and the Asia Pacific Heart Rhythm Society. Europace 2015; 17:1169-96. [PMID: 26108808 PMCID: PMC6281310 DOI: 10.1093/europace/euv202] [Citation(s) in RCA: 117] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
- Giuseppe Boriani
- Corresponding author. Giuseppe Boriani, Institute of Cardiology, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, S.Orsola-Malpighi University Hospital, Via Massarenti 9, 40138 Bologna, Italy. Tel: +39 051 349858; fax: +39 051 344859. E-mail address:
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Tischer TS, Schneider R, Lauschke J, Nesselmann C, Klemm A, Diedrich D, Kundt G, Bänsch D. Prevalence of atrial fibrillation in patients with high CHADS2- and CHA2DS2VASc-scores: anticoagulate or monitor high-risk patients? PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2015; 37:1651-7. [PMID: 25621351 PMCID: PMC4282384 DOI: 10.1111/pace.12470] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background In patients with known atrial fibrillation (AF) different scores are utilized to estimate the risk of thromboembolic events and guide oral anticoagulation. Diagnosis of AF strongly depends on the duration of electrocardiogram monitoring. The aim of this study was to use established scores to predict the prevalence of AF. Methods The CHADS2- (Congestive Heart failure, hypertension, Age >75 years, Diabetes, Stroke [doubled]) and CHA2DS2VASc-score (Congestive Heart failure, hypertension, Age ≥75 years [doubled], Diabetes, Stroke [doubled], Vascular disease, Age 65–74 years, Sex category [female sex]) was calculated in 150,408 consecutive patients, referred to the University Hospital of Rostock between 2007 and 2012. All factors constituting these scores and a history of AF were prospectively documented with the ICD-10 admission codes. Results Mean age of our study population was 67.6 ± 13.6 years with a mean CHADS2-score of 1.65 ± 0.92 and CHA2DS2VASc-score of 3.04 ± 1.42. AF was prevalent in 15.9% of the participants. The prevalence of AF increased significantly with every CHADS2- and CHA2DS2VASc-score point up to 54.2% in CHADS2-score of 6 and 71.4% in CHA2DS2VASc-score of 9 (P < 0.001). Conclusion The prevalence of AF increases with increasing CHADS2- and CHA2DS2VASc-score. In intermediate scores intensified monitoring may be recommended. In high scores, thromboembolic complications occurred irrespective of the presence of AF and anticoagulant therapy may be initiated irrespective of documented AF.
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Affiliation(s)
- Tina S Tischer
- Heart Center Rostock, University HospitalRostock, Germany
| | | | - Jörg Lauschke
- Heart Center Rostock, University HospitalRostock, Germany
| | | | - Anke Klemm
- Department of Controlling, University HospitalRostock, Germany
| | - Doreen Diedrich
- Institute for Biostatistics and Informatics in Medicine and Ageing Research, University HospitalRostock, Germany
| | - Günther Kundt
- Institute for Biostatistics and Informatics in Medicine and Ageing Research, University HospitalRostock, Germany
| | - Dietmar Bänsch
- Heart Center Rostock, University HospitalRostock, Germany
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Moon J, Lee HJ, Kim JY, Pak HN, Lee MH, Kim YJ, Joung B. Prognostic Implications of Right and Left Atrial Enlargement after Radiofrequency Catheter Ablation in Patients with Nonvalvular Atrial Fibrillation. Korean Circ J 2015; 45:301-9. [PMID: 26240584 PMCID: PMC4521108 DOI: 10.4070/kcj.2015.45.4.301] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Revised: 03/23/2015] [Accepted: 03/26/2015] [Indexed: 12/22/2022] Open
Abstract
Background and Objectives The prognostic role of the right atrium (RA) compared with that of the left atrium (LA) is unclear in patients with atrial fibrillation (AF). We assessed structural changes in both atria and determined their association with recurrence of AF after radiofrequency catheter ablation (RFCA). Subjects and Methods All 111 patients with nonvalvular AF (87 men; mean age, 57±11 years; 68 with paroxysmal AF) who underwent RFCA were enrolled consecutively. Three-dimensional volumes of both atria measured from computed tomography images were compared between subjects with and without recurrence of AF during the follow-up. Results Early (<3 months), 6-month, and 1-year recurrence was documented in 26 (24%), 30 (27%), and 36 (32%) patients, respectively. Significantly larger RA and LA volume indices (RAVI and LAVI) were observed in the early, 6-month, and 1-year recurrence groups (p<0.05 for all). In multivariate analysis, Early recurrence was independently associated with RAVI (for each 10 mL/m2 increase; odds ratio [OR], 1.31; 95% confidence interval [CI], 1.03-1.66, p= 0.03), but not with LAVI. However, both RAVI and LAVI failed to predict 6-month outcomes independently. LAVI was the only independent predictor of 1-year recurrence (for each 10 mL/m2 increase; OR, 1.36; 95% CI, 1.08-1.71, p=0.009). Conclusion RA enlargement was more closely related to early recurrence of AF after RFCA than LA size. However, LA size, rather than RA volume, was a determinant of long-term AF prognosis after RFCA. These findings suggest a temporal pattern in the prognostic implication of enlargement in each atrium that switches over time after RFCA for AF.
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Affiliation(s)
- Jeonggeun Moon
- Cardiology Division, Department of Internal Medicine, Gachon University of Medicine and Science, Incheon, Korea
| | - Hye-Jeong Lee
- Department of Radiology, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Korea
| | - Jong-Youn Kim
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Hui-Nam Pak
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Moon-Hyoung Lee
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Young Jin Kim
- Department of Radiology, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Korea
| | - Boyoung Joung
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
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Bhave PD, Lu X, Girotra S, Kamel H, Vaughan Sarrazin MS. Race- and sex-related differences in care for patients newly diagnosed with atrial fibrillation. Heart Rhythm 2015; 12:1406-12. [PMID: 25814418 PMCID: PMC4787261 DOI: 10.1016/j.hrthm.2015.03.031] [Citation(s) in RCA: 117] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Indexed: 01/26/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) is associated with an increased risk of stroke and death. Uniform utilization of appropriate therapies for AF may help reduce those risks. OBJECTIVE We sought to determine whether significant race and sex differences exist in the treatment of newly diagnosed AF in Medicare beneficiaries. METHODS We used administrative encounter data for Medicare beneficiaries to identify patients with newly diagnosed AF during 2010-2011. Services received after initial AF diagnosis were cataloged, including visits with a cardiologist or electrophysiologist, catheter ablation procedures, and use of oral anticoagulants, rate control agents, and antiarrhythmic drugs. RESULTS Overall, 517,941 patients met study criteria, of whom 452,986 (87%) were white, 36,425 (7%) black, and 28,530 (6%) Hispanic. Male patients comprised 209,788 (41%) of the cohort. In multivariate analysis, there were statistically significant differences in the use of AF-related services by both race and sex, with white patients and male patients receiving the most care. The most notable disparities were for catheter ablation (Hispanic vs white: adjusted hazard ratio [AHR] 0.70; 95% confidence interval [CI] 0.63-0.79; P < .001; female vs male: AHR 0.65; 95% CI 0.63-0.68; P < .001) and receipt of oral anticoagulation (black vs white: AHR 0.94; 95% CI 0.92-0.95; P < .001; Hispanic vs white: AHR 0.94; 95% CI 0.93-0.97; P < .001; female vs male: AHR 0.93; 95% CI 0.93-0.94; P < .001). CONCLUSION Race and sex appear to have a significant effect on the health care provided to this cohort of Medicare beneficiaries diagnosed with AF. Possible explanations include racial differences in access, patient preferences, treatment bias, and unmeasured clinical characteristics.
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Affiliation(s)
| | - Xin Lu
- University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Saket Girotra
- University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Hooman Kamel
- Feil Family Brain and Mind Research Institute, New York, New York; Department of Neurology, Weill Cornell Medical College, New York, New York
| | - Mary S Vaughan Sarrazin
- University of Iowa Hospitals and Clinics, Iowa City, Iowa; Center for Access and Delivery Research and Evaluation (CADRE), Iowa City Veterans Affairs Medical Center, Iowa City, Iowa
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Shi LZ, Heng R, Liu SM, Leng FY. Effect of catheter ablation versus antiarrhythmic drugs on atrial fibrillation: A meta-analysis of randomized controlled trials. Exp Ther Med 2015; 10:816-822. [PMID: 26622399 DOI: 10.3892/etm.2015.2545] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Accepted: 05/18/2015] [Indexed: 01/01/2023] Open
Abstract
The aim of the present study was to compare the health outcomes of catheter ablation therapy against those of antiarrhythmic drugs (AADs) in the management of atrial fibrillation (AF). The effects of catheter ablation and AADs on a number of parameters were compared, including AF recurrence, all-cause mortality, stroke/transient ischemic attack (TIA) and quality of life (QoL). A systematic literature search of PubMed, Embase and the Cochrane Central Register of Controlled Trials was conducted to obtain relevant randomized controlled trials. The relative risks (RRs) and 95% confidence intervals (CIs) of AF recurrence, all-cause mortality and stroke/TIA between catheter ablation and AADs were subsequently calculated. Weighted mean differences (WMDs) and 95% CIs were used to evaluate the QoL between the two therapy groups. In total, 11 randomized trials, which included 1,763 AF patients, were eligible for the meta-analysis. Overall, the results indicated that catheter ablation produces superior outcomes compared with AADs in reducing AF recurrence (RR, 0.47; 95% CI, 0.38-0.58; P<0.001) and improving the QoL (physical component summary: WMD, 2.23; 95% CI, 0.24-4.21; P=0.03; mental component summary: WMD, 2.69; 95% CI, 0.04-5.35; P=0.05). However, no statistically significant difference was identified between the two groups with regard to the incidence of all-cause mortality (RR, 0.87; 95% CI, 0.37-2.06; P=0.76) and stroke/TIA (RR, 1.83; 95% CI, 0.73-4.55; P=0.20). In summary, catheter ablation was demonstrated to markedly reduce AF recurrence and improve QoL when compared with AAD therapy. However, the incidence rates of all-cause mortality and stroke/TIA were comparable between catheter ablation and AAD therapy.
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Affiliation(s)
- Lei-Zhi Shi
- Department of Thoracic Surgery, Linyi People's Hospital, Linyi, Shandong 276000, P.R. China
| | - Rui Heng
- Department of Thoracic Surgery, Linyi People's Hospital, Linyi, Shandong 276000, P.R. China
| | - Shi-Min Liu
- Department of Internal Medicine, Linyi People's Hospital, Linyi, Shandong 276000, P.R. China
| | - Fei-Yan Leng
- Department of Thoracic Surgery, Linyi People's Hospital, Linyi, Shandong 276000, P.R. China
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Kilickiran Avci B, Vatan B, Ozden Tok O, Aidarova T, Sahinkus S, Uygun T, Gunduz H, Karakaya O, Yuksel H, Ongen Z. The Trends in Utilizing Nonvitamin K Antagonist Oral Anticoagulants in Patients With Nonvalvular Atrial Fibrillation: A Real-Life Experience. Clin Appl Thromb Hemost 2015; 22:785-791. [PMID: 25878174 DOI: 10.1177/1076029615581365] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Dabigatran and rivaroxaban are novel nonvitamin K antagonist oral anticoagulants (NOACs) approved for thromboprophylaxis in atrial fibrillation (AF). In Turkey, like other countries, the efficacy of translation of the clinical trial results and current guideline recommendations into daily clinical practice is yet to be discovered. Using data from medical records of three tertiary care cardiology centers, we identified patients with nonvalvular AF on dabigatran or rivaroxaban treatment. Baseline characteristics and utilization trends were compared between dabigatran and rivaroxaban groups. Secondarily, clinical events including ischemic stroke and/or transient ischemic attack, systemic embolism, and bleeding were evaluated. Among 294 patients with AF included, dabigatran was utilized in 177 (60.2%) and rivaroxaban in 117 (39.8%). Overall, 76% of patients had received long-term warfarin therapy. The use of 110 mg twice a day (55.4%) was the prevailing strategy in dabigatran group, whereas in rivaroxaban group 20 mg every day (67.5%) was the preferred option. Of the patients, 37.3% had severe valvular disease in which mitral regurgitation was the predominant valve abnormality. Scores of CHADS2, CHA2DS2VASc, and HAS-BLED were similar in both the groups. Of the patients, 24% in dabigatran group and 13.7% in rivaroxaban group were prescribed the lower dose inappropriately. The two NOACs did not differ significantly in terms of clinical events. The results of this study indicate that in daily practice, the physicians' behavior in utilizing the NOACs is shaped by the clinical trials and the guideline recommendations. On the other hand, in dose selection, this adherence is not of high quality.
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Affiliation(s)
- Burcak Kilickiran Avci
- Department of Cardiology, Cerrahpasa Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Bulent Vatan
- Department of Cardiology, Faculty of Medicine, Sakarya University, Sakarya, Turkey
| | - Ozge Ozden Tok
- Department of Cardiology, Bakırkoy Dr Sadi Konuk Research and Training Hospital, Istanbul, Turkey
| | - Tamara Aidarova
- Department of Cardiology, Cerrahpasa Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Salih Sahinkus
- Department of Cardiology, Faculty of Medicine, Sakarya University, Sakarya, Turkey
| | - Turgut Uygun
- Department of Cardiology, Bakırkoy Dr Sadi Konuk Research and Training Hospital, Istanbul, Turkey
| | - Huseyin Gunduz
- Department of Cardiology, Faculty of Medicine, Sakarya University, Sakarya, Turkey
| | - Osman Karakaya
- Department of Cardiology, Bakırkoy Dr Sadi Konuk Research and Training Hospital, Istanbul, Turkey
| | - Husniye Yuksel
- Department of Cardiology, Cerrahpasa Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Zeki Ongen
- Department of Cardiology, Cerrahpasa Faculty of Medicine, Istanbul University, Istanbul, Turkey
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“Asymptomatic” persistent or permanent atrial fibrillation: A misnomer in selected patients. Int J Cardiol 2015; 185:112-3. [DOI: 10.1016/j.ijcard.2015.03.122] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Accepted: 03/07/2015] [Indexed: 11/21/2022]
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Velagapudi P, Turagam MK, Agrawal H, Mittal M, Kocheril AG, Aggarwal K. Antithrombotics in atrial fibrillation and coronary disease. Expert Rev Cardiovasc Ther 2015; 12:977-86. [PMID: 25046150 DOI: 10.1586/14779072.2014.937427] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia and approximately 18-45% of AF patients have concomitant coronary artery disease (CAD). Several studies have demonstrated that oral anticoagulation is the mainstay of therapy for stroke prevention in AF. Similarly, antiplatelet therapy including aspirin and P2Y12 inhibitor is recommended in the management of acute coronary syndrome and stable CAD. Despite the high prevalence of CAD with AF, practice guidelines are scarce on the appropriate antithrombotic regimen due to lack of large-scale randomized clinical trials. The use of direct thrombin and factor Xa inhibitors for stroke prevention in AF has also complicated the possible combinations of antithrombotic therapies. This review aims to discuss the available evidence regarding aspirin as an antithrombotic strategy, the role of novel anticoagulants and the specific clinical situations where aspirin may be beneficial in patients with AF and CAD.
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Affiliation(s)
- Poonam Velagapudi
- Department of Cardiovascular Medicine, University of Missouri-Columbia, School of Medicine, Columbia, MO, USA
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Atienza F, Climent AM, Guillem MS, Berenfeld O. Frontiers in Non-invasive Cardiac Mapping: Rotors in Atrial Fibrillation-Body Surface Frequency-Phase Mapping. Card Electrophysiol Clin 2015; 7:59-69. [PMID: 25729463 DOI: 10.1016/j.ccep.2014.11.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Experimental and clinical data demonstrate that atrial fibrillation (AF) maintenance in animals and groups of patients depends on localized reentrant sources localized primarily to the pulmonary veins (PVs) and the left atrium(LA) posterior wall in paroxysmal AF but elsewhere, including the right atrium (RA), in persistent AF. Moreover, AF can be eliminated by directly ablating AF-driving sources or "rotors," that exhibit high-frequency, periodic activity. The RADAR-AF randomized trial demonstrated that an ablation procedure based on a more target-specific strategy aimed at eliminating high frequency sites responsible for AF maintenance is as efficacious as and safer than empirically isolating all the PVs. In contrast to the standard ECG, global atrial noninvasive frequency analysis allows non-invasive identification of high-frequency sources before the arrival at the electrophysiology laboratory for ablation. Body surface potential map (BSPM) replicates the endocardial distribution of DFs with localization of the highest DF (HDF) and can identify small areas containing the high-frequency sources. Overall, BSPM had a sensitivity of 75% and specificity of 100% for capturing intracardiac EGMs as having LARA DF gradient. However, raw BSPM data analysis of AF patterns of activity showed incomplete and instable reentrant patterns of activation. Thus, we developed an analysis approach whereby a narrow band-pass filtering allowed selecting the electrical activity projected on the torso at the HDF, which stabilized the projection of rotors that potentially drive AF on the surface. Consequently, driving reentrant patterns ("rotors") with spatiotemporal stability during >70% of the AF time could be observed noninvasibly after HDF-filtering. Moreover, computer simulations found that the combination of BSPM phase mapping with DF analysis enabled the discrimination of true rotational patterns even during the most complex AF. Altogether, these studies show that the combination of DF analysis with phase maps of HDF-filtered surface ECG recordings allows noninvasive localization of atrial reentries during AF and further a physiologically-based rationale for personalized diagnosis and treatment of patients with AF.
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Affiliation(s)
- Felipe Atienza
- Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - María S Guillem
- Bio-ITACA, Universitat Politécnica de Valencia, Valencia, Spain
| | - Omer Berenfeld
- Center for Arrhythmia Research, University of Michigan, Ann Arbor, Michigan
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Guo QZ, Zhu D, Bai ZX, Shi J, Shi YK, Guo YQ. A Novel “Box Lesion” Minimally Invasive Totally Thoracoscopic Surgical Ablation for Atrial Fibrillation. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2015. [DOI: 10.47102/annals-acadmedsg.v44n1p6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Introduction: Minimally invasive surgical ablation is an emerging alternative method to catheter ablation and the full surgical maze procedure for nonpharmacologic treatment of atrial fibrillation (AF). We present a totally thoracoscopic “box lesion” radiofrequency ablation procedure in patients with paroxysmal or persistent AF. Materials and Methods: From June 2011 to October 2012, 14 patients with lone paroxysmal (n = 7) or persistent AF (n = 7) were enrolled in this study. Procedures were performed through 3 5-12 mm holes on each side of the chest wall. A bipolar ablation device was used to create a box lesion in the posterior wall of the left atrium that encircled the 4 pulmonary veins (achieving bilateral pulmonary vein/posterior left atrial wall isolation). Perioperative complications were recorded for all patients. Freedom from AF was assessed by 24-hour Holter monitoring every 3 months or during symptoms of arrhythmia. Results: The ablation was successfully performed in all patients, with median operation time of 128 minutes (range, 45 to 180 minutes). No operative mortality or morbidity were noted during the study period. Freedom from AF was achieved in 12 patients (85.7%) during follow-up (median follow-up 9 months). One patient with persistent AF was shifted to paroxysmal AF. No atrial flutter or atrial tachycardia was noted during the follow-up. Conclusion: These early results show that totally thoracoscopic surgical ablation using a unique “box lesion” procedure for persistent or paroxysmal AF is a feasible and effective method with good short-term results. Further study is necessary to validate this result.
Key words: Arrhythmia therapy, Flutter, Surgery, Thoracoscopy
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Affiliation(s)
- Qiu Zhe Guo
- West China Hospital, Sichuan University, People's Republic of China
| | - Da Zhu
- West China Hospital, Sichuan University, People's Republic of China
| | - Zhi Xuan Bai
- West China Hospital, Sichuan University, People's Republic of China
| | - Jun Shi
- West China Hospital, Sichuan University, People's Republic of China
| | - Ying Kang Shi
- West China Hospital, Sichuan University, People's Republic of China
| | - Ying Qiang Guo
- West China Hospital, Sichuan University, People's Republic of China
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Raparelli V, Proietti M, Buttà C, Di Giosia P, Sirico D, Gobbi P, Corrao S, Davì G, Vestri AR, Perticone F, Corazza GR, Violi F, Basili S. Medication prescription and adherence disparities in non valvular atrial fibrillation patients: an Italian portrait from the ARAPACIS study. Intern Emerg Med 2014; 9:861-70. [PMID: 24990547 DOI: 10.1007/s11739-014-1096-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Accepted: 06/09/2014] [Indexed: 01/02/2023]
Abstract
Non-valvular atrial fibrillation (NVAF) represents a major health-care problem, needing an extensive and strict thrombosis prevention for stroke and cardiovascular (CV) disease risks. NVAF management guidelines recommend adequate antithrombotic and anti-atherosclerotic therapies. Medication adherence has been recognized as a pivotal element in health quality promotion and in the achievement of better clinical outcomes. We conducted a post-hoc analysis of the "Atrial fibrillation Registry for Ankle-brachial index Prevalence Assessment-Collaborative Italian Study (ARAPACIS)" with the aim of discerning differences in pharmacological management and medication adherence among NVAF Italian patients. Furthermore, data were analysed according to Italian geographical macro-regions (North, Center, South) to evaluate whether socioeconomic conditions might also influence medication adherence. Thus, we selected 1,366 NVAF patients that fulfilled the Morisky Medication Adherence Scale-4 items. Regional disparities in drug prescriptions were observed. In particular, in high-risk patients (CHA2DS2-VASc ≥2) oral anticoagulants were more prescribed in Northern and Center patients (61 and 60 %, respectively) compared to 53 % of high-risk Southern patients. Also, medication adherence showed a progressive decrease from North to South (78 vs. 60 %, p < 0.001). This disparity was independent of the number of drugs consumed for any reason, since prevalence of poly-therapy among the three macro-regions was similar. Our results show regional differences in NVAF patients' antithrombotic management and medication adherence, potentially reflecting well-known disparities in socioeconomic status among Italian regions. Future interventions promoting campaigns to global health-care education may be desirable to improve clinical outcomes in NVAF patients.
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