Randomized Study of Angiotensin II Type 1 Receptor Blocker vs Dihydropiridine Calcium Antagonist for the Treatment of Paroxysmal Atrial Fibrillation in Patients With Hypertension The J-RHYTHM II Study Design for the Investigation of Upstream Therapy for Atrial Fibrillation

Left heart function evaluation of patients with essential hypertension and paroxysmal atrial fibrillation by two-dimensional speckle tracking imaging combined with real-time three-dimensional ultrasound imaging

Background

This study aims to assess the value of two-dimensional speckle tracking imaging (2D-STI) combined with real-time 3-dimensional echocardiography (RT-3DE) in evaluating left heart function in patients with combined ETH and PAF.

Methods

A prospective study was designed, and the research period was from January 2017 to January 2020. A PAF observation group comprised of patients with ETH and PAF, a PAF control group of patients with ETH but without PAF, and a healthy volunteer group referred to as the healthy group, each comprised of 50 patients was established. All patients underwent routine ultrasound imaging examination using 2D-STI and RT-3DE. The interventricular septum thickness (IVST), left and right atrioventricular diameter (LAD), left ventricular posterior wall thickness (PWT), left ventricular ejection fraction (LVEF), the mean left atrium peak strain (mSs, mSe, mSa), strain rate (mSRs, mSRe, mSRa), the left ventricular mass (LVM), left ventricular mass index (LVMI), and left atrial total emptying volume (LATEV), the left atrial volume index (LAVI), left atrial total emptying fraction (LATEF), left atrium expansion index (LAEI), left atrium passive ejection fraction (LAPEF), and left atrial active ejection fraction (LAAEF) were calculated. Patients in the PAF observation group received telmisartan combined with rosuvastatin after diagnosis and 12- and 24-month-follow up visits were conducted. During these visits, 2D-STI combined with RT-3DE was used to evaluate cardiac function and each patient's blood pressure was monitored.

Results

Patients in the PAF observation group had a significantly longer course of ETH than patients in the PAF control group (13.5±4.4 vs. 10.32±5.6, P=0.002). The comparison of routine 2D-STI and RT-3DE ultrasound indexes among the three groups also showed significant differences (P<0.01). During the 2-year follow-up period, the IVST, LAD, PWT, and LVEF of remaining patients significantly improved as treatment progressed (P<0.05). The LAVI, LATEF, and LAEI also improved significantly as the treatment progressed (P<0.05). After 12 months of treatment, the recurrence rate of atrial fibrillation was 16.33% (8/45) and after 24 months this was 34.21% (13/38).

Conclusions

Cardiac function could be evaluated comprehensively by 2D-STI combined with RT-3DE in patients with ETH combined with PAF at initial diagnosis and follow-up.

Association between the quality of life and asymptomatic episodes of paroxysmal atrial fibrillation in the J-RHYTHM II study

BACKGROUND

Paroxysmal atrial fibrillation (AF) patients have a reduced quality-of-life (QoL) despite the fact that the majority of AF episodes are asymptomatic. Asymptomatic AF is likely to be associated with substantial morbidity and mortality rates similar to those with symptomatic AF, whereas its effect on the QoL has not yet been clarified.

PURPOSE

We studied the specific contribution of asymptomatic AF episodes to reducing the QoL.

METHODS

We assessed the QoL in 233 patients with paroxysmal AF and hypertension (age 64.9 ± 9.7 years, 71% male) enrolled in the Japanese Rhythm Management Trial II for Atrial Fibrillation (J-RHYTHM II study) using an AF-specific QoL questionnaire (AFQLQ). The AFQLQ comprised 3 components: AFQLQ1, the frequency and duration of symptoms; AFQLQ2, severity of symptoms; and AFQLQ3, limitations in daily activities and mental anxiety. Higher scores indicated a better QoL. Each patient transmitted electrocardiograms for 30s daily at a predetermined time as well as whenever arrhythmia-related symptoms were experienced. We examined the relationship between the 3 AFQLQ components and frequency of symptomatic and asymptomatic AF episodes (days/month) during 12 months of follow-up.

RESULTS

The symptomatic and asymptomatic AF frequencies were 0.9 ± 3.1 days/month and 1.5 ± 3.5 days/month, respectively. AFQLQ1 negatively correlated with the symptomatic AF frequency (Spearman's correlation coefficient: r = -0.332, p < 0.001). AFQLQ2 and AFQLQ3 correlated with both the symptomatic AF frequency (r = -0.27, p < 0.001 and r = -0.265, p < 0.001, respectively) and asymptomatic AF frequency (r = -0.197, p < 0.01 and r = -0.229, p < 0.005, respectively).

CONCLUSION

The asymptomatic AF episode frequency correlates with a reduced QoL in patients with paroxysmal AF, suggesting that there would be psychological benefits to its reduction.

Cost effectiveness of radiofrequency catheter ablation vs. medical treatment for atrial fibrillation in Japan. -Cost performance for atrial fibrillation-

BACKGROUND

Radiofrequency catheter ablation (RF) has recently become widely available for the treatment of atrial fibrillation (AF) and has broadened treatment options while confusing the selection of medication therapy or RF.

METHODS AND RESULTS

Two drugs for the maintenance of sinus rhythm (Ry) and 2 drugs for control of the pulse rate (Ra) were selected and the costs of medication therapy were calculated. RF procedures were grouped into 2 groups each for persistent or paroxysmal AF (RF) and for chronic AF (RFChr), according to the cost of the devices used. The calculated cost of medication therapy was 5,270-23,560 yen per month. The calculated cost of RF procedures was 1,063,200-2,029,640 yen. The costs of RF corresponded to those of Ry for 3.8-14.3 years. The costs of RFChr corresponded to those of Ra for 16.6-63.9 years. The treatment of complications ranged from 360,000 to 1,241,500 yen.

CONCLUSIONS

From the aspect of medical costs and complications, RF should be considered for the treatment of patients with AF detected early or early-stage AF, whereas treatment for its complications should be given priority in patients with chronic AF associated with reduced cardiac function.

Inhibition of the renin-angiotensin system for prevention of atrial fibrillation

Atrial fibrillation (AF) is a source of considerable morbidity and mortality. There has been compelling evidence supporting the role of renin-angiotensin system (RAS) in the genesis and perpetuation of AF through atrial remodeling, and experimental studies have validated the utilization of RAS inhibition for AF prevention. This article reviews clinical trials on the use of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) for the prevention of AF. Results have been variable, depending on the clinical background of treated patients. ACEIs and ARBs appear beneficial for primary prevention of AF in patients with heart failure, whereas they are not equally effective in hypertensive patients with normal left ventricular function. Furthermore, the use of ACEIs or ARBs for secondary prevention of AF has been found beneficial only after electrical cardioversion. Additional data are needed to establish the potential clinical role of renin-angiotensin inhibition for prevention of AF.

Is catheter ablation a mature fruit for treatment of atrial fibrillation?--is catheter ablation established as a treatment optionof atrial fibrillation? (Con)

In recent years, catheter ablation for atrial fibrillation (AF) has evolved in tandem with the results from many large-scale randomized clinical studies with antiarrhythmic drugs. The current situations seem to be a concerted move from pharmacological to non-pharmacological treatment. However, the clinical studies with medications have revealed an important viewpoint for the management of AF: the importance of the core aim of AF treatment and the position of electrographic findings as a surrogate marker. Catheter ablation is under challenge as the answers to these issues are awaited. Moreover, many problems with this invasive therapy are to be solved, most of them deriving from the vague definition of success of ablation and no standardization of the technique. For these reasons, catheter ablation is still on the way to maturation and multicenter studies in Japan are required to set a fair benchmark for Japanese patients, drawing a lesson from randomized clinical studies with medications.

Hypertension and atrial fibrillation

Atrial fibrillation (AF) is an emerging public health problem. The most important risk factor for developing chronic AF is uncontrolled hypertension. Uncontrolled hypertension promotes the initiation and perpetuation of AF through atrial remodeling. Experimental evidence has demonstrated the important role of the renin-angiotensin system in atrial remodeling. Retrospective analysis of several large clinical trials and small prospective trials suggests the beneficial role of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in preventing the onset and recurrence of AF in different populations. Several large prospective trials with longer follow-up periods are in progress. These trials may provide definitive evidence for the use of these agents in the prevention of AF.

Downregulation of angiotensin converting enzyme II is associated with pacing-induced sustained atrial fibrillation

Atrial fibrillation (AF), the most common cardiac arrhythmia, is frequently accompanied by atrial interstitial fibrosis. Angiotensin II (Ang II) dependent signaling pathways have been implicated in interstitial fibrosis during the development of AF. However, Ang II could be further degraded by angiotensin converting enzyme II (ACE2). We examined expression of ACE2 in the fibrillating atria of pigs and its involvement in fibrotic pathogenesis during AF. Nine adult pigs underwent continuous rapid atrial pacing to induce sustained AF and six pigs were sham controls (i.e., sinus rhythm; SR). In the histological examinations, extensive accumulation of extracellular matrix in the interstitial space of the atria, as evidenced by Masson's trichrome stain, were found in fibrillating atria. The relative amount of collagen type I in the atria with AF was significantly increased as compared with that in the SR. Local ACE activity in the fibrillating atria was also markedly higher than that in the SR subjects. ACE2 gene and protein expression in the AF subjects were significantly decreased compared with those in the SR subjects, whereas expression of mitogen-activated/ERK kinase 1/2 (MEK1/2), extracellular signal-regulated protein kinase 2 (ERK2), and activated ERK2 were significantly greater in the AF subjects. We propose that decreasing ACE2 expression during AF may affect the Ang II-dependent signaling pathway. In addition, our results suggest that atrial fibrosis in AF may be induced by antagonistic regulation between ACE and ACE2 expression.