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Rachieru C, Luca CT, Văcărescu C, Petrescu L, Cirin L, Cozma D. Future Perspectives to Improve CHA 2DS 2VASc Score: The Role of Left Atrium Remodelling, Inflammation and Genetics in Anticoagulation of Atrial Fibrillation. Clin Interv Aging 2023; 18:1737-1748. [PMID: 37873054 PMCID: PMC10590594 DOI: 10.2147/cia.s427748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 10/07/2023] [Indexed: 10/25/2023] Open
Abstract
In 10% of ischemic strokes, non-valvular atrial fibrillation (NVAF) is detected retroactively. Milder, or even asymptomatic forms of NVAF have shown high mortality, thrombotic risk, and deterioration of cognitive function. The current guidelines for the diagnosis and treatment of AF contain "grey areas", such as the one related to anticoagulant treatment in men with CHA2DS2-VASc score 1 and women with score 2. Moreover, parameters such as renal function, patient weight or left atrium remodelling are missing from the recommended guidelines scores. Vulnerable categories of patients including the elderly population, high hemorrhagic risk patients or patients with newly diagnosed paroxysmal episodes of atrial high rate at device interrogation are at risk of underestimation of the thrombotic risk. This review presents a systematic exposure of the most important gaps in evaluation of thrombotic and hemorrhagic risk in patients with NVAF. The authors propose new algorithms and risk factors that should be taken into consideration for an accurate thrombotic and hemorrhagic risk estimation, especially in vulnerable categories of patients.
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Affiliation(s)
- Ciprian Rachieru
- Faculty of Medicine, Department of Internal Medicine I, Discipline of Medical Semiology I “Victor Babes” University of Medicine and Pharmacy, Timisoara, 300041, Romania
- Internal Medicine Department, County Emergency Hospital, Timisoara, 300079, Romania
- Center for Advanced Research in Cardiovascular Pathology and Hemostaseology, “Victor Babes” University of Medicine and Pharmacy, Timisoara, 300041, Romania
| | - Constantin-Tudor Luca
- Cardiology Department, “Victor Babes” University of Medicine and Pharmacy, Timisoara, 300041, Romania
- Institute of Cardiovascular Diseases Timisoara, Timisoara, 300310, Romania
- Research Center of the Institute of Cardiovascular Diseases Timisoara, Timisoara, 300310, Romania
| | - Cristina Văcărescu
- Cardiology Department, “Victor Babes” University of Medicine and Pharmacy, Timisoara, 300041, Romania
- Institute of Cardiovascular Diseases Timisoara, Timisoara, 300310, Romania
- Research Center of the Institute of Cardiovascular Diseases Timisoara, Timisoara, 300310, Romania
| | - Lucian Petrescu
- Cardiology Department, “Victor Babes” University of Medicine and Pharmacy, Timisoara, 300041, Romania
| | - Liviu Cirin
- Cardiology Department, “Victor Babes” University of Medicine and Pharmacy, Timisoara, 300041, Romania
| | - Dragos Cozma
- Cardiology Department, “Victor Babes” University of Medicine and Pharmacy, Timisoara, 300041, Romania
- Institute of Cardiovascular Diseases Timisoara, Timisoara, 300310, Romania
- Research Center of the Institute of Cardiovascular Diseases Timisoara, Timisoara, 300310, Romania
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Enríquez-Vázquez D, Quintanilla JG, García-Escolano A, Couselo-Seijas M, Simón-Chica A, Lee P, Alfonso-Almazán JM, Mahía P, Redondo-Rodríguez A, Modrego J, Ortega-Hernández A, Marcos-Alberca P, Magni R, Calvo E, Gómez-Gordo R, Yan P, La Rosa G, Bustamante-Madrión J, Pérez-García CN, Martín-Sánchez FJ, Calvo D, de la Hera JM, García-Torrent MJ, García-Osuna Á, Ordonez-Llanos J, Vázquez J, Pérez-Villacastín J, Pérez-Castellano N, Loew LM, Sánchez-González J, Gómez-Garre D, Filgueiras-Rama D. Non-invasive electromechanical assessment during atrial fibrillation identifies underlying atrial myopathy alterations with early prognostic value. Nat Commun 2023; 14:4613. [PMID: 37542075 PMCID: PMC10403561 DOI: 10.1038/s41467-023-40196-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 07/18/2023] [Indexed: 08/06/2023] Open
Abstract
Electromechanical characterization during atrial fibrillation (AF) remains a significant gap in the understanding of AF-related atrial myopathy. This study reports mechanistic insights into the electromechanical remodeling process associated with AF progression and further demonstrates its prognostic value in the clinic. In pigs, sequential electromechanical assessment during AF progression shows a progressive decrease in mechanical activity and early dissociation from its electrical counterpart. Atrial tissue samples from animals with AF reveal an abnormal increase in cardiomyocytes death and alterations in calcium handling proteins. High-throughput quantitative proteomics and immunoblotting analyses at different stages of AF progression identify downregulation of contractile proteins and progressive increase in atrial fibrosis. Moreover, advanced optical mapping techniques, applied to whole heart preparations during AF, demonstrate that AF-related remodeling decreases the frequency threshold for dissociation between transmembrane voltage signals and intracellular calcium transients compared to healthy controls. Single cell simulations of human atrial cardiomyocytes also confirm the experimental results. In patients, non-invasive assessment of the atrial electromechanical relationship further demonstrate that atrial electromechanical dissociation is an early prognostic indicator for acute and long-term rhythm control.
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Affiliation(s)
- Daniel Enríquez-Vázquez
- Novel Arrhythmogenic Mechanisms Program, Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
- Servicio de Cardiología, Instituto de Investigación Biomédica A Coruña (INIBIC), Complexo Hospitalario Universitario A Coruña, A Coruña, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Jorge G Quintanilla
- Novel Arrhythmogenic Mechanisms Program, Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
- Cardiovascular Institute, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Alba García-Escolano
- Novel Arrhythmogenic Mechanisms Program, Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
- ETSI Telecomunicación, Universidad Politécnica de Madrid, Madrid, Spain
| | - Marinela Couselo-Seijas
- Novel Arrhythmogenic Mechanisms Program, Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
| | - Ana Simón-Chica
- Novel Arrhythmogenic Mechanisms Program, Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
| | - Peter Lee
- Essel Research and Development Inc., Toronto, ON, Canada
| | - José Manuel Alfonso-Almazán
- Novel Arrhythmogenic Mechanisms Program, Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
| | - Patricia Mahía
- Cardiovascular Institute, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Andrés Redondo-Rodríguez
- Novel Arrhythmogenic Mechanisms Program, Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
| | - Javier Modrego
- Novel Arrhythmogenic Mechanisms Program, Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
- Laboratorio de Microbiota y Biología Vascular, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Adriana Ortega-Hernández
- Laboratorio de Microbiota y Biología Vascular, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Pedro Marcos-Alberca
- Cardiovascular Institute, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Ricardo Magni
- Novel Arrhythmogenic Mechanisms Program, Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
| | - Enrique Calvo
- Novel Arrhythmogenic Mechanisms Program, Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Rubén Gómez-Gordo
- Laboratorio de Microbiota y Biología Vascular, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Ping Yan
- Richard D. Berlin Center for Cell Analysis and Modeling, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Giulio La Rosa
- Novel Arrhythmogenic Mechanisms Program, Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
| | - José Bustamante-Madrión
- Emergency Department, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Carlos Nicolás Pérez-García
- Novel Arrhythmogenic Mechanisms Program, Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
- Cardiovascular Institute, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - F Javier Martín-Sánchez
- Emergency Department, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - David Calvo
- Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain
| | - Jesús M de la Hera
- Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain
| | | | - Álvaro García-Osuna
- Department of Clinical Biochemistry, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Institut de Recerca de l'Hospital Santa Creu i Sant Pau, Institut d'Investigacions Biomèdiques, IIB Sant Pau, Barcelona, Spain
| | - Jordi Ordonez-Llanos
- Department of Clinical Biochemistry, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Universidad Autónoma, Barcelona, Spain
- Foundation for Clinical Biochemistry & Molecular Pathology, Madrid, Spain
| | - Jesús Vázquez
- Novel Arrhythmogenic Mechanisms Program, Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Julián Pérez-Villacastín
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
- Cardiovascular Institute, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
- Fundación Interhospitalaria para la Investigación Cardiovascular (FIC), Madrid, Spain
| | - Nicasio Pérez-Castellano
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
- Cardiovascular Institute, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
- Fundación Interhospitalaria para la Investigación Cardiovascular (FIC), Madrid, Spain
| | - Leslie M Loew
- Richard D. Berlin Center for Cell Analysis and Modeling, University of Connecticut School of Medicine, Farmington, CT, USA
| | | | - Dulcenombre Gómez-Garre
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
- Laboratorio de Microbiota y Biología Vascular, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - David Filgueiras-Rama
- Novel Arrhythmogenic Mechanisms Program, Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain.
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.
- Cardiovascular Institute, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain.
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Wang W, Zhang Y, Li Y, Zhai WH. Electrical cardioversion intervention in a patient with heat stroke accompanied by rapid atrial fibrillation: A case report and literature review. Heliyon 2023; 9:e15636. [PMID: 37206040 PMCID: PMC10189177 DOI: 10.1016/j.heliyon.2023.e15636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 01/31/2023] [Accepted: 04/17/2023] [Indexed: 05/21/2023] Open
Abstract
This report highlights the feasibility of electrical cardioversion intervention for the treatment of heat stroke complicated by rapid atrial fibrillation. There has never been any mentions in the previous literature of the possibility of electrical cardioversion in the event of heat stroke complicated by rapid arrhythmia. A 61-year-old man with classic heat stroke complicated by rapid atrial fibrillation was admitted to our emergency department. In the early stages of treatment, hemodynamics were not stable under the treatments of aggressive cooling and volume-expanding rehydration. It was considered to be related to rapid atrial fibrillation, and the administration of drug cardiover and control of ventricular rate failed. Subsequently, synchronous electrical cardioversion was given 3 times (biphasic wave, energy: 70J-80J-100J, respectively), successfully cardioversion and hemodynamically stable. Although the patient eventually died of progressive deterioration of multiple organ failure, timely cardioversion might be effective for the treatment of heat stroke complicated by rapid atrial fibrillation.
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López-Galvez R, Rivera-Caravaca JM, Roldán V, Orenes-Piñero E, Esteve-Pastor MA, López-García C, Saura D, González J, Lip GYH, Marín F. Imaging in atrial fibrillation: A way to assess atrial fibrosis and remodeling to assist decision-making. Am Heart J 2023; 258:1-16. [PMID: 36526006 DOI: 10.1016/j.ahj.2022.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 11/22/2022] [Accepted: 12/10/2022] [Indexed: 05/11/2023]
Abstract
The 2020 ESC atrial fibrillation (AF) guidelines suggest the novel 4S-AF scheme for the characterization of AF. Imaging techniques could be helpful for this objective in everyday clinical practice, and information derived from these techniques reflects basic aspects of the pathophysiology of AF, which may facilitate treatment decision-making, and optimal management of AF patients. The aim of this review is to provide an overview of the mechanisms associated with atrial fibrosis and to describe imaging techniques that may help the management of AF patients in clinical practice. Transthoracic echocardiography is the most common procedure given its versatility, safety, and simplicity. Transesophageal echocardiography provides higher resolution exploration, and speckle tracking echocardiography can provide incremental functional and prognostic information over conventional echocardiographic parameters. In addition, LA deformation imaging, including LA strain and strain rate, are related to the extent of fibrosis. On the other hand, multidetector-row computed tomography and cardiac magnetic resonance provide higher resolution data and more accurate assessment of the dimensions, structure, and spatial relationships of the LA. Imaging is central when deciding on catheter ablation or cardioversion, and helps in selecting those patients who will really benefit from these procedures. Moreover, imaging enhances the understanding of the underlying mechanisms of atrial remodeling and might assists in refining the risk of stroke, which help to select the best medical therapies/interventions. In summary, evaluation of LA enlargement, LA remodeling and fibrosis with imaging techniques adds clinical and prognostic information and should be assessed as a part of routine comprehensive AF evaluation.
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Affiliation(s)
- Raquel López-Galvez
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain
| | - José Miguel Rivera-Caravaca
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain; School of Nursing, University of Murcia, Murcia, Spain; Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom.
| | - Vanessa Roldán
- Department of Hematology and Clinical Oncology, Hospital General Universitario Morales Meseguer, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - Esteban Orenes-Piñero
- Department of Biochemistry and Molecular Biology, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain
| | - María Asunción Esteve-Pastor
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain
| | - Cecilia López-García
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain
| | - Daniel Saura
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain
| | - Josefa González
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Francisco Marín
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain
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The Complex Relation between Atrial Cardiomyopathy and Thrombogenesis. Cells 2022; 11:cells11192963. [PMID: 36230924 PMCID: PMC9563762 DOI: 10.3390/cells11192963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 09/16/2022] [Accepted: 09/19/2022] [Indexed: 11/17/2022] Open
Abstract
Heart disease, as well as systemic metabolic alterations, can leave a ‘fingerprint’ of structural and functional changes in the atrial myocardium, leading to the onset of atrial cardiomyopathy. As demonstrated in various animal models, some of these changes, such as fibrosis, cardiomyocyte hypertrophy and fatty infiltration, can increase vulnerability to atrial fibrillation (AF), the most relevant manifestation of atrial cardiomyopathy in clinical practice. Atrial cardiomyopathy accompanying AF is associated with thromboembolic events, such as stroke. The interaction between AF and stroke appears to be far more complicated than initially believed. AF and stroke share many risk factors whose underlying pathological processes can reinforce the development and progression of both cardiovascular conditions. In this review, we summarize the main mechanisms by which atrial cardiomyopathy, preceding AF, supports thrombogenic events within the atrial cavity and myocardial interstitial space. Moreover, we report the pleiotropic effects of activated coagulation factors on atrial remodeling, which may aggravate atrial cardiomyopathy. Finally, we address the complex association between AF and stroke, which can be explained by a multidirectional causal relation between atrial cardiomyopathy and hypercoagulability.
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Malavasi VL, Fantecchi E, Tordoni V, Melara L, Barbieri A, Vitolo M, Lip GYH, Boriani G. Atrial fibrillation pattern and factors affecting the progression to permanent atrial fibrillation. Intern Emerg Med 2021; 16:1131-1140. [PMID: 33161524 DOI: 10.1007/s11739-020-02551-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Accepted: 10/22/2020] [Indexed: 12/12/2022]
Abstract
Atrial fibrillation (AF) may progress from a non-permanent to a permanent form, and improvement in prediction may help in decision-making. In- and outpatients with non-permanent AF were enrolled in a prospective study and followed every 6 months. At baseline, 314 out of 523 patients (60%) had non-permanent AF (25.5% paroxysmal AF, 52.5% persistent, 2% first diagnosed AF). They were mostly males (188, 59.9%), median age 71 years [interquartile range (IQ) 62-77], median CHA2DS2VASc 3 (IQ 1-4), median HATCH score 1 (IQ 1-2). During a follow-up of 701 (IQ 437-902) days, 66 patients (21%) developed permanent AF. CHA2DS2VASc and HATCH scores were incrementally associated with AF progression (p for trend CHA2DS2VASc < 0.001, HATCH p = 0.001). Cox multivariable proportional hazard regression analysis showed that age [hazard ratio (HR) 1.042; 95%CI 1.005-1.080; p = 0.025], moderate-severe left atrial (LA) enlargement at echo (HR 2.072, 95%CI, 1.121-3.831; p = 0.020), antiarrhythmics drugs (HR 0.087, 95%CI 0.011-0.659, p = 0.018), EHRA score > 2 (HR 0.358, 95%CI 0.162-0.791, p = 0.011) and valvular disease (HR 2.196, 95%CI 1.072-4.499, p = 0.032) were significantly associated with AF progression. Adding "moderate-severe LA dilation" to clinical scores, eg. HATCH score (HATCH-LA) with 2 points (Cox multivariable regression analysis) improved prediction of AF progression vs. HATCH score (p = 0.0225). In patients without permanent AF, progression of AF was independently associated with age, LA dilation, AF symptoms severity, antiarrhythmic drugs and valvular disease. Adding LA dilation (moderate-severe volume increase) to clinical scores improved prediction of progression to permanent AF.
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Affiliation(s)
- Vincenzo Livio Malavasi
- Cardiology Division, Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico Di Modena, Via del Pozzo 71, 41121, Modena, Italy
| | - Elisa Fantecchi
- Cardiology Division, Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico Di Modena, Via del Pozzo 71, 41121, Modena, Italy
| | - Virginia Tordoni
- Cardiology Division, Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico Di Modena, Via del Pozzo 71, 41121, Modena, Italy
| | - Laura Melara
- Cardiology Division, Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico Di Modena, Via del Pozzo 71, 41121, Modena, Italy
| | - Andrea Barbieri
- Cardiology Division, Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico Di Modena, Via del Pozzo 71, 41121, Modena, Italy
| | - Marco Vitolo
- Cardiology Division, Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico Di Modena, Via del Pozzo 71, 41121, Modena, Italy
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Giuseppe Boriani
- Cardiology Division, Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico Di Modena, Via del Pozzo 71, 41121, Modena, Italy.
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