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Miyama H, Ikemura N, Kimura T, Katsumata Y, Yamashita S, Yamaoka K, Ibe S, Sekine O, Ueda I, Nakamura I, Negishi K, Kohsaka S, Takatsuki S, Ieda M. Predictors and incidence of health status deterioration in patients with early atrial fibrillation. Heart Rhythm 2024:S1547-5271(24)02341-5. [PMID: 38599472 DOI: 10.1016/j.hrthm.2024.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Revised: 03/08/2024] [Accepted: 04/04/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND Various treatment approaches for atrial fibrillation (AF) have demonstrated improved health status, yet the significance of these therapeutic interventions in individual patients remains unclear. OBJECTIVE This study aimed to evaluate health status changes in patients with early AF, focusing on those who experience clinically significant deterioration after treatment initiation. METHODS We analyzed data from a multicenter, prospective registry of newly diagnosed patients with AF. One-year changes in health status across different treatment strategies were assessed by the Atrial Fibrillation Effect on QualiTy-of-life Overall Summary (AFEQT-OS) score. Clinically relevant deterioration and improvement in health status were defined as ≥5-point decrease and increase in AFEQT-OS score, respectively; no change was -5 to 5 points. RESULTS Overall, 1960 patients with AF were evaluated. Mean AFEQT-OS scores at baseline and 1-year follow-up were 76.7 ± 17.7 and 85.4 ± 14.8, respectively. Although most patients (53.9%) experienced clinically important improvement, a considerable proportion had no change (28.7%) or deterioration (17.4%) in their health status. Proportions of patients with no change or deterioration varied by treatment strategy: 59.9%, 53.9%, and 32.0% in rate control, antiarrhythmic drug, and catheter ablation groups, respectively. The multivariable model identified older age, female sex, heart failure, coronary artery disease, and higher baseline AFEQT-OS score as independent predictors of worsening health status, regardless of treatment strategy. CONCLUSION Many patients with early AF experience worsening or no change in health status irrespective of treatment strategy. Standardizing patients' health status assessment, especially for patients with comorbidities, may aid in patients' selection and their outcomes.
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Affiliation(s)
- Hiroshi Miyama
- Department of Cardiology, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Nobuhiro Ikemura
- Department of Cardiology, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan; Healthcare Institute for Innovations in Quality, University of Missouri, and Saint Luke's Mid America Heart Institute, Kansas City, Missouri
| | - Takehiro Kimura
- Department of Cardiology, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Yoshinori Katsumata
- Department of Cardiology, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Shuhei Yamashita
- Department of Cardiology, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Koki Yamaoka
- Department of Cardiology, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Susumu Ibe
- Department of Cardiology, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Otoya Sekine
- Department of Cardiology, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Ikuko Ueda
- Department of Cardiology, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Iwao Nakamura
- Department of Cardiology, Hino Municipal Hospital, Hino, Tokyo, Japan
| | - Koji Negishi
- Department of Cardiology, Yokohama Municipal Citizen's Hospital, Kanagawa-ku, Yokohama, Japan
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Seiji Takatsuki
- Department of Cardiology, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan.
| | - Masaki Ieda
- Department of Cardiology, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
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Zhu X, Sun X, Muheyati M, Lv J, Goh Y, Loh Y, Luan Y. Rate control or revascularisation in managing atrial fibrillation-induced myocardial infarction and heart failure? Clin Med (Lond) 2024; 24:100034. [PMID: 38580210 DOI: 10.1016/j.clinme.2024.100034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2024]
Abstract
Acute myocardial infarction (MI) is a common and severe cardiovascular emergency that requires immediate treatment. Angina pectoris, which typically signals myocardial ischaemia, can appear in MI cases with myriad causes aside from coronary artery disease. However, not all MI patients benefit from invasive revascularisation therapy. We herein report a case involving a 78-year-old female patient with a complex medical history, including non-ST-segment elevation MI and coronary artery bypass grafting, who experienced recurrent chest pain. Instead of a direct result of coronary artery disease, her chest pain was later found to be primarily induced by atrial fibrillation (AF). Consequently, we shifted the focus of management to effective rate control for the AF after careful evaluation and achieved a satisfactory result. This case highlights the successful identification and timely application of intensive heart rate control management in an MI case induced by AF.
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Affiliation(s)
- Xianfeng Zhu
- Department of Cardiology, Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, China; School of Medicine, Zhejiang University, China; Department of Critical Care Medicine, Hangzhou Ninth People's Hospital, China
| | | | - Muergen Muheyati
- Department of Cardiology, Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, China; School of Medicine, Zhejiang University, China
| | - Jingyi Lv
- School of Medicine, Zhejiang University, China
| | - Yenfang Goh
- School of Medicine, Zhejiang University, China
| | - Yihao Loh
- School of Medicine, Zhejiang University, China
| | - Yi Luan
- Department of Cardiology, Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, China; School of Medicine, Zhejiang University, China; School of Medicine, Shaoxing University, China.
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Mattice AMS, Adler S, Eagles D, Yadav K, Hui S, Azward A, Pandey N, Stiell IG. Assessment of physician compliance to the CAEP 2021 Atrial Fibrillation Best Practices Checklist for rate and rhythm control in the emergency department. CAN J EMERG MED 2024:10.1007/s43678-024-00669-5. [PMID: 38519830 DOI: 10.1007/s43678-024-00669-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 02/25/2024] [Indexed: 03/25/2024]
Abstract
OBJECTIVES Acute atrial fibrillation and flutter (AF/AFL) are common arrhythmias treated in the emergency department (ED). The 2021 CAEP Best Practices Checklist provides clear recommendations for management of patients with acute AF/AFL. This study aimed to evaluate physician compliance to Checklist recommendations for risk assessment and ED management of AF/AFL. METHODS This health records review assessed the management of adult patients presenting to two tertiary care EDs for management of acute AF/AFL from January to August, 2022. All ECGs demonstrating AF/AFL with a heart rate greater than 100 were compiled to capture primary and secondary causes. All visits were assessed for rate and rhythm control management, adverse events, return to ED, and safety criteria. Study physicians classified safety criteria from the Checklist into high and moderate concerns. The primary outcome was the proportion of cases with safety concerns and adverse events occurring during management in the ED. Data were analyzed using simple descriptive statistics. RESULTS We included 429 patients with a mean age of 67.7 years and 57.1% male. ED management included rate control (20.4%), electrical (40.1%), and pharmacological (20.1%) cardioversion. Adverse events occurred in 9.5% of cases: 12.5% in rate control, 13.4% in electrical cardioversion, and 6.9% in pharmacologic cardioversion. Overall, 7.9% of cases had management safety concerns. Moderate safety concerns occurred in 4.9% of cases including failure to attain recommended heart rate at time of discharge (3.9%). Severe concerns were identified in 3.0% of cases including failure to cardiovert unstable patients (1.2%). The 30-day return-to-ED rate was 16.5% secondary to AF/AFL. CONCLUSION ED management of AF/AFL was consistent with the CAEP Checklist and was safe overall. Opportunities for optimizing care include attaining recommended targets during rate control, avoidance of calcium channel and beta blockers in patients with systolic dysfunction, and earlier cardioversion for clinically unstable patients.
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Affiliation(s)
- Amanda M S Mattice
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.
| | - Samara Adler
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Debra Eagles
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Krishan Yadav
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Sean Hui
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Althaf Azward
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Nikesh Pandey
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Ian G Stiell
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
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Gupta D, Rienstra M, van Gelder IC, Fauchier L. Atrial fibrillation: better symptom control with rate and rhythm management. Lancet Reg Health Eur 2024; 37:100801. [PMID: 38362560 PMCID: PMC10866934 DOI: 10.1016/j.lanepe.2023.100801] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 11/07/2023] [Accepted: 11/15/2023] [Indexed: 02/17/2024]
Abstract
Atrial fibrillation (AF) is often associated with limiting symptoms, and with significant impairment in quality of life. As such, treatment strategies aimed at symptom control form an important pillar of AF management. Such treatments include a wide variety of drugs and interventions, including, increasingly, catheter ablation. These strategies can be utilised either singly or in combination, to improve and restore quality of life for patients, and this review covers the current evidence base underpinning their use. In this Review, we discuss the pros and cons of rate vs. rhythm control, while offering practical tips to non-specialists on how to utilise various treatments and counsel patients about all relevant treatment options. These include antiarrhythmic and rate control medications, as well as interventions such as cardioversion, catheter ablation, and pace-and-ablate.
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Affiliation(s)
- Dhiraj Gupta
- Liverpool Heart & Chest Hospital, Thomas Drive, Liverpool, United Kingdom
- Liverpool Centre for Cardiovascular Science, University of Liverpool, United Kingdom
| | - Michiel Rienstra
- Department of Cardiology, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Isabelle C. van Gelder
- Department of Cardiology, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Laurent Fauchier
- Faculté de Médecine, Centre Hospitalier Universitaire Trousseau, Université François Rabelais, Tours, France
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Long B, Brady WJ, Gottlieb M. Emergency medicine updates: Atrial fibrillation with rapid ventricular response. Am J Emerg Med 2023; 74:57-64. [PMID: 37776840 DOI: 10.1016/j.ajem.2023.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 09/03/2023] [Accepted: 09/14/2023] [Indexed: 10/02/2023] Open
Abstract
INTRODUCTION Atrial fibrillation (AF) may lead to stroke, heart failure, and death. When AF occurs in the context of a rapid ventricular rate/response (RVR), this can lead to complications, including hypoperfusion and cardiac ischemia. Emergency physicians play a key role in the diagnosis and management of this dysrhythmia. OBJECTIVE This paper evaluates key evidence-based updates concerning AF with RVR for the emergency clinician. DISCUSSION Differentiating primary and secondary AF with RVR and evaluating hemodynamic stability are vital components of ED assessment and management. Troponin can assist in determining the risk of adverse outcomes, but universal troponin testing is not required in patients at low risk of acute coronary syndrome or coronary artery disease - especially patients with recurrent episodes of paroxysmal AF that are similar to their prior events. Emergent cardioversion is indicated in hemodynamically unstable patients. Rate or rhythm control should be pursued in hemodynamically stable patients. Elective cardioversion is a safe option for select patients and may reduce AF symptoms and risk of AF recurrence. Rate control using beta blockers or calcium channel blockers should be pursued in those with AF with RVR who do not undergo cardioversion. Anticoagulation is an important component of management, and several tools (e.g., CHA2DS2-VASc) are available to assist with this decision. Direct oral anticoagulants are the first-line medication class for anticoagulation. Disposition can be challenging, and several risk assessment tools (e.g., RED-AF, AFFORD, and the AFTER (complex, modified, and pragmatic) scores) are available to assist with disposition decisions. CONCLUSION An understanding of the recent updates in the literature concerning AF with RVR can assist emergency clinicians in the care of these patients.
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Affiliation(s)
- Brit Long
- SAUSHEC, Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
| | - William J Brady
- Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA.
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, USA
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Knudsen Pope M, Hall TS, Virdone S, Atar D, John Camm A, Pieper KS, Jansky P, Haas S, Goto S, Panchenko E, Baron-Esquivias G, Angchaisuksiri P, Kakkar AK. Rhythm versus rate control in patients with newly diagnosed atrial fibrillation - Observations from the GARFIELD-AF registry. Int J Cardiol Heart Vasc 2023; 49:101302. [PMID: 38020059 PMCID: PMC10656718 DOI: 10.1016/j.ijcha.2023.101302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 11/10/2023] [Indexed: 12/01/2023]
Abstract
Background Investigate real-world outcomes of early rhythm versus rate control in patients with recent onset atrial fibrillation. Methods The Global Anticoagulant Registry in the FIELD-AF (GARFIELD-AF) is an international multi-centre, non-interventional prospective registry of newly diagnosed (≤6 weeks' duration) atrial fibrillation patients at risk for stroke. Patients were stratified according to treatment initiated at baseline (≤48 days post enrolment), and outcome risks evaluated by overlap propensity weighted Cox proportional-hazards models. Results Of 45,382 non-permanent atrial fibrillation patients, 23,858 (52.6 %) received rhythm control and 21,524 (47.4 %) rate control. Rhythm-controlled patients had lower median age (68.0 [Q1;Q3: 60.0;76.0] versus 73.0 [65.0;79.0]), fewer histories of stroke/transient ischemic attack/systemic embolism (9.4 % versus 13.0 %), and lower expected probabilities of death (median GARFIELD-AF death score 4.0 [2.3;7.5] versus 5.1 [2.8;9.2]). The two groups had the same median CHA2DS2-VASc scores (3.0 [2.0;4.0]) and similar proportions of anticoagulated patients (rhythm control: 66.0 %, rate control: 65.5 %). The propensity-score-weighted hazard ratios of rhythm vs rate control (reference) were 0.85 (95 % CI: 0.79-0.92, p-value < 0.0001) for all-cause mortality, 0.84 (0.72-0.97, p-value 0.020) for non-haemorrhagic stroke/systemic embolism and 0.90 (0.78-1.04, p-value 0.164) for major bleeding. Conclusion Rhythm control strategy was initiated in about half of the patients with newly diagnosed non-valvular non-permanent atrial fibrillation. After balancing confounders, significantly lower risks of all-cause mortality and non-haemorrhagic stroke were observed in patients who received early rhythm control.
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Affiliation(s)
| | - Trygve S. Hall
- Department of Cardiology, Oslo University Hospital, Ullevål, Oslo, Norway
| | - Saverio Virdone
- Thrombosis Research Institute, London, the United Kingdom of Great Britain and Northern Ireland
| | - Dan Atar
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Cardiology, Oslo University Hospital, Ullevål, Oslo, Norway
| | - A. John Camm
- Cardiology Clinical Academic Group Molecular & Clinical Sciences Research Institute, St. George’s University of London, London, the United Kingdom of Great Britain and Northern Ireland
| | - Karen S Pieper
- Thrombosis Research Institute, London, the United Kingdom of Great Britain and Northern Ireland
| | - Petr Jansky
- Department of Cardiovascular Surgery, Motol University Hospital, Prague, Czech Republic
| | - Sylvia Haas
- Sylvia Haas: Formerly Department of Medicine, Technical University of Munich, Munich, Germany
| | | | - Elizaveta Panchenko
- National Medical Research Center of Cardiology of Ministry of Health of the Russian Federation, Moscow, Russian Federation
| | - Gonzalo Baron-Esquivias
- Servicio de Cardiología y Cirugía Cardíaca, Hospital Universitario Virgen del Rocío., Universidad de Sevilla., Sevilla. Departamento Cardiovascular, Instituto de Biotecnología de Sevilla (IBIS), Spain
| | | | - Ajay K Kakkar
- Thrombosis Research Institute, London, the United Kingdom of Great Britain and Northern Ireland
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Katheria A, Kapoor A, Sahu A, Raut K, Khare H, Khanna R, Kumar S, Garg N, Tewari S. A pilot study evaluating the role of ivabradine for rate control in patients with rheumatic atrial fibrillation. Indian Heart J 2023; 75:376-382. [PMID: 37666416 PMCID: PMC10568053 DOI: 10.1016/j.ihj.2023.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 08/28/2023] [Accepted: 08/29/2023] [Indexed: 09/06/2023] Open
Abstract
OBJECTIVES Ivabradine may have a role in rate control of atrial fibrillation (AF) due to effects on HCN channels in AV node. We studied role of Ivabradine in rate control of rheumatic AF. METHODS 80 patients, rheumatic AF, HR > 100 bpm (age 47 ± 11 yrs, AF duration 6.8 ± 2.9 years, rate 131 ± 16 bpm) on maximally tolerated ββ or CCB's, randomized to Ivabradine or escalated ββ/CCB. Ivabradine started @ 2.5 mg BD; increased to 5 mg BD if inadequate response at 1 week (failure to decrease HR < 10% vs baseline). After Holter at 1 month, dose escalated to 7.5 mg BD if needed. RESULTS Ivabradine resulted in significantly lower HR (81 ± 10 vs 99 ± 9) at 3 months and 6 months (79 ± 8 vs 94 ± 8, p < 0.001). Absolute reduction in HR: 56 ± 15 vs 31 ± 14 bpm and % change in HR: 41 ± 7 vs 24 ± 9%, both p < 0.00001). At 6 months, Ivabradine group had. 1Significantly lower NT Pro BNP (1168 vs 1314 pg/ml), higher 6 min walk distance (410 ± 47 vs 349 ± 54 m, all p < 0.001) 2Better symptom class (EHRA score 1: asymptomatic 84% vs 40%), improvement >1 EHRA class; baseline 60% vs 17% 3Better LA Strain (22.8 ± 2.8% vs 20.6 ± 2.5%) Ivabradine was well tolerated and there was no drug withdrawal. CONCLUSION Our data suggest that Ivabradine can be an option for rate control in rheumatic AF.
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Affiliation(s)
- Arpita Katheria
- Department of Cardiology, Sanjay Gandhi PGIMS, Lucknow, 226014, India.
| | - Aditya Kapoor
- Department of Cardiology, Sanjay Gandhi PGIMS, Lucknow, 226014, India
| | - Ankit Sahu
- Department of Cardiology, Sanjay Gandhi PGIMS, Lucknow, 226014, India
| | - Kamlesh Raut
- Department of Cardiology, Sanjay Gandhi PGIMS, Lucknow, 226014, India
| | - Harshit Khare
- Department of Cardiology, Sanjay Gandhi PGIMS, Lucknow, 226014, India
| | - Roopali Khanna
- Department of Cardiology, Sanjay Gandhi PGIMS, Lucknow, 226014, India
| | - Sudeep Kumar
- Department of Cardiology, Sanjay Gandhi PGIMS, Lucknow, 226014, India
| | - Naveen Garg
- Department of Cardiology, Sanjay Gandhi PGIMS, Lucknow, 226014, India
| | - Satyendra Tewari
- Department of Cardiology, Sanjay Gandhi PGIMS, Lucknow, 226014, India
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Cold IM, Feinberg JB, Brandes A, Davidsen U, Dixen U, Dominguez H, Gang UJO, Gluud C, Hadad R, Kristensen KE, van Le DT, Nielsen EE, Olsen MH, Pedersen OD, Raymond IE, Sajadieh A, Soja AMB, Jakobsen JC. Lenient rate control versus strict rate control for atrial fibrillation: a statistical analysis plan for the Danish Atrial Fibrillation (DanAF) randomized clinical trial. Trials 2023; 24:250. [PMID: 37005636 PMCID: PMC10068144 DOI: 10.1186/s13063-023-07247-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 03/13/2023] [Indexed: 04/04/2023] Open
Abstract
BACKGROUND A key decision in the treatment of atrial fibrillation is choosing between a rhythm control strategy or a rate control strategy as the main strategy. When choosing rate control, the optimal heart rate target is uncertain. The Danish Atrial Fibrillation trial is a randomized, multicenter, two-group, superiority trial comparing strict rate control versus lenient rate control in patients with either persistent or permanent atrial fibrillation at inclusion. To prevent bias arising from selective reporting and data-driven analyses, we developed a predefined description of the statistical analysis. METHODS The primary outcome of this trial is the physical component score of the SF-36 questionnaire. A total of 350 participants will be enrolled based on a minimal important difference of 3 points on the physical component score of the SF-36 questionnaire, a standard deviation of 10 points, a statistical power of 80% (beta of 20%), and an acceptable risk of type I error of 5%. All secondary, exploratory, and echocardiographic outcomes will be hypothesis-generating. The analyses of all outcomes will be based on the intention-to-treat principle. We will analyze continuous outcomes using linear regression adjusting for "site," type of atrial fibrillation at inclusion (persistent/ permanent), left ventricular ejection fraction (≥ 40% or < 40%), and the baseline value of the outcome (all as fixed effects). We define our threshold for statistical significance as a p-value of 0.05 and assessments of clinical significance will be based on the anticipated intervention effects defined in the sample size and power estimations. Thresholds for both statistical and clinical significance will be assessed according to the 5-step procedure proposed by Jakobsen and colleagues. DISCUSSION This statistical analysis plan will be published prior to enrolment completion and before any data are available and is sought to increase the validity of the DANish Atrial Fibrillation trial. TRIAL REGISTRATION Clinicaltrials.gov NCT04542785. Registered on Sept 09, 2020.
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Affiliation(s)
- Isak Mazanti Cold
- The Faculty of Health and Medical Sciences, The University of Copenhagen, Copenhagen, Denmark.
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark.
- Department of Internal Medicine - Section of Cardiology, Holbaek Hospital, Holbaek, Region Zealand, Denmark.
| | - Joshua Buron Feinberg
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Internal Medicine - Section of Cardiology, Holbaek Hospital, Holbaek, Region Zealand, Denmark
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Axel Brandes
- Department of Cardiology, Odense University Hospital, Odense C, Denmark
- Department of Cardiology, Esbjerg Hospital - University Hospital of Southern Denmark, Esbjerg, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Ulla Davidsen
- Department of Cardiology, Copenhagen University Hospital Bispebjerg and Frederiksberg, Copenhagen, Capital Region of Denmark, Denmark
| | - Ulrik Dixen
- Department of Cardiology, University Hospital Amager and Hvidovre, Copenhagen, Denmark
| | - Helena Dominguez
- Department of Cardiology, Copenhagen University Hospital Bispebjerg and Frederiksberg, Copenhagen, Capital Region of Denmark, Denmark
- Department of Biomedicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Uffe Jakob Ortved Gang
- Department of Cardiology, Zealand University Hospital Roskilde, Roskilde, Region Zealand, Denmark
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Rakin Hadad
- Department of Cardiology, Copenhagen University Hospital Bispebjerg and Frederiksberg, Copenhagen, Capital Region of Denmark, Denmark
| | | | - Doan Tuyet van Le
- Department of Cardiology, Zealand University Hospital Roskilde, Roskilde, Region Zealand, Denmark
| | - Emil Eik Nielsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Internal Medicine - Section of Cardiology, Holbaek Hospital, Holbaek, Region Zealand, Denmark
| | - Michael Hecht Olsen
- Department of Internal Medicine - Section of Cardiology, Holbaek Hospital, Holbaek, Region Zealand, Denmark
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Ole Dyg Pedersen
- Department of Cardiology, Zealand University Hospital Roskilde, Roskilde, Region Zealand, Denmark
| | - Ilan Esra Raymond
- Department of Cardiology, University Hospital Amager and Hvidovre, Copenhagen, Denmark
| | - Ahmad Sajadieh
- Department of Cardiology, Copenhagen University Hospital Bispebjerg and Frederiksberg, Copenhagen, Capital Region of Denmark, Denmark
| | - Anne Merete Boas Soja
- Department of Internal Medicine - Section of Cardiology, Holbaek Hospital, Holbaek, Region Zealand, Denmark
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
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9
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Uruthirakumar P, Surenthirakumaran R, Gooden TE, Lip GYH, Thomas GN, Moore DJ, Nirantharakumar K, Kumarendran B, Subaschandran K, Kaneshamoorthy S, Sheron VA, Guruparan M. The impact of rate and rhythm control strategies on quality of life for patients with atrial fibrillation: a protocol for a systematic review. Syst Rev 2023; 12:52. [PMID: 36945026 PMCID: PMC10029179 DOI: 10.1186/s13643-023-02197-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 02/24/2023] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND Atrial fibrillation (AF) is the most common heart arrhythmia globally and it adversely affects the quality of life (QoL). Available rate and rhythm control strategies equally reduce mortality but may impact QoL differently. A number of systematic reviews have focused on the impact of specific strategies on QoL, though a 2006 review synthesized the evidence on the effect of all strategies on QoL, allowing for a clinically important comparison between the types of strategies. Many trials have been published since the review undertook the search in 2005; therefore, an update is needed. This systematic review aims to provide an update to the 2006 review on the impact of all rate and rhythm control strategies on QoL in people with AF. METHODS The following four databases and three clinical trial registries will be searched for primary studies: CENTRAL, MEDLINE, Embase, CINAHL, WHO International Clinical Trials Registry Platform, ClinicalTrials.gov, and ClinicalTrialsRegister.eu. No language restriction will be applied. The search will be limited to 2004 or later publication year to allow overlap with the search conducted by the 2006 review authors. Any randomized control trial that reports the QoL of adult (≥ 18 years) AF patients following an eligible rate or rhythm control intervention will be eligible for inclusion. Eligible interventions (and comparators) include pacing, atrioventricular node junction and bundle of HIS ablation, pharmacological therapy, radio frequency catheter ablation, cryoablation, pulmonary vein isolation, maze operation, pace maker implantation, and defibrillator implantation. Two reviewers will independently screen for eligible studies, extract the data using a piloted tool, and assess bias by QoL outcome using the RoB 2 tool. The suitability of conducting a meta-analysis will be assessed by the clinical and methodology similarities of included studies. If it is feasible, standardized mean differences will be pooled using a random-effects model and assessed appropriately. DISCUSSION The findings from this review will allow for meaningful comparisons between various rate and rhythm control strategies regarding their impact on QoL. This review will be useful for a wide range of stakeholders and will be crucial for optimizing the overall wellbeing of AF patients. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42021290542.
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Affiliation(s)
- Powsiga Uruthirakumar
- Department of Community and Family Medicine, Faculty of Medicine, University of Jaffna, Jaffna, Sri Lanka
| | - Rajendra Surenthirakumaran
- Department of Community and Family Medicine, Faculty of Medicine, University of Jaffna, Jaffna, Sri Lanka.
| | - Tiffany E Gooden
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Gregory Y H Lip
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK.
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK.
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
| | - G Neil Thomas
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - David J Moore
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | - Balachandran Kumarendran
- Department of Community and Family Medicine, Faculty of Medicine, University of Jaffna, Jaffna, Sri Lanka
| | - Kumaran Subaschandran
- Department of Community and Family Medicine, Faculty of Medicine, University of Jaffna, Jaffna, Sri Lanka
| | - Shribavan Kaneshamoorthy
- Department of Community and Family Medicine, Faculty of Medicine, University of Jaffna, Jaffna, Sri Lanka
| | - Vethanayagam Antony Sheron
- Department of Community and Family Medicine, Faculty of Medicine, University of Jaffna, Jaffna, Sri Lanka
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10
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Chaumont C, Auquier N, Milhem A, Mirolo A, Arnaout AA, Popescu E, Algrin A, Dupasquier V, Viart G, Godin B, Savouré A, Eltchaninoff H, Anselme F. His-bundle pacing and atrioventricular nodal ablation for noncontrolled atrial arrhythmia: A technical challenge with major clinical benefits. Heart Rhythm 2022:S1547-5271(22)02728-X. [PMID: 36549630 DOI: 10.1016/j.hrthm.2022.12.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 12/01/2022] [Accepted: 12/15/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND His-bundle pacing (HBP) is an appealing alternative to right ventricular pacing in patients referred for permanent ventricular pacing and atrioventricular nodal ablation (AVNA) because it preserves physiological ventricular activation. Only limited data regarding HBP combined with AVNA are available in the literature. OBJECTIVE The purpose of this study was to provide further evidence on the feasibility and efficacy of this therapeutic approach in patients with uncontrolled atrial arrhythmia. METHODS We prospectively included all patients who had undergone AVNA after HBP in 3 different hospitals between 2017 and 2022. RESULTS AVNA following HBP lead implantation was performed in 75 patients. Complete atrioventricular (AV) block was obtained in 58 patients (77%), and significant modulation of AV nodal conduction (heart rate <60 bpm) was obtained in 12 patients (16%). AVNA failure was observed in 5 patients (7%). Recording of an atrial signal by the HBP lead was more frequently observed in patients with AVNA modulation/failure than in patients with complete AV block (11/17 vs 5/58; P <.001). No lead dislodgment occurred during the AVNA procedures. Acute His-bundle (HB) capture threshold increase >1 V occurred in 11 patients (15%), with return to baseline value on day 1 in 9 patients. New York Heart Association functional class and left ventricular ejection fraction significantly improved from baseline to last follow-up (3.0 ± 0.7 vs 1.6 ± 0.5; P <.001; and 47% ± 14% vs 60% ± 9%; P <.0001, respectively). CONCLUSION AVNA combined with HBP for noncontrolled atrial arrhythmia was feasible and clinically efficient. Implanting the HB lead on the ventricular aspect of the tricuspid annulus avoiding atrial signal recording can facilitate AVNA.
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11
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Goette A, Brandner S. [Atrial fibrillation on the intensive care unit : The special prognostic importance of the first manifestation]. Herzschrittmacherther Elektrophysiol 2022; 33:391-397. [PMID: 36156739 DOI: 10.1007/s00399-022-00899-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 09/01/2022] [Indexed: 06/16/2023]
Abstract
Atrial fibrillation (AF) is the most common arrhythmia in the intensive care unit (ICU) and is associated with increased mortality. The AF is classified into five different forms, initially diagnosed AF, paroxysmal AF, persistent AF, long-standing persistent AF and permanent AF. Studies could confirm that the first manifestation of AF (new onset AF) is of particular importance in intensive care patients. The mortality and costs are much higher than for patients with chronic AF. This important clinical difference of the AF pattern should be taken into consideration in the treatment of intensive care patients. The treatment of comorbidities is essential in the treatment concept on the ICU. In patients with an increased risk of thromboembolic complications, therapeutic anticoagulation is indicated, although the greatly increased risk of bleeding during intensive care treatment should be considered in individual cases. In cases of hemodynamic instability electrical cardioversion should immediately be carried out. Otherwise, pharmacological cardioversion can also be carried out. Apart from a few exceptions, amiodarone is the antiarrhythmic drug of choice for rhythm control due to the contraindications for other drugs.
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Affiliation(s)
- Andreas Goette
- Medizinische Klinik II: Kardiologie und Intensivmedizin, St. Vincenz-Krankenhaus Paderborn, Am Busdorf 2, 33098, Paderborn, Deutschland.
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12
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Hesse K. Target heart rate in heart failure with reduced ejection fraction and atrial fibrillation: Goldilocks zone. Am Heart J Plus 2022; 23:100218. [PMID: 38560658 PMCID: PMC10978401 DOI: 10.1016/j.ahjo.2022.100218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 09/13/2022] [Accepted: 10/14/2022] [Indexed: 04/04/2024]
Abstract
The rates of atrial fibrillation (AF) and heart failure with reduced ejection fraction (HFrEF) continue to grow with many patients suffering from their combined impact on quality of life and prognosis. A lower heart rate (HR) in HFrEF is associated with reduced morbidity and mortality due to beta-blocker and ivabradine therapy. Postulated mechanisms include reduced neurohumoral activation, increased diastolic filling time and myocardial energy conservation. In contrast, the landmark randomised controlled non-inferiority RACE II trial demonstrated that a lenient rate control strategy (target HR <110 beats per minute [bpm]) was more attainable and safer than a strict rate control strategy (resting HR <80 bpm) in permanent AF. Physiologically, a higher HR is needed to compensate for the lost 'atrial kick' that contributes to the cardiac output by coordinated atrial contractions in normal sinus rhythm. This leaves the not insignificant number of patients with HFrEF and AF in a conundrum over optimal HR control. Retrospective analyses of AF and HR control in landmark HFrEF trials (e.g. CHARM, PARADIGM and ATMOSPHERE) point towards better outcomes with a less stringent target HR. However, this association disappears after adjustment for known prognostic markers in HFrEF, including left ventricular ejection fraction, New York Heart Association class and NT-proBNP levels. There is a clear need for dedicated randomised controlled trials, investigating rate control strategies in this increasingly large subgroup of patients. Regardless of rate control strategy, effective anti-coagulation and guideline-directed medical therapy must not be forgotten in the treatment of patients with HFrEF and AF.
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Affiliation(s)
- Kerrick Hesse
- Sunderland Royal Hospital, Kayll Road, Sunderland SR4 7TP, UK
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13
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Abstract
In the present article, we will focus on the pharmacologic treatment of atrial flutter aimed either at restoring/maintaining sinus rhythm or controlling the ventricular response during tachyarrhythmia. To provide a comprehensive description we will start discussing the electroanatomic substrate underlying the development of atrial flutter and the complex relationship with atrial fibrillation. We will then describe the available drugs for the treatment of atrial flutter on the bases of their electrophysiological effects and data from available clinical studies. We will conclude by discussing the general principles of rhythm and rate control treatment during atrial flutter.
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14
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Chapalain X, Oilleau JF, Henaff L, Lorillon PharmD P, Saout DL, Kha P, Pluchon K, Bezon E, Huet O. Short acting intravenous beta-blocker as a first line of treatment for atrial fibrillation after cardiac surgery: a prospective observational study. Eur Heart J Suppl 2022; 24:D34-D42. [PMID: 35706899 PMCID: PMC9190753 DOI: 10.1093/eurheartjsupp/suac025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Post-operative atrial fibrillation (POAF) defined as a new-onset of atrial fibrillation (AF) following surgery occurs frequently after cardiac surgery. For non-symptomatic patients, rate control strategy seems to be as effective as rhythm control one in surgical patients. Landiolol is a new highly cardio-selective beta-blocker agent with interesting pharmacological properties that may have some interest in this clinical situation. This is a prospective, monocentric, observational study. All consecutive adult patients (age >18 years old) admitted in the intensive care unit following cardiac surgery with a diagnosed episode of AF were eligible. Success of landiolol administration was defined by a definitive rate control from the beginning of infusion to the 72th h. We also evaluated rhythm control following landiolol infusion. Safety analysis was focused on haemodynamic, renal and respiratory side effects. From 1 January 2020 to 30 June 2021, we included 54 consecutive patients. A sustainable rate control was obtained for 49 patients (90.7%). Median time until a sustainable rate control was 4 h (1, 22). Median infusion rate of landiolol needed for a sustainable rate control was 10 µg/kg/min (6, 19). Following landiolol infusion, median time until pharmacological cardioversion was 24 h. During landiolol infusion, maintenance of mean arterial pressure target requires a concomitant very low dose of norepinephrine. We did not find any other side effects. Low dose of landiolol used for POAF treatment was effective and safe for a rapid and sustainable rate and rhythm control after cardiac surgery.
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Affiliation(s)
- X Chapalain
- Department of Anesthesiology and Surgical intensive care unit, Brest University Hospital, 29200 Brest, France
| | - J F Oilleau
- Department of Anesthesiology and Surgical intensive care unit, Brest University Hospital, 29200 Brest, France
| | - L Henaff
- Department of Anesthesiology and Surgical intensive care unit, Brest University Hospital, 29200 Brest, France
| | - P Lorillon PharmD
- Department of Pharmacy, Brest University Hospital, 29200 Brest, France
| | - D Le Saout
- Department of Anesthesiology and Surgical intensive care unit, Brest University Hospital, 29200 Brest, France
| | - P Kha
- Department of Anesthesiology and Surgical intensive care unit, Brest University Hospital, 29200 Brest, France
| | - K Pluchon
- Department of Cardiovascular and Thoracic Surgery, Brest University Hospital, 29200 Brest, France
| | - E Bezon
- Department of Cardiovascular and Thoracic Surgery, Brest University Hospital, 29200 Brest, France
| | - O Huet
- Department of Anesthesiology and Surgical intensive care unit, Brest University Hospital, 29200 Brest, France
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15
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Guo Y, Kotalczyk A, Wang Y, Lip GYH. Digoxin use and clinical outcomes in elderly Chinese patients with atrial fibrillation: a report from the Optimal Thromboprophylaxis in Elderly Chinese Patients with Atrial Fibrillation (ChiOTEAF) registry. Europace 2022; 24:1076-1083. [PMID: 35025995 DOI: 10.1093/europace/euab319] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 12/13/2021] [Indexed: 11/13/2022] Open
Abstract
AIMS Prior studies have reported conflicting results on digoxin's impact on clinical outcomes and quality of life, and there are limited data from Asia. The aim of this study is to evaluate the use of digoxin and its impact on clinical outcomes and quality of life in a high-risk cohort of elderly Chinese atrial fibrillation (AF) patients. METHODS AND RESULTS The Optimal Thromboprophylaxis in Elderly Chinese Patients with Atrial Fibrillation (ChiOTEAF) registry is a prospective, multicentre nationwide study conducted from October 2014 to December 2018. Endpoints of interest were the composite outcome of all-cause death/any thromboembolism (TE), all-cause death, cardiovascular death, sudden cardiac death, and TE events, as well as the quality of life. The eligible cohort for this analysis included 6391 individuals, of whom 751 (11.8%) patients were treated with digoxin. On multivariate analysis, the use of digoxin was associated with a higher odds ratio (OR) of composite outcome [OR: 1.71; 95% confidence interval (CI): 1.32-2.22], all-cause death (OR: 1.62; 95% CI: 1.23-2.14), and any TE (OR: 1.78; 95% CI: 1.08-2.95). Results were consistent in a subgroup of patients with diagnosed heart failure (HF) and patients with permanent AF. The use of digoxin was associated with worse health-related quality of life (mean EQ index: 0.76 ± 0.19 vs. 0.84 ± 0.18; P < 0.001). CONCLUSIONS In this nationwide cohort study, digoxin use was associated with an overall higher risk of the composite outcome of all-cause death/any TE, all-cause death, and any TE, regardless of HF diagnosis. Patients treated with digoxin had a worse health-related quality of life.
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Affiliation(s)
- Yutao Guo
- Department of Pulmonary Vessel and Thrombotic Disease, Sixth Medical Centre, Chinese PLA General Hospital, Beijing 100142, China.,Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool Heart & Chest Hospital, Liverpool L14 3PE, UK
| | - Agnieszka Kotalczyk
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool Heart & Chest Hospital, Liverpool L14 3PE, UK.,Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Medical University of Silesia, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Yutang Wang
- Department of Cardiology, Second Medical Centre, Chinese PLA General Hospital, Beijing 100853, China
| | - Gregory Y H Lip
- Department of Pulmonary Vessel and Thrombotic Disease, Sixth Medical Centre, Chinese PLA General Hospital, Beijing 100142, China.,Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool Heart & Chest Hospital, Liverpool L14 3PE, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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16
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Sharda SC, Bhatia MS. Comparison of diltiazem and metoprolol for atrial fibrillation with rapid ventricular rate: Systematic review and meta-analysis. Indian Heart J 2022; 74:494-499. [PMID: 36334652 PMCID: PMC9773285 DOI: 10.1016/j.ihj.2022.10.195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 09/08/2022] [Accepted: 10/31/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Intravenous calcium channel blockers or beta-blockers are the preferred rate control medications for hemodynamically stable patients with atrial fibrillation with rapid ventricular rate (AF-RVR) in the emergency department. OBJECTIVES To compare the efficacy of intravenous diltiazem and metoprolol for rate control and safety with respect to development of hypotension and bradycardia in patients with AF-RVR. METHODS For this systematic review and meta-analysis, we searched PubMed, Embase, Cochrane databases, and the clinicaltrials.gov registry between database inception and 30th May 2021. Articles were included if they compared efficacy and safety of diltiazem versus metoprolol in critically ill adult patients hospitalized with AF-RVR. Outcome measures were achievement of rate control, development of new hypotension, and bradycardia after drug administration. RESULTS Of 86 records identified, 14 were eligible, all of which had a low to moderate risk of overall bias. The meta-analysis (Mantel-Haenszel, random-effects model) showed that diltiazem use was associated with increased achievement of rate control target compared to metoprolol [14 studies, n = 1732, Odds Ratio (OR): 1.92; 95% Confidence Intervals (CI):1.26 to 2.90; I2 = 61%]. In the pooled analysis, no differences were seen in hypotension using diltiazem vs metoprolol [12 studies, n = 1477, OR: 0.96; 95% CI:0.61 to 1.52; I2 = 35%] or bradycardia [9 studies, n = 1203, OR: 2.44; 95% CI: 0.82 to 7.31; I2 = 48%]. CONCLUSIONS Intravenous diltiazem is associated with increased achievement of rate control target in patients with AF-RVR compared to metoprolol, while both medications are associated with similar incidence of hypotension and bradycardia.
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Affiliation(s)
| | - Mandip S. Bhatia
- Corresponding author. 27, F-Block, Level-4, Nehru Hospital, Postgraduate Institute of Medical Education and Research (P.G.I.M.E.R.), Chandigarh 160012, India.
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17
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Subramanya V, Claxton JS, Lutsey PL, MacLehose RF, Chen LY, Chamberlain AM, Norby FL, Alonso A. Sex differences in treatment strategy and adverse outcomes among patients 75 and older with atrial fibrillation in the MarketScan database. BMC Cardiovasc Disord 2021; 21:598. [PMID: 34915858 PMCID: PMC8679994 DOI: 10.1186/s12872-021-02419-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Accepted: 12/03/2021] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Women with atrial fibrillation (AF) experience greater symptomatology, worse quality of life, and have a higher risk of stroke as compared to men, but are less likely to receive rhythm control treatment. Whether these differences exist in elderly patients with AF, and whether sex modifies the effectiveness of rhythm versus rate control therapy has not been assessed. METHODS We studied 135,850 men and 139,767 women aged ≥ 75 years diagnosed with AF in the MarketScan Medicare database between 2007 and 2015. Anticoagulant use was defined as use of warfarin or a direct oral anticoagulant. Rate control was defined as use of rate control medication or atrioventricular node ablation. Rhythm control was defined by use of anti-arrhythmic medication, catheter ablation or cardioversion. We used multivariable Poisson and Cox regression models to estimate the association of sex with treatment strategy and to determine whether the association of treatment strategy with adverse outcomes (bleeding, heart failure and stroke) differed by sex. RESULTS At the time of AF, women were on average (SD) 83.8 (5.6) years old and men 82.5 (5.2) years, respectively. Compared to men, women were less likely to receive an anticoagulant or rhythm control treatment. Rhythm control (vs. rate) was associated with a greater risk for heart failure with a significantly stronger association in women (HR women = 1.41, 95% CI 1.34-1.49; HR men = 1.21, 95% CI 1.15-1.28, p < 0.0001 for interaction). No sex differences were observed for the association of treatment strategy with the risk of bleeding or stroke. CONCLUSION Sex differences exist in the treatment of AF among patients aged 75 years and older. Women are less likely to receive an anticoagulant and rhythm control treatment. Women were also at a greater risk of experiencing heart failure as compared to men, when treated with rhythm control strategies for AF. Efforts are needed to enhance use AF therapies among women. Future studies will need to delve into the mechanisms underlying these differences.
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Affiliation(s)
- Vinita Subramanya
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, 30322, USA.
| | - J'Neka S Claxton
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, 30322, USA
| | - Pamela L Lutsey
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Richard F MacLehose
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Lin Y Chen
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Alanna M Chamberlain
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Faye L Norby
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Health System, Los Angeles, CA, USA
| | - Alvaro Alonso
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, 30322, USA
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Abstract
Patients with atrial fibrillation (AF) were largely excluded from the major clinical trials of cardiac resynchronization therapy (CRT), despite the presence of AF in up to 40% of patients receiving CRT in clinical practice. AF appears to attenuate the response to CRT, by the combination of a reduction in biventricular pacing and the loss of atrioventricular synchrony. In addition, remodeling secondary to CRT may influence the progression of AF. Management options for patients with AF and CRT include rate control, with drugs or atrioventricular node ablation, or rhythm control, with electrical cardioversion and antiarrhythmic therapy, or AF catheter ablation. The evidence for these therapies in patients with CRT is largely limited to observational studies or inferred from randomized studies in the general heart failure population. In this review, we explore the complex interaction between AF, heart failure, and CRT and discuss the evidence for the treatment options in this difficult patient cohort.
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Affiliation(s)
- Mark K. Elliott
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
- Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Vishal S. Mehta
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
- Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Dejana Martic
- Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Baldeep S. Sidhu
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
- Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Steven Niederer
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
| | - Christopher A. Rinaldi
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
- Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
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Suzuki S, Yamashita T, Otsuka T, Arita T, Yagi N, Kishi M, Semba H, Kano H, Matsuno S, Kato Y, Uejima T, Oikawa Y, Matsuhama M, Iida M, Inoue T, Yajima J. Identifying risk patterns in older adults with atrial fibrillation by hierarchical cluster analysis: A retrospective approach based on the risk probability for clinical events. Int J Cardiol Heart Vasc 2021; 37:100883. [PMID: 34632044 PMCID: PMC8487977 DOI: 10.1016/j.ijcha.2021.100883] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 09/05/2021] [Accepted: 09/21/2021] [Indexed: 12/25/2022]
Abstract
In older AF patients, representative AF-related outcomes compete, causing difficulty in decision making. We proposed cluster analysis using risk probability for four AF-related outcomes. Older adults with AF were classified into 3 clusters. The clusters could possibly identify older adults with AF with good/poor responses to AF-related treatment.
Background Older adults with atrial fibrillation (AF) have highly diverse risk levels for mortality, heart failure (HF), thromboembolism (TE), and major bleeding (MB), thus an integrated risk-pattern algorithm is warranted. Methods We analyzed 573 AF patients aged ≥ 75 years from our single-center cohort (Shinken Database 2010–2018). The 3-year risk scores (risk probability) for mortality (M-score), HF (HF-score), TE (TE-score), and MB (MB-score) were estimated for each patient by logistic regression analysis. Using the four risk scores, cluster analysis was performed with Ward’s linkage hierarchical algorithm. Results Three clusters were identified: Clusters 1 (n = 429, 74%), 2 (n = 24, 5%), and 3 (n = 120, 21%). The clusters were characterized as standard risk (Cluster 1), high TE- and MB-risk (Cluster 2), and high M- and HF-risk (Cluster 3). Oral anticoagulants were prescribed for over 80% of the patients in each cluster. Catheter ablation for AF was performed only in Cluster 1 (8.9%). Compared with Cluster 1, Cluster 2 was more closely associated with males, asymptomatic AF, history of cerebral infarction or transient ischemic attack, history of intracranial hemorrhage, high HAS-BLED score (≥3), and low body mass index (<18.0 kg/m2). Cluster 3 was more closely associated with old age, heart failure, and low estimated creatinine clearance (<30 mL/min). Conclusion The cluster analysis identified those at a high risk for all-cause death and HF or a high risk for TE and MB and could support decision making in older adults with AF.
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Affiliation(s)
- Shinya Suzuki
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Tokyo, Japan
| | - Takeshi Yamashita
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Tokyo, Japan
| | - Takayuki Otsuka
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Tokyo, Japan
| | - Takuto Arita
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Tokyo, Japan
| | - Naoharu Yagi
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Tokyo, Japan
| | - Mikio Kishi
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Tokyo, Japan
| | - Hiroaki Semba
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Tokyo, Japan
| | - Hiroto Kano
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Tokyo, Japan
| | - Shunsuke Matsuno
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Tokyo, Japan
| | - Yuko Kato
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Tokyo, Japan
| | - Tokuhisa Uejima
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Tokyo, Japan
| | - Yuji Oikawa
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Tokyo, Japan
| | - Minoru Matsuhama
- Department of Cardiovascular Surgery, The Cardiovascular Institute, Tokyo, Japan
| | - Mitsuru Iida
- Department of Cardiovascular Surgery, The Cardiovascular Institute, Tokyo, Japan
| | - Tatsuya Inoue
- Department of Cardiovascular Surgery, The Cardiovascular Institute, Tokyo, Japan
| | - Junji Yajima
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Tokyo, Japan
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Okutucu S, Gorenek B. Current Recommendations on Atrial Fibrillation: A Comparison of the Recent European and Canadian Guidelines. Cardiology 2021; 147:81-89. [PMID: 34547752 DOI: 10.1159/000519465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 07/24/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Guidelines for the diagnosis and management of atrial fibrillation (AF) are frequently published and updated, reflecting the rapid evolution in AF pathogenesis and treatment modalities. SUMMARY Recently, 2 important guidelines for the diagnosis and management of atrial AF have been published by the European Society of Cardiology (ESC), and Canadian Cardiovascular Society (CCS). Although the evidence-based recommendations and statements are quite similar, there are some important differences between the ESC and CCS guidelines for AF. Herein, we compared the current recommendations and highlighted the differences from the most recent guidelines for AF. Key Messages: Specifically, key differences can be observed in methods evaluating the recommendations; classifications and the definitions; the symptom score used to guide management decisions, longitudinal patient assessment, and structured characterization; the stroke risk stratification algorithm used to determine indications for oral anticoagulation therapy; the role of acetylsalicylic acid in stroke prevention in AF; the antithrombotic regimens that are employed in the setting of chronic coronary syndromes, acute coronary syndromes, and percutaneous coronary intervention; the target heart rate for rate control; and the algorithms for integrated or holistic management of AF. Differences are observed, particularly when the quality of evidence is moderate or low. More research and randomized controlled studies on major gaps identified in current guidelines will further clarify and modify our future management strategies in AF.
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Affiliation(s)
- Sercan Okutucu
- Department of Cardiology, Memorial Ankara Hospital, Memorial Healthcare Group, Ankara, Turkey
| | - Bulent Gorenek
- Department of Cardiology, Faculty of Medicine, Eskisehir Osmangazi University, Eskisehir, Turkey
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21
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Proietti M, Vitolo M, Harrison SL, Lane DA, Fauchier L, Marin F, Nabauer M, Potpara TS, Dan GA, Boriani G, Lip GYH. Real-world applicability and impact of early rhythm control for European patients with atrial fibrillation: a report from the ESC-EHRA EORP-AF Long-Term General Registry. Clin Res Cardiol 2021; 111:70-84. [PMID: 34448931 PMCID: PMC8766399 DOI: 10.1007/s00392-021-01914-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 07/20/2021] [Indexed: 12/12/2022]
Abstract
Background Use of rate/rhythm control is essential to control symptoms in patients with atrial fibrillation (AF). Recently, the EAST-AFNET 4 trial described how early rhythm control strategy was associated with a lower risk of adverse clinical outcomes. Objectives The aim was to evaluate the real-world applicability and impact of an early rhythm control strategy in patients with AF. Methods Use of an early rhythm control strategy was assessed in a European cohort of AF patients derived from the EHRA-ESC EORP-AF General Long-Term Registry. Early rhythm control was defined as use of antiarrhythmic drugs or cardioversion/catheter ablation. The primary outcome included cardiovascular death, stroke, acute coronary syndrome, and worsening of heart failure. Quality of life and health-care resource usage were also assessed as outcomes. Results Among the 10,707 patients evaluated for eligibility to EAST-AFNET 4, a total of 3774 (34.0%) were included. Early rhythm control was associated with better quality of life, but with greater use of health-care resources. During follow-up, the primary outcome occurred less often in early rhythm control patients than in those with no rhythm control (13.6% vs. 18.5%, p < 0.001). In the multivariate adjusted Cox regression model, no significant difference was found between no rhythm control and early rhythm control, for the primary outcome. No difference in the primary outcome between early rhythm control and ‘no rhythm control patients’ adherent to Atrial fibrillation Better Care (ABC) pathway’ was evident (p = 0.753) Conclusions Use of an early rhythm control strategy was associated with a lower rate of major adverse events, but this difference was non-significant on multivariate analysis, being mediated by differences in baseline characteristics and clinical risk profile. Early rhythm control was associated with a higher use of health-care resources and risk of hospital admission, despite showing better quality of life. Graphic abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1007/s00392-021-01914-y.
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Affiliation(s)
- Marco Proietti
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, UK. .,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy. .,Geriatric Unit, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy.
| | - Marco Vitolo
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, UK.,Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Stephanie L Harrison
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, UK.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Laurent Fauchier
- Service de Cardiologie, Centre Hospitalier Universitaire Trousseau, Tours, France
| | - Francisco Marin
- Department of Cardiology, Hospital Universitario Virgen de la Arrixaca, IMIB-Arrixaca, University of Murcia, CIBERCV, Murcia, Spain
| | - Michael Nabauer
- Department of Cardiology, Ludwig-Maximilians-University, Munich, Germany
| | - Tatjana S Potpara
- School of Medicine, University of Belgrade, Belgrade, Serbia.,Intensive Arrhythmia Care, Cardiology Clinic, Clinical Center of Serbia, Belgrade, Serbia
| | - Gheorghe-Andrei Dan
- Colentina University Hospital, 'Carol Davila' University of Medicine, Bucharest, Romania
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, UK. .,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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22
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Koldenhof T, Wijtvliet PEPJ, Pluymaekers NAHA, Rienstra M, Folkeringa RJ, Bronzwaer P, Elvan A, Elders J, Tukkie R, Luermans JGLM, van Kuijk SMJ, Tijssen JGP, van Gelder IC, Crijns HJGM, Tieleman RG. Rate control drugs differ in the prevention of progression of atrial fibrillation. Europace 2021; 24:384-389. [PMID: 34414430 PMCID: PMC8892061 DOI: 10.1093/europace/euab191] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 07/14/2021] [Indexed: 01/02/2023] Open
Abstract
Aims We hypothesize that in patients with paroxysmal atrial fibrillation (AF), verapamil is associated with lower AF progression compared to beta blockers or no rate control. Methods and results In this pre-specified post hoc analysis of the RACE 4 randomized trial, the effect of rate control medication on AF progression in paroxysmal AF was analysed. Patients using Vaughan-Williams Class I or III antiarrhythmic drugs were excluded. The primary outcome was a composite of first electrical cardioversion (ECV), chemical cardioversion (CCV), or atrial ablation. Event rates are displayed using Kaplan–Meier curves and multivariable Cox regression analyses are used to adjust for baseline differences. Out of 666 patients with paroxysmal AF, 47 used verapamil, 383 used beta blockers, and 236 did not use rate control drugs. The verapamil group was significantly younger than the beta blocker group and contained more men than the no rate control group. Over a mean follow-up of 37 months, the primary outcome occurred in 17% in the verapamil group, 33% in the beta blocker group, and 33% in the no rate control group (P = 0.038). After adjusting for baseline characteristics, patients using verapamil have a significantly lower chance of receiving ECV, CCV, or atrial ablation compared to patients using beta blockers [hazard ratio (HR) 0.40, 95% confidence interval (CI) 0.19–0.83] and no rate control (HR 0.64, 95% CI 0.44–0.93). Conclusion In patients with newly diagnosed paroxysmal AF, verapamil was associated with less AF progression, as compared to beta blockers and no rate control.
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Affiliation(s)
- Tim Koldenhof
- Department of Cardiology, Martini Hospital, Van Swietenplein 1, 9728 NT Groningen, The Netherlands.,Department of Cardiology, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Petra E P J Wijtvliet
- Department of Cardiology, Martini Hospital, Van Swietenplein 1, 9728 NT Groningen, The Netherlands.,Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
| | - Nikki A H A Pluymaekers
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
| | - Michiel Rienstra
- Department of Cardiology, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Richard J Folkeringa
- Department of Cardiology, Medical Centre Leeuwarden, Henri Dunantweg 2, 8934 AD Leeuwarden, The Netherlands
| | - Patrick Bronzwaer
- Department of Cardiology, Zaans Medical Centre, Kon. Julianaplein 58, 1502 DV Zaandam, The Netherlands
| | - Arif Elvan
- Department of Cardiology, Isala Hospital, Dokter van Heesweg 2, 8025 AB Zwolle, The Netherlands
| | - Jan Elders
- Department of Cardiology, Canisius Wilhelmina Hospital, Weg door Jonkerbos 100, 6532 SZ Nijmegen, The Netherlands
| | - Raymond Tukkie
- Department of Cardiology, Spaarne Hospital, Boerhaavelaan 22, 2035 RC Haarlem, The Netherlands
| | - Justin G L M Luermans
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
| | - Sander M J van Kuijk
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
| | - Jan G P Tijssen
- Amsterdam University Medical Centre (AMC), Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Isabelle C van Gelder
- Department of Cardiology, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Harry J G M Crijns
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
| | - Robert G Tieleman
- Department of Cardiology, Martini Hospital, Van Swietenplein 1, 9728 NT Groningen, The Netherlands.,Department of Cardiology, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
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23
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Fabritz L, Crijns HJGM, Guasch E, Goette A, Häusler KG, Kotecha D, Lewalter T, Meyer C, Potpara TS, Rienstra M, Schnabel RB, Willems S, Breithardt G, Camm AJ, Chan A, Chua W, de Melis M, Dimopoulou C, Dobrev D, Easter C, Eckardt L, Haase D, Hatem S, Healey JS, Heijman J, Hohnloser SH, Huebner T, Ilyas BS, Isaacs A, Kutschka I, Leclercq C, Lip GYH, Marinelli EA, Merino JL, Mont L, Nabauer M, Oldgren J, Pürerfellner H, Ravens U, Savelieva I, Sinner MF, Sitch A, Smolnik R, Steffel J, Stein K, Stoll M, Svennberg E, Thomas D, Van Gelder IC, Vardar B, Wakili R, Wieloch M, Zeemering S, Ziegler PD, Heidbuchel H, Hindricks G, Schotten U, Kirchhof P. Dynamic risk assessment to improve quality of care in patients with atrial fibrillation: the 7th AFNET/EHRA Consensus Conference. Europace 2021; 23:329-344. [PMID: 33555020 DOI: 10.1093/europace/euaa279] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 11/28/2020] [Indexed: 01/07/2023] Open
Abstract
AIMS The risk of developing atrial fibrillation (AF) and its complications continues to increase, despite good progress in preventing AF-related strokes. METHODS AND RESULTS This article summarizes the outcomes of the 7th Consensus Conference of the Atrial Fibrillation NETwork (AFNET) and the European Heart Rhythm Association (EHRA) held in Lisbon in March 2019. Sixty-five international AF specialists met to present new data and find consensus on pressing issues in AF prevention, management and future research to improve care for patients with AF and prevent AF-related complications. This article is the main outcome of an interactive, iterative discussion between breakout specialist groups and the meeting plenary. AF patients have dynamic risk profiles requiring repeated assessment and risk-based therapy stratification to optimize quality of care. Interrogation of deeply phenotyped datasets with outcomes will lead to a better understanding of the cardiac and systemic effects of AF, interacting with comorbidities and predisposing factors, enabling stratified therapy. New proposals include an algorithm for the acute management of patients with AF and heart failure, a call for a refined, data-driven assessment of stroke risk, suggestions for anticoagulation use in special populations, and a call for rhythm control therapy selection based on risk of AF recurrence. CONCLUSION The remaining morbidity and mortality in patients with AF needs better characterization. Likely drivers of the remaining AF-related problems are AF burden, potentially treatable by rhythm control therapy, and concomitant conditions, potentially treatable by treating these conditions. Identifying the drivers of AF-related complications holds promise for stratified therapy.
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Affiliation(s)
- Larissa Fabritz
- Institute of Cardiovascular Sciences, University of Birmingham, UK.,Department of Cardiology, University Hospital Birmingham, UK
| | - Harry J G M Crijns
- School for Cardiovascular Diseases, Maastricht University Medical Centre, the Netherlands
| | - Eduard Guasch
- Hospital Clinic, IDIBAPS, CIBERCV, University of Barcelona, Spain
| | - Andreas Goette
- Medical Clinic II, St. Vincenz Krankenhaus, Paderborn, Germany.,Atrial Fibrillation NETwork (AFNET), Münster, Germany
| | | | - Dipak Kotecha
- Institute of Cardiovascular Sciences, University of Birmingham, UK
| | - Thorsten Lewalter
- Atrial Fibrillation NETwork (AFNET), Münster, Germany.,Internistisches Klinikum München Süd, Germany
| | - Christian Meyer
- University Heart Center, University Hospital Hamburg-Eppendorf, Germany
| | - Tatjana S Potpara
- School of Medicine, University of Belgrade, Clinical Centre of Serbia, Serbia
| | | | - Renate B Schnabel
- Atrial Fibrillation NETwork (AFNET), Münster, Germany.,University Heart Center, University Hospital Hamburg-Eppendorf, Germany
| | - Stephan Willems
- Atrial Fibrillation NETwork (AFNET), Münster, Germany.,Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
| | - Guenter Breithardt
- Atrial Fibrillation NETwork (AFNET), Münster, Germany.,Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany.,Department of Cardiovascular Medicine, University Hospital Münster, Germany
| | - A John Camm
- St George's Hospital Medical School, University of London, UK
| | | | - Winnie Chua
- Institute of Cardiovascular Sciences, University of Birmingham, UK
| | | | | | - Dobromir Dobrev
- Department of Cardiology, University Hospital Essen, Germany
| | - Christina Easter
- Institute of Cardiovascular Sciences, University of Birmingham, UK
| | - Lars Eckardt
- Atrial Fibrillation NETwork (AFNET), Münster, Germany.,Department of Cardiovascular Medicine, University Hospital Münster, Germany
| | - Doreen Haase
- Atrial Fibrillation NETwork (AFNET), Münster, Germany
| | - Stephane Hatem
- Department of Cardiology, Sorbonne Universités, Faculté de médecine UPMC, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Paris, France
| | - Jeff S Healey
- Population Health Research Institute Hamilton, Canada
| | - Jordi Heijman
- Department of Cardiology, University Hospital Birmingham, UK
| | | | | | | | - Aaron Isaacs
- School for Cardiovascular Diseases, Maastricht University Medical Centre, the Netherlands
| | - Ingo Kutschka
- Atrial Fibrillation NETwork (AFNET), Münster, Germany.,Klinik für Thorax-, Herz- und Gefäßchirurgie, University Hospital Göttingen, Germany
| | | | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, UK
| | | | - Jose L Merino
- Arrhythmia & Robotic EP Unit, La Paz University Hospital, Spain
| | - Lluís Mont
- Hospital Clinic, Universitat de Barcelona, Barcelona, Catalonia, Spain
| | - Michael Nabauer
- Atrial Fibrillation NETwork (AFNET), Münster, Germany.,Medizinische Klinik und Poliklinik I, University Hospital Munich, Germany
| | - Jonas Oldgren
- Department of Medical Sciences, Uppsala Clinical Research Center, Uppsala University, Sweden
| | - Helmut Pürerfellner
- Department für Rhythmologie und Elektrophysiologie, Ordensklinikum Linz, Austria
| | - Ursula Ravens
- Atrial Fibrillation NETwork (AFNET), Münster, Germany.,Institut für Experimentelle Kardiovaskuläre Medizin, Universitätsherzzentrum Freiburg, Bad Krozingen, Germany
| | | | - Moritz F Sinner
- Medizinische Klinik und Poliklinik I, University Hospital Munich, Germany
| | - Alice Sitch
- Institute of Cardiovascular Sciences, University of Birmingham, UK
| | | | | | | | - Monika Stoll
- School for Cardiovascular Diseases, Maastricht University Medical Centre, the Netherlands
| | - Emma Svennberg
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Karolinska Institutet, Danderyd's Hospital Stockholm, Sweden
| | - Dierk Thomas
- Atrial Fibrillation NETwork (AFNET), Münster, Germany.,Department of Internal Medicine III-Cardiology, Angiology and Pneumonology, Medical University Hospital Heidelberg, Germany
| | - Isabelle C Van Gelder
- Department of Cardiology, University Medical Center Groningen, University of Groningen, the Netherlands
| | | | - Reza Wakili
- Atrial Fibrillation NETwork (AFNET), Münster, Germany.,Department of Cardiology, University Hospital Essen, Germany
| | | | - Stef Zeemering
- Department of Cardiology, University Medical Center Groningen, University of Groningen, the Netherlands
| | | | - Hein Heidbuchel
- Department of Cardiology, Antwerp University, University Hospital, Belgium
| | - Gerhard Hindricks
- Department of Electrophysiology, Heart Center Leipzig, University of Leipzig, Germany
| | - Ulrich Schotten
- School for Cardiovascular Diseases, Maastricht University Medical Centre, the Netherlands.,Atrial Fibrillation NETwork (AFNET), Münster, Germany.,Department of Cardiology, University Medical Center Groningen, University of Groningen, the Netherlands
| | - Paulus Kirchhof
- Institute of Cardiovascular Sciences, University of Birmingham, UK.,Atrial Fibrillation NETwork (AFNET), Münster, Germany.,University Heart Center, University Hospital Hamburg-Eppendorf, Germany
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24
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Tsigkas G, Apostolos A, Despotopoulos S, Vasilagkos G, Kallergis E, Leventopoulos G, Mplani V, Davlouros P. Heart failure and atrial fibrillation: new concepts in pathophysiology, management, and future directions. Heart Fail Rev 2021; 27:1201-1210. [PMID: 34218400 DOI: 10.1007/s10741-021-10133-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/22/2021] [Indexed: 12/11/2022]
Abstract
A bidirectional pathophysiological link connects heart failure and atrial fibrillation, creating a frequent and challenging comorbidity, which includes neurohormonal hyperactivation, fibrosis development, and electrophysiologic remodeling, while they share mutual risk factors. Management for these devastating comorbidities includes most of the established treatment measures for heart failure as well as rhythm or rate control and anticoagulation mostly for atrial fibrillation, which can be achieved with either pharmaceutical or non-pharmaceutical approaches. The current manuscript aims to review the existing literature regarding the underlying pathophysiology, to present the novel trends of treatment, and to predict the future perspective of these two linked diseases with the numerous unanswered questions.
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Affiliation(s)
- Grigorios Tsigkas
- Department of Cardiology, University Hospital of Patras, Patras, Greece.
| | | | | | | | | | | | - Virginia Mplani
- Department of Cardiology, University Hospital of Patras, Patras, Greece
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25
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Ramesh T, Lee PYK, Mitta M, Allencherril J. Intravenous magnesium in the management of rapid atrial fibrillation: A systematic review and meta-analysis. J Cardiol 2021; 78:375-381. [PMID: 34162502 DOI: 10.1016/j.jjcc.2021.06.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 05/07/2021] [Accepted: 05/27/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND The aim of this meta-analysis is to investigate the effectiveness of intravenous magnesium (IV Mg2+) in rate and rhythm control of rapid atrial fibrillation (AF) when administered in addition to standard-of-care for non-post-operative patients. Previous meta-analyses on this topic have demonstrated the efficacy of IV Mg2+ in achieving rate control, but not rhythm control. METHODS Six randomized controlled trials comparing IV Mg2+ to placebo in the treatment of rapid AF were obtained from electronic databases totaling 745 patients. Outcomes were analyzed using a Mantel-Haenszel random-effects model and expressed as odds ratios (OR) for dichotomous outcomes with their 95% confidence intervals (CIs). RESULTS Our pooled analysis showed that IV Mg2+ given in addition to standard-of-care was superior in achieving rate control (63% vs 40%; OR 2.49, 95% CI 1.80-3.45) and rhythm conversion to sinus (21% vs. 14%, OR 1.75, 95% CI 1.08-2.84) compared to standard-of-care alone. Flushing was more frequently observed in patients receiving IV Mg2+ compared to placebo (9% vs. 0.4%, OR 19.79, 95% CI 4.30-91.21). Subgroup analysis showed the superiority of a lower dose of IV Mg2+, which we designated as 5 g or lower (24% vs 13%, OR 2.10, 95% CI 1.22-3.61) compared to the higher dose (>5 g) (16% vs 13%, OR 1.23, 95% CI 0.65-2.32) in rhythm control when compared to placebo. CONCLUSIONS IV Mg2+ administered in conjunction with standard-of-care is effective for rate control and modestly effective for restoration of sinus rhythm in rapid AF without clinically significant adverse effects.
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Affiliation(s)
- Tushar Ramesh
- Division of Cardiology, University of Cincinnati, Cincinnati, OH.
| | - Paul Yong Kyu Lee
- Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ
| | - Monica Mitta
- Department of Emergency Medicine, Eastern Virginia Medical School, Norfolk, VA
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26
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Kozieł M, Mihajlovic M, Nedeljkovic M, Pavlovic N, Paparisto V, Music L, Trendafilova E, Dan AR, Kusljugic Z, Dan GA, Lip GYH, Potpara TS. Quality indicators in the management of atrial fibrillation: the BALKAN-AF survey. Int J Cardiol 2021; 333:105-109. [PMID: 33621622 DOI: 10.1016/j.ijcard.2021.02.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 01/23/2021] [Accepted: 02/12/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND The implementation of quality indicators in the atrial fibrillation (AF) care should be considered to improve quality of management and patient outcome. METHODS In the post-hoc analysis of the BALKAN-AF dataset, we assessed concordance with quality indicators for AF management. Available domains for AF management [patient assessment (baseline), anticoagulation, rate control strategy, rhythm control strategy and risk factor management] were identified and assessed at baseline visit. RESULTS Among 132 patients with a CHA2DS2-VASc score of 0 (men) or 1 (women), 75 (56.8%) were prescribed oral anticoagulation (OAC). Of 2539 patients with a CHA2DS2-VASc score ≥ 1 for men and ≥ 2 for women, 1890 (74.4%) were prescribed OAC. Among 1088 patients with permanent AF, 110 (10.1%) individuals were prescribed antiarrhythmic drugs (AADs). Of 1616 patients with structural heart disease, 37 (2.2%) were prescribed class IC AADs. Of 1624 patients with paroxysmal or persistent AF, 59 (3.6%) were offered catheter ablation. Among 2712 AF patients, 2121 (78.2%) had hypertension, 671 (24.7%) were obese, 53 (2.0%) had obstructive sleep apnoea, 110 (4.0%) had alcohol abuse and 340 (12.5%) were smokers. CONCLUSIONS In the BALKAN-AF cohort, the use of OAC for stroke prevention was poorly associated with patients stroke risk. The use of AADs in patients with permanent AF was low. The prescription of class IC AADs to patients with structural heart disease was infrequent. A large proportion of AF patients had their modifiable risk factors identified.
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Affiliation(s)
- Monika Kozieł
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; 1st Department of Cardiology and Angiology, Silesian Centre for Heart Diseases, Zabrze, Poland
| | | | - Milan Nedeljkovic
- Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia; School of Medicine, Belgrade University, Belgrade, Serbia
| | | | - Vilma Paparisto
- Clinic of Cardiology, University Hospital Center Mother Theresa, Tirana, Albania
| | - Ljilja Music
- Cardiology Clinic, University Clinical Center of Montenegro, University of Podgorica, Medical Faculty, Podgorica, Montenegro
| | | | - Anca Rodica Dan
- Colentina University Hospital, Cardiology Department, Bucharest, Romania
| | - Zumreta Kusljugic
- Clinic of Internal Medicine, Cardiology Department, University Clinical Center Tuzla, Medical Faculty, Tuzla, Bosnia and Herzegovina
| | - Gheorghe-Andrei Dan
- Medicine University "Carol Davila", Colentina University Hospital, Bucharest, Romania
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; 1st Department of Cardiology and Angiology, Silesian Centre for Heart Diseases, Zabrze, Poland; School of Medicine, Belgrade University, Belgrade, Serbia; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Tatjana S Potpara
- Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia; School of Medicine, Belgrade University, Belgrade, Serbia.
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27
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Kusayama T, Wan J, Yuan Y, Liu X, Li X, Shen C, Fishbein MC, Everett TH, Chen PS. Effects of subcutaneous nerve stimulation with blindly inserted electrodes on ventricular rate control in a canine model of persistent atrial fibrillation. Heart Rhythm 2021; 18:261-270. [PMID: 32956842 DOI: 10.1016/j.hrthm.2020.09.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 09/04/2020] [Accepted: 09/14/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND Subcutaneous nerve stimulation (ScNS) delivered directly to large subcutaneous nerves can be either antiarrhythmic or proarrhythmic, depending on the stimulus output. OBJECTIVE The purpose of this study was to perform a prospective randomized study in a canine model of persistent AF to test the hypothesis that high-output ScNS using blindly inserted subcutaneous electrodes can reduce ventricular rate (VR) during persistent atrial fibrillation (AF) whereas low-output ScNS would have opposite effects. METHODS We prospectively randomized 16 male and 15 female dogs with sustained AF (>48 hours) induced by rapid atrial pacing into 3 groups (sham, 0.25 mA, 3.5 mA) for 4 weeks of ScNS (10 Hz, alternating 20-seconds ON and 60-seconds OFF). RESULTS ScNS at 3.5 mA, but not 0.25 mA or sham, significantly reduced VR and stellate ganglion nerve activity (SGNA), leading to improvement of left ventricular ejection fraction (LVEF). No differences were found between the 0.25-mA and sham groups. Histologic studies showed a significant reduction of bilateral atrial fibrosis in the 3.5-mA group compared with sham controls. Only 3.5-mA ScNS had significant fibrosis in bilateral stellate ganglions. The growth-associated protein 43 (GAP43) staining of stellate ganglions indicated the suppression of GAP43 protein expression in the 3.5-mA group. There were no significant differences of nerve sprouting among all groups. There was no interaction between sex and ScNS effects on reduction of VR and SGNA, LVEF improvement, or results of histologic studies. CONCLUSION We conclude that 3.5-mA ScNS with blindly inserted electrodes can improve VR control, reduce atrial fibrosis, and partially improve LVEF in a canine model of persistent AF.
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Affiliation(s)
- Takashi Kusayama
- Krannert Institute of Cardiology, Division of Cardiology, Department of Medicine, Indianapolis, Indiana; Department of Cardiology, Kanazawa University Graduate School of Medical Sciences, Ishikawa, Japan
| | - Juyi Wan
- Krannert Institute of Cardiology, Division of Cardiology, Department of Medicine, Indianapolis, Indiana; Department of Cardiothoracic Surgery, the Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province, China
| | - Yuan Yuan
- Krannert Institute of Cardiology, Division of Cardiology, Department of Medicine, Indianapolis, Indiana; Department of Cardiac Surgery, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xiao Liu
- Krannert Institute of Cardiology, Division of Cardiology, Department of Medicine, Indianapolis, Indiana; Cedars-Sinai Medical Center, Los Angeles, California
| | - Xiaochun Li
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Changyu Shen
- The Richard and Susan Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Michael C Fishbein
- Department of Pathology and Laboratory Medicine, University of California, Los Angeles, California
| | - Thomas H Everett
- Krannert Institute of Cardiology, Division of Cardiology, Department of Medicine, Indianapolis, Indiana
| | - Peng-Sheng Chen
- Krannert Institute of Cardiology, Division of Cardiology, Department of Medicine, Indianapolis, Indiana; Cedars-Sinai Medical Center, Los Angeles, California.
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Lu N, MacGillivray J, Andrade JG, Krahn AD, Hawkins NM, Laksman Z, Deyell MW, Chakrabarti S, Yeung-Lai-Wah JA, Bennett MT. Effectiveness of a simple medication adjustment protocol for optimizing peri-cardioversion rate control: A derivation and validation cohort study. Heart Rhythm O2 2021; 2:46-52. [PMID: 34113904 PMCID: PMC8183961 DOI: 10.1016/j.hroo.2021.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background Rate control medications are foundational in the management of persistent atrial fibrillation (AF). There are no guidelines for adjusting these medications prior to elective direct-current cardioversion (DCCV). Objective To derive and validate a preprocedural medication adjustment protocol that maintains peri-DCCV rate control and minimizes risk of postconversion bradycardia, pauses, need for pacing, and cardiopulmonary resuscitation (CPR). Methods Consecutive patients with persistent AF awaiting elective DCCV across 2 hospitals were screened for inclusion into derivation, validation, and control cohorts. In the derivation cohort, each patient taking an atrioventricular (AV) nodal blocker had medications adjusted based on heart rate (HR) 2 days before DCCV, and the magnitude of dose adjustment was compared with peri-DCCV HR. The adjustment protocol that achieved the highest percentage of optimal peri-DCCV rate control was tested prospectively in the validation cohort and compared to a standard-of-care control group. Results The optimal protocol from the derivation cohort (n = 71), based on the 2-day pre-DCCV HR, was to (1) CONTINUE AV nodal blocker for HR ≥ 100 beats per minute (bpm), (2) reduce dose by ONE increment when 80–99 bpm, (3) reduce dose by TWO increments when 60–79 bpm, and (4) HOLD when <60 bpm. In the prospective validation cohort (n = 106), this protocol improved peri-DCCV rate control (82% vs 62%, P < .001) compared to current standard of care (n = 107). There were no conversion pauses ≥5 seconds, need for pacing, or CPR post-DCCV. Conclusion This simple preprocedural medication adjustment protocol provides an effective strategy of optimizing peri-DCCV rate control in patients with AF.
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Affiliation(s)
- Nelson Lu
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Jenny MacGillivray
- Lower Mainland Pharmacy Services, Vancouver General Hospital, Vancouver, Canada
| | - Jason G Andrade
- Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Andrew D Krahn
- Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Nathaniel M Hawkins
- Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Zachary Laksman
- Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Marc W Deyell
- Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Shanta Chakrabarti
- Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, Canada
| | - John A Yeung-Lai-Wah
- Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Matthew T Bennett
- Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, Canada
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Ashida A, Ozaki N, Kishi K, Odanaka Y, Nemoto S, Konishi H, Ashida A. Safety and Efficacy of Landiolol Hydrochloride in Children with Tachyarrhythmia of Various Etiologies. Pediatr Cardiol 2021; 42:1700-5. [PMID: 34097085 DOI: 10.1007/s00246-021-02653-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 05/26/2021] [Indexed: 10/25/2022]
Abstract
The safety and efficacy of landiolol have not been fully elucidated in pediatric patients. This study aimed to clarify the safety and efficacy of landiolol in a pediatric cohort. We retrospectively assessed the clinical features of 21 pediatric patients who were administered landiolol at our hospital. We also investigated the rates of sinus rhythm conversion and heart rate response. The median patient age was 7 months (interquartile range 1-13 months). The etiology of tachyarrhythmia was junctional ectopic tachycardia in 10 patients (47.6%), atrial tachycardia in 10 patients (47.6%), and ventricular tachycardia in 1 patient (4.8%). Of the 21 children, 18 (85.7%) had congenital heart defects, including 14 (77.8%) in whom a landiolol infusion was performed perioperatively. The landiolol infusion was effective in 18 pediatric patients (85.7%), as measured by the conversion to sinus rhythm or a reduced heart rate. Atrial tachycardia in the perioperative period was terminated in all patients. Of 7 patients with tachyarrhythmias unrelated to the perioperative period, landiolol was effective in 5. No adverse effects were reported in any patient. Landiolol infusion is effective and safe in pediatric patients with tachyarrhythmia of various etiologies, especially those with atrial tachyarrhythmia during the perioperative period.
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Yang E, Tang O, Metkus T, Berger RD, Spragg DD, Calkins HG, Marine JE. The role of timing in treatment of atrial fibrillation: An AFFIRM substudy. Heart Rhythm 2021; 18:674-81. [PMID: 33383228 DOI: 10.1016/j.hrthm.2020.12.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 12/21/2020] [Accepted: 12/22/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND In contrast to historical trials, the Early Treatment of Atrial Fibrillation for Stroke Prevention Trial (EAST-AFNET 4) suggests the superiority of early rhythm control over rate control in patients with recent-onset atrial fibrillation (AF). The relative contribution of timing vs improvement in AF therapeutics over time is unclear. OBJECTIVE This study aimed to isolate the assessment of early intervention for AF from temporal changes in AF treatments through a secondary analysis of subjects from the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) study. METHODS We compared rate and rhythm control treatments in AFFIRM subjects stratified by time from their diagnosis of AF. Time-to-event analysis was performed to compare all-cause mortality, cardiovascular hospitalizations, stroke, and number of hospitalization days. RESULTS Of the 4060 AFFIRM subjects, 2526 subjects (62.2%) had their first episode of AF within 6 months of study enrollment. Participants with "new" AF had a decreased risk of all-cause mortality (P = .001) than did those with prior AF diagnoses. Individuals previously diagnosed with AF were similar in age and demographic characteristics, but had more medical comorbidities, including myocardial infarction (P = .006), diabetes mellitus (P = .002), smoking (P = .003), and hepatic or renal comorbidities (P = .008). There were no differences in mortality, cardiovascular hospitalizations, or stroke between rate and rhythm control strategies in either AF subgroup. CONCLUSION AFFIRM subjects diagnosed with AF within 6 months of study enrollment showed no difference in survival, cardiovascular hospitalization, or ischemic stroke between rate and rhythm control strategies. Superiority of rhythm control strategies reported by newer AF trials may be more attributable to the refinement of AF therapies and less related to the timing of intervention.
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McGrath P, Kersten B, Chilbert MR, Rusch C, Nadler M. Evaluation of metoprolol versus diltiazem for rate control of atrial fibrillation in the emergency department. Am J Emerg Med 2021; 46:585-90. [PMID: 33257143 DOI: 10.1016/j.ajem.2020.11.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The purpose of this study was to compare the effectiveness and safety of the metoprolol and diltiazem administration in the Emergency Department (ED) for rate control of supraventricular tachycardia. METHODS This was a retrospective cohort study of adult patients who presented to the ED with ventricular rates ≥120 beats per minute (bpm) and who received bolus doses of either intravenous metoprolol or intravenous diltiazem. The primary outcome was achievement of rate control, defined as heart rate < 110 bpm, at two hours after administration of the last bolus dose of metoprolol or diltiazem. Safety outcomes included occurrence of hypotension, defined as systolic blood pressure < 90 mmHg or diastolic blood pressure < 60 mmHg, and bradycardia, defined as heart rate < 60 bpm. RESULTS There were 166 patients receiving metoprolol and 183 patients receiving diltiazem included in the study. The primary outcome, rate control at two hours after the last bolus dose of metoprolol or diltiazem was similar between the two groups (45.8% vs 42.6%, p = 0.590, respectively). The percentage of patients achieving rate control was also similar (47.0% vs 41.6%, p = 0.333) at one hour. At 0.5 h HR had a significantly greater numerical (diltiazem: 29.3 ± 23.1 bpm vs metoprolol: 21.8 ± 18.9 bpm, p = 0.012) and percent decrease (21.1% vs 15.94%, p = 0.014) in the diltiazem group compared to metoprolol. There was no significant difference in occurrence of bradycardia in the two groups (diltiazem: 3.83% vs metoprolol: 1.2%, p = 0.179). More patients in the diltiazem group compared to the metoprolol group experienced hypotension (39.3% vs 23.5%, p = 0.002). The difference in systolic hypotension events was not significantly different (9.29% vs 5.42%, p = 0.221), while the difference in diastolic hypotension events was significantly different (37.7% vs 22.3%, p = 0.002). CONCLUSION There was no difference in acute rate control effectiveness two hours after the last bolus dose of diltiazem and metoprolol for supraventricular tachycardias. There was a significantly higher occurrence of hypotension in the diltiazem group which was driven by higher rates of diastolic blood pressures less than 60 mmHg.
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Marijon E. [Atrial fibrillation: 10 key messages]. Rev Prat 2020; 70:921. [PMID: 33739702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Affiliation(s)
- Eloi Marijon
- Unité de rythmologie, département de cardiologie, Hôpital européen Georges-Pompidou, Paris, France
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Abstract
Atrial fibrillation (AF) is the most common non-physiological arrhythmia in dogs and humans. Its high prevalence in both species and the impact it has on survival time and quality of life of affected patients, makes it a very relevant topic for medical research. In dogs, the diagnosis of AF is usually fairly straightforward, but optimal management can be complicated. Rate control is the most commonly used strategy; rhythm control can also be considered in very specific cases. Concurrent congestive heart failure is frequently identified, which represents an extra challenge for the clinicians. This article reviews the current recommendations for the diagnosis and management considerations of AF in dogs. Future perspectives, focusing on new drugs that may prevent development of AF based on recent discoveries, will also be discussed.
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Abstract
In the past 20 years the Netherlands-based RACE trials have investigated important concepts in clinical atrial fibrillation (AF). Their scope ranged from rhythm versus rate control to early or delayed cardioversion and also included early comprehensive management of AF in two trials, one focusing on early 'upstream therapy' and risk factor management and the other on integrated chronic nurse-led care. Studies were mostly triggered by simple clinical observations including futility of electrical cardioversion in persistent AF; many patients with permanent AF tolerating day-after-day 'uncontrolled' resting heart rates of up till 110 beats/min; patients being threatened more by vascular risks than AF itself; and insufficient guideline-based treatments for AF. Also the observation that recent-onset atrial fibrillation generally converts spontaneously, obviating cardioversion, triggered one of the studies. The RACE trials shifted a number of paradigms and by that could change the AF guidelines. The initial 'shock-and-forget' attitude made place for increased attention for anticoagulation, and in turn, broader vascular risks were recognised. In a nutshell, the adage eventually became: 'look beyond the ECG, treat the patient'.
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Affiliation(s)
- H J G M Crijns
- Department of Cardiology and the Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands.
| | - I C Van Gelder
- Department of Cardiology, Thoraxcenter, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Farmakis D, Chrysohoou C, Giamouzis G, Giannakoulas G, Hamilos M, Naka K, Tzeis S, Xydonas S, Karavidas A, Parissis J. The management of atrial fibrillation in heart failure: an expert panel consensus. Heart Fail Rev 2020; 26:1345-1358. [PMID: 32468277 DOI: 10.1007/s10741-020-09978-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Heart failure (HF) and atrial fibrillation (AF) often coexist, being closely interrelated as the one increases the prevalence and incidence and worsens the prognosis of the other. Their frequent coexistence raises several challenges, including under-diagnosis of HF with preserved ejection fraction in AF and of AF in HF, characterization and diagnosis of atrial cardiomyopathy, target and impact of rate control therapy on outcomes, optimal rhythm control strategy in the era of catheter ablation, HF-related thromboembolic risk and management of anticoagulation in patients with comorbidities, such as chronic kidney disease or transient renal function worsening, coronary artery disease or acute coronary syndromes, valvular or structural heart disease interventions and cancer. In the present document, derived by an expert panel meeting, we sought to focus on the above challenging issues, outlining the existing evidence and identifying gaps in knowledge that need to be addressed.
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Affiliation(s)
- Dimitrios Farmakis
- Shakolas Educational Center for Clinical Medicine, University of Cyprus Medical School, Palaios dromos Lefkosias Lemesou No.215/6, Aglantzia, 2029, Nicosia, Cyprus.
- Heart Failure Unit, Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece.
| | - Christina Chrysohoou
- First Department of Cardiology, Hippokratio Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | | | - George Giannakoulas
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Michalis Hamilos
- Department of Cardiology, University Hospital of Heraklion, Heraklion, Greece
| | - Katerina Naka
- Second Department of Cardiology, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - Stylianos Tzeis
- Department of Cardiology, Mitera General Hospital, Athens, Greece
| | | | | | - John Parissis
- Heart Failure Unit, Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
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Hadjamu N, Azizy O, Wakili R. [Approaches to atrial fibrillation with tachycardia transition]. Herzschrittmacherther Elektrophysiol 2020; 31:20-25. [PMID: 32055925 DOI: 10.1007/s00399-020-00670-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 01/13/2020] [Indexed: 06/10/2023]
Abstract
Atrial fibrillation, the most common cardiac arrhythmia in the daily clinical routine, is a challenge in in-hospital and prehospital emergency medicine and is associated with increased morbidity and mortality if left untreated. Especially tachyarrhythmia, caused by atrial fibrillation, leads to various unspecified symptoms and in some cases to severely impaired circulation. Thus, an individualized therapeutic regimen is required. A fundamental distinction between rhythm control and rate control strategies must be made. In symptomatic but hemodynamically stable patients rate control is the method of choice. This applies in particular to patients with no pre-existing anticoagulation, especially if left atrial thrombi are not excluded. In hemodynamically unstable patients, considering the potential complications of sedation, electrical cardioversion is preferred. Pharmacological therapy of atrial fibrillation has to be divided into AV conduction modulating drugs-like short- or long-acting β‑blockers, calcium antagonists or cardiac glycosides-and the heterogeneous group of antiarrhythmic drugs aiming for rhythm control. Pulmonary vein ablation is the current long-term treatment of choice for symptomatic drug-refractory atrial fibrillation.
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Affiliation(s)
- Nino Hadjamu
- Klinik für Kardiologie und Angiologie, Westdeutsches Herzzentrum des Universitätsklinikum Essen, Hufelandstraße 55, 45122, Essen, Deutschland
| | - Obayda Azizy
- Klinik für Kardiologie und Angiologie, Westdeutsches Herzzentrum des Universitätsklinikum Essen, Hufelandstraße 55, 45122, Essen, Deutschland
| | - Reza Wakili
- Klinik für Kardiologie und Angiologie, Westdeutsches Herzzentrum des Universitätsklinikum Essen, Hufelandstraße 55, 45122, Essen, Deutschland.
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Abstract
Atrial fibrillation is the most common sustained arrhythmia encountered in primary care practice and represents a significant burden on the health care system with a higher than expected hospitalization rate from the emergency department. The first goal of therapy is to assess the patient's symptoms and hemodynamic status. There are multiple acute management strategies for atrial fibrillation including heart rate control, immediate direct-current cardioversion, or pharmacologic cardioversion. Given the variety of approaches to acute atrial fibrillation, it is often difficult to consistently provide cost-effectiveness care. The likelihood of spontaneous conversion of acute atrial fibrillation to sinus rhythm is reported to be really high. Although active cardioversion of recent-onset atrial fibrillation is generally considered to be safe, the question arises of whether the strategy of immediate treatment for a condition that is likely to resolve spontaneously is acceptable for hemodynamically stable patients. Based on published data, non-managed acute treatment of atrial fibrillation appears to be cost-saving. The observation of a patient with recent-onset atrial fibrillation in a dedicated unit within the emergency department reduces the need for acute cardioversion in almost two-thirds of the patients, and reduces the median length of stay, without negatively affecting long-term outcome, thus reducing the related health care costs. However, to let these results broadly applicable, defined treatment algorithms and access to prompt follow-up are needed, which may not be practical in all settings.
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Affiliation(s)
- Giovanni Luca Botto
- Department of Electrophysiology and Clinical Arrhythmology, ASST Rhodense, Rho and Garbagnate M.se Hospitals, C.so Europa 250, Rho, 20017, Milan, Italy.
| | - Giovanni Tortora
- Department of Electrophysiology and Clinical Arrhythmology, ASST Rhodense, Rho and Garbagnate M.se Hospitals, C.so Europa 250, Rho, 20017, Milan, Italy
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Abstract
Symptomatic atrial fibrillation (AF) is a common cause of emergency department (ED) referrals. In case of hemodynamic stability, the choice to either perform early cardioversion (pharmacologic or electrical) or to prescribe rate-lowering drugs and differ any attempts to restore sinus rhythm (i.e., wait-and-see approach) has been widely debated. Results of the recent Rate Control versus Electrical Cardioversion Trial 7-Acute Cardioversion versus Wait and See (RACE 7 ACWAS) have been considered a strong argument in favor of the wait-and-see approach. In this debate, we discuss several issues that would support early cardioversion, ranging from patients' satisfaction and costs to concerns about safety. Furthermore, the wait-and-see approach may translate into a missed opportunity to encourage widespread use of a "pill-in-the-pocket" home treatment: this underused option could allow rapid solving of many AF episodes, potentially avoiding future ED referrals. Our opinion is that a delayed cardioversion may introduce unneeded complications in the straightforward management of a common clinical problem. Therefore, early cardioversion should continue to be the preferred option because of its proven efficacy, safety and convenience.
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Affiliation(s)
- Alessandro Capucci
- Cardiology and Arrhythmology Clinic, Marche Polytechic University, University Hospital "Ospedali Riuniti", Ancona, Italy
| | - Paolo Compagnucci
- Cardiology and Arrhythmology Clinic, Marche Polytechic University, University Hospital "Ospedali Riuniti", Ancona, Italy.
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Kozieł M, Simovic S, Pavlovic N, Nedeljkovic M, Paparisto V, Music L, Goshev E, Dan AR, Manola S, Kusljugic Z, Trendafilova E, Dobrev D, Dan GA, Lip GY, Potpara TS. Management of patients with newly-diagnosed atrial fibrillation: Insights from the BALKAN-AF survey. Int J Cardiol Heart Vasc 2019; 26:100461. [PMID: 32140551 PMCID: PMC7046541 DOI: 10.1016/j.ijcha.2019.100461] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Accepted: 12/18/2019] [Indexed: 12/13/2022]
Abstract
23.6% of patients in the survey had newly-diagnosed atrial fibrillation (AF). Those patients had different risk profiles than those with a history of AF. The specificity of the management of first-diagnosed AF patients was presented.
Background BALKAN-AF evaluated patterns of atrial fibrillation (AF) management in real-world clinical practice in the Balkans. The objectives were: to assess the proportion of patients with first-diagnosed AF in the BALKAN-AF cohort and to compare the management of patients with newly-diagnosed AF and those with previously known AF in clinical practice. Methods Consecutive patients from 7 Balkan countries were enrolled prospectively to the snapshot BALKAN-AF survey. Results Of 2712 enrolled patients, 2677 (98.7%) with complete data were included. 631 (23.6%) patients had newly-diagnosed AF and 2046 (76.4%) patients had known AF. Patients with newly-diagnosed AF were more likely to be hospitalized for AF and to receive single antiplatelet therapy (SAPT) alone and less likely to receive OACs than those with known AF (all p < 0.001). The use of OAC was not significantly associated with the CHA2DS2-VASc (p = 0.624) or HAS-BLED score (p = 0.225) on univariate analysis. Treatment in capital city, hypertension, dilated cardiomyopathy, mitral valve disease, country of residence or rate control strategy were independent predictors of OAC use, whilst non-emergency centre, treatment by cardiologist, paroxysmal AF, palpitations, symptoms attributable to AF (as judged by physician), mean heart rate and AF as the main reason for hospitalization were independent predictors of rhythm control strategy use. Conclusions In BALKAN-AF survey, patients with newly-diagnosed AF were more often hospitalized, less often received OAC and were more likely to receive SAPT alone. The use of OAC for stroke prevention has not been driven by the individual patient stroke risk.
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Affiliation(s)
- Monika Kozieł
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Medical University of Silesia, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Stefan Simovic
- Cardiology Clinic, University Clinical Center of Kragujevac, Kragujevac, Serbia
| | | | - Milan Nedeljkovic
- Cardiology Clinic, Clinical Center of Serbia, Belgrade, Serbia
- School of Medicine, Belgrade University, Belgrade, Serbia
| | - Vilma Paparisto
- Clinic of Cardiology, University Hospital Center Mother Theresa, Tirana, Albania
| | - Ljilja Music
- Cardiology Clinic, University Clinical Center of Montenegro, University of Podgorica, Medical Faculty, Podgorica, Montenegro
| | - Evgenii Goshev
- National Heart Hospital, Coronary Care Unit, Sofia, Bulgaria
| | - Anca Rodica Dan
- Colentina University Hospital, Cardiology Department, Bucharest, Romania
| | - Sime Manola
- Clinical Center Sestre Milosrdnice, Zagreb, Croatia
| | - Zumreta Kusljugic
- Clinic of Internal Medicine, Cardiology Department, University Clinical Center Tuzla, Medical Faculty, Tuzla, Bosnia and Herzegovina
| | | | - Dobromir Dobrev
- Institute of Pharmacology, West German Heart and Vascular Center, University Duisburg-Essen, Essen, Germany
| | - Gheorghe-Andrei Dan
- Medicine University “Carol Davila”, Colentina University Hospital, Bucharest, Romania
| | - Gregory Y.H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Medical University of Silesia, Silesian Centre for Heart Diseases, Zabrze, Poland
- School of Medicine, Belgrade University, Belgrade, Serbia
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Tatjana S. Potpara
- Cardiology Clinic, Clinical Center of Serbia, Belgrade, Serbia
- School of Medicine, Belgrade University, Belgrade, Serbia
- Corresponding author at: Cardiology Clinic, Clinical Center of Serbia, Visegradska 26, 11000 Belgrade, Serbia.
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Ward SM, Radke J, Calhoun C, Caporossi J, Hall GA, Matuskowitz AJ, Weeda ER, Weant KA. Weight-based versus non-weight-based diltiazem dosing in the setting of atrial fibrillation with rapid ventricular response. Am J Emerg Med 2019; 38:2271-2276. [PMID: 31753621 DOI: 10.1016/j.ajem.2019.09.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 09/06/2019] [Accepted: 09/25/2019] [Indexed: 11/25/2022] Open
Abstract
PURPOSE There is conflicting evidence to support the superiority of weight-based (WB) dosing of intravenous (IV) diltiazem over non-weight-based (NWB) dosing strategies in the management of atrial fibrillation (AFib) with rapid ventricular response (RVR). METHODS A retrospective review evaluated patients presenting to the emergency department (ED) in AFib with RVR and receiving IV diltiazem from 2015 to 2018. Those receiving a NWB dose were compared with those receiving a WB dose based on actual body weight (ABW). Secondary analyses evaluated safety profiles of the regimens and compared response in groups defined by ABW or ideal body weight (IBW). RESULTS A total of 371 patients were included in the analysis. No significant difference was observed in achieving a therapeutic response (66.5% vs. 73.1%, p = 0.18) or adverse events between the groups. Patients receiving a WB dose were significantly more likely to have a HR < 100 bpm than those receiving a NWB dose (40.9% vs. 53.5%, p = 0.01). When groups were defined by IBW, WB dosing was associated with a significantly higher incidence of achieving a therapeutic response (62.7% vs. 74.3%, p = 0.02). CONCLUSION In patients presenting with AF with RVR, there was no significant difference in achieving a therapeutic response between the two strategies. A WB dosing approach did result in a greater proportion of patients with a HR < 100 bpm. The utilization of IBW for WB dosing may result in an increased achievement of a therapeutic response.
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Affiliation(s)
- Sara M Ward
- Department of Pharmacy, Medical University of South Carolina, United States; Medical University of South Carolina College of Pharmacy, Charleston, SC, United States
| | - Jennifer Radke
- Medical University of South Carolina College of Pharmacy, Charleston, SC, United States
| | - Chara Calhoun
- Department of Pharmacy, Medical University of South Carolina, United States; Medical University of South Carolina College of Pharmacy, Charleston, SC, United States
| | - Jeffrey Caporossi
- Department of Emergency Medicine, Medical University of South Carolina, United States
| | - Gregory A Hall
- Department of Emergency Medicine, Medical University of South Carolina, United States
| | - Andrew J Matuskowitz
- Department of Emergency Medicine, Medical University of South Carolina, United States
| | - Erin R Weeda
- Medical University of South Carolina College of Pharmacy, Charleston, SC, United States
| | - Kyle A Weant
- Department of Pharmacy, Medical University of South Carolina, United States; Medical University of South Carolina College of Pharmacy, Charleston, SC, United States.
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Ward SM, Radke J, Calhoun C, Caporossi J, Hall GA, Matuskowitz AJ, Weeda ER, Weant KA. Weight-based versus non-weight-based diltiazem dosing in the setting of atrial fibrillation with rapid ventricular response. Am J Emerg Med 2019. [PMID: 31753621 DOI: 10.1016/j.ajem.2019.09.020.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2022] Open
Abstract
PURPOSE There is conflicting evidence to support the superiority of weight-based (WB) dosing of intravenous (IV) diltiazem over non-weight-based (NWB) dosing strategies in the management of atrial fibrillation (AFib) with rapid ventricular response (RVR). METHODS A retrospective review evaluated patients presenting to the emergency department (ED) in AFib with RVR and receiving IV diltiazem from 2015 to 2018. Those receiving a NWB dose were compared with those receiving a WB dose based on actual body weight (ABW). Secondary analyses evaluated safety profiles of the regimens and compared response in groups defined by ABW or ideal body weight (IBW). RESULTS A total of 371 patients were included in the analysis. No significant difference was observed in achieving a therapeutic response (66.5% vs. 73.1%, p = 0.18) or adverse events between the groups. Patients receiving a WB dose were significantly more likely to have a HR < 100 bpm than those receiving a NWB dose (40.9% vs. 53.5%, p = 0.01). When groups were defined by IBW, WB dosing was associated with a significantly higher incidence of achieving a therapeutic response (62.7% vs. 74.3%, p = 0.02). CONCLUSION In patients presenting with AF with RVR, there was no significant difference in achieving a therapeutic response between the two strategies. A WB dosing approach did result in a greater proportion of patients with a HR < 100 bpm. The utilization of IBW for WB dosing may result in an increased achievement of a therapeutic response.
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Affiliation(s)
- Sara M Ward
- Department of Pharmacy, Medical University of South Carolina, United States; Medical University of South Carolina College of Pharmacy, Charleston, SC, United States
| | - Jennifer Radke
- Medical University of South Carolina College of Pharmacy, Charleston, SC, United States
| | - Chara Calhoun
- Department of Pharmacy, Medical University of South Carolina, United States; Medical University of South Carolina College of Pharmacy, Charleston, SC, United States
| | - Jeffrey Caporossi
- Department of Emergency Medicine, Medical University of South Carolina, United States
| | - Gregory A Hall
- Department of Emergency Medicine, Medical University of South Carolina, United States
| | - Andrew J Matuskowitz
- Department of Emergency Medicine, Medical University of South Carolina, United States
| | - Erin R Weeda
- Medical University of South Carolina College of Pharmacy, Charleston, SC, United States
| | - Kyle A Weant
- Department of Pharmacy, Medical University of South Carolina, United States; Medical University of South Carolina College of Pharmacy, Charleston, SC, United States.
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Kusayama T, Douglas A 2nd, Wan J, Doytchinova A, Wong J, Mitscher G, Straka S, Shen C, Everett TH 4th, Chen PS. Skin sympathetic nerve activity and ventricular rate control during atrial fibrillation. Heart Rhythm 2020; 17:544-52. [PMID: 31756526 DOI: 10.1016/j.hrthm.2019.11.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND The relationship between the ventricular rate (VR) during atrial fibrillation (AF) and skin sympathetic nerve activity (SKNA) remains unclear. OBJECTIVE The purpose of this study was to test the hypothesis that SKNA bursts accelerate VR during AF. METHODS We simultaneously recorded electrocardiogram and SKNA in 8 patients (median age 66.0 years [interquartile range {IQR} 59.0-77.0 years]; 4 men [50%]) with 30 paroxysmal AF episodes (all >10-minute long) and 12 patients (73.0 years [IQR 60.5-80.0 years]; 6 men [50%]) with persistent AF. The average amplitude of SKNA (aSKNA [μV]) during AF was analyzed in 1-minute windows and binned, showing 2 Gaussian distributions. We used the mean + 3SD of the first Gaussian distribution as the threshold that separates burst from baseline (nonburst) SKNA. All 1-minute aSKNA values above the threshold were detected, and the area between aSKNA and baseline of every 1 minute was calculated and added as burst area. RESULTS VR was higher during SKNA bursts than during the nonburst period (103 beats/min [IQR 83-113 beats/min] vs 88 beats/min [IQR 76-101 beats/min], respectively; P = .003). In the highest quartile of the burst area during persistent AF, the scatterplot of maximal aSKNA and VR during each SKNA burst shows higher aSKNA and VR. The overall estimate of the correlation between maximal VR and aSKNA during bursts show a positive correlation in the highest quartile of the burst area (0.64; 95% confidence interval 0.54-0.74; P < .0001). CONCLUSION SKNA bursts are associated with VR acceleration. These SKNA bursts may be new therapeutic targets for rate control during AF.
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Fontenla A, López-Gil M, Tamargo-Menéndez J, Matía-Francés R, Salgado-Aranda R, Rey-Blas JR, Miracle-Blanco Á, Mejía-Martínez E, Pastor-Fuentes A, Toquero-Ramos J, Arias MÁ, Montilla I, Gómez de la Cámara A, Arribas F. Ivabradine for chronic heart rate control in persistent atrial fibrillation. Design of the BRAKE-AF project. ACTA ACUST UNITED AC 2019; 73:368-375. [PMID: 31631048 DOI: 10.1016/j.rec.2019.09.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 06/11/2019] [Indexed: 10/25/2022]
Abstract
INTRODUCTION AND OBJECTIVES Ivabradine is an inhibitor of the If channel, the main determinant of the pacemaker function of the sinus node. The drug has been approved for the treatment of angina and heart failure. There is some evidence of its role as an inhibitor of atrial-ventricular node (AVN) conduction. The aim of the BRAKE-AF project is to assess ivabradine use for rate control in atrial fibrillation (AF). METHODS A multicenter, randomized, parallel, open-label, noninferiority phase III clinical trial will be conducted to compare ivabradine vs digoxin in 232 patients with uncontrolled permanent AF despite beta-blockers or calcium channel blockers. The primary efficacy endpoint is the reduction in daytime heart rate measured by 24-hour Holter monitoring at 3 months. This clinical trial will be supported by an electrophysiological study of the effect of ivabradine on the action potential of the human AVN. To do this, an experimental model will be used with Chinese hamster ovarium cells transfected with the DNA encoding the expression of the t channels involved in this action potential and recording of the ionic currents with patch clamp techniques. RESULTS New data will be obtained on the effect of ivabradine on the human AVN and its safety and efficacy in patients with permanent AF. CONCLUSIONS The results of the BRAKE-AF project might allow inclusion of ivabradine within the limited arsenal of drugs currently available for rate control in AF. CLINICAL TRIAL REGISTRATION http://www.clinicaltrials.gov. Identifier: NCT03718273.
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Affiliation(s)
- Adolfo Fontenla
- Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain.
| | - María López-Gil
- Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Juan Tamargo-Menéndez
- Departamento de Farmacología, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | | | | | | | | | | | | | - Jorge Toquero-Ramos
- Servicio de Cardiología, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | | | - Isabel Montilla
- Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Agustín Gómez de la Cámara
- Unidad de Investigación Clínica en Ensayos Clínicos (UICEC), Hospital 12 de Octubre, Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Fernando Arribas
- Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain
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Abstract
PURPOSE OF REVIEW Atrial fibrillation (AF) and heart failure (HF) commonly coexist and are associated with an increased risk of hospitalization, morbidity, and mortality. Both conditions develop into epidemics due to the ageing of the population and lead to poorer prognosis for the individual patients. Therapeutic strategies include treatment with oral anticoagulation, and rate and rhythm control concepts to prevent stroke and improve the cardiovascular outcome. RECENT FINDINGS Especially in HF patients, data suggest that catheter ablation of AF is superior to medical treatment. In patients with both AF and HF undergoing catheter ablation, significant increases in left ventricular ejection fraction and quality of life and decreases in related symptoms and major adverse cardiac events are reported. In addition, catheter ablation has been shown to reduce mortality and HF hospitalization in the medium term. For patients with AF and HF, an effective individualized therapeutic strategy to minimize potential complications and improve clinical outcomes is needed. Catheter ablation of AF seems to provide advantages in HF patients with AF. However, results of further long-term studies are awaited.
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45
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Abstract
Atrial fibrillation often occurs as a cause or consequence of heart failure. Clinical outcomes are worse when atrial fibrillation and heart failure coexist. There are important sex-related differences in the incidence, prevalence, pathophysiology, treatment, and outcomes of these patients. Women with heart failure are at greater risk of developing atrial fibrillation than men, and more women with atrial fibrillation develop heart failure. More women die of atrial fibrillation-related strokes. Despite significant morbidity and mortality, current treatments for women are inadequate. This review explores sex differences in atrial fibrillation and heart failure, emphasizing risk stratification and treatments to improve clinical outcomes.
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Affiliation(s)
- Nidhi Madan
- Department of Medicine, Cardiology Division, Rush University Medical Center, 1653 West Congress Parkway, Chicago, IL 60612, USA
| | - Dipti Itchhaporia
- Department of Medicine, Cardiology Division, Hoag Memorial Hospital, University of California, Irvine, 520 Superior Avenue, Newport Beach, CA 92663, USA
| | - Christine M Albert
- Department of Medicine, Cardiology Division, Brigham and Women's Medical Center, 75 Francis Street Towers 3a, Boston, MA 02115, USA
| | - Neelum T Aggarwal
- Department of Neurological Sciences, Rush Alzheimer's Disease Center, Rush University Medical Center, 1750 W. Harrison, Suite 1000, Chicago, IL 60612, USA
| | - Annabelle Santos Volgman
- Department of Medicine, Cardiology Division, Rush University Medical Center, 1725 W. Harrison Street, Room 1159, Chicago, IL 60612, USA.
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Guerra F, Brambatti M, Nieuwlaat R, Marcucci M, Dudink E, Crijns HJGM, Matassini MV, Capucci A. Symptomatic atrial fibrillation and risk of cardiovascular events: data from the Euro Heart Survey. Europace 2018; 19:1922-1929. [PMID: 29106537 DOI: 10.1093/europace/eux205] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 05/29/2017] [Indexed: 11/13/2022] Open
Abstract
Aims Atrial fibrillation (AF) is associated with a wide range of clinical presentations. Whether and how AF symptoms can affect prognosis is still unclear. Aims of the present analysis were to investigate potential predictors of symptomatic AF and to determine if symptoms are associated with higher incidence of cardiovascular (CV) events at 1-year follow-up. Methods and results The Euro Heart Survey on Atrial Fibrillation included 3607 consecutive patients with documented AF and available follow-up regarding symptoms status. Patients found symptomatic at baseline were classified into still symptomatic (SS group; n = 896) and asymptomatic (SA; n = 1556) at 1 year. Similarly, asymptomatic patients at baseline were classified into still asymptomatic (AA group; n = 903) and symptomatic (AS group; n = 252) at 1 year. Demographics, as well as clinical variables and medical treatments, were tested as potential predictors of symptoms persistence/development at 1-year. We also compared CV events between SS and SA groups, and AS and AA groups at 1-year follow-up. Both persistence and development of AF symptoms were associated with an increased risk of CV hospitalization, stroke, heart failure worsening, and thrombo-embolism. AF type, hypothyroidism, chronic heart failure, and chronic obstructive pulmonary disease (COPD), were independently associated with an increased risk of symptomatic status at 1-year follow-up between SS and SA groups. Conclusion Persistence or development of symptoms after medical treatment are associated with an increased risk of CV events during a 1-year follow-up. Type of AF, along with hypothyroidism, COPD and chronic heart failure are significantly associated with symptoms persistence despite medical treatment.
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Affiliation(s)
- Federico Guerra
- Department of Biomedical Sciences and Public Health, Cardiology and Arrhythmology Clinic, Marche Polytechnic University, University Hospital "Ospedali Riuniti", Via Conca 71, Ancona, Italy
| | - Michela Brambatti
- Department of Biomedical Sciences and Public Health, Cardiology and Arrhythmology Clinic, Marche Polytechnic University, University Hospital "Ospedali Riuniti", Via Conca 71, Ancona, Italy.,Department of Medicine, Division of Cardiology, University of California San Diego, 9444 Medical Center Dr, La Jolla, CA 92037, USA
| | - Robby Nieuwlaat
- Department of Health Research Methods, Evidence and Impact, McMaster University, 1280 Main Street West, Hamilton, ON L8S 4K1, Canada
| | - Maura Marcucci
- Department of Health Research Methods, Evidence and Impact, McMaster University, 1280 Main Street West, Hamilton, ON L8S 4K1, Canada.,Department of Clinical Sciences and Community Health, University of Milan & Geriatrics, Fondazione-IRCSS Cá Granda, Ospedale Maggiore Policlinico, Via Pace 9, 20122, Milan, Italy
| | - Elton Dudink
- Department of Cardiology, Maastricht University Medical Centre, P.Debyelaan 25, 6229 HX, Maastricht, The Netherlands
| | - Harry J G M Crijns
- Department of Cardiology, Maastricht University Medical Centre, P.Debyelaan 25, 6229 HX, Maastricht, The Netherlands
| | - Maria Vittoria Matassini
- Department of Biomedical Sciences and Public Health, Cardiology and Arrhythmology Clinic, Marche Polytechnic University, University Hospital "Ospedali Riuniti", Via Conca 71, Ancona, Italy
| | - Alessandro Capucci
- Department of Biomedical Sciences and Public Health, Cardiology and Arrhythmology Clinic, Marche Polytechnic University, University Hospital "Ospedali Riuniti", Via Conca 71, Ancona, Italy
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47
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Abstract
New-onset atrial fibrillation (NOAF) is the most common perioperative complication of heart surgery, typically occurring in the perioperative period. NOAF commonly occurs in patients who are elderly, or have left atrial enlargement, or left ventricular hypertrophy. Various factors have been identified as being involved in the development of NOAF, and numerous approaches have been proposed for its prevention and treatment. Risk factors include diabetes, obesity, and metabolic syndrome. For prevention of NOAF, β-blockers and amiodarone are particularly effective and are recommended by guidelines. NOAF can be treated by rhythm/rate control, and antithrombotic therapy. Treatment is required in patients with decreased cardiac function, a heart rate exceeding 130 beats/min, or persistent NOAF lasting for ≥ 48 h. It is anticipated that anticoagulant therapies, as well as hemodynamic management, will also play a major role in the management of NOAF. When using warfarin as an anticoagulant, its dose should be adjusted based on PT-INR. PT-INR should be controlled between 2.0 and 3.0 in patients aged < 70 years and between 1.6 and 2.6 in those aged ≥ 70 years. Rate control combined with antithrombotic therapies for NOAF is expected to contribute to further advances in treatment and improvement of survival.
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Affiliation(s)
- Takeshi Omae
- Department of Anesthesiology and Pain Clinic, Juntendo University Shizuoka Hospital, 1129 Nagaoka, Izunokuni, Shizuoka, 410-2295, Japan. .,Department of Anesthesiology and Pain Medicine, School of Medicine, Juntendo University, Tokyo, Japan.
| | - Eiichi Inada
- Department of Anesthesiology and Pain Medicine, School of Medicine, Juntendo University, Tokyo, Japan
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Pedro B, Dukes-McEwan J, Oyama MA, Kraus MS, Gelzer AR. Retrospective Evaluation of the Effect of Heart Rate on Survival in Dogs with Atrial Fibrillation. J Vet Intern Med 2017; 32:86-92. [PMID: 29205499 PMCID: PMC5787213 DOI: 10.1111/jvim.14896] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 10/23/2017] [Accepted: 11/07/2017] [Indexed: 12/17/2022] Open
Abstract
Background Atrial fibrillation (AF) usually is associated with a rapid ventricular rate. The optimal heart rate (HR) during AF is unknown. Hypothesis/Objectives Heart rate affects survival in dogs with chronic AF. Animals Forty‐six dogs with AF and 24‐hour ambulatory recordings were evaluated. Methods Retrospective study. Holter‐derived HR variables were analyzed as follows: mean HR (meanHR, 24‐hour average), minimum HR (minHR, 1‐minute average), maximum HR (maxHR, 1‐minute average). Survival times were recorded from the time of presumed adequate rate control. The primary endpoint was all‐cause mortality. Cox proportional hazards analysis identified variables independently associated with survival; Kaplan‐Meier survival analysis estimated the median survival time of dogs with meanHR <125 bpm versus ≥125 bpm. Results All 46 dogs had structural heart disease; 31 of 46 had congestive heart failure (CHF), 44 of 46 received antiarrhythmic drugs. Of 15 dogs with cardiac death, 14 had CHF. Median time to all‐cause death was 524 days (Interquartile range (IQR), 76–1,037 days). MeanHR was 125 bpm (range, 62–203 bpm), minHR was 82 bpm (range, 37–163 bpm), maxHR was 217 bpm (range, 126–307 bpm). These were significantly correlated with all‐cause and cardiac‐related mortality. For every 10 bpm increase in meanHR, the risk of all‐cause mortality increased by 35% (hazard ratio, 1.35; 95% CI, 1.17–1.55; P < 0.001). Median survival time of dogs with meanHR<125 bpm (n = 23) was significantly longer (1,037 days; range, 524‐open) than meanHR ≥125 bpm (n = 23; 105 days; range, 67–267 days; P = 0.0012). Mean HR was independently associated with all‐cause and cardiovascular mortality (P < 0.003). Conclusions and Clinical Importance Holter‐derived meanHR affects survival in dogs with AF. Dogs with meanHR <125 bpm lived longer than those with meanHR ≥ 125 bpm.
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Affiliation(s)
- B Pedro
- Institute of Veterinary Science, University of Liverpool, Neston, UK
| | - J Dukes-McEwan
- Institute of Veterinary Science, University of Liverpool, Neston, UK
| | - M A Oyama
- Department of Clinical Studies & Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA
| | - M S Kraus
- Department of Clinical Studies & Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA
| | - A R Gelzer
- Department of Clinical Studies & Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA
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49
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Abstract
The prevalence of atrial fibrillation is increasing rapidly, resulting in more patients presenting for care in the emergency department and in-hospital settings. To reduce morbidity and mortality, and improve patient quality of life, clinicians working in these settings need to be both current and facile in their approach to management of these patients. Frequent updates to guideline recommendations (based on emerging research) make this challenging for practicing physicians. This article reviews the acute management of atrial fibrillation in the emergency and in-hospital settings, including practical approaches to rhythm and rate control, anticoagulation, and special situations, incorporating the most up-to-date guidelines.
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Affiliation(s)
- Clare L Atzema
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Sunnybrook Health Sciences Centre, Institute for Clinical Evaluative Sciences, 2075 Bayview Avenue, G146, Toronto, ON M4N 3M5, Canada.
| | - Sheldon M Singh
- Division of Cardiology, Department of Medicine, University of Toronto, Schulich Heart Program, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, A222, Toronto, ON M4N 3M5, Canada
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50
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Penttilä T, Mäkynen H, Hartikainen J, Hyppölä H, Lauri T, Lehto M, Lund J, Raatikainen MJP. Antiarrhythmic drug therapy among patients presenting to emergency department with symptomatic atrial fibrillation - a prospective nationwide cohort. Scand J Trauma Resusc Emerg Med 2017; 25:81. [PMID: 28810904 PMCID: PMC5558694 DOI: 10.1186/s13049-017-0424-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 08/02/2017] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Atrial fibrillation (AF) is a common arrhythmia that causes numerous visits to emergency departments (ED). The aim of the FinFib2 study was to evaluate whether treatment of patients with AF in ED is consistent with the contemporary European Society of Cardiology (ESC) management guidelines. Here we report the results of antiarrhythmic drug therapy (AAD) in ED. METHODS All patients within the two-week study period whose primary reason for the ED visit was symptomatic AF were included into this prospective multicentre study. Comprehensive data on factors contributing to the treatment of AF were collected, including a data of previous use of ADDs, and changes made for them during a visit in ED. RESULTS The study population consisted of 1013 consecutive patients (mean age 70 ± 13 years, 47.6% female). The mean European Heart Rhythm Association (EHRA) symptom score was 2.2 ± 0.8. Rhythm control strategy was opt for 498 (63.8%) and 140 (64.5%) patients with previously and newly diagnosed AF, respectively. In patients with previously diagnosed AF the most frequently used AAD was a beta blocker (80.9%). Prior use of class I (11.4%) and III (9.1%) AADs as well as start or adjustment of their dosage (7.4%) were uncommon. Most of the patients with newly diagnosed AF were prescribed a beta blocker (71.0%) or a calcium channel antagonist (24.0%), and only two of them received class I or class III AADs. CONCLUSIONS Our data demonstrated that in patients presenting to the ED with recurrent symptomatic AF and aimed for rhythm control strategy, the use of class I and class III AADs was rare despite ESC guideline recommendations. It is possible that early adaptation of a more aggressive rhythm control strategy might improve a quality of life for symptomatic patients and alleviate the ED burden associated with AF. Beta blockers were used by majority of patients as rate control therapy both in rate and rhythm control groups. TRIAL REGISTRATION NCT01990105 . Registered 15 November 2013.
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Affiliation(s)
- Tero Penttilä
- Heart Center Co. Tampere University Hospital, P.O. Box 2000, -33521, Tampere, FI, Finland.
| | - Heikki Mäkynen
- Heart Center Co. Tampere University Hospital, P.O. Box 2000, -33521, Tampere, FI, Finland
| | | | - Harri Hyppölä
- Emergency Department, Kuopio University Hospital, Kuopio, Finland
| | | | - Mika Lehto
- Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
| | - Juha Lund
- Turku University Hospital, Turku, Finland
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