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Yu GI, Kim D, Sung JH, Jang E, Yu HT, Kim TH, Pak HN, Lee MH, Lip GYH, Yang PS, Joung B. Impact of frailty on early rhythm control outcomes in older adults with atrial fibrillation: A nationwide cohort study. Front Cardiovasc Med 2023; 9:1050744. [PMID: 36684588 PMCID: PMC9853018 DOI: 10.3389/fcvm.2022.1050744] [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: 09/22/2022] [Accepted: 12/12/2022] [Indexed: 01/07/2023] Open
Abstract
Purpose Rhythm-control therapy administered early following the initial diagnosis of atrial fibrillation (AF) has superior cardiovascular outcomes compared to rate-control therapy. Frailty is a key factor in identifying older patients' potential for improvement after rhythm-control therapy. This study evaluated whether frailty affects the outcome of early rhythm-control therapy in older patients with AF. Methods From the Korean National Health Insurance Service database (2005-2015), we collected 20,611 populations aged ≥65 years undergoing rhythm- or rate-control therapy initiated within 1 year of AF diagnosis. Participants were emulated by the EAST-AFNET4 trial, and stratified into non-frail, moderately frail, and highly frail groups based on the hospital frailty risk score (HFRS). A composite outcome of cardiovascular-related mortality, myocardial infarction, hospitalization for heart failure, and ischemic stroke was compared between rhythm- and rate-control. Results Early rhythm-control strategy showed a 14% lower risk of the primary composite outcome in the non-frail group [weighted incidence 7.3 vs. 8.6 per 100 person-years; hazard ratio (HR) 0.86, 95% confidence interval (CI) 0.79-0.93, p < 0.001] than rate-control strategy. A consistent trend toward a lower risk of early rhythm-control was observed in the moderately frail (HR 0.91, 95% CI 0.81-1.02, p = 0.09) and highly frail (HR 0.93, 95% CI 0.75-1.17, p = 0.55) groups. Conclusion Although the degree attenuated with increasing frailty, the superiority of cardiovascular outcomes of early rhythm-control in AF treatment was maintained without increased risk for safety outcomes. An individualized approach is required on the benefits of early rhythm-control therapy in older patients with AF, regardless of their frailty status.
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Affiliation(s)
- Ga-In Yu
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Daehoon Kim
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jung-Hoon Sung
- Division of Cardiology, CHA Bundang Medical Center, CHA University, Seongnam, Republic of Korea
| | - Eunsun Jang
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hee Tae Yu
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Tae-Hoon Kim
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hui-Nam Pak
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Moon-Hyoung Lee
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Pil-Sung Yang
- Division of Cardiology, CHA Bundang Medical Center, CHA University, Seongnam, Republic of Korea,Pil-Sung Yang,
| | - Boyoung Joung
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea,*Correspondence: Boyoung Joung,
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Suresh MR, Mills AC, Britton GW, Pfeiffer WB, Grant MC, Rizzo JA. Initial treatment strategies in new-onset atrial fibrillation in critically ill burn patients. Int J Burns Trauma 2022; 12:251-260. [PMID: 36660265 PMCID: PMC9845808] [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] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 12/05/2022] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Atrial fibrillation is associated with increased morbidity and mortality in critically ill patients. Few studies have specifically examined this arrhythmia in burn patients. Given the significant clinical implications of atrial fibrillation, understanding the optimal management strategy of this arrhythmia in burn patients is important. Consequently, the purpose of this study was to examine rate- and rhythm-control strategies in the management of new onset atrial fibrillation (NOAF) and assess their short term outcomes in critically ill burn patients. METHODS We identified all patients admitted to our institution's burn intensive care unit between January 2007 and May 2018 who developed NOAF. Demographic information and burn injury characteristics were captured. Patients were grouped into two cohorts based on the initial pharmacologic treatment strategy: rate-(metoprolol or diltiazem) or rhythm-control (amiodarone). The primary outcome was conversion to sinus rhythm. Secondary outcomes included relapse or recurrence of atrial fibrillation, drug-related adverse events, and complications and mortality within 30 days of the NOAF episode. RESULTS There were 68 patients that experienced NOAF, and the episodes occurred on median days 8 and 9 in the rate- and rhythm-control groups, respectively. The length of the episodes was not significantly different between the groups. Conversion to sinus rhythm occurred more often in the rhythm-control group (P = 0.04). There were no differences in the incidences of relapse and recurrence of atrial fibrillation, and the complications and mortality between the groups. Hypotension was the most common drug-related adverse event and occurred more frequently in the rate-control group, though this difference was not significant. CONCLUSIONS Conversion to sinus rhythm occurred more often in the rhythm-control group. Outcomes were otherwise similar in terms of mortality, complications, and adverse events. Hypotension occurred less frequently in the rhythm-control group, and although this difference was not significant, episodes of hypotension can have important clinical implications. Given these factors, along with burn patients having unique injury characteristics and a hypermetabolic state that may contribute to the development of NOAF, when choosing between rate- and rhythm control strategies, rhythm-control with amiodarone may be a better choice for managing NOAF in burn patients.
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Affiliation(s)
- Mithun R Suresh
- Department of Medicine, CentraCare-St.Cloud Hospital1406 6th Ave N, St. Cloud 56303, MN, USA
| | - Alexander C Mills
- Department of Surgery, University of Texas Health Science Center at Houston6410 Fannin Street, Houston 77030, TX, USA
| | - Garrett W Britton
- Burn Center, United States Army Institute of Surgical Research3698 Chambers Pass STE B, JBSA Ft. Sam Houston 78234, TX, USA
| | - Wilson B Pfeiffer
- Department of Anesthesiology, Brooke Army Medical Center3551 Roger Brooke Dr, JBSA Ft. Sam Houston 78234, TX, USA
| | - Marissa C Grant
- Department of Anesthesiology, Brooke Army Medical Center3551 Roger Brooke Dr, JBSA Ft. Sam Houston 78234, TX, USA
| | - Julie A Rizzo
- Department of Trauma, Brooke Army Medical Center3551 Roger Brooke Dr, JBSA Ft. Sam Houston 78234, TX, USA,Department of Surgery, Uniformed Services University of The Health Sciences4301 Jones Bridge Rd, Bethesda 20814, MD, USA
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Roman S, Patel K, Hana D, Guice KC, Patel J, Stadnick C, Basta A, Khouzam RN. Rate versus rhythm control for atrial fibrillation: from AFFIRM to EAST-AFNET 4 - a paradigm shift. Future Cardiol 2022; 18:354-353. [PMID: 35255732 DOI: 10.2217/fca-2021-0034] [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: 11/21/2022] Open
Abstract
The clinical choice between rate or rhythm control therapies has been debated over the years. In 2002, the AFFIRM trial demonstrated that the rhythm-control strategy had no survival advantage over the rate-control strategy. Eighteen years later, EAST-AFNET 4 showed that the rhythm-control approach is better than rate control in reducing adverse cardiovascular outcomes in patients with a recent diagnosis of atrial fibrillation (AF). During the time between AFFIRM and EAST-AFNET 4, rhythm control understanding, specifically ablation, improved, while rate-control strategies remained the same possibly leading to the change in results seen in EAST-AFNET 4. This review seeks to evaluate the rate- and rhythm-control strategies, focusing on the important clinical trials in the past two decades. These trials have shown great advancement in AF management; however, the search for the best approach to controlling AF and minimizing the burden of symptoms is still a work in progress and needs further research.
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Affiliation(s)
- Sherif Roman
- Department of Medicine, St Joseph's University Medical Center, NJ 07503, USA
| | - Kevin Patel
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN 38163, USA
| | - David Hana
- Department of Medicine, Loyola University Medical Center/Trinity - Mercy Hospital, IL 60616, USA
| | - Kenneth C Guice
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN 38163, USA
| | - Jay Patel
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN 38163, USA
| | - Christopher Stadnick
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN 38163, USA
| | - Amir Basta
- Department of Medicine, Ain Shams University, Cairo, 1181, Egypt
| | - Rami N Khouzam
- Department of Medicine, Division of Cardiovascular Diseases, University of Tennessee Health Science Center, Memphis, TN 38163, USA
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Waechter C, Ausbuettel F, Chatzis G, Cheko J, Fischer D, Nef H, Barth S, Halbfass P, Deneke T, Kerber S, Kikec J, Mueller HH, Divchev D, Schieffer B, Luesebrink U. Impact of Rhythm vs. Rate Control in Atrial Fibrillation on the Long-Term Outcome of Patients Undergoing Transcatheter Edge-to-Edge Mitral Valve Repair. J Clin Med 2021; 10:5044. [PMID: 34768567 PMCID: PMC8584691 DOI: 10.3390/jcm10215044] [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: 09/15/2021] [Revised: 10/20/2021] [Accepted: 10/28/2021] [Indexed: 11/16/2022] Open
Abstract
Atrial fibrillation (AF) is a highly prevalent comorbidity in patients with severe mitral valve regurgitation (MR) undergoing transcatheter mitral valve repair (TMVR) and has been shown to significantly worsen their outcome. However, data on the impact of AF treatment strategy in this rapidly growing cohort of patients is unknown. In a multicenter, observational cohort study, 542 consecutive patients undergoing TMVR were enrolled, and subsequently, comprehensive survival analyses according to AF status and therapy were performed using propensity score matching and Cox regression. In the analyzed cohort, 373 (73.3%) of the TMVR patients had concomitant AF. Of these patients, 212 (59%) were on rate control therapy and 161 (41%) were on rhythm control therapy. At 3 years, significantly reduced cumulative survival was observed for patients on rhythm compared to patients on rate control (46.7% (75/161) vs. 56.5% (91/161), p = 0.032). Amiodarone was used to a substantial extent for rhythm control and found to be an independent mortality predictor (Hazard Ratio 1.5, 95%CI 1.1-2.1, p = 0.04). The adverse outcome of concomitant AF in TMVR patients was confirmed (AF: 47.3% (126/266) vs. non-AF: 58.3% (78/133), p = 0.047). Rhythm control achieved almost exclusively pharmacologically is associated with an adverse outcome compared to the rate control of AF in TMVR. This raises awareness of the importance of AF and its treatment, as this seems to be a promising key point for improving the prognosis of TMVR patients.
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Affiliation(s)
- Christian Waechter
- Department of Cardiology, University Hospital Marburg, Baldingerstraße, 35043 Marburg, Germany; (C.W.); (F.A.); (G.C.); (J.C.); (D.D.); (B.S.)
| | - Felix Ausbuettel
- Department of Cardiology, University Hospital Marburg, Baldingerstraße, 35043 Marburg, Germany; (C.W.); (F.A.); (G.C.); (J.C.); (D.D.); (B.S.)
| | - Georgios Chatzis
- Department of Cardiology, University Hospital Marburg, Baldingerstraße, 35043 Marburg, Germany; (C.W.); (F.A.); (G.C.); (J.C.); (D.D.); (B.S.)
| | - Juan Cheko
- Department of Cardiology, University Hospital Marburg, Baldingerstraße, 35043 Marburg, Germany; (C.W.); (F.A.); (G.C.); (J.C.); (D.D.); (B.S.)
| | - Dieter Fischer
- Department of Cardiology, Cardiovascular Center Rotenburg/Fulda, Heinz-Meise-Straße 100, 36199 Rotenburg/Fulda, Germany; (D.F.); (H.N.)
| | - Holger Nef
- Department of Cardiology, Cardiovascular Center Rotenburg/Fulda, Heinz-Meise-Straße 100, 36199 Rotenburg/Fulda, Germany; (D.F.); (H.N.)
- Department of Cardiology, University Hospital Giessen, Klinikstraße 33, 35392 Giessen, Germany
| | - Sebastian Barth
- Department of Cardiology, Cardiovascular Center Bad Neustadt/Saale, Von-Guttenberg-Straße 11, 97616 Bad Neustadt/Saale, Germany; (S.B.); (P.H.); (T.D.); (S.K.); (J.K.)
| | - Philipp Halbfass
- Department of Cardiology, Cardiovascular Center Bad Neustadt/Saale, Von-Guttenberg-Straße 11, 97616 Bad Neustadt/Saale, Germany; (S.B.); (P.H.); (T.D.); (S.K.); (J.K.)
| | - Thomas Deneke
- Department of Cardiology, Cardiovascular Center Bad Neustadt/Saale, Von-Guttenberg-Straße 11, 97616 Bad Neustadt/Saale, Germany; (S.B.); (P.H.); (T.D.); (S.K.); (J.K.)
| | - Sebastian Kerber
- Department of Cardiology, Cardiovascular Center Bad Neustadt/Saale, Von-Guttenberg-Straße 11, 97616 Bad Neustadt/Saale, Germany; (S.B.); (P.H.); (T.D.); (S.K.); (J.K.)
| | - Jan Kikec
- Department of Cardiology, Cardiovascular Center Bad Neustadt/Saale, Von-Guttenberg-Straße 11, 97616 Bad Neustadt/Saale, Germany; (S.B.); (P.H.); (T.D.); (S.K.); (J.K.)
| | - Hans-Helge Mueller
- Institute for Bioinformatics and Biostatistics, Philipps University, Bunsenstraße 3, 35037 Marburg, Germany;
| | - Dimitar Divchev
- Department of Cardiology, University Hospital Marburg, Baldingerstraße, 35043 Marburg, Germany; (C.W.); (F.A.); (G.C.); (J.C.); (D.D.); (B.S.)
| | - Bernhard Schieffer
- Department of Cardiology, University Hospital Marburg, Baldingerstraße, 35043 Marburg, Germany; (C.W.); (F.A.); (G.C.); (J.C.); (D.D.); (B.S.)
| | - Ulrich Luesebrink
- Department of Cardiology, University Hospital Marburg, Baldingerstraße, 35043 Marburg, Germany; (C.W.); (F.A.); (G.C.); (J.C.); (D.D.); (B.S.)
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Fumagalli S, Boni S, Pupo S, Migliorini M, Marozzi I, Barghini E, Sacco F, Marchionni N. Rate-control vs rhythm-control of atrial fibrillation in elderly patients. From new, age-oriented outcomes to a more complex management strategy. Monaldi Arch Chest Dis 2018; 88:955. [PMID: 29877664 DOI: 10.4081/monaldi.2018.955] [Citation(s) in RCA: 2] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 05/11/2018] [Accepted: 05/11/2018] [Indexed: 11/23/2022] Open
Abstract
Atrial fibrillation (AF) is the most frequent arrhythmia in elderly people. Findings derived from clinical trials seem to demonstrate that a rate-control strategy of AF in aged patients improves prognosis if compared to a rhythm-control one. However, epidemiological studies concordantly show that the arrhythmia is associated to increased hospitalization and mortality rates. In last years, the proportion of patients admitted to hospital for AF has progressively increased; this trend is observed in subjects >75 and >85 years, while no change was found in younger cohorts. Importantly, in aged individuals, probably because of the loss of atrial activity, the increase of heart rate and the irregularity of RR intervals, AF begins a vicious cycle, leading from heart failure, through the compromise of functional and neurocognitive status, to overt disability, dementia and increased mortality. Evidence specifically aimed at clarifying the effects of arrhythmia management on outcomes characteristic of aged people is completely lacking. In the elderly, the question regarding the effects of a rate- or a rhythm-control strategy of AF should be considered as an aspect of a more complex strategy, addressed to reduce disability and hospitalizations, and to improve quality of life and survival.
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Affiliation(s)
- Stefano Fumagalli
- University of Florence, AOU Careggi, Geriatric Intensive Care Unit and Geriatric Arrhythmia Unit.
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Amerena J, Chen SA, Sriratanasathavorn C, Cho JG, Dejia H, Omar R, Fat TH, King A. An Observational, Prospective Survey Assessing the Control of Atrial Fibrillation in Asia Pacific: Rationale and Design of the RecordAF-AP Registry. Clin Med Insights Cardiol 2011; 5:1-6. [PMID: 21344019 PMCID: PMC3041235 DOI: 10.4137/cmc.s6289] [Citation(s) in RCA: 3] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND The literature suggests that the prevalence of atrial fibrillation (AF) may be lower in Asian countries than in Western countries. Nevertheless, AF remains a significant public health problem in the region. The burden of AF, the experiences of previous trials and the lack of data on AF and its management in Asia Pacific highlight the need for a comprehensive prospective study of AF management. METHODS The REgistry on Cardiac rhythm disORDers assessing the control of Atrial Fibrillation Asia Pacific (RecordAF-AP) is a prospective, observational survey of the management of recently diagnosed AF patients with 1-year follow-up in 8 countries across Asia Pacific. Eligible patients presenting with AF, treated or not, will be included in the registry and data will be recorded prospectively during follow-up visits at 6 and 12 months. RESULTS RecordAF-AP will recruit more than 3000 patients. Study recruitment commenced in April 2009 and the final results anticipated at the end of 2011. CONCLUSIONS RecordAF-AP will assess the real-life management of AF patients in Asia Pacific, including a comparison of clinical outcomes in rhythm versus rate control strategies, providing much needed insight into the costs, treatment choices and clinical outcomes of AF patients in this region.
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Affiliation(s)
- John Amerena
- Geelong Cardiology Research Centre Deakin University, VIC, Australia
| | | | | | | | | | - Razali Omar
- National heart Institute, Kuala Lumpur, Malaysia
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