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Ibrahim Abushouk A, Ashraf Ali A, Abdou Mohamed A, El-Sherif L, Abdelsamed MA, Kamal Mohamed M, Kamal Sayed M, Alaa Mohamed N, Abdelbaset Osman A, M Shaheen S, M. Abdel-Daim M. Rhythm Versus Rate Control for Atrial Fibrillation: A Meta-analysis of Randomized Controlled Trials. ACTA ACUST UNITED AC 2018. [DOI: 10.13005/bpj/1413] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Atrial fibrillation (AF) is a common, sustained tachyarrhythmia, associated with an increased risk of mortality and thromboembolic events. We performed this meta-analysis to compare the clinical efficacy of rate and rhythm control strategies in patients with AF in a meta-analysis framework. A comprehensive search of PubMed, OVID, Cochrane-CENTRAL, EMBASE, Scopus, and Web of Science was conducted, using relevant keywords. Dichotomous data on mortality and other clinical events were extracted and pooled as risk ratios (RRs), with their 95% confidence-interval (CI), using RevMan software (version 5.3). Twelve studies (8451 patients) were pooled in the final analysis. The overall effect-estimate did not favor rate or rhythm control strategies in terms of all-cause mortality (RR= 1.13, 95% CI [0.88, 1.45]), stroke (RR= 0.97, 95% CI [0.79, 1.20]), thromboembolism (RR= 1.06, 95% CI [0.64, 1.76]), and major bleeding (RR= 1.10, 95% CI [0.90, 1.35]) rates. These findings were consistent in AF patients with concomitant heart failure (HF). The rate of rehospitalization was significantly higher (RR= 0.72, 95% CI [0.57, 0.92]) in the rhythm control group, compared to the rate control group. In younger patients (<65 years), rhythm control was superior to rate control in terms of lowering the risk of all-cause mortality (p=0.0003), HF (p=0.003) and major bleeding (p=0.02). In older AF patients and those with concomitant HF, both rate and rhythm control strategies have similar rates of mortality and major clinical outcomes; therefore, choosing an appropriate strategy should consider individual variations, such as patient preferences, comorbidities, and treatment cost.
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Sethi NJ, Feinberg J, Nielsen EE, Safi S, Gluud C, Jakobsen JC. The effects of rhythm control strategies versus rate control strategies for atrial fibrillation and atrial flutter: A systematic review with meta-analysis and Trial Sequential Analysis. PLoS One 2017; 12:e0186856. [PMID: 29073191 PMCID: PMC5658096 DOI: 10.1371/journal.pone.0186856] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 10/09/2017] [Indexed: 01/16/2023] Open
Abstract
Background Atrial fibrillation and atrial flutter may be managed by either a rhythm control strategy or a rate control strategy but the evidence on the clinical effects of these two intervention strategies is unclear. Our objective was to assess the beneficial and harmful effects of rhythm control strategies versus rate control strategies for atrial fibrillation and atrial flutter. Methods We searched CENTRAL, MEDLINE, Embase, LILACS, Web of Science, BIOSIS, Google Scholar, clinicaltrials.gov, TRIP, EU-CTR, Chi-CTR, and ICTRP for eligible trials comparing any rhythm control strategy with any rate control strategy in patients with atrial fibrillation or atrial flutter published before November 2016. Our primary outcomes were all-cause mortality, serious adverse events, and quality of life. Our secondary outcomes were stroke and ejection fraction. We performed both random-effects and fixed-effect meta-analysis and chose the most conservative result as our primary result. We used Trial Sequential Analysis (TSA) to control for random errors. Statistical heterogeneity was assessed by visual inspection of forest plots and by calculating inconsistency (I2) for traditional meta-analyses and diversity (D2) for TSA. Sensitivity analyses and subgroup analyses were conducted to explore the reasons for substantial statistical heterogeneity. We assessed the risk of publication bias in meta-analyses consisting of 10 trials or more with tests for funnel plot asymmetry. We used GRADE to assess the quality of the body of evidence. Results 25 randomized clinical trials (n = 9354 participants) were included, all of which were at high risk of bias. Meta-analysis showed that rhythm control strategies versus rate control strategies significantly increased the risk of a serious adverse event (risk ratio (RR), 1.10; 95% confidence interval (CI), 1.02 to 1.18; P = 0.02; I2 = 12% (95% CI 0.00 to 0.32); 21 trials), but TSA did not confirm this result (TSA-adjusted CI 0.99 to 1.22). The increased risk of a serious adverse event did not seem to be caused by any single component of the composite outcome. Meta-analysis showed that rhythm control strategies versus rate control strategies were associated with better SF-36 physical component score (mean difference (MD), 6.93 points; 95% CI, 2.25 to 11.61; P = 0.004; I2 = 95% (95% CI 0.94 to 0.96); 8 trials) and ejection fraction (MD, 4.20%; 95% CI, 0.54 to 7.87; P = 0.02; I2 = 79% (95% CI 0.69 to 0.85); 7 trials), but TSA did not confirm these results. Both meta-analysis and TSA showed no significant differences on all-cause mortality, SF-36 mental component score, Minnesota Living with Heart Failure Questionnaire, and stroke. Conclusions Rhythm control strategies compared with rate control strategies seem to significantly increase the risk of a serious adverse event in patients with atrial fibrillation. Based on current evidence, it seems that most patients with atrial fibrillation should be treated with a rate control strategy unless there are specific reasons (e.g., patients with unbearable symptoms due to atrial fibrillation or patients who are hemodynamically unstable due to atrial fibrillation) justifying a rhythm control strategy. More randomized trials at low risk of bias and low risk of random errors are needed. Trial registration PROSPERO CRD42016051433
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Affiliation(s)
- Naqash J. Sethi
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- * E-mail:
| | - Joshua Feinberg
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Emil E. Nielsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Sanam Safi
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- The Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Janus C. Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- The Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Cardiology, Holbæk Hospital, Holbæk, Denmark
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Díaz-Martínez JC, Duque-Ramírez M, Marín-Velásquez JE, Aristizábal-Aristizábal JM, Velásquez-Vélez JE, Uribe-Arango W. Costos asociados a la fibrilación auricular. REVISTA COLOMBIANA DE CARDIOLOGÍA 2016. [DOI: 10.1016/j.rccar.2016.10.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Maan A, Mansour M, N Ruskin J, Heist EK. Current Evidence and Recommendations for Rate Control in Atrial Fibrillation. Arrhythm Electrophysiol Rev 2013; 2:30-5. [PMID: 26835037 PMCID: PMC4711525 DOI: 10.15420/aer.2013.2.1.30] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Accepted: 04/15/2013] [Indexed: 01/29/2023] Open
Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia encountered in clinical practice, which is associated with substantial risk of stroke and thromboembolism. As an arrhythmia that is particularly common in the elderly, it is an important contributor towards morbidity and mortality. Ventricular rate control has been a preferred and therapeutically convenient treatment strategy for the management of AF. Recent research in the field of rhythm control has led to the advent of newer antiarrhythmic drugs and catheter ablation techniques as newer therapeutic options. Currently available antiarrhythmic drugs still remain limited by their suboptimal efficacy and significant adverse effects. Catheter ablation as a newer modality to achieve sinus rhythm (SR) continues to evolve, but data on long-term outcomes on its efficacy and mortality outcomes are not yet available. Despite these current developments, rate control continues to be the front-line treatment strategy, especially in older and minimally symptomatic patients who might not tolerate the antiarrhythmic drug treatment. This review article discusses the current evidence and recommendations for ventricular rate control in the management of AF. We also highlight the considerations for rhythm control strategy in the management of patients of AF.
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Affiliation(s)
| | | | | | - E Kevin Heist
- Assistant Professor of Medicine, Harvard Medical School and Massachusetts General Hospital, Boston, US
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Brüggenjürgen B, Kohler S, Ezzat N, Reinhold T, Willich SN. Cost effectiveness of antiarrhythmic medications in patients suffering from atrial fibrillation. PHARMACOECONOMICS 2013; 31:195-213. [PMID: 23444271 DOI: 10.1007/s40273-013-0028-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Atrial fibrillation (AF), a supraventricular tachycardia disorder, is the most common sustained cardiac arrhythmia affecting 1-2 % of the general population. Prevalence is highly related to age, with every fourth individual older than 40 years old developing AF during his lifetime. Due to an aging population, the prevalence of AF is estimated to at least double within the next 50 years. This article presents AF-related cost-of-illness studies and reviews 19 cost-effectiveness studies and six cost studies published roughly over the past decade, which have compared different antiarrhythmic medications for AF. A systematic literature search for studies published between June 2000 and December 2011 was conducted in PubMed using the combination of keywords ((atrial fibrillation OR atrial flutter) AND cost). Current cost-effectiveness analyses of dronedarone and the pill-in-the-pocket strategy are subject to substantial uncertainties with regard to clinical benefit. Comparing rate control with rhythm control, a cost-effectiveness advantage for rate control was shown in several but not all studies. Within antiarrhythmic drug treatments, magnesium added onto ibutilide was shown to be more cost effective than ibutilide alone. Comparing chemical and electrical cardioversion, the latter was recommended as more cost effective from the healthcare system perspective in all reviewed studies but one. Catheter ablation appeared more cost effective than antiarrhythmic drugs in the medium to long run after 3.2-63.9 years. Admissions to hospital, inpatient care and interventional procedures as well as mortality benefit are key drivers for the cost effectiveness of AF medications. No clear cost-effectiveness advantage emerged for one specific antiarrhythmic drug from the studies that compared antiarrhythmic agents. Rate control as well as catheter ablation appear more cost effective than rhythm control in the treatment of AF. Rate control treatment also seems more cost effective than electrical cardioversion in AF patients.
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Affiliation(s)
- Bernd Brüggenjürgen
- Institute for Health Economics, Steinbeis-Hochschule-Berlin, Steinbeis-Haus, Gürtelstraße 29A/30, 10247, Berlin, Germany.
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CHATTERJEE SAURAV, SARDAR PARTHA, LICHSTEIN EDGAR, MUKHERJEE DEBABRATA, AIKAT SHAMIK. Pharmacologic Rate versus Rhythm-Control Strategies in Atrial Fibrillation: An Updated Comprehensive Review and Meta-Analysis. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2012; 36:122-33. [DOI: 10.1111/j.1540-8159.2012.03513.x] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2012] [Accepted: 07/09/2012] [Indexed: 01/23/2023]
Affiliation(s)
- SAURAV CHATTERJEE
- From the Preventive Cardiology; Brown University and the Providence VAMC; Providence; Rhode Island
| | - PARTHA SARDAR
- Department of Internal Medicine; New York Metropolitan Hospital; New York; New York
| | | | | | - SHAMIK AIKAT
- Gill Heart Institute; University of Kentucky; Lexington; Kentucky
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Kim MH. Do the benefits of anti-arrhythmic drugs outweigh the associated risks? A tale of treatment goals in atrial fibrillation. Expert Rev Clin Pharmacol 2012; 5:163-71. [PMID: 22390559 DOI: 10.1586/ecp.12.5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Atrial fibrillation (AF) is the most common cardiac rhythm disorder and places a substantial burden on the US healthcare system. Unfortunately, there is no consensus as to whether patients should be treated with a primary rate- or rhythm-control strategy. The use of anti-arrhythmic drugs in the treatment of AF is discussed in the broader context of AF disease-management strategies with a focus on rhythm control. Outside of rhythm/ECG, AF treatment targets and cardiovascular outcomes are highlighted.
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Affiliation(s)
- Michael H Kim
- Northwestern University, Feinberg School of Medicine, Cardiac Electrophysiology Laboratory, Northwestern Memorial Hospital, 251 E. Huron Street, Suite 8-503, Feinberg Pavilion, Chicago, IL 60611, USA.
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Caldeira D, David C, Sampaio C. Rate versus rhythm control in atrial fibrillation and clinical outcomes: Updated systematic review and meta-analysis of randomized controlled trials. Arch Cardiovasc Dis 2012; 105:226-38. [DOI: 10.1016/j.acvd.2011.11.005] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2011] [Revised: 11/16/2011] [Accepted: 11/16/2011] [Indexed: 10/14/2022]
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Bash LD, Buono JL, Davies GM, Martin A, Fahrbach K, Phatak H, Avetisyan R, Mwamburi M. Systematic Review and Meta-analysis of the Efficacy of Cardioversion by Vernakalant and Comparators in Patients with Atrial Fibrillation. Cardiovasc Drugs Ther 2012; 26:167-79. [DOI: 10.1007/s10557-012-6374-4] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Wodchis WP, Bhatia RS, Leblanc K, Meshkat N, Morra D. A review of the cost of atrial fibrillation. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2012; 15:240-248. [PMID: 22433754 DOI: 10.1016/j.jval.2011.09.009] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2010] [Revised: 07/18/2011] [Accepted: 09/19/2011] [Indexed: 05/31/2023]
Abstract
OBJECTIVES To systematically review and synthesize the literature on the costs of atrial fibrillation (AF) with attention to study design and costing methods, geography, and intervention approaches. METHODS A systematic search for previously published studies reporting the costs for AF patients was conducted. Data were analyzed in three steps: first by evaluating overall system costs; second by evaluating the relative contribution of specific cost components; and third by examining variations across study designs, across primary treatment approach, and by geography. Finally, a specific review of the treatment costs associated with anticoagulation treatment was examined given the clinical importance and attention given to these costs in the literature. RESULTS The literature search resulted in 115 articles. On review of the abstracts or full text of these articles, 21 articles met all study criteria and reported on health system AF-related direct costs. A further six articles focused exclusively on anticoagulation costs for patients with AF. The overall average annual system cost across 27 estimates obtained from the literature was $5450 (SD = $3624) in 2010 Canadian dollars and ranged from a low of $1,632 to a high of $21,099. About one-third of these costs could be attributed to anticoagulation management. The largest cost component was acute care, followed by outpatient and physician and then medication-related costs. CONCLUSION AF-related medical costs are high, reflecting resource-intensive and long-term treatments including anticoagulation treatment. These costs, accompanied with increasing prevalence, justify increased attention to the management of patients with AF. Future studies of AF cost should ensure a broad assessment of the incremental direct medical and societal cost associated with this diagnosis.
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Affiliation(s)
- Walter P Wodchis
- Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada.
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Martin-Doyle W, Reynolds MR. Is AF Ablation Cost Effective? J Atr Fibrillation 2010; 3:286. [PMID: 28496663 DOI: 10.4022/jafib.286] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2010] [Revised: 08/09/2010] [Accepted: 08/14/2010] [Indexed: 11/10/2022]
Abstract
The use of catheter ablation to treat AF is increasing rapidly, but there is presently an incomplete understanding of its cost-effectiveness. AF ablation procedures involve significant up-front expenditures, but multiple randomized trials have demonstrated that ablation is more effective than antiarrhythmic drugs at maintaining sinus rhythm in a second-line and possibly first-line rhythm control setting. Although truly long-term data are limited, ablation, as compared with antiarrrhythmic drugs, also appears associated with improved symptoms and quality of life and a reduction in downstream hospitalization and other health care resource utilization. Several groups have developed cost effectiveness models comparing AF ablation primarily to antiarrhythmic drugs and the model results suggest that ablation likely falls within the range generally accepted as cost-effective in developed nations. This paper will review available information on the cost-effectiveness of catheter ablation for the treatment of atrial fibrillation, and discuss continued areas of uncertainty where further research is required.
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Affiliation(s)
| | - Matthew R Reynolds
- Beth Israel Deaconess Medical Center.,Harvard Clinical Research Institute, Boston, MA
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Jönsson L, Eliasson A, Kindblom J, Almgren O, Edvardsson N. Cost of illness and drivers of cost in atrial fibrillation in Sweden and Germany. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2010; 8:317-325. [PMID: 20804224 DOI: 10.2165/11319880-000000000-00000] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) is an important public health problem in European countries. AF is associated with increased morbidity and mortality, e.g. from heart failure and thromboembolic events. Little data have previously been presented regarding the costs of treatment in patients with AF. OBJECTIVE To estimate total direct and indirect costs in patients with AF in Sweden and Germany, and to identify determinants of total costs. METHODS A cross-sectional observational study was conducted through surveys to patients and their treating physician in primary care and in hospital outpatient cardiology departments in Sweden and Germany. A total of 922 patients with AF as diagnosed in clinical practice were enrolled and completed the study. Data were collected on medical history, treatment, medical and non-medical resource use, and employment status. Costs (year 2005 values) were calculated by multiplying resources used with prices specific for Sweden and Germany, respectively. RESULTS Total annual costs per patient were €7241 in Sweden and €5586 in Germany. Slightly less than 70% of total costs were judged as being AF related in both countries. Costs of AF-related medication were about 2% of total costs in both countries. In a generalized regression model, costs were found to increase with age, but were lower in patients aged>65 years than in those aged<or=65 years, due to the absence of indirect costs in older patients. Costs were highest in patients with persistent AF and lowest in those with permanent AF. Co-morbidities with a significant influence on costs included coronary heart disease, cerebrovascular disease, heart failure and asthma. CONCLUSIONS Current costs in AF patients are driven by the consequences of AF, while costs for specific treatments for AF are low. The addition of new, effective and safe treatment options could potentially reduce overall healthcare costs in AF.
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Kim MH, Lin J, Hussein M, Battleman D. Incidence and economic burden of suspected adverse events and adverse event monitoring during AF therapy. Curr Med Res Opin 2009; 25:3037-47. [PMID: 19852699 DOI: 10.1185/03007990903368716] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Rhythm- and rate-control therapies are an essential part of atrial fibrillation (AF) management; however, the use of existing agents is often limited by the occurrence of adverse events. The aim of this study was to evaluate suspected adverse events and adverse event monitoring, and associated medical costs, in patients receiving AF rhythm-control and/or rate-control therapy. RESEARCH DESIGN AND METHODS This retrospective cohort study used claims data from the Integrated Healthcare Information Systems National Managed Care Benchmark Database from 2002-2006. Patients hospitalized for AF (primary diagnosis), and who had at least 365 days' enrollment before and after the initial (index) AF hospitalization, were included in the analysis. Suspected AF therapy-related adverse events and function tests for adverse event monitoring were identified according to pre-specified diagnosis codes/procedures, and examined over the 12 months following discharge from the index hospitalization. Events/function tests had to have occurred within 90 days of a claim for AF therapy to be considered a suspected adverse event/adverse event monitoring. RESULTS Of 4174 AF patients meeting the study criteria, 3323 received AF drugs; 428 received rhythm-control only (12.9%), 2130 rate-control only (64.1%), and 765 combined rhythm/rate-control therapy (23.0%). Overall, 50.1% of treated patients had a suspected adverse event and/or function test for adverse event monitoring (45.5% with rate-control, 53.5% with rhythm-control, and 61.2% with combined rhythm/rate-control). Suspected cardiovascular adverse events were the most common events (occurring in 36.1% of patients), followed by pulmonary (6.1%), and endocrine events (5.9%). Overall, suspected adverse events/function tests were associated with mean annual per-patient costs of $3089 ($1750 with rhythm-control, $2041 with rate control, and $6755 with combined rhythm/rate-control). LIMITATIONS As a retrospective analysis, the study is subject to potential selection bias, while its reliance on diagnostic codes for identification of AF and suspected adverse events is a source of potential investigator error. A direct cause-effect relationship between suspected adverse events/function tests and AF therapy cannot be confirmed based on the claims data available. CONCLUSIONS The incidence of suspected adverse events and adverse event monitoring during AF rhythm-control and/or rate-control therapy is high. Costs associated with adverse events and adverse event monitoring are likely to add considerably to the overall burden of AF management.
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Affiliation(s)
- M H Kim
- Northwestern University, Chicago, IL 60611, USA.
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Ringborg A, Nieuwlaat R, Lindgren P, Jönsson B, Fidan D, Maggioni AP, Lopez-Sendon J, Stepinska J, Cokkinos DV, Crijns HJGM. Costs of atrial fibrillation in five European countries: results from the Euro Heart Survey on atrial fibrillation. Europace 2008; 10:403-11. [PMID: 18326853 DOI: 10.1093/europace/eun048] [Citation(s) in RCA: 147] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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