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Shoureshi P, Tan AY, Koneru J, Ellenbogen KA, Kaszala K, Huizar JF. Arrhythmia-Induced Cardiomyopathy: JACC State-of-the-Art Review. J Am Coll Cardiol 2024; 83:2214-2232. [PMID: 38811098 DOI: 10.1016/j.jacc.2024.03.416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 03/12/2024] [Accepted: 03/14/2024] [Indexed: 05/31/2024]
Abstract
Arrhythmias frequently accompany heart failure and left ventricular dysfunction. Tachycardias, atrial fibrillation, and premature ventricular contractions can induce a reversible form of dilated cardiomyopathy (CM) known as arrhythmia-induced CM (AiCM). The intriguing question is why certain individuals are more susceptible to AiCM, despite similar arrhythmia burdens. The primary challenge is determining the extent of arrhythmias' contribution to left ventricular systolic dysfunction. AiCM should be considered in patients with a mean heart rate of >100 beats/min, atrial fibrillation, or a PVC burden of >10%. Confirmation of AiCM occurs when CM reverses upon eliminating the responsible arrhythmia. Therapy choice depends on the specific arrhythmia, patient comorbidities, and preferences. After left ventricular function is restored, ongoing follow-up is essential if an abnormal myocardial substrate persists. Accurate diagnosis and treatment of AiCM have the potential to enhance patients' quality of life, improve clinical outcomes, and reduce hospital admissions and overall health care costs.
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Affiliation(s)
- Pouria Shoureshi
- Virginia Commonwealth University/Pauley Heart Center, Richmond, Virginia, USA; Central Virginia Veterans Affair Health Care System, Richmond, Virginia, USA
| | - Alex Y Tan
- Virginia Commonwealth University/Pauley Heart Center, Richmond, Virginia, USA; Central Virginia Veterans Affair Health Care System, Richmond, Virginia, USA
| | - Jayanthi Koneru
- Virginia Commonwealth University/Pauley Heart Center, Richmond, Virginia, USA
| | | | - Karoly Kaszala
- Virginia Commonwealth University/Pauley Heart Center, Richmond, Virginia, USA; Central Virginia Veterans Affair Health Care System, Richmond, Virginia, USA
| | - Jose F Huizar
- Virginia Commonwealth University/Pauley Heart Center, Richmond, Virginia, USA; Central Virginia Veterans Affair Health Care System, Richmond, Virginia, USA.
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2
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Dhananjay B, Kumar RP, Neelapu BC, Pal K, Sivaraman J. A Q-transform-based deep learning model for the classification of atrial fibrillation types. Phys Eng Sci Med 2024; 47:621-631. [PMID: 38353927 DOI: 10.1007/s13246-024-01391-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 01/11/2024] [Indexed: 06/12/2024]
Abstract
According to the World Health Organization (WHO), Atrial Fibrillation (AF) is emerging as a global epidemic, which has resulted in a need for techniques to accurately diagnose AF and its various subtypes. While the classification of cardiac arrhythmias with AF is common, distinguishing between AF subtypes is not. Accurate classification of AF subtypes is important for making better clinical decisions and for timely management of the disease. AI techniques are increasingly being considered for image classification and detection in various ailments, as they have shown promising results in improving diagnosis and treatment outcomes. This paper reports the development of a custom 2D Convolutional Neural Network (CNN) model with six layers to automatically differentiate Non-Atrial Fibrillation (Non-AF) rhythm from Paroxysmal Atrial Fibrillation (PAF) and Persistent Atrial Fibrillation (PsAF) rhythms from ECG images. ECG signals were obtained from a publicly available database and segmented into 10-second segments. Applying Constant Q-Transform (CQT) to the segmented ECG signals created a time-frequency depiction, yielding 98,966 images for Non-AF, 16,497 images for PAF, and 52,861 images for PsAF. Due to class imbalance in the PAF and PsAF classes, data augmentation techniques were utilized to increase the number of PAF and PsAF images to match the count of Non-AF images. The training, validation, and testing ratios were 0.7, 0.15, and 0.15, respectively. The training set consisted of 207,828 images, whereas the testing and validation set consisted of 44,538 images and 44,532 images, respectively. The proposed model achieved accuracy, precision, sensitivity, specificity, and F1 score values of 0.98, 0.98, 0.98, 0.97, and 0.98, respectively. This model has the potential to assist physicians in selecting personalized AF treatment and reducing misdiagnosis.
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Affiliation(s)
- B Dhananjay
- Department of Biotechnology and Medical Engineering, National Institute of Technology Rourkela, Rourkela, Odisha, 769008, India
| | - R Pradeep Kumar
- Department of Cardiac Sciences, Jaiprakash Hospital and Research Centre, Rourkela, Odisha, 769004, India
| | - Bala Chakravarthy Neelapu
- Department of Biotechnology and Medical Engineering, National Institute of Technology Rourkela, Rourkela, Odisha, 769008, India
| | - Kunal Pal
- Department of Biotechnology and Medical Engineering, National Institute of Technology Rourkela, Rourkela, Odisha, 769008, India
| | - J Sivaraman
- Department of Biotechnology and Medical Engineering, National Institute of Technology Rourkela, Rourkela, Odisha, 769008, India.
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3
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Ma C, Wu S, Liu S, Han Y. Chinese guidelines for the diagnosis and management of atrial fibrillation. Pacing Clin Electrophysiol 2024. [PMID: 38687179 DOI: 10.1111/pace.14920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 11/30/2023] [Indexed: 05/02/2024]
Abstract
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, significantly impacting patients' quality of life and increasing the risk of death, stroke, heart failure, and dementia. Over the past two decades, there have been significant breakthroughs in AF risk prediction and screening, stroke prevention, rhythm control, catheter ablation, and integrated management. During this period, the scale, quality, and experience of AF management in China have greatly improved, providing a solid foundation for the development of the guidelines for the diagnosis and management of AF. To further promote standardized AF management, and apply new technologies and concepts to clinical practice timely and fully, the Chinese Society of Cardiology of Chinese Medical Association and the Heart Rhythm Committee of Chinese Society of Biomedical Engineering jointly developed the Chinese Guidelines for the Diagnosis and Management of Atrial Fibrillation. The guidelines comprehensively elaborated on various aspects of AF management and proposed the CHA2DS2‑VASc‑60 stroke risk score based on the characteristics of the Asian AF population. The guidelines also reevaluated the clinical application of AF screening, emphasized the significance of early rhythm control, and highlighted the central role of catheter ablation in rhythm control.
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Affiliation(s)
- Changsheng Ma
- Chinese Society of Cardiology, Chinese Medical Association, Heart Rhythm Committee of Chinese Society of Biomedical Engineering, Beijing, China
| | - Shulin Wu
- Chinese Society of Cardiology, Chinese Medical Association, Heart Rhythm Committee of Chinese Society of Biomedical Engineering, Beijing, China
| | - Shaowen Liu
- Chinese Society of Cardiology, Chinese Medical Association, Heart Rhythm Committee of Chinese Society of Biomedical Engineering, Beijing, China
| | - Yaling Han
- Chinese Society of Cardiology, Chinese Medical Association, Heart Rhythm Committee of Chinese Society of Biomedical Engineering, Beijing, China
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4
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Okhotin A, Osipov M, Osipov V, Barchuk A. Atrial fibrillation: real-life experience of a rhythm control with electrical cardioversion in a community hospital. BMC Cardiovasc Disord 2024; 24:213. [PMID: 38632510 PMCID: PMC11022487 DOI: 10.1186/s12872-024-03885-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 04/09/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Atrial fibrillation is the most prevalent sustained cardiac arrhythmia. Electrical cardioversion, a well-established part of the rhythm control strategy, is probably underused in community settings. Here, we describe its use, safety, and effectiveness in a cohort of patients with atrial fibrillation treated in rural settings. METHODS It is a retrospective cohort study. Data on all procedures from January 1, 2016, till December 1, 2022, in Tarusa Hospital, serving mostly a rural population of 15,000 people, were extracted from electronic health records. Data on the procedure's success, age, gender, body mass index, comorbidities, previous procedures, echocardiographic parameters, type and duration of arrhythmia, anticoagulation, antiarrhythmic drugs, transesophageal echocardiography, and settings were available. RESULTS Altogether, 1,272 procedures in 435 patients were performed during the study period. The overall effectiveness of the procedure was 92%. Effectiveness was similar across all prespecified subgroups. Electrical cardioversion was less effective in patients undergoing the procedure for the first time (86%, 95% CI: 82-90) compared to repeated procedures (95%, 95% CI: 93-96), OR 0.39 (95% CI: 0.26-0.59). Complications were encountered in 13 (1.02%) procedures but were not serious. CONCLUSIONS Electrical cardioversion is an immediately effective procedure that can be safely performed in community hospitals, both in inpatient and outpatient settings. Further studies with longer follow-up are needed to investigate the rate of sinus rhythm maintenance in these patients.
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Affiliation(s)
- Artemiy Okhotin
- ITMO University, Kronverkskiy Prospekt, 49, 197101, St. Petersburg, Russia.
- Tarusa Hospital, K. Libknekhta ulitsa, 16, 249100, Tarusa, Russia.
| | - Maxim Osipov
- Tarusa Hospital, K. Libknekhta ulitsa, 16, 249100, Tarusa, Russia
| | - Vasilij Osipov
- Tarusa Hospital, K. Libknekhta ulitsa, 16, 249100, Tarusa, Russia
| | - Anton Barchuk
- ITMO University, Kronverkskiy Prospekt, 49, 197101, St. Petersburg, Russia
- Institute for Interdisciplinary Health Research, European University at St. Petersburg, Shpalernaya Ulitsa 1, 191187, St. Petersburg, Russia
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5
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Seiffge DJ, Cancelloni V, Räber L, Paciaroni M, Metzner A, Kirchhof P, Fischer U, Werring DJ, Shoamanesh A, Caso V. Secondary stroke prevention in people with atrial fibrillation: treatments and trials. Lancet Neurol 2024; 23:404-417. [PMID: 38508836 DOI: 10.1016/s1474-4422(24)00037-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 01/19/2024] [Accepted: 01/24/2024] [Indexed: 03/22/2024]
Abstract
Atrial fibrillation is one of the most common cardiac arrhythmias and is a major cause of ischaemic stroke. Recent findings indicate the importance of atrial fibrillation burden (device-detected, subclinical, or paroxysmal and persistent or permanent) and whether atrial fibrillation was known before stroke onset or diagnosed after stroke for the risk of recurrence. Secondary prevention in patients with atrial fibrillation and stroke aims to reduce the risk of recurrent ischaemic stroke. Findings from randomised controlled trials assessing the optimal timing to introduce direct oral anticoagulant therapy after a stroke show that early start (ie, within 48 h for minor to moderate strokes and within 4-5 days for large strokes) seems safe and could reduce the risk of early recurrence. Other promising developments regarding early rhythm control, left atrial appendage occlusion, and novel factor XI inhibitor oral anticoagulants suggest that these therapies have the potential to further reduce the risk of stroke. Secondary prevention strategies in patients with atrial fibrillation who have a stroke despite oral anticoagulation therapy is an unmet medical need. Research advances suggest a heterogeneous spectrum of causes, and ongoing trials are investigating new approaches for secondary prevention in this vulnerable patient group. In patients with atrial fibrillation and a history of intracerebral haemorrhage, the latest data from randomised controlled trials on stroke prevention shows that oral anticoagulation reduces the risk of ischaemic stroke but more data are needed to define the safety profile.
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Affiliation(s)
- David J Seiffge
- Department of Neurology, Inselspital University Hospital Bern and University of Bern, Switzerland.
| | - Virginia Cancelloni
- Stroke Unit, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Lorenz Räber
- Department of Cardiology, Inselspital University Hospital Bern and University of Bern, Switzerland
| | - Maurizio Paciaroni
- Stroke Unit, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Andreas Metzner
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Center Hamburg Eppendorf, Hamburg, Germany; German Center for Cardiovascular Research, partner site Hamburg, Kiel, and Lübeck, Germany
| | - Paulus Kirchhof
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Center Hamburg Eppendorf, Hamburg, Germany; German Center for Cardiovascular Research, partner site Hamburg, Kiel, and Lübeck, Germany; Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Urs Fischer
- Department of Neurology, Inselspital University Hospital Bern and University of Bern, Switzerland; Department of Neurology, University Hospital Basel, Switzerland
| | - David J Werring
- Stroke Research Centre, UCL Queen Square Institute of Neurology, London, UK
| | - Ashkan Shoamanesh
- Division of Neurology, Department of Medicine, Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Valeria Caso
- Stroke Unit, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
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Tsiachris D, Argyriou N, Tsioufis P, Antoniou CK, Laina A, Oikonomou G, Doundoulakis I, Kordalis A, Dimitriadis K, Gatzoulis K, Tsioufis K. Aggressive Rhythm Control Strategy in Atrial Fibrillation Patients Presenting at the Emergency Department: The HEROMEDICUS Study Design and Initial Results. J Cardiovasc Dev Dis 2024; 11:109. [PMID: 38667727 PMCID: PMC11049958 DOI: 10.3390/jcdd11040109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 03/26/2024] [Accepted: 03/26/2024] [Indexed: 04/28/2024] Open
Abstract
Atrial fibrillation has progressively become a more common reason for emergency department visits, representing 0.5% of presenting reasons. Registry data have indicated that about 60% of atrial fibrillation patients who present to the emergency department are admitted, emphasizing the need for more efficient management of atrial fibrillation in the acute phase. Management of atrial fibrillation in the setting of the emergency department varies between countries and healthcare systems. The most plausible reason to justify a conservative rather than an aggressive strategy in the management of atrial fibrillation is the absence of specific guidelines from diverse societies. Several trials of atrial fibrillation treatment strategies, including cardioversion, have demonstrated that atrial fibrillation in the emergency department can be treated safely and effectively, avoiding admission. In the present study, we present the epidemiology and characteristics of atrial fibrillation patients presenting to the emergency department, as well as the impact of diverse management strategies on atrial-fibrillation-related hospital admissions. Lastly, the design and initial data of the HEROMEDICUS protocol will be presented, which constitutes an electrophysiology-based aggressive rhythm control strategy in patients with atrial fibrillation in the emergency department setting.
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Affiliation(s)
- Dimitrios Tsiachris
- First Department of Cardiology, School of Medicine, Hippokration General Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece; (N.A.); (P.T.); (C.K.A.); (A.L.); (G.O.); (A.K.); (K.D.); (K.G.); (K.T.)
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7
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MA CS, WU SL, LIU SW, HAN YL. Chinese Guidelines for the Diagnosis and Management of Atrial Fibrillation. J Geriatr Cardiol 2024; 21:251-314. [PMID: 38665287 PMCID: PMC11040055 DOI: 10.26599/1671-5411.2024.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024] Open
Abstract
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, significantly impacting patients' quality of life and increasing the risk of death, stroke, heart failure, and dementia. Over the past two decades, there have been significant breakthroughs in AF risk prediction and screening, stroke prevention, rhythm control, catheter ablation, and integrated management. During this period, the scale, quality, and experience of AF management in China have greatly improved, providing a solid foundation for the development of guidelines for the diagnosis and management of AF. To further promote standardized AF management, and apply new technologies and concepts to clinical practice in a timely and comprehensive manner, the Chinese Society of Cardiology of the Chinese Medical Association and the Heart Rhythm Committee of the Chinese Society of Biomedical Engineering have jointly developed the Chinese Guidelines for the Diagnosis and Management of Atrial Fibrillation. The guidelines have comprehensively elaborated on various aspects of AF management and proposed the CHA2DS2-VASc-60 stroke risk score based on the characteristics of AF in the Asian population. The guidelines have also reevaluated the clinical application of AF screening, emphasized the significance of early rhythm control, and highlighted the central role of catheter ablation in rhythm control.
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8
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Crawford M, Steinberg BA, Ranjan R, Konstantinidis K, Navaravong L, Bunch TJ. Mortality benefit with AF ablation: Impact of normal sinus rhythm seen in CABANA and EAST AFnet. J Cardiovasc Electrophysiol 2024; 35:538-546. [PMID: 38131368 DOI: 10.1111/jce.16160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 12/08/2023] [Accepted: 12/11/2023] [Indexed: 12/23/2023]
Abstract
Atrial fibrillation (AF) is significantly associated with morbidity and mortality and erodes the quality and quantity of life. It is standard of care to treat patients with AF and an increased risk of stroke with oral anticoagulation therapy, but the more daunting question many clinicians face is whether to pursue a "rate-only" or "rhythm" control strategy. Historical studies over the years have sought to answer this question but have found no significant difference in major clinical outcomes between the two strategies. There are opportunities based on new data to improve the natural history of the disease. The EAST AFnet trial for the first time revealed a significant morbidity and mortality advantage to rhythm control therapy when performed early in the disease process of AF and in the setting of comprehensive medical management that was maintained. The CABANA trial clearly demonstrated that catheter ablation was a more effective long-term treatment of AF in general and significantly lowers risk of AF progression compared to medical therapy. Like multiple prior trials of rhythm management strategies, when rhythm control was effective in these trials, independent of therapy assignment, there was a significantly lower risk of adverse outcomes and death. These contemporary data provide optimism that the pervasive mortality risk in patients with AF observed over the past 50 years may be improved by the timing, use, and efficacy of use of therapeutic interventions.
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Affiliation(s)
- Michael Crawford
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Benjamin A Steinberg
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Ravi Ranjan
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Klitos Konstantinidis
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Leenhapong Navaravong
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Thomas J Bunch
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
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Bucci T, Nabrdalik K, Shantsila A, Romiti GF, Teo WS, Park HW, Shimizu W, Tse HF, Proietti M, Chao TF, Lip GYH. Adverse Events and Clinical Correlates in Asian Patients with Atrial Fibrillation and Diabetes Mellitus: A Report from Asia Pacific Heart Rhythm Society Atrial Fibrillation Registry. J Clin Med 2024; 13:1274. [PMID: 38592107 PMCID: PMC10932296 DOI: 10.3390/jcm13051274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 01/12/2024] [Accepted: 02/19/2024] [Indexed: 04/10/2024] Open
Abstract
Aims. To evaluate the adverse events (and its clinical correlates) in a large prospective cohort of Asian patients with atrial fibrillation (AF) and diabetes mellitus (DM). Material and Methods. We recruited patients with atrial fibrillation (AF) from the Asia-Pacific Heart Rhythm Society (APHRS) AF Registry and included those for whom the diabetic mellitus (DM) status was known. We used Cox-regression analysis to assess the 1-year risk of all-cause death, thromboembolic events, acute coronary syndrome, heart failure and major bleeding. Results. Of 4058 patients (mean age 68.5 ± 11.8 years; 34.4% females) considered for this analysis, 999 (24.6%) had DM (age 71 ± 11 years, 36.4% females). Patients with DM had higher mean CHA2DS2-VASc (2.3 ± 1.6 vs. 4.0 ± 1.5, p < 0.001) and HAS-BLED (1.3 ± 1.0 vs. 1.7 ± 1.1, p < 0.001) risk scores and were less treated with rhythm control strategies compared to patients without DM (18.7% vs. 22.0%). After 1-year of follow-up, patients with DM had higher incidence of all-cause death (4.9% vs. 2.3%, p < 0.001), cardiovascular death (1.3% vs. 0.4%, p = 0.003), and major bleeding (1.8% vs. 0.9%, p = 0.002) compared to those without DM. On Cox regression analysis, adjusted for age, sex, heart failure, coronary and peripheral artery diseases and previous thromboembolic event, DM was independently associated with a higher risk of all-cause death (HR 1.48, 95% CI 1.00-2.19), cardiovascular death (HR 2.33, 95% CI 1.01-5.40), and major bleeding (HR 1.91, 95% 1.01-3.60). On interaction analysis, the impact of DM in determining the risk of all-cause death was greater in young than in older patients (p int = 0.010). Conclusions. Given the high rates of adverse outcomes in these Asian AF patients with DM, efforts to optimize the management approach of these high-risk patients in a holistic or integrated care approach are needed.
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Affiliation(s)
- Tommaso Bucci
- Liverpool Centre of Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool L7 8TX, UK (K.N.); (A.S.); (G.F.R.)
- Department of General and Specialized Surgery, Sapienza University of Rome, 00185 Rome, Italy
| | - Katarzyna Nabrdalik
- Liverpool Centre of Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool L7 8TX, UK (K.N.); (A.S.); (G.F.R.)
- Department of Internal Diseases, Diabetology and Nephrology in Zabrze, Medical University of Silesia in Katowice, 40-055 Katowice, Poland
| | - Alena Shantsila
- Liverpool Centre of Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool L7 8TX, UK (K.N.); (A.S.); (G.F.R.)
| | - Giulio Francesco Romiti
- Liverpool Centre of Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool L7 8TX, UK (K.N.); (A.S.); (G.F.R.)
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy
| | - Wee-Siong Teo
- Department of Cardiology, National Heart Centre, Singapore 610041, Singapore;
| | - Hyung-Wook Park
- Department of Cardiovascular Medicine, Chonnam National University Hospital, Gwangju 61469, Republic of Korea;
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo 113-8602, Japan;
| | - Hung-Fat Tse
- Division of Cardiology, Department of Medicine, School of Clinical Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong SAR 999077, China;
| | - Marco Proietti
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy;
- Division of Subacute Care, IRCCS Institute Clinici Scientifici Maugeri, 20138 Milan, Italy
| | - Tze-Fan Chao
- Institute of Clinical Medicine, Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei 112, Taiwan
| | - Gregory Y. H. Lip
- Liverpool Centre of Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool L7 8TX, UK (K.N.); (A.S.); (G.F.R.)
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, 9220 Aalborg, Denmark
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10
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Brandes A, Tojaga N. Stroke prevention and symptom control in atrial fibrillation-handling a global and major health crisis. THE LANCET REGIONAL HEALTH. EUROPE 2024; 37:100833. [PMID: 38362557 PMCID: PMC10866926 DOI: 10.1016/j.lanepe.2023.100833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 12/20/2023] [Indexed: 02/17/2024]
Affiliation(s)
- Axel Brandes
- Department of Cardiology, Esbjerg Hospital – University Hospital of Southern Denmark, Esbjerg, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Nedim Tojaga
- Department of Cardiology, Esbjerg Hospital – University Hospital of Southern Denmark, Esbjerg, Denmark
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11
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Gupta D, Rienstra M, van Gelder IC, Fauchier L. Atrial fibrillation: better symptom control with rate and rhythm management. THE LANCET REGIONAL HEALTH. EUROPE 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] [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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12
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Könemann H, Güler-Eren S, Ellermann C, Frommeyer G, Eckardt L. Antiarrhythmic Treatment in Heart Failure. Curr Heart Fail Rep 2024; 21:22-32. [PMID: 38224446 PMCID: PMC10828006 DOI: 10.1007/s11897-023-00642-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/29/2023] [Indexed: 01/16/2024]
Abstract
PURPOSE OF REVIEW Arrhythmias are common in patients with heart failure (HF) and are associated with a significant risk of mortality and morbidity. Optimal antiarrhythmic treatment is therefore essential. Here, we review current approaches to antiarrhythmic treatment in patients with HF. RECENT FINDINGS In atrial fibrillation, rhythm control and ventricular rate control are accepted therapeutic strategies. In recent years, clinical trials have demonstrated a prognostic benefit of early rhythm control strategies and AF catheter ablation, especially in patients with HF with reduced ejection fraction. Prevention of sudden cardiac death with ICD therapy is essential, but optimal risk stratification is challenging. For ventricular tachycardias, recent data support early consideration of catheter ablation. Antiarrhythmic drug therapy is an adjunctive therapy in symptomatic patients but has no prognostic benefit and well-recognized (proarrhythmic) adverse effects. Antiarrhythmic therapy in HF requires a systematic, multimodal approach, starting with guideline-directed medical therapy for HF and integrating pharmacological, device, and interventional therapy.
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Affiliation(s)
- Hilke Könemann
- Department of Cardiology II: Electrophysiology, University Hospital Münster, Münster, Germany.
| | - Sati Güler-Eren
- Department of Cardiology II: Electrophysiology, University Hospital Münster, Münster, Germany
| | - Christian Ellermann
- Department of Cardiology II: Electrophysiology, University Hospital Münster, Münster, Germany
| | - Gerrit Frommeyer
- Department of Cardiology II: Electrophysiology, University Hospital Münster, Münster, Germany
| | - Lars Eckardt
- Department of Cardiology II: Electrophysiology, University Hospital Münster, Münster, Germany
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13
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Shantsila E, Choi EK, Lane DA, Joung B, Lip GY. Atrial fibrillation: comorbidities, lifestyle, and patient factors. THE LANCET REGIONAL HEALTH. EUROPE 2024; 37:100784. [PMID: 38362547 PMCID: PMC10866737 DOI: 10.1016/j.lanepe.2023.100784] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 09/25/2023] [Accepted: 11/02/2023] [Indexed: 02/17/2024]
Abstract
Modern anticoagulation therapy has dramatically reduced the risk of stroke and systemic thromboembolism in people with atrial fibrillation (AF). However, AF still impairs quality of life, increases the risk of stroke and heart failure, and is linked to cognitive impairment. There is also a recognition of the residual risk of thromboembolic complications despite anticoagulation. Hence, AF management is evolving towards a more comprehensive understanding of risk factors predisposing to the development of this arrhythmia, its' complications and interventions to mitigate the risk. This review summarises the recent advances in understanding of risk factors for incident AF and managing these risk factors. It includes a discussion of lifestyle, somatic, psychological, and socioeconomic risk factors. The available data call for a practice shift towards a more individualised approach considering an increasingly broader range of health and patient factors contributing to AF-related health burden. The review highlights the needs of people living with co-morbidities (especially with multimorbidity), polypharmacy and the role of the changing population demographics affecting the European region and globally.
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Affiliation(s)
- Eduard Shantsila
- Department of Primary Care and Mental Health, University of Liverpool, United Kingdom
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Brownlow Group GP Practice, Liverpool, United Kingdom
| | - Eue-Keun Choi
- Division of Cardiology, Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Hospital, Seoul, Republic of Korea
| | - Deirdre A. Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Department of Cardiovascular and Metabolic Medicine, University of Liverpool, United Kingdom
- Department of Clinical Medicine, Aalborg University, Denmark
| | - Boyoung Joung
- Division of Cardiology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Gregory Y.H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Department of Cardiovascular and Metabolic Medicine, University of Liverpool, United Kingdom
- Department of Clinical Medicine, Aalborg University, Denmark
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14
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Rahman RA, Zaman B, Khan MR, Islam MS, Rashid MH. Computational Studies Show How the H463R Mutation Turns hKv1.5 into an Inactivation State. J Phys Chem B 2024; 128:429-439. [PMID: 38179652 DOI: 10.1021/acs.jpcb.3c05634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2024]
Abstract
The KCNA5 gene provides the code for the α-subunit of the potassium channel Kv1.5. The genetic variant H463R in the Kv1.5 channel has been reported to cause a functional loss in atrial fibrillation (AF) patients. Understanding the mutations at a molecular level is key to developing improved therapeutics concerning cardiac hKv1.5 and hKv1.4 channels. Molecular dynamics and umbrella sampling free energy simulations are an effective tool to understand the mutation's effect on ion conduction, which we have employed and found that the hKv1.5[H463R] mutation imposes an energy barrier on the ion conduction pathway compared to the wild-type channel's ion free energy and pore structure. These results imply that the arginine mutation associated with the AF disease in particular modulates the inactivation process of hKv1.5. Kv1.4, encoded by the KCNA4 gene, is also present in the heart. Therefore, we considered simulation studies of the equivalent H507R mutation in the hKv1.4 channel and found that the mutation slightly reduces the ion conduction barrier in the ion conduction pathway, making it insignificant.
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Affiliation(s)
- Ramisha A Rahman
- Department of Mathematics & Physics, North South University, Plot # 15, Dhaka 1229, Bangladesh
| | - Bushra Zaman
- Department of Mathematics & Physics, North South University, Plot # 15, Dhaka 1229, Bangladesh
| | - Mohammad Radid Khan
- Department of Mathematics & Physics, North South University, Plot # 15, Dhaka 1229, Bangladesh
| | - Md Shariful Islam
- Department of Mathematics & Physics, North South University, Plot # 15, Dhaka 1229, Bangladesh
- Department of Chemistry and Biochemistry, New Mexico State University, Las Cruces, New Mexico 88003, United States
| | - Md Harunur Rashid
- Department of Mathematics & Physics, North South University, Plot # 15, Dhaka 1229, Bangladesh
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15
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Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2024; 149:e1-e156. [PMID: 38033089 PMCID: PMC11095842 DOI: 10.1161/cir.0000000000001193] [Citation(s) in RCA: 131] [Impact Index Per Article: 131.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
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Affiliation(s)
| | | | | | | | | | | | - Anita Deswal
- ACC/AHA Joint Committee on Clinical Practice Guidelines liaison
| | | | | | | | | | - Paul L Hess
- ACC/AHA Joint Committee on Performance Measures liaison
| | | | | | | | | | - Kazuhiko Kido
- American College of Clinical Pharmacy representative
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16
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Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2024; 83:109-279. [PMID: 38043043 PMCID: PMC11104284 DOI: 10.1016/j.jacc.2023.08.017] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Patients With Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
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17
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Estes NAM, Jain S, Saba S. Improving Outcomes in Atrial Fibrillation: Evidence Guiding Clinical Care. Am J Cardiol 2024; 210:297-299. [PMID: 37865147 DOI: 10.1016/j.amjcard.2023.10.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 10/13/2023] [Indexed: 10/23/2023]
Affiliation(s)
- Nathan A Mark Estes
- The Heart and Vascular Institute, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
| | - Sandeep Jain
- The Heart and Vascular Institute, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Samir Saba
- The Heart and Vascular Institute, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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18
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Deering TF, Goyal SK, Bhimani AA, Hoosien M, Karimianpour A, Krishnasamy KP, Nilsson KR, Omar A, Lakkireddy D, Gopinathannair R, Katapadi A, Sohns C. Atrial fibrillation ablation in heart failure patients: Where do we stand in 2023? - State of the art review. Pacing Clin Electrophysiol 2024; 47:88-100. [PMID: 38071456 DOI: 10.1111/pace.14888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 11/08/2023] [Accepted: 11/15/2023] [Indexed: 01/11/2024]
Abstract
Atrial fibrillation (AF) and heart failure are common overlapping cardiovascular disorders. Despite important therapeutic advances over the past several decades, controversy persists about whether a rate control or rhythm control approach constitutes the best option in this population. There is also considerable debate about whether antiarrhythmic drug therapy or ablation is the best approach when rhythm control is pursued. A brief historical examination of the literature addressing this issue will be performed. An analysis of several important clinical outcomes observed in the prospective, randomized studies, which have compared AF ablation to non-ablation treatment options, will be discussed. This review will conclude with recommendations to guide clinicians on the status of AF ablation as a treatment option when considering management options in heart failure patients with atrial fibrillation.
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Affiliation(s)
- Thomas F Deering
- Department of Cardiac Electrophysiology, Piedmont Heart Institute, Atlanta, Georgia, USA
- Department of Cardiology, Augusta University, Athens, Georgia, USA
| | - Sandeep K Goyal
- Department of Cardiac Electrophysiology, Piedmont Heart Institute, Atlanta, Georgia, USA
| | - Ashish A Bhimani
- Department of Cardiac Electrophysiology, Piedmont Heart Institute, Atlanta, Georgia, USA
| | - Michael Hoosien
- Department of Cardiac Electrophysiology, Piedmont Heart Institute, Atlanta, Georgia, USA
| | - Ahmadreza Karimianpour
- Department of Cardiac Electrophysiology, Piedmont Heart Institute, Atlanta, Georgia, USA
| | - Kavita P Krishnasamy
- Department of Cardiac Electrophysiology, Piedmont Heart Institute, Atlanta, Georgia, USA
| | - Kent R Nilsson
- Department of Cardiac Electrophysiology, Piedmont Heart Institute, Atlanta, Georgia, USA
- Department of Cardiology, Augusta University, Athens, Georgia, USA
| | - Abdullah Omar
- Department of Cardiac Electrophysiology, Piedmont Heart Institute, Atlanta, Georgia, USA
| | - Dhanunjaya Lakkireddy
- Kansas City Heart Rhythm Institute and Research Foundation, Overland Park, Kansas, USA
| | - Rakesh Gopinathannair
- Kansas City Heart Rhythm Institute and Research Foundation, Overland Park, Kansas, USA
| | - Aashish Katapadi
- Kansas City Heart Rhythm Institute and Research Foundation, Overland Park, Kansas, USA
| | - Christian Sohns
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
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19
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Patel PJ, Ahmed AS. Interventional Management of Atrial Fibrillation in the Chronic Heart Failure Population. Heart Fail Clin 2024; 20:15-28. [PMID: 37953018 DOI: 10.1016/j.hfc.2023.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
Atrial fibrillation (AF) and heart failure (HF) synergistically interact to exacerbate each other. However, treatment of one entity can greatly improve management of the other. Although historically, permissive medical therapy was the mainstay of AF management in the HF population, recent data strongly favor early, often invasive, intervention for AF to reduce hard HF outcomes. It seems that intervening earlier in the time course of AF, though still not excluding persistent AF from treatment, may have more pronounced effects.
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Affiliation(s)
- Parin J Patel
- Department of Cardiac Electrophysiology, Ascension St. Vincent Heart Center, 8333 Naab Road #400, Indianapolis, IN 46260, USA.
| | - Asim S Ahmed
- Department of Cardiac Electrophysiology, Ascension Sacred Heart Cardiology, 5151 North 9th Avenue #200, Pensacola, FL 32504, USA. https://twitter.com/AsimAhmedEP
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20
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Tamimi O, Tamimi F, Gorthi J. Clinical Outcomes of Decompensated Heart Failure With Reduced Ejection Fraction Admissions With or Without Atrial Fibrillation and Atrial Flutter. Curr Probl Cardiol 2024; 49:102014. [PMID: 37544625 DOI: 10.1016/j.cpcardiol.2023.102014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 08/01/2023] [Indexed: 08/08/2023]
Abstract
The aim of our retrospective study is to determine the influence of co-morbid atrial fibrillation or flutter (AF) on decompensated congestive heart failure (CHF) admissions using data from the 2020 nationwide inpatient sample. We identified 76,835 adults admitted nonelectively with decompensated CHF. After multivariate adjustment, we found decompensated heart failure with reduced ejection fraction (HFrEF) admissions with AF had 37% higher odds of in-hospital mortality, (OR 1.38 [95% CI 1.1-1.72] P < 0.01), 33% higher odds for mechanical ventilation (MV) (OR 1.33 [95% CI 1.14-1.55] P < 0.01), 39% higher odds of early MV (OR 1.39 [95% CI 1.16-1.66] P < 0.01), 54% higher odds of cardiogenic shock (OR 1.54 [95% CI 1.29-1.84] P < 0.01), 61% increased odds of mechanical circulatory support (MCS) requirement (OR 1.61 [95% CI 1.12-2.31] P < 0.02), significantly higher odds of acute renal failure (AKI) necessitating dialysis (OR 2.20 [95% CI 1.39-2.48] P < 0.01), 1-day increase in mean length of stay (LOS) (6.7 vs 5.7 days, adjusted difference: 0.99, P < 0.01), $13,281 increase in total hospitalization charges ($84,316 vs $74,279, adjusted difference: $13,281, P < 0.05) compared to the non-AF cohort. Moreover, we found decompensated heart failure with preserved ejection fraction (HFpEF) admissions with AF had a 23% increased odds of MV (OR 1.23 [95% CI 1.01-1.50] P < 0.01), 24% higher odds of early MV (OR 1.24 [95% CI 1.00-1.53] P < 0.01), 0.36 days increase in mean LOS (5.5 vs 5.2 days, adjusted difference: 0.36, P = < 0.01), but no significant difference in in-hospital mortality (OR 1.23 [95% CI 0.86-1.75] P = 0.25), cardiogenic shock (OR 1.75 [95% CI 0.96-3.19] P < 0.07), dialysis-dependent AKI (OR 0.46 [95% CI 0.18-1.17] P < 0.10), or mean total hospitalization charges ($52,086 vs $47,990, adjusted difference: $5584, P = 0.06) compared to the non-AF cohort.
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Affiliation(s)
- Omar Tamimi
- Department of Medicine, Houston Methodist Hospital, Houston, TX.
| | - Faisal Tamimi
- Department of Medicine, Jamaica Medical Center, Queens, NY
| | - Janardhana Gorthi
- Department of Medicine, Houston Methodist Hospital, Houston, TX; DeBakey Heart and Vascular Institute, Division of Cardiology, Houston Methodist Hospital, Houston, TX
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21
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Velliou M, Sanidas E, Diakantonis A, Ventoulis I, Parissis J, Polyzogopoulou E. The Optimal Management of Patients with Atrial Fibrillation and Acute Heart Failure in the Emergency Department. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:2113. [PMID: 38138216 PMCID: PMC10744575 DOI: 10.3390/medicina59122113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 11/29/2023] [Accepted: 11/30/2023] [Indexed: 12/24/2023]
Abstract
Atrial fibrillation (AF) and acute heart failure (AHF) are two closely interrelated conditions that frequently coexist in a manifold manner, with AF serving either as the causative factor or as the consequence or even as an innocent bystander. The interplay between these two clinical conditions is complex, given that they share common pathophysiological pathways and they can reciprocally exacerbate each other, thus triggering a vicious cycle that worsens the prognosis and increases the thromboembolic risk. The optimal management of AF in the context of AHF in the emergency department remains a challenge depending on the time onset, as well as the nature and the severity of the associated symptoms. Acute rate control, along with early rhythm control, when indicated, and anticoagulation represent the main pillars of the therapeutic intervention. The purpose of this review is to elucidate the pathophysiological link between AF and AHF and accordingly present a stepwise algorithmic approach for the management of AF in AHF patients in the emergency setting.
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Affiliation(s)
- Maria Velliou
- Emergency Medicine Department, Attikon University Hospital, 12462 Athens, Greece; (M.V.); (A.D.); (J.P.)
| | - Elias Sanidas
- Department of Cardiology, Laiko General Hospital, 11527 Athens, Greece;
| | - Antonis Diakantonis
- Emergency Medicine Department, Attikon University Hospital, 12462 Athens, Greece; (M.V.); (A.D.); (J.P.)
| | - Ioannis Ventoulis
- Department of Occupational Therapy, University of Western Macedonia, 50200 Ptolemaida, Greece;
| | - John Parissis
- Emergency Medicine Department, Attikon University Hospital, 12462 Athens, Greece; (M.V.); (A.D.); (J.P.)
| | - Effie Polyzogopoulou
- Emergency Medicine Department, Attikon University Hospital, 12462 Athens, Greece; (M.V.); (A.D.); (J.P.)
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22
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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. IJC HEART & VASCULATURE 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] [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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23
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Dacunka M, Sanchez S, Raoul F, Chapoutot L, Maillier B, Marchais A. [Republication of: Evaluation of the implementation of the 2021 guidelines of the European Society of Cardiology for heart failure with reduced ejection fraction in patients aged over 75]. Ann Cardiol Angeiol (Paris) 2023; 72:101680. [PMID: 37839136 DOI: 10.1016/j.ancard.2023.101680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2023]
Abstract
INTRODUCTION Heart failure is a frequent pathology with a poor prognosis which mainly concerns elderly patients. The recommandations concerning the pharmagical treatment in heart failure with LVEF are reduced on randomized trials carried out on a young population. The aim of this work is to evaluate their application on a population aged ≥ 75. MATERIALS AND METHODS This is a retrospective, bicentric cohort, concerning patients hospitalized between September 1, 2021 and March 31, 2023, at the hospital centers of Troyes and Romilly sur Seine. The primary endpoint was a composite endpoint combining rehospitalisation rate or all-cause death rate at 6 months. RESULTS A group of 81 patients was included in the study. The average number of treatments is associated with a significant reduction in the rate of hospitalisations ord deaths at 6 months (p = 0,005); as it concerns the level of titration, the analysing comparing the "therapeutic inertia" group and the "current titration/maximum tolerated dose" group did not reveal any significant difference (p = 0,169). CONCLUSION Our study highlighted the potential positive impact of the application of the latest ESC recommendations concerning first-line drug treatment on the rate of rehospitalisation or death from all causes, in patients with heart failure reduced LVEF aged over 75.
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Affiliation(s)
- Marianne Dacunka
- Service de cardiologie, Centre Hospitalier de Troyes, Troyes France.
| | - Stéphane Sanchez
- Pôle territoriale Santé Publique et Performance, Centre Hospitalier de Troyes, Troyes France; Vieillissement fragilité, Université de Reims Champagne-Ardenne, Reims, EA3797 France.
| | - Florian Raoul
- Service de cardiologie, Centre Hospitalier de Troyes, Troyes France.
| | - Laurent Chapoutot
- Service de cardiologie, Centre Hospitalier de Troyes, Troyes France.
| | - Bruno Maillier
- Service de cardiologie, Centre Hospitalier de Troyes, Troyes France.
| | - Aurélie Marchais
- Service de cardiologie, Centre Hospitalier de Troyes, Troyes France.
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24
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Dacunka M, Sanchez S, Raoul F, Chapoutot L, Maillier B, Marchais A. [Evaluation of the implementation of the 2021 guidelines of the European Society of Cardiology for heart failure with reduced ejection fraction in patients aged over 75]. Ann Cardiol Angeiol (Paris) 2023; 72:101646. [PMID: 37689044 DOI: 10.1016/j.ancard.2023.101646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 08/04/2023] [Accepted: 08/16/2023] [Indexed: 09/11/2023]
Abstract
INTRODUCTION Heart failure is a frequent pathology with a poor prognosis which mainly concerns elderly patients. The recommandations concerning the pharmagical treatment in heart failure with LVEF are reduced on randomized trials carried out on a young population. The aim of this work is to evaluate their application on a population aged ≥ 75. MATERIALS AND METHODS This is a retrospective, bicentric cohort, concerning patients hospitalized between September 1, 2021 and March 31, 2023, at the hospital centers of Troyes and Romilly sur Seine. The primary endpoint was a composite endpoint combining rehospitalisation rate or all-cause death rate at 6 months. RESULTS A group of 81 patients was included in the study. The average number of treatments is associated with a significant reduction in the rate of hospitalisations ord deaths at 6 months (p = 0,005); as it concerns the level of titration, the analysing comparing the "therapeutic inertia" group and the "current titration/maximum tolerated dose" group did not reveal any significant difference (p = 0,169). CONCLUSION Our study highlighted the potential positive impact of the application of the latest ESC recommendations concerning first-line drug treatment on the rate of rehospitalisation or death from all causes, in patients with heart failure reduced LVEF aged over 75.
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Affiliation(s)
- Marianne Dacunka
- Service de cardiologie, Centre Hospitalier de Troyes, Troyes France.
| | - Stéphane Sanchez
- Pôle territoriale Santé Publique et Performance, Centre Hospitalier de Troyes, Troyes France; Vieillissement fragilité, Université de Reims Champagne-Ardenne, Reims, EA3797 France.
| | - Florian Raoul
- Service de cardiologie, Centre Hospitalier de Troyes, Troyes France.
| | - Laurent Chapoutot
- Service de cardiologie, Centre Hospitalier de Troyes, Troyes France.
| | - Bruno Maillier
- Service de cardiologie, Centre Hospitalier de Troyes, Troyes France.
| | - Aurélie Marchais
- Service de cardiologie, Centre Hospitalier de Troyes, Troyes France.
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25
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Abu-Qaoud MR, Kumar A, Tarun T, Abraham S, Ahmad J, Khadke S, Husami R, Kulbak G, Sahoo S, Januzzi JL, Neilan TG, Baron SJ, Martin D, Nohria A, Reynolds MR, Kosiborod M, Dani SS, Ganatra S. Impact of SGLT2 Inhibitors on AF Recurrence After Catheter Ablation in Patients With Type 2 Diabetes. JACC Clin Electrophysiol 2023; 9:2109-2118. [PMID: 37565953 DOI: 10.1016/j.jacep.2023.06.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 05/31/2023] [Accepted: 06/07/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND The effects of sodium-glucose cotransporter 2 inhibitors (SGLT2-Is) on recurrent atrial fibrillation (AF) among patients undergoing catheter ablation is not well described. OBJECTIVES This study sought to assess the impact of SGLT2-Is on the recurrence of AF among patients with type 2 diabetes mellitus (DM) after catheter ablation. METHODS Using the TriNetX research network, we identified, by means of Current Procedural Terminology codes, patients ≥18 years of age with type 2 diabetes mellitus (DM) who had undergone AF ablation from April 1, 2014, to November 30, 2021. Patients were stratified based on the baseline SGLT2-I use. Propensity-score matching resulted in 2,225 patients in each cohort. The primary outcome was a composite of cardioversion, new antiarrhythmic drug (AAD) therapy, or re-do AF ablation after a blanking period after the index ablation. Additional outcomes included heart failure exacerbations, ischemic stroke, all-cause hospitalization, and death during 12 months of follow-up. RESULTS SGLT2-I use in patients with type 2 DM undergoing AF ablation was associated with a significantly lower risk of cardioversion, new AAD therapy, and re-do AF ablation (adjusted OR: 0.68; 95% CI: 0.602-0.776; P < 0.0001). At 12 months, patients on SGLT2-Is had a higher probability of event-free survival (HR: 0.85, 95% CI: 0.77-0.95; log-rank test chi-square = 8.7; P = 0.003). All secondary outcomes were lower in the SGLT2I group; however, the ischemic stroke did not differ between groups. CONCLUSIONS Use of SGLT2-Is in patients with type 2 DM is associated with a lower risk of arrhythmia recurrence after AF ablation and thence a reduced need for cardioversion, AAD therapy, or re-do AF ablation.
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Affiliation(s)
- Moh'd Rasheed Abu-Qaoud
- Division of Cardiovascular Medicine, Department of Medicine, Lahey Hospital and Medical Center, Beth Israel Lahey Health, Burlington, Massachusetts, USA
| | - Ashish Kumar
- Division of Internal Medicine, Cleveland Clinic, Akron, Ohio, USA
| | - Tushar Tarun
- Division of Cardiovascular Medicine, Department of Medicine, University of Arkansas for Medical Sciences, Arkansas, USA
| | - Sonu Abraham
- Division of Cardiovascular Medicine, Department of Medicine, Lahey Hospital and Medical Center, Beth Israel Lahey Health, Burlington, Massachusetts, USA
| | - Javaria Ahmad
- Division of Cardiovascular Medicine, Department of Medicine, Lahey Hospital and Medical Center, Beth Israel Lahey Health, Burlington, Massachusetts, USA
| | - Sumanth Khadke
- Division of Cardiovascular Medicine, Department of Medicine, Lahey Hospital and Medical Center, Beth Israel Lahey Health, Burlington, Massachusetts, USA
| | - Raya Husami
- Division of Cardiovascular Medicine, Department of Medicine, Lahey Hospital and Medical Center, Beth Israel Lahey Health, Burlington, Massachusetts, USA
| | - Guy Kulbak
- Division of Cardiovascular Medicine, Department of Medicine, Lahey Hospital and Medical Center, Beth Israel Lahey Health, Burlington, Massachusetts, USA
| | - Sibasis Sahoo
- U.N. Mehta Institute of Cardiology and Reserch Center, Ahmedabad, Gujarat, India
| | - James L Januzzi
- Division of Cardiovascular Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Tomas G Neilan
- Division of Cardiovascular Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Suzanne J Baron
- Division of Cardiovascular Medicine, Department of Medicine, Lahey Hospital and Medical Center, Beth Israel Lahey Health, Burlington, Massachusetts, USA
| | - David Martin
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Anju Nohria
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Matthew R Reynolds
- Division of Cardiovascular Medicine, Department of Medicine, Lahey Hospital and Medical Center, Beth Israel Lahey Health, Burlington, Massachusetts, USA
| | - Mikhail Kosiborod
- Saint Luke's Mid America Heart Institute, University of Missouri, Kansas City, Missouri, USA
| | - Sourbha S Dani
- Division of Cardiovascular Medicine, Department of Medicine, Lahey Hospital and Medical Center, Beth Israel Lahey Health, Burlington, Massachusetts, USA
| | - Sarju Ganatra
- Division of Cardiovascular Medicine, Department of Medicine, Lahey Hospital and Medical Center, Beth Israel Lahey Health, Burlington, Massachusetts, USA.
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26
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Miyama H, Takatsuki S, Ikemura N, Kimura T, Katsumata Y, Yamashita S, Yamaoka K, Ibe S, Seki Y, Yamashita T, Hashimoto K, Ueda I, Ueno K, Ohki T, Fukuda K, Kohsaka S. Prognostic Implications and Efficacy of Catheter Ablation by Atrial Fibrillation Type. J Am Heart Assoc 2023; 12:e029321. [PMID: 37681532 PMCID: PMC10547271 DOI: 10.1161/jaha.122.029321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 07/18/2023] [Indexed: 09/09/2023]
Abstract
Background Catheter ablation (CA) for atrial fibrillation (AF) is preferred for paroxysmal AF (PAF) but selectively performed in patients with persistent AF (PersAF). This study aimed to investigate the prognostic differences and consequences of CA based on the AF type. Methods and Results Data from a multicenter AF cohort study were analyzed, categorizing patients as PAF or PersAF according to AF duration (≤7 or >7 days, respectively). A composite of all-cause death, heart failure hospitalization, stroke, and bleeding events during 2-year follow-up and changes in the Atrial Fibrillation Effect on Quality-of-life score were compared. Additionally, propensity score matching was performed to compare clinical outcomes of patients with and without CA in both AF types. Among 2788 patients, 51.6% and 48.4% had PAF and PersAF, respectively. Patients with PersAF had a higher incidence of the composite outcome (12.8% versus 7.2%; P<0.001) and smaller improvements in Atrial Fibrillation Effect on Quality-of-life scores than those with PAF. After adjusting for baseline characteristics, PersAF was an independent predictor of adverse outcomes (adjusted hazard ratio, 1.35 [95% CI, 1.30-1.78], P=0.031) and was associated with poor improvements in Atrial Fibrillation Effect on Quality-of-life scores. Propensity score matching analysis showed that the CA group had significantly fewer adverse events than the medication group among patients with PAF (odds ratio, 0.31 [95% CI, 0.18-0.68]; P=0.002). Patients with PersAF showed a similar but nonsignificant trend. Conclusions PersAF is a risk factor for worse clinical outcomes, including patients' health status. CA is associated with fewer adverse events, although careful consideration is required based on the AF type.
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Affiliation(s)
- Hiroshi Miyama
- Department of CardiologyKeio University School of MedicineTokyoJapan
| | - Seiji Takatsuki
- Department of CardiologyKeio University School of MedicineTokyoJapan
| | - Nobuhiro Ikemura
- Department of CardiologyKeio University School of MedicineTokyoJapan
- Division of Molecular EpidemiologyJikei University School of MedicineTokyoJapan
| | - Takehiro Kimura
- Department of CardiologyKeio University School of MedicineTokyoJapan
| | | | - Shuhei Yamashita
- Department of CardiologyKeio University School of MedicineTokyoJapan
| | - Koki Yamaoka
- Department of CardiologyKeio University School of MedicineTokyoJapan
| | - Susumu Ibe
- Department of CardiologyKeio University School of MedicineTokyoJapan
| | - Yuta Seki
- Department of CardiologyKeio University School of MedicineTokyoJapan
| | | | - Kenji Hashimoto
- Department of CardiologyKeio University School of MedicineTokyoJapan
| | - Ikuko Ueda
- Department of CardiologyKeio University School of MedicineTokyoJapan
| | - Koji Ueno
- Department of CardiologySaiseikai Utsunomiya HospitalTochigiJapan
| | - Takahiro Ohki
- Department of CardiologyTokyo Dental College Ichikawa General HospitalChibaJapan
| | - Keiichi Fukuda
- Department of CardiologyKeio University School of MedicineTokyoJapan
| | - Shun Kohsaka
- Department of CardiologyKeio University School of MedicineTokyoJapan
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27
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Suzuki S, Kitai T, Skoularigis J, Spiliopoulos K, Xanthopoulos A. Catheter Ablation for Atrial Fibrillation in Patients with Heart Failure: Current Evidence and Future Opportunities. J Pers Med 2023; 13:1394. [PMID: 37763161 PMCID: PMC10532515 DOI: 10.3390/jpm13091394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 09/14/2023] [Accepted: 09/15/2023] [Indexed: 09/29/2023] Open
Abstract
Atrial fibrillation (AF) and heart failure (HF) are highly prevalent cardiac disorders worldwide, and both are associated with poor prognosis. The incidence of AF and HF has been increasing substantially in recent years, mainly due to the progressive aging of the population. These disorders often coexist, and may have a causal relationship, with one contributing to the development or progression of the other. AF is a significant risk factor for adverse outcomes in HF patients, including mortality, hospitalization, and stroke. Although the optimal treatment for AF with HF remains unclear, catheter ablation (CA) has emerged as a promising treatment option. This review provides a comprehensive overview of the current scientific evidence regarding the efficacy of CA for managing AF in HF patients. In addition, the potential benefits and risks associated with CA are also discussed. We will also explore the factors that may influence treatment outcomes and highlight the remaining gaps in knowledge in this field.
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Affiliation(s)
- Sho Suzuki
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka 564-8565, Japan
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Nagano 390-8621, Japan
| | - Takeshi Kitai
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka 564-8565, Japan
| | - John Skoularigis
- Department of Cardiology, University Hospital of Larissa, 41110 Larissa, Greece
| | - Kyriakos Spiliopoulos
- Department of Cardiothoracic Surgery, University of Thessaly, Biopolis, 41110 Larissa, Greece
| | - Andrew Xanthopoulos
- Department of Cardiology, University Hospital of Larissa, 41110 Larissa, Greece
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28
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Sayed A, Awad AK, Abdelfattah OM, Elsayed M, Herzallah K, Marine JE, Passman R, Bunch JT. The impact of catheter ablation in patient's heart failure and atrial fibrillation: a meta-analysis of randomized clinical trials. J Interv Card Electrophysiol 2023; 66:1487-1497. [PMID: 36572800 DOI: 10.1007/s10840-022-01451-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 12/05/2022] [Indexed: 12/28/2022]
Abstract
BACKGROUND Recent trial data suggest a benefit to catheter ablation (CA) compared to medical therapy for atrial fibrillation (AF) in patients with heart failure (HF). Nevertheless, because of mixed trial evidence, contemporary guidelines give it a class 2 recommendation. Accordingly, we sought to assess the currently available evidence for CA in HF with AF. METHODS Electronic databases were searched to identify randomized clinical trials (RCTs) comparing CA to medical therapy in patients with AF and HF. Study data was pooled using fixed and random effects, and the number needed to treat (NNT) was calculated to gauge absolute risk differences. Heterogeneity was quantified using I2. Our primary outcome was all-cause mortality. RESULTS Nine trials (CA 1075 patients; medical therapy 1083 patients) were included. Ablation reduced the relative risk of all-cause mortality by 31.5% (95% CI 13.7 to 45.6%; NNT = 23), cardiovascular mortality by 39.3% (95% CI 10.9 to 58.7%; NNT = 31), cardiovascular hospitalization by 29.1% (95% CI 9.4 to 44.6%; NNT = 9), and heart failure hospitalization by 28.5% (95% CI 6.5 to 45.4%; NNT = 22). Improvements in quality of life were observed with CA using the Minnesota Living with Heart Failure Questionnaire (mean difference - 5.26; 95% CI - 2.73 to - 7.78) and the Atrial Fibrillation Effect on Quality of Life (mean difference 5.36; 95% CI 2.72 to 8.00). CONCLUSION Compared to medical therapy, CA for AF in patients with HF reduces all-cause mortality, cardiovascular mortality, cardiovascular hospitalizations, and heart failure hospitalizations, and may improve quality of life.
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Affiliation(s)
- Ahmed Sayed
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Ahmed K Awad
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Omar M Abdelfattah
- Internal Medicine Department, Morristown Medical Center, Atlantic Health System, Morristown, NJ, USA
- Department of Cardiovascular Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Mahmoud Elsayed
- Section of Cardiac Electrophysiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | | | - Joseph E Marine
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Rod Passman
- Section of Cardiac Electrophysiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Jared T Bunch
- Division of Cardiovascular Medicine, University of Utah Health Sciences Center, 30 North 1900 East, Room 4A100, Salt Lake City, UT, 84132, USA.
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29
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Sakamoto K, Tohyama T, Ide T, Mukai Y, Enzan N, Nagata T, Ikeda M, Takase S, Nagayama T, Fujino T, Matsushima S, Tsutsui H. Efficacy of Early Catheter Ablation for Atrial Fibrillation After Admission for Heart Failure. JACC Clin Electrophysiol 2023; 9:1948-1959. [PMID: 37480855 DOI: 10.1016/j.jacep.2023.05.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 05/11/2023] [Accepted: 05/24/2023] [Indexed: 07/24/2023]
Abstract
BACKGROUND Advances in catheter ablation (CA) for atrial fibrillation (AF) have improved the prognosis of patients with heart failure (HF) and AF. However, its optimal timing remains to be fully elucidated. OBJECTIVES The aim of this study was to investigate the prognostic impact of early CA in patients with HF and AF hospitalized for worsening HF. METHODS From JROADHF (Japanese Registry of Acute Decompensated Heart Failure) (n = 13,238), patients with HF and AF who underwent CA within 90 days after admission for HF (early CA; n = 103) and those who did not (control; n = 2,683) were identified. Mortality was compared between these groups in the crude cohort, as well as in the propensity-matched cohort (n = 83 in each group). RESULTS In the crude cohort, all-cause mortality was significantly lower in the early CA group than in the control group (log-rank P < 0.001; HR: 0.38; 95% CI: 0.24-0.60). In the matched cohort, all-cause mortality was likewise significantly lower in the early CA group (log-rank P = 0.014; HR: 0.47; 95% CI: 0.25-0.88). Cardiovascular death and HF mortality were significantly lower in both cohorts (crude: Gray' test: P < 0.001 and P = 0.005; subdistribution HR: 0.28 [95% CI: 0.13-0.63] and HR: 0.31 [95% CI: 0.13-0.75]; matched: Gray's test: P = 0.006 and P = 0.017; subdistribution HR: 0.24 [95% CI: 0.08-0.70] and HR: 0.28 [95% CI: 0.09-0.84], respectively). CONCLUSIONS In a nationwide representative real-world cohort, CA for AF within 90 days after admission for HF was associated with improved long-term outcomes, including cardiovascular and HF death in patients with HF and AF.
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Affiliation(s)
- Kazuo Sakamoto
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takeshi Tohyama
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan; Center for Clinical and Translational Research of Kyushu University Hospital, Fukuoka, Japan
| | - Tomomi Ide
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan.
| | - Yasushi Mukai
- Division of Cardiology, Japanese Red-Cross Fukuoka Hospital, Fukuoka, Japan
| | - Nobuyuki Enzan
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takuya Nagata
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Masataka Ikeda
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan; Division of Cardiovascular Medicine, Research Institute of Angiocardiology, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Susumu Takase
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Tomomi Nagayama
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takeo Fujino
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan; Department of Advanced Cardiopulmonary Failure, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shouji Matsushima
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan; Division of Cardiovascular Medicine, Research Institute of Angiocardiology, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan; School of Medicine and Graduate School, International University of Health and Welfare, Otawara, Japan
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30
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Hussain S, Sohrabi C, Providencia R, Ahsan S, Papageorgiou N. Catheter Ablation for the Management of Atrial Fibrillation: An Update of the Literature. Life (Basel) 2023; 13:1784. [PMID: 37629641 PMCID: PMC10455869 DOI: 10.3390/life13081784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 08/10/2023] [Accepted: 08/15/2023] [Indexed: 08/27/2023] Open
Abstract
Catheter ablation has been shown to be more effective at maintaining sinus rhythm and improving quality of life when compared to antiarrhythmic drugs. Radiofrequency and cryoablation are two effective methods. However, catheter-only ablation strategies have not consistently produced high success rates in treating longstanding and persistent AF patients. The emerging treatment of choice for such cases is hybrid ablation, which involves a multidisciplinary and minimally invasive approach to achieve surgical ablation of the direct posterior left atrial wall in combination with endocardial catheter ablation. Studies have shown promising results for the hybrid approach when compared with catheter ablation alone, but it is not without risks. Large and randomised studies are necessary to further evaluate these strategies for managing AF.
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Affiliation(s)
- Shahana Hussain
- Electrophysiology Department, Barts Heart Centre, St Bartholomew’s Hospital, London EC1A 7BE, UK
| | - Catrin Sohrabi
- Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | - Rui Providencia
- Electrophysiology Department, Barts Heart Centre, St Bartholomew’s Hospital, London EC1A 7BE, UK
| | - Syed Ahsan
- Electrophysiology Department, Barts Heart Centre, St Bartholomew’s Hospital, London EC1A 7BE, UK
| | - Nikolaos Papageorgiou
- Electrophysiology Department, Barts Heart Centre, St Bartholomew’s Hospital, London EC1A 7BE, UK
- Institute of Cardiovascular Science, University College London, London WC1E 6BT, UK
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31
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Zhang Z, Li L, Hu Z, Zhou L, Zhang Z, Xiong Y, Yao Y. Causal effects between atrial fibrillation and heart failure: evidence from a bidirectional Mendelian randomization study. BMC Med Genomics 2023; 16:187. [PMID: 37580781 PMCID: PMC10424396 DOI: 10.1186/s12920-023-01606-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 07/12/2023] [Indexed: 08/16/2023] Open
Abstract
BACKGROUND Observational studies have suggested a close association between atrial fibrillation (AF) and heart failure (HF), yet the causal effect remains uncertain. In this study, we employed a bidirectional Mendelian randomization analysis to investigate the causal effect of one disease on the other. METHODS Genetic instrumental variables were obtained from large-scale summary-level genome-wide association studies of AF (n = 1,030,836) and HF(n = 1,665,481), respectively. Two-sample Mendelian randomization was conducted to establish causal inferences. Inverse-variance weighted (IVW) was the primary estimate, while additional analyses including MR Pleiotropy RESidual Sum and Outlier (MR-PRESSO), MR-Egger, and Weighted median were performed to validate robustness and identify pleiotropy. RESULTS After accounting for confounding variables, MR analysis suggested a potential causal relationship between AF and HF. An augmented genetic predisposition to atrial fibrillation was associated with an elevated risk of heart failure (odds ratio (OR) = 1.18, 95% confidence interval (CI):1.14-1.22). Likewise, genetically determined heart failure also increased the risk of heart failure (OR = 1.44, 95%CI:1.23-1.68). The robustness of the findings was corroborated through MR sensitivity analyses, and the causal estimates remained consistent when the instrument P-value threshold was tightened. CONCLUSIONS Our bidirectional Mendelian randomization study supports a reciprocal causal relationship between AF and HF. The shared genetic profile of these conditions may provide crucial insights into potential therapeutic targets for the prevention and progression of both disorders. These findings underscore the necessity for further investigation into the underlying molecular mechanisms linking AF and HF, as well as the potential for personalized treatment strategies grounded in genetic profiling.
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Affiliation(s)
- Zhuxin Zhang
- Fuwai Hospital, National Center for Cardiovascular Diseases, National Key Laboratory, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Le Li
- Fuwai Hospital, National Center for Cardiovascular Diseases, National Key Laboratory, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhao Hu
- Fuwai Hospital, National Center for Cardiovascular Diseases, National Key Laboratory, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Likun Zhou
- Fuwai Hospital, National Center for Cardiovascular Diseases, National Key Laboratory, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhenhao Zhang
- Fuwai Hospital, National Center for Cardiovascular Diseases, National Key Laboratory, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yulong Xiong
- Fuwai Hospital, National Center for Cardiovascular Diseases, National Key Laboratory, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yan Yao
- Fuwai Hospital, National Center for Cardiovascular Diseases, National Key Laboratory, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
- Cardiac Arrhythmia Center, Chinese Academy of Medical Sciences, Fu Wai Hospital, Beijing, 100037, China.
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32
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de Vere F, Wijesuriya N, Elliott MK, Mehta V, Howell S, Bishop M, Strocchi M, Niederer SA, Rinaldi CA. Managing arrhythmia in cardiac resynchronisation therapy. Front Cardiovasc Med 2023; 10:1211560. [PMID: 37608808 PMCID: PMC10440957 DOI: 10.3389/fcvm.2023.1211560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 06/30/2023] [Indexed: 08/24/2023] Open
Abstract
Arrhythmia is an extremely common finding in patients receiving cardiac resynchronisation therapy (CRT). Despite this, in the majority of randomised trials testing CRT efficacy, patients with a recent history of arrhythmia were excluded. Most of our knowledge into the management of arrhythmia in CRT is therefore based on arrhythmia trials in the heart failure (HF) population, rather than from trials dedicated to the CRT population. However, unique to CRT patients is the aim to reach as close to 100% biventricular pacing (BVP) as possible, with HF outcomes greatly influenced by relatively small changes in pacing percentage. Thus, in comparison to the average HF patient, there is an even greater incentive for controlling arrhythmia, to achieve minimal interference with the effective delivery of BVP. In this review, we examine both atrial and ventricular arrhythmias, addressing their impact on CRT, and discuss the available evidence regarding optimal arrhythmia management in this patient group. We review pharmacological and procedural-based approaches, and lastly explore novel ways of harnessing device data to guide treatment of arrhythmia in CRT.
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Affiliation(s)
- Felicity de Vere
- School of Biomedical Engineering and Imaging Sciences, King’s College, London, United Kingdom
- Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Nadeev Wijesuriya
- School of Biomedical Engineering and Imaging Sciences, King’s College, London, United Kingdom
- Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Mark K. Elliott
- School of Biomedical Engineering and Imaging Sciences, King’s College, London, United Kingdom
- Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Vishal Mehta
- School of Biomedical Engineering and Imaging Sciences, King’s College, London, United Kingdom
- Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Sandra Howell
- School of Biomedical Engineering and Imaging Sciences, King’s College, London, United Kingdom
- Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Martin Bishop
- School of Biomedical Engineering and Imaging Sciences, King’s College, London, United Kingdom
| | - Marina Strocchi
- School of Biomedical Engineering and Imaging Sciences, King’s College, London, United Kingdom
| | - Steven A. Niederer
- School of Biomedical Engineering and Imaging Sciences, King’s College, London, United Kingdom
| | - Christopher A. Rinaldi
- School of Biomedical Engineering and Imaging Sciences, King’s College, London, United Kingdom
- Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
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33
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Ray L, Geier C, DeWitt KM. Pathophysiology and treatment of adults with arrhythmias in the emergency department, part 1: Atrial arrhythmias. Am J Health Syst Pharm 2023; 80:1039-1055. [PMID: 37227130 DOI: 10.1093/ajhp/zxad108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Indexed: 05/26/2023] Open
Abstract
PURPOSE This article, the first in a 2-part review, aims to reinforce current literature on the pathophysiology of cardiac arrhythmias and various evidence-based treatment approaches and clinical considerations in the acute care setting. Part 1 of this series focuses on atrial arrhythmias. SUMMARY Arrhythmias are prevalent throughout the world and a common presenting condition in the emergency department (ED) setting. Atrial fibrillation (AF) is the most common arrhythmia worldwide and expected to increase in prevalence. Treatment approaches have evolved over time with advances in catheter-directed ablation. Based on historic trials, heart rate control has been the long-standing accepted outpatient treatment modality for AF, but the use of antiarrhythmics is often still indicated for AF in the acute setting, and ED pharmacists should be prepared and poised to help in AF management. Other atrial arrhythmias include atrial flutter (AFL), atrioventricular nodal reentry tachycardia (AVNRT), and atrioventricular reentrant tachycardia (AVRT), which warrant distinction due to their unique pathophysiology and because each requires a different approach to utilization of antiarrhythmics. Atrial arrhythmias are typically associated with greater hemodynamic stability than ventricular arrhythmias but still require nuanced management according to patient subset and risk factors. Since antiarrhythmics can also be proarrhythmic, they may destabilize the patient due to adverse effects, many of which are the focus of black-box label warnings that can be overreaching and limit treatment options. Electrical cardioversion for atrial arrhythmias is generally successful and, depending on the setting and/or hemodynamics, often indicated. CONCLUSION Atrial arrhythmias arise from a variety of mechanisms, and appropriate treatment depends on various factors. A firm understanding of physiological and pharmacological concepts serves as a foundation for exploring evidence supporting agents, indications, and adverse effects in order to provide appropriate care for patients.
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Affiliation(s)
- Lance Ray
- Denver Health and Hospital Authority, Denver, CO
- Department of Emergency Medicine, University of Colorado, Aurora, CO, USA
| | - Curtis Geier
- San Francisco General Hospital, San Francisco, CA, USA
| | - Kyle M DeWitt
- University of Vermont Medical Center, Burlington, VT, USA
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Lip GYH, Proietti M, Potpara T, Mansour M, Savelieva I, Tse HF, Goette A, Camm AJ, Blomstrom-Lundqvist C, Gupta D, Boriani G. Atrial fibrillation and stroke prevention: 25 years of research at EP Europace journal. Europace 2023; 25:euad226. [PMID: 37622590 PMCID: PMC10451006 DOI: 10.1093/europace/euad226] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 07/17/2023] [Indexed: 08/26/2023] Open
Abstract
Stroke prevention in patients with atrial fibrillation (AF) is one pillar of the management of this common arrhythmia. Substantial advances in the epidemiology and associated pathophysiology underlying AF-related stroke and thrombo-embolism are evident. Furthermore, the introduction of the non-vitamin K antagonist oral anticoagulants (also called direct oral anticoagulants) has clearly changed our approach to stroke prevention in AF, such that the default should be to offer oral anticoagulation for stroke prevention, unless the patient is at low risk. A strategy of early rhythm control is also beneficial in reducing strokes in selected patients with recent onset AF, when compared to rate control. Cardiovascular risk factor management, with optimization of comorbidities and attention to lifestyle factors, and the patient's psychological morbidity are also essential. Finally, in selected patients with absolute contraindications to long-term oral anticoagulation, left atrial appendage occlusion or exclusion may be considered. The aim of this state-of-the-art review article is to provide an overview of the current status of AF-related stroke and prevention strategies. A holistic or integrated care approach to AF management is recommended to minimize the risk of stroke in patients with AF, based on the evidence-based Atrial fibrillation Better Care (ABC) pathway, as follows: A: Avoid stroke with Anticoagulation; B: Better patient-centred, symptom-directed decisions on rate or rhythm control; C: Cardiovascular risk factor and comorbidity optimization, including lifestyle changes.
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Affiliation(s)
- Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Marco Proietti
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy
| | - Tatjana Potpara
- School of Medicine, Belgrade University, Belgrade, Serbia
- Cardiology Clinic, University Clinical Centre of Serbia, Belgrade, Serbia
| | | | - Irina Savelieva
- Clinical Academic Group, Molecular and Clinical Sciences Institute, St. George’s University of London, Cranmer Terrace London SW17 0RE, UK
| | - Hung Fat Tse
- Cardiology Division, Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, University of Hong Kong, Hong Kong, China
| | - Andreas Goette
- Medizinische Klinik II: Kardiologie und Intensivmedizin, St. Vincenz-Krankenhaus Paderborn, Am Busdorf 2, 33098 Paderborn, Germany
| | - A John Camm
- Clinical Academic Group, Molecular and Clinical Sciences Institute, St. George’s University of London, Cranmer Terrace London SW17 0RE, UK
| | - Carina Blomstrom-Lundqvist
- Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Cardiology, Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, via del Pozzo 71, 41125 Modena, Italy
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Malaty MM, Sivagangabalan G, Qian PC. Beyond Conventional Cardiac Resynchronisation Therapy: A Review of Electrophysiological Options in the Management of Chronic Heart Failure. Heart Lung Circ 2023; 32:905-913. [PMID: 37286460 DOI: 10.1016/j.hlc.2023.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 05/10/2023] [Accepted: 05/15/2023] [Indexed: 06/09/2023]
Abstract
The incidence of heart failure (HF) continues to grow and burden our health care system. Electrophysiological aberrations are common amongst patients with heart failure and can contribute to worsening symptoms and prognosis. Targeting these abnormalities with cardiac and extra-cardiac device therapies and catheter ablation procedures augments cardiac function. Newer technologies aimed to improvement procedural outcomes, address known procedural limitations and target newer anatomical sites have been trialled recently. We review the role and evidence base for conventional cardiac resynchronisation therapy (CRT) and its optimisation, catheter ablation therapies for atrial arrhythmias, cardiac contractility and autonomic modulation therapies.
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Affiliation(s)
- Michael M Malaty
- Department of Cardiology, Blacktown Hospital, Western Sydney Local Health District, Sydney, NSW, Australia
| | - Gopal Sivagangabalan
- Department of Cardiology, Westmead Hospital, Western Sydney Local Health District, Sydney, NSW, Australia; School of Medicine, Sydney Campus, University of Notre Dame, Sydney, NSW, Australia
| | - Pierre C Qian
- Department of Cardiology, Blacktown Hospital, Western Sydney Local Health District, Sydney, NSW, Australia; Department of Cardiology, Westmead Hospital, Western Sydney Local Health District, Sydney, NSW, Australia; Westmead Applied Research Centre, University of Sydney, Sydney, NSW, Australia.
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Kataoka N, Imamura T. How to Improve Clinical Outcomes in Patients with Tachycardia-Induced Cardiomyopathy. Comment on Katz et al. Long-Term Outcomes of Tachycardia-Induced Cardiomyopathy Compared with Idiopathic Dilated Cardiomyopathy. J. Clin. Med. 2023, 12, 1412. J Clin Med 2023; 12:5065. [PMID: 37568467 PMCID: PMC10419911 DOI: 10.3390/jcm12155065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 05/17/2023] [Accepted: 07/28/2023] [Indexed: 08/13/2023] Open
Abstract
The clinical course of tachycardia-induced cardiomyopathy (TICM) has not yet been well studied thus far [...].
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Affiliation(s)
| | - Teruhiko Imamura
- Second Department of Internal Medicine, University of Toyama, Toyama 930-0194, Japan
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Al-Khatib SM. Atrial Fibrillation. Ann Intern Med 2023; 176:ITC97-ITC112. [PMID: 37429028 DOI: 10.7326/aitc202307180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/12/2023] Open
Abstract
Evidence for diagnosis and treatment of atrial fibrillation (AF) has expanded substantially since 2017, when In the Clinic last considered this subject. Direct oral anticoagulants have become the predominant therapy for thromboembolic disease, and antidotes for these drugs are now available. Device-based left atrial appendage occlusion is frequently used in patients who cannot tolerate systemic anticoagulation, and growing evidence suggests that early rhythm control improves outcomes. Catheter ablation is now frequently performed to prevent recurrent AF. Managing risk factors for AF, such as hypertension, diabetes, and obesity, remains paramount in prevention of this condition.
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Zhu X, Chen R, Zhang Y, Hu J, Jiang Y, Huang K, Wang J, Li W, Shi B, Chen Y, Li L, Li B, Cheng X, Yu B, Wang Y, Kan H. Low ambient temperature increases the risk and burden of atrial fibrillation episodes: A nationwide case-crossover study in 322 Chinese cities. THE SCIENCE OF THE TOTAL ENVIRONMENT 2023; 880:163351. [PMID: 37030388 DOI: 10.1016/j.scitotenv.2023.163351] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 03/23/2023] [Accepted: 04/03/2023] [Indexed: 05/27/2023]
Abstract
BACKGROUND Non-optimum ambient temperature has recently been acknowledged as an independent risk factor for disease burden, but its impact on atrial fibrillation (AF) episodes was rarely evaluated. OBJECTIVES To examine the associations between ambient non-optimum temperature and symptom onset of AF episodes and calculate the corresponding disease burden. METHODS We conducted an individual-level, time-stratified, case-crossover analysis based on a nationwide registry, which comprises of 94,711 eligible AF patients from 1993 hospitals in 322 Chinese cities from January 2015 to December 2021. Multiple moving 24 h average temperatures prior to the symptom onset of AF episodes were calculated as lag days. The associations were analyzed using conditional logistic regression combined with distributed lag non-linear models with a duration of lag 0-7 days, after controlling for criteria air pollutants. Stratification analyses were performed to explore possible effect modifiers. RESULTS There was a monotonically increasing relationship of AF onset risk with decreasing temperature. The excess AF risk occurred at lag 1 d and lasted for 5 days. Nationally, the cumulative relative risk of AF episode onset associated with extremely low temperature (-9.3 °C) over lag 0-7 d was 1.25 (95 % confidence interval: 1.08, 1.45), compared with the reference temperature (31.5 °C). The exposure-response curve was steeper in the south than in the north where there was levelling-off at lower temperature. Nationally, 7.59 % of acute AF episodes could be attributable to non-optimum temperatures. The attributable fraction was larger for southern residents, males and patients <65 years. CONCLUSION This nationwide study provides novel and robust evidence that declining ambient temperature could increase the risk of AF episode onset. We also provide the first-hand evidence that a considerable proportion of acute AF episodes could be attributable to non-optimum temperatures.
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Affiliation(s)
- Xinlei Zhu
- School of Public Health, Key Lab of Public Health Safety of the Ministry of Education, NHC Key Lab of Health Technology Assessment, Fudan University, Shanghai, China
| | - Renjie Chen
- School of Public Health, Key Lab of Public Health Safety of the Ministry of Education, NHC Key Lab of Health Technology Assessment, Fudan University, Shanghai, China
| | - Yong Zhang
- Department of Emergency, Wuhan Asia General Hospital, Wuhan, China
| | - Jialu Hu
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Yixuan Jiang
- School of Public Health, Key Lab of Public Health Safety of the Ministry of Education, NHC Key Lab of Health Technology Assessment, Fudan University, Shanghai, China
| | - Kai Huang
- Department of Cardiology, Institute of Cardiovascular Disease, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jianan Wang
- Department of Cardiology, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Wei Li
- Department of Cardiology, the Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Bei Shi
- Department of Cardiology, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Yundai Chen
- Senior Department of Cardiology, the Sixth Medical Center of PLA General Hospital, Beijing, China
| | - Lang Li
- Department of Cardiology, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Bao Li
- Department of Cardiology, the Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Xiaoshu Cheng
- Department of Cardiology, the Second Affiliated Hospital of Nanchang University, Jiangxi, China
| | - Bo Yu
- Department of Cardiology, The 2nd Affiliated Hospital of Harbin Medical University, Harbin, China.
| | - Yan Wang
- Department of Cardiology, Xiamen Cardiovascular Hospital Xiamen University, Xiamen, China.
| | - Haidong Kan
- School of Public Health, Key Lab of Public Health Safety of the Ministry of Education, NHC Key Lab of Health Technology Assessment, Fudan University, Shanghai, China; Shanghai Institute of Pollution Control and Ecological Security, Shanghai, China.
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He P, Pan Y, Jiang J, Fan F, Zhou J, Xia Y, Liu J, Yang N, Hao Y, Li J, Liu J, Zhao D, Huo Y. In-hospital therapies and determinants of treatment strategy selection in patients with atrial fibrillation and left ventricular systolic dysfunction in China: a retrospective study based on the Improving Care for Cardiovascular Disease in China-Atrial Fibrillation (CCC-AF) project, 2015-2019. BMJ Open 2023; 13:e070070. [PMID: 37277219 DOI: 10.1136/bmjopen-2022-070070] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/07/2023] Open
Abstract
OBJECTIVES The optimal treatment strategy remains debatable in patients with atrial fibrillation (AF) and heart failure. Our objectives were to summarise in-hospital therapies and determine factors associated with treatment strategy selections. DESIGN A retrospective study analysing the Improving Care for Cardiovascular Disease in China-Atrial Fibrillation (CCC-AF) project from 2015 to 2019. SETTING The CCC-AF project included patients from 151 tertiary and 85 secondary hospitals across 30 provinces in China. PARTICIPANTS Patients with AF and left ventricular systolic dysfunction (LVSD, defined as left ventricular ejection fraction<50%) were included, with 5560 patients in the study sample. METHODS Patients were classified by treatment strategies. In-hospital treatments and trends of therapies were analysed. Multiple logistic regression models were used to find determinants of treatment strategies. RESULTS Rhythm control therapies were used in 16.9% of patients with no significant trends (p trend=0.175). Catheter ablation was used in 5.5% of patients, increasing from 3.3% in 2015 to 6.6% in 2019 (p trend<0.001). Factors negatively associated with rhythm control included increased age (OR 0.973, 95% CI 0.967 to 0.980), valvular AF (OR 0.618, 95% CI 0.419 to 0.911), AF types (persistent: OR 0.546, 95% CI 0.462 to 0.645; long-standing persistent: OR 0.298, 95% CI 0.240 to 0.368), larger left atrial diameters (OR 0.966, 95% CI 0.957 to 0.976) and higher Charlson Comorbidity Index scores (CCI 1-2: OR 0.630, 95% CI 0.529 to 0.750; CCI≥3: OR 0.551, 95% CI 0.390 to 0.778). Higher platelet counts (OR 1.025, 95% CI 1.013 to 1.037) and prior rhythm control attempts (electrical cardioversion: OR 4.483, 95% CI 2.369 to 8.483; catheter ablation: OR 4.957, 95% CI 3.072 to 7.997) were positively associated with rhythm control strategies. CONCLUSION In China, non-rhythm control strategy remained the dominant choice in patients with AF and LVSD. Age, AF types, prior treatments, left atrial diameters, platelet counts and comorbidities were major determinants of treatment strategies. Guideline-adherent therapies should be further promoted. STUDY REGISTRATION NUMBER NCT02309398.
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Affiliation(s)
- Pengkang He
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Yannan Pan
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Jie Jiang
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Fangfang Fan
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Jing Zhou
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Yulong Xia
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Jun Liu
- Department of Epidemiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Na Yang
- Department of Epidemiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Yongchen Hao
- Department of Epidemiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Jianping Li
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Jing Liu
- Department of Epidemiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Dong Zhao
- Department of Epidemiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Yong Huo
- Department of Cardiology, Peking University First Hospital, Beijing, China
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Kittleson MM, Panjrath GS, Amancherla K, Davis LL, Deswal A, Dixon DL, Januzzi JL, Yancy CW. 2023 ACC Expert Consensus Decision Pathway on Management of Heart Failure With Preserved Ejection Fraction: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol 2023; 81:1835-1878. [PMID: 37137593 DOI: 10.1016/j.jacc.2023.03.393] [Citation(s) in RCA: 71] [Impact Index Per Article: 71.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
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Yamashita A, Kiuchi S, Ikeda T. A Case of Non-Tachycardic Atrial Fibrillation Whose Left Ventricular Systolic Dysfunction Improved After Catheter Ablation. J Clin Med Res 2023; 15:274-278. [PMID: 37303466 PMCID: PMC10251699 DOI: 10.14740/jocmr4908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 04/29/2023] [Indexed: 06/13/2023] Open
Abstract
It is difficult to identify the causes and optimal treatment of heart failure (HF) in patients with atrial fibrillation (AF) and HF with reduced ejection fraction (EF) (HFrEF). Tachyarrhythmia can cause left ventricular (LV) systolic dysfunction called tachycardia-induced cardiomyopathy (TIC). In patients with TIC, conversion to sinus rhythm may lead to improvement in LV systolic dysfunction. However, it is unclear whether we should try to convert patients with AF without tachycardia to sinus rhythm. A 46-year-old man with chronic AF and HFrEF came to our hospital. His New York Heart Association (NYHA) classification was class II. The blood test showed a brain natriuretic peptide of 105 pg/mL. Electrocardiogram (ECG) and 24-h ECG showed AF without tachycardia. Transthoracic echocardiography (TTE) showed left atrial (LA) dilatation, LV dilatation, and diffuse LV hypokinesis (EF was 40%). Although he was optimized medically, NYHA classification II persisted. Therefore, he underwent direct current cardioversion and catheter ablation. After his AF converted to a sinus rhythm of heart rate (HR) 60 - 70 beats per minute (bpm), TTE showed improvement in LV systolic dysfunction. We gradually reduced oral medications for arrhythmia and HF. We subsequently succeeded in discontinuing all medications 1 year after catheter ablation. TTE performed between 1 and 2 years after catheter ablation showed normal LV function and normal cardiac size. During the 3 years of follow-up, there was no recurrence of AF, and he was not readmitted to the hospital. This patient showed the effectiveness of converting AF to sinus rhythm in patients without tachycardia.
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Affiliation(s)
- Asami Yamashita
- Division of Cardiovascular Medicine, Department of Internal Medicine, Toho University Faculty of Medicine, Ota-ku, Tokyo 143-8541, Japan
| | - Shunsuke Kiuchi
- Department of Cardiovascular Medicine, Toho University Graduate School of Medicine, Ota-ku, Tokyo 143-8541, Japan
| | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Graduate School of Medicine, Ota-ku, Tokyo 143-8541, Japan
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A comprehensive meta-analysis comparing radiofrequency ablation versus pharmacological therapy for the treatment of atrial fibrillation in patients with heart failure. Int J Cardiol 2023; 377:66-72. [PMID: 36709925 DOI: 10.1016/j.ijcard.2023.01.070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Revised: 01/10/2023] [Accepted: 01/24/2023] [Indexed: 01/27/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) and heart failure (HF) are both associated with worse prognosis and often coexist in the same patients. Whether catheter ablation (CA) is superior to pharmacological therapy in reducing major clinical endpoints in patients with AF and HF is still unsettled. OBJECTIVE To conduct a comprehensive meta-analysis comparing CA with medical therapy (MT) in this population. METHODS We systematically searched for randomized and observational studies comparing clinical outcomes between patients with AF and HF treated with CA or MT. The studied outcomes were mortality, hospitalization, left ventricle ejection fraction (LVEF) and 6-min walking test (6MWT) improvement. RESULTS A total of 12 studies counting 41,377 patients (3611 treated with CA and 37,766 with MT) were included in the analysis. The random-effect model revealed a clear trend in favor of CA in reducing unexpected HF hospitalization (RR 0.72; 95%CI 0.51-1.00; P = 0.05), all-cause death (RR 0.77; 95%CI 0.59-1.01; P = 0.06), all-cause hospitalization (RR 0.84; 95%CI 0.68-1.03; P = 0.09), and the composite of HF hospitalization and death (RR 0.77; 95%CI 0.58-1.02; P = 0.07), compared with MT. Patients treated with CA experienced a better improvement in LVEF (mean difference 6.17; 95%CI 2.98-9.37; P = 0.0002) and 6MWT (mean difference 13.70; 95%CI 3.95-23.45; P = 0.006). When the analysis was limited to randomized controlled trial, CA was found to significantly reduce all-cause death (RR 0.68; 95%CI 0.54-0.86; P = 0.001). CONCLUSION As compared to MT, CA is associated with a better improvement in functional capacity and LVEF, and with a reduction in major clinical endpoints in patients with HF and AF.
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Eckardt L, Wolfes J, Frommeyer G. Benefits of early rhythm control of atrial fibrillation. Trends Cardiovasc Med 2023:S1050-1738(23)00041-5. [PMID: 37054762 DOI: 10.1016/j.tcm.2023.04.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 03/29/2023] [Accepted: 04/07/2023] [Indexed: 04/15/2023]
Abstract
In contrast to current guidelines and earlier trials, recent studies demonstrated superiority of rhythm- over rate-control and challenged the strategy of "rate versus rhythm" therapy in patients with atrial fibrillation. These newer studies have started to shift the use of rhythm-control therapy from the symptom-driven therapy of current guidelines to a risk-reducing strategy aimed at restoring and maintaining sinus rhythm. This review discusses recent data and presents an overview on the current discourse: The concept of early rhythm control seems attractive. Patients with rhythm control may undergo less atrial remodeling compared to those with rate control. In addition, in EAST-AFNET 4 an outcome-reducing effect of rhythm control was achieved by delivering therapy with relatively few complications early after the initial AF diagnosis. Successful rhythm control therapy and most likely reduced AF burden, estimated by the presence of sinus rhythm at 12 months after randomization, explained most of the reduction in cardiovascular outcomes achieved by rhythm control. However, it is too early to call for early rhythm control for all AF patients. Rhythm control may raise concerns regarding the generalizability of trial results in routine practice involving important questions on the definition of "early" and "successful", and the relevant issue of antiarrhythmic drugs versus catheter ablation. Further information is required to select patients who will benefit from an early ablative or non-ablative rhythm management.
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Affiliation(s)
- L Eckardt
- Department of Cardiology II - Electrophysiology, University Hospital Münster, Germany; Atrial Fibrillation Network (AFNET), Münster, Germany.
| | - J Wolfes
- Department of Cardiology II - Electrophysiology, University Hospital Münster, Germany; Atrial Fibrillation Network (AFNET), Münster, Germany
| | - G Frommeyer
- Department of Cardiology II - Electrophysiology, University Hospital Münster, Germany; Atrial Fibrillation Network (AFNET), Münster, Germany
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Mboweni N, Maseko M, Tsabedze N. Heart failure with reduced ejection fraction and atrial fibrillation: a Sub-Saharan African perspective. ESC Heart Fail 2023; 10:1580-1596. [PMID: 36934444 DOI: 10.1002/ehf2.14332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 01/06/2023] [Accepted: 02/07/2023] [Indexed: 03/20/2023] Open
Abstract
Cardiovascular diseases are a well-established cause of death in high-income countries. In the last 20 years, Sub-Saharan Africa (SSA) has seen one of the sharpest increases in cardiovascular disease-related mortality, superseding that of infectious diseases, including HIV/AIDS, in South Africa. This increase is evidenced by a growing burden of heart failure and atrial fibrillation (AF) risk factors. AF is a common comorbidity of heart failure with reduced ejection fraction (HFrEF), which predisposes to an increased risk of stroke, rehospitalizations, and mortality compared with patients in sinus rhythm. AF had the largest relative increase in cardiovascular disease burden between 1990 and 2010 in SSA and the second highest (106.4%) increase in disability-adjusted life-years (DALY) between 1990 and 2017. Over the last decade, significant advancements in the management of both HFrEF and AF have emerged. However, managing HFrEF/AF remains a clinical challenge for physicians, compounded by the suboptimal efficacy of guideline-mandated pharmacotherapy in this group of patients. There may be an essential role for racial differences and genetic influence on therapeutic outcomes of HFrEF/AF patients, further complicating our overall understanding of the disease and its pathophysiology. In SSA, the lack of accurate and up-to-date epidemiological data on this subgroup of patients presents a challenge in our quest to prevent and reduce adverse outcomes. This narrative review provides a contemporary overview of the epidemiology of HFrEF/AF in SSA. We highlight important differences in the demographic and aetiological profile and the management of this subpopulation, emphasizing what is currently known and, more importantly, what is still unknown about HFrEF/AF in SSA.
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Affiliation(s)
- Nonkanyiso Mboweni
- School of Physiology, University of the Witwatersrand, Johannesburg, South Africa.,Department of Internal Medicine, Division of Cardiology, Charlotte Maxeke Johannesburg Academic Hospital, University of the Witwatersrand, Gauteng, Johannesburg, South Africa
| | - Muzi Maseko
- School of Physiology, University of the Witwatersrand, Johannesburg, South Africa
| | - Nqoba Tsabedze
- Department of Internal Medicine, Division of Cardiology, Charlotte Maxeke Johannesburg Academic Hospital, University of the Witwatersrand, Gauteng, Johannesburg, South Africa
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Treatment of Arrhythmias During Pregnancy. Clin Obstet Gynecol 2023; 66:163-175. [PMID: 36162092 DOI: 10.1097/grf.0000000000000747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Cardiac disease is the most common cause of maternal mortality in developed nations. Cardiac arrhythmias are frequent among patients with structural heart disease and may require immediate treatment to prevent hemodynamic instability leading to acute maternal and fetal decompensation. Antiarrhythmic therapy during pregnancy should follow the same principles recommended for nonpregnant individuals. Although multidisciplinary management is recommended, obstetricians, and maternal-fetal medicine specialists may sometimes need to emergently recognize and treat rhythm anomalies before support services become available.
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Han S, Jia R, Cen Z, Guo R, Zhao S, Bai Y, Xie M, Cui K. Early rhythm control vs. rate control in atrial fibrillation: A systematic review and meta-analysis. Front Cardiovasc Med 2023; 10:978637. [PMID: 36815025 PMCID: PMC9939510 DOI: 10.3389/fcvm.2023.978637] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 01/19/2023] [Indexed: 02/08/2023] Open
Abstract
Objective It has long been debated whether rhythm control vs. rate control strategies have differing effects on mortality and morbidity for atrial fibrillation (AF). Recently, several randomized controlled studies (RCTs) and observational trials described that an early rhythm management method was linked to a lower likelihood of negative clinical outcomes in individuals with AF. We wanted to see if an early rhythm management method may help patients with AF. Methods We performed a systematic search to retrieve studies assessing the outcomes of early rhythm control vs. rate control in AF by using PubMed, Web of Science, Cochrane Library, and Embase published between 01/01/2000 and 15/04/2022. Results Finally, two RCTs, one retrospective analysis of RCTs, and four observational studies were identified. Compared with rate control, early rhythm control has been linked to lower all-cause mortality. [risk ratio (RR), 0.76; 95% CI 0.69-0.83; P < 0.00001; I 2 = 77%]. The early rhythm control group was also associated with a lower risk of cardiovascular mortality (RR, 0.68; 95% CI 0.63-0.74; P < 0.00001; I 2 = 33), stroke (RR, 0.77; 95% CI 0.67-0.87; P < 0.001; I 2 = 64), and heart failure hospitalization (RR, 0.74; 95% CI 0.59-0.93; P = 0.0009; I 2 = 93%). We found no significant difference in nights spent in hospital per year, acute coronary syndrome, major bleeding, and cardiac arrest/ventricular arrhythmia between the groups. Conclusion In this meta-analysis, early rhythm therapy was linked to a lower risk of all-cause mortality, cardiovascular mortality, stroke, and heart failure hospitalization compared with the rate control group. Systematic review registration https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42022333592.
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Affiliation(s)
- Shaojie Han
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Ruikun Jia
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Zhifu Cen
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Ran Guo
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Shenyu Zhao
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Yixuan Bai
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Min Xie
- Department of Cardiology, Chengdu Seventh People’s Hospital, Chengdu, Sichuan, China,Min Xie,
| | - Kaijun Cui
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China,*Correspondence: Kaijun Cui,
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Younes H, Noujaim C, Mekhael M, Chouman N, Assaf A, Kreidieh O, Lim C, Marrouche N, Donnellan E. Atrial fibrillation ablation as first-line therapy for patients with heart failure with reduced ejection fraction (HFrEF): evaluating the impact on patient survival. Expert Rev Cardiovasc Ther 2023; 21:111-121. [PMID: 36680789 DOI: 10.1080/14779072.2023.2172402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Atrial fibrillation and congestive heart failure share several pathophysiological mechanisms. As a result of their association, patients have worse outcomes than if either condition were present alone. AREAS COVERED While multiple trials report no significant difference between the use of pharmacological rhythm control and the use of rate control in terms of mortality and morbidity in patients with HFrEF, there is evidence to suggest that catheter ablation is beneficial in this patient population. The present review aims to provide a comprehensive overview of catheter ablation as a treatment modality for atrial fibrillation in patients with HFrEF as well as evaluate its outcome on survival. EXPERT OPINION An appropriate patient selection strategy for patients with HFrEF could be the next step in determining which patients might benefit most from catheter ablation. Future atrial fibrillation management may incorporate digital health and pulsed-field ablation.
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Affiliation(s)
- Hadi Younes
- Tulane Research and Innovation for Arrhythmia Discoveries- TRIAD Center, Tulane University School of Medicine, New Orleans, LA, USA
| | - Charbel Noujaim
- Tulane Research and Innovation for Arrhythmia Discoveries- TRIAD Center, Tulane University School of Medicine, New Orleans, LA, USA
| | - Mario Mekhael
- Tulane Research and Innovation for Arrhythmia Discoveries- TRIAD Center, Tulane University School of Medicine, New Orleans, LA, USA
| | - Nour Chouman
- Tulane Research and Innovation for Arrhythmia Discoveries- TRIAD Center, Tulane University School of Medicine, New Orleans, LA, USA
| | - Ala Assaf
- Tulane Research and Innovation for Arrhythmia Discoveries- TRIAD Center, Tulane University School of Medicine, New Orleans, LA, USA
| | - Omar Kreidieh
- Tulane Research and Innovation for Arrhythmia Discoveries- TRIAD Center, Tulane University School of Medicine, New Orleans, LA, USA
| | - Chanho Lim
- Tulane Research and Innovation for Arrhythmia Discoveries- TRIAD Center, Tulane University School of Medicine, New Orleans, LA, USA
| | - Nassir Marrouche
- Tulane Research and Innovation for Arrhythmia Discoveries- TRIAD Center, Tulane University School of Medicine, New Orleans, LA, USA
| | - Eoin Donnellan
- Tulane Research and Innovation for Arrhythmia Discoveries- TRIAD Center, Tulane University School of Medicine, New Orleans, LA, USA
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Elia A, Fossati S. Autonomic nervous system and cardiac neuro-signaling pathway modulation in cardiovascular disorders and Alzheimer's disease. Front Physiol 2023; 14:1060666. [PMID: 36798942 PMCID: PMC9926972 DOI: 10.3389/fphys.2023.1060666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 01/19/2023] [Indexed: 01/31/2023] Open
Abstract
The heart is a functional syncytium controlled by a delicate and sophisticated balance ensured by the tight coordination of its several cell subpopulations. Accordingly, cardiomyocytes together with the surrounding microenvironment participate in the heart tissue homeostasis. In the right atrium, the sinoatrial nodal cells regulate the cardiac impulse propagation through cardiomyocytes, thus ensuring the maintenance of the electric network in the heart tissue. Notably, the central nervous system (CNS) modulates the cardiac rhythm through the two limbs of the autonomic nervous system (ANS): the parasympathetic and sympathetic compartments. The autonomic nervous system exerts non-voluntary effects on different peripheral organs. The main neuromodulator of the Sympathetic Nervous System (SNS) is norepinephrine, while the principal neurotransmitter of the Parasympathetic Nervous System (PNS) is acetylcholine. Through these two main neurohormones, the ANS can gradually regulate cardiac, vascular, visceral, and glandular functions by turning on one of its two branches (adrenergic and/or cholinergic), which exert opposite effects on targeted organs. Besides these neuromodulators, the cardiac nervous system is ruled by specific neuropeptides (neurotrophic factors) that help to preserve innervation homeostasis through the myocardial layers (from epicardium to endocardium). Interestingly, the dysregulation of this neuro-signaling pathway may expose the cardiac tissue to severe disorders of different etiology and nature. Specifically, a maladaptive remodeling of the cardiac nervous system may culminate in a progressive loss of neurotrophins, thus leading to severe myocardial denervation, as observed in different cardiometabolic and neurodegenerative diseases (myocardial infarction, heart failure, Alzheimer's disease). This review analyzes the current knowledge on the pathophysiological processes involved in cardiac nervous system impairment from the perspectives of both cardiac disorders and a widely diffused and devastating neurodegenerative disorder, Alzheimer's disease, proposing a relationship between neurodegeneration, loss of neurotrophic factors, and cardiac nervous system impairment. This overview is conducive to a more comprehensive understanding of the process of cardiac neuro-signaling dysfunction, while bringing to light potential therapeutic scenarios to correct or delay the adverse cardiovascular remodeling, thus improving the cardiac prognosis and quality of life in patients with heart or neurodegenerative disorders.
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Guo Y, Romiti GF, Corica B, Proietti M, Bonini N, Zhang H, Lip GY. Mobile health-technology integrated care in atrial fibrillation patients with heart failure: A report from the mAFA-II randomized clinical trial. Eur J Intern Med 2023; 107:46-51. [PMID: 36347740 DOI: 10.1016/j.ejim.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 10/28/2022] [Accepted: 11/01/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND To assess the effect of mobile health (mHealth) technology-implemented 'Atrial fibrillation Better Care' (ABC) pathway-approach (mAFA intervention) in AF patients with Heart Failure (HF). METHODS From the Mobile Health Technology for Improved Screening and Optimized Integrated Care in AF (mAFA-II) cluster randomized trial, we evaluated the effect of mAFA intervention on the risk of major outcomes in patients with HF using Inverse Probability of Treatment Weighting. Primary outcome was the composite outcome of stroke/thromboembolism, all-cause death, and rehospitalization. The effect of mAFA and the interaction with HF at baseline was assessed through Cox-regressions. RESULTS Among the 3,324 patients originally enrolled in the trial, 714 (21.5%; mean age: 72.7±13.1 years; 39.9% females) had HF. The effect of mAFA intervention on the primary outcome was consistent in patients with and without HF (Hazard Ratio, (HR): 0.59, 95% Confidence Interval (CI): 0.29-1.22 vs. HR: 0.40, 95%CI: 0.21-0.76, p for interaction=0.438); similar findings were found for rehospitalisations and bleeding events. A trend towards lower efficacy of mAFA in HF patients was observed for all-cause death, while the risk of the composite outcome of 'recurrent AF, HF and acute coronary syndrome' was higher among AF-HF patients allocated to mAFA (p for interaction: <0.001). CONCLUSION A mHealth-technology implemented ABC pathway provides consistent effects on the risks of primary outcome, rehospitalisation and bleeding, in AF patients both with and without HF. However, AF-HF patients may need tailored approaches to improve their overall prognosis, specifically to reduce the risk of recurrent AF, HF and acute coronary syndrome.
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Affiliation(s)
- Yutao Guo
- Department of Pulmonary Vessel and Thrombotic Disease, Medical School of Chinese PLA, Chinese PLA General Hospital, Beijing, China; Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Giulio Francesco Romiti
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Department of Translational and Precision Medicine, Sapienza - University of Rome, Rome, Italy
| | - Bernadette Corica
- Department of Translational and Precision Medicine, Sapienza - University of Rome, Rome, Italy
| | - Marco Proietti
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy; Geriatric Unit, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy
| | - Niccolò Bonini
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Hui Zhang
- Department of Pulmonary Vessel and Thrombotic Disease, Medical School of Chinese PLA, Chinese PLA General Hospital, Beijing, China
| | - Gregory Yh Lip
- Department of Pulmonary Vessel and Thrombotic Disease, Medical School of Chinese PLA, Chinese PLA General Hospital, Beijing, China; Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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Jensen M, Suling A, Metzner A, Schnabel RB, Borof K, Goette A, Haeusler KG, Zapf A, Wegscheider K, Fabritz L, Diener HC, Thomalla G, Kirchhof P. Early rhythm-control therapy for atrial fibrillation in patients with a history of stroke: a subgroup analysis of the EAST-AFNET 4 trial. Lancet Neurol 2023; 22:45-54. [PMID: 36517170 DOI: 10.1016/s1474-4422(22)00436-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 10/17/2022] [Accepted: 10/18/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Patients with atrial fibrillation and a history of stroke are at high risk of recurrent stroke and cardiovascular complications. In the EAST-AFNET 4 trial we showed that a systematic strategy of early rhythm control was associated with a lower risk of cardiovascular outcomes than usual care in patients with atrial fibrillation diagnosed in the past 12 months. In this pre-specified subgroup analysis we aimed to assess whether a strategy of early rhythm control is safe and can prevent adverse cardiovascular outcomes compared with usual care in such patients. METHODS EAST-AFNET 4 was a randomised, open-label trial with blinded-outcome assessment done at 135 hospitals and secondary care practices in 11 European countries. Adults with early atrial fibrillation (ie, diagnosed ≤12 months before enrolment) were randomly assigned (1:1) to either early rhythm control or usual care, with stratification according to site and variable block lengths used for concealment. The first primary outcome was time to first occurrence of the composite of cardiovascular death, ischaemic or haemorrhagic stroke, or hospital admission with worsening of heart failure or acute coronary syndrome. The second primary outcome was the number of nights spent in hospital in 1 year. The primary safety outcome was the composite of any death, stroke, or serious adverse events related to rhythm-control therapy. Here we present the results of these outcomes in patients with a history of stroke. Analyses were done in the intention-to-treat population. EAST-AFNET 4 is registered with ClinicalTrials.gov (NCT01288352), EudraCT (2010-021258-20), and ISRCTN (ISRCTN04708680). FINDINGS Between July 28, 2011, and Dec 30, 2016, 2789 patients were randomly assigned in the EAST-AFNET 4 trial to either early rhythm control (n=1395) or usual care (n=1394). Of these patients, five had no information on history of stroke and were excluded from this subgroup analysis. 217 (8%) patients had a history of stroke, of whom 110 were assigned to early rhythm control and 107 to usual care. The median age of participants with a history of stroke was 72·0 years (IQR 66·0-76·0). 95 (44%) participants were female and 122 (56%) were male. During a median follow-up of 4·7 years (3·5-6·4) for patients with a history of stroke, a first primary outcome event occurred in 18 (16%) of 110 patients in the early rhythm-control group (3·7 per 100 person-years) and 33 (31%) of 107 in the usual care group (7·4 per 100 person-years; hazard ratio [HR] 0·52, 95% CI 0·29-0·93). The mean number of nights spent in hospital per year was 5·1 (SD 13·2) for patients with a history of stroke assigned to early rhythm control and 6·6 (10·1) for those assigned to usual care (incidence rate ratio 0·87, 95% CI 0·55-1·38). Among patients with a history of stroke, primary safety events occurred in 17 (15%) patients in the early rhythm-control group versus 30 (28%) in the usual care group. INTERPRETATION In this prespecified subgroup analysis in patients with recently diagnosed atrial fibrillation and a history of stroke, the effects of early rhythm control were consistent with the findings of the primary analysis. As the evidence from this subgroup analysis is considered supportive and exploratory, further research is needed to confirm the safety and efficacy of this approach in patients with a history of stroke. FUNDING German Ministry of Education and Research, German Center for Cardiovascular Research (DZHK), Atrial Fibrillation Network (AFNET), European Heart Rhythm Association, St Jude Medical-Abbott, Sanofi, and the German Heart Foundation.
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Affiliation(s)
- Märit Jensen
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; German Centre for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany.
| | - Anna Suling
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andreas Metzner
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; German Centre for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Renate B Schnabel
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; German Centre for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany; Atrial Fibrillation Network, Münster, Germany
| | - Katrin Borof
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andreas Goette
- St Vincenz Hospital Paderborn, Paderborn, Germany; Atrial Fibrillation Network, Münster, Germany
| | - Karl Georg Haeusler
- Atrial Fibrillation Network, Münster, Germany; Department of Neurology, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Antonia Zapf
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Karl Wegscheider
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Atrial Fibrillation Network, Münster, Germany
| | - Larissa Fabritz
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; University Center of Cardiovascular Sciences, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; German Centre for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany; Atrial Fibrillation Network, Münster, Germany; Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Hans-Christoph Diener
- Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; German Centre for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Paulus Kirchhof
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; German Centre for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany; Atrial Fibrillation Network, Münster, Germany; Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
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