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Döring C, Richter U, Ulbrich S, Wunderlich C, Ebert M, Richter S, Linke A, Sveric KM. The Impact of Right Atrial Size to Predict Success of Direct Current Cardioversion in Patients With Persistent Atrial Fibrillation. Korean Circ J 2023; 53:331-343. [PMID: 37161747 PMCID: PMC10172272 DOI: 10.4070/kcj.2022.0291] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 01/29/2023] [Accepted: 02/08/2023] [Indexed: 05/11/2023] Open
Abstract
BACKGROUND AND OBJECTIVES The prognostic implication of right atrial (RA) and left atrial (LA) size for an immediate success of direct current cardioversion (DCCV) in atrial fibrillation (AF) remains unclear. This study aimed to compare RA and LA size for the prediction of DCCV success. METHODS Between 2012 and 2018, 734 consecutive outpatients were screened for our prospective registry. Each eligible patient received a medical history, blood analysis, and transthoracic echocardiography with a focus on indexed RA (iRA) area and LA volume (iLAV) prior to DCCV with up to three biphasic shocks (200-300-360 J) or additional administration of amiodarone or flecainide to restore sinus rhythm. RESULTS We enrolled 589 patients, and DCCV was in 89% (n=523) successful. Mean age was 68 ± 10 years, and 40% (n=234) had New York heart association class >II. A prevalence of the male sex (64%, n=376) and of persistent AF (86%, n=505) was observed. Although DCCV success was associated with female sex (odds ratio [OR], 1.88; 95% confidence interval [CI], 1.06-3.65), with absence of coronary heart disease and normal left ventricular function (OR, 2.24; 95% CI, 1.26-4.25), with short AF duration (OR, 1.93; 95% CI, 1.05-4.04) in univariable regression, only iRA area remained a stable and independent predictor of DCCV success (OR, 0.27; 95% CI, 0.12-0.69; area under the curve 0.71), but not iLAV size (OR, 1.16; 95% CI, 1.05-1.56) in multivariable analysis. CONCLUSIONS iRA area is superior to iLAV for the prediction of immediate DCCV success in AF.
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Affiliation(s)
- Christoph Döring
- Department for Internal Medicine and Cardiology, Herzzentrum Dresden, Technische Universität Dresden, Dresden, Germany
| | - Utz Richter
- Department for Internal Medicine and Cardiology, Herzzentrum Dresden, Technische Universität Dresden, Dresden, Germany
| | - Stefan Ulbrich
- Department for Internal Medicine and Cardiology, Herzzentrum Dresden, Technische Universität Dresden, Dresden, Germany
| | - Carsten Wunderlich
- Department of Internal Medicine II, Helios Hospital Pirna, Pirna, Germany
| | - Micaela Ebert
- Department for Internal Medicine and Cardiology, Herzzentrum Dresden, Technische Universität Dresden, Dresden, Germany
| | - Sergio Richter
- Department for Internal Medicine and Cardiology, Herzzentrum Dresden, Technische Universität Dresden, Dresden, Germany
| | - Axel Linke
- Department for Internal Medicine and Cardiology, Herzzentrum Dresden, Technische Universität Dresden, Dresden, Germany
| | - Krunoslav Michael Sveric
- Department for Internal Medicine and Cardiology, Herzzentrum Dresden, Technische Universität Dresden, Dresden, Germany.
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Massaro G, Spagni S, Martignani C, Bettazzoni L, Spadotto A, Ziacchi M, Biffi M, Galiè N, Boriani G, Frisoni J, Diemberger I. Personalizing configuration for atrial fibrillation external electrical cardioversion to improve first shock efficacy. J Cardiovasc Med (Hagerstown) 2022; 23:655-662. [PMID: 36099072 DOI: 10.2459/jcm.0000000000001352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Despite the common use of biphasic electrical cardioversion (ECV) to convert atrial fibrillation (AF), we lack definite recommendations on electrode configuration. METHODS We adopted a quasi-experimental design enrolling all candidates to ECV for AF. In the first stage, two units were involved, one using antero-apical pads (AAP) and the second antero-posterior adhesive patches (APP). These data enabled the creation of a decision algorithm to personalize the ECV approach, which was subsequently validated during the second stage. RESULTS A total of 492 patients were enrolled overall. In the first stage, APP and AAP presented similar conversion rates (87.4 vs. 86.9% at first attempt of a step-up protocol, P = 0.661). While body surface area (BSA) ≤2.12 m2 was an independent predictor in the overall population, the two components (height and weight) acted differently in the two configurations: being height ≤1.73 m2 a significant cut-off value in the AAP subgroup, and weight <83 kg in the APP subgroup. Considering these cut-offs, we developed a decision algorithm for electrode configuration. In the second stage, algorithm validation confirmed an improvement in the first shock efficacy with respect to the results of the first stage (93.2 vs. 87.2%, P = 0.025), with a significant reduction in shock impedance (70.8 ± 15.3 vs. 81.8 ± 15.6, P < 0.001). CONCLUSION Patients with high BSA require high energy shocks for sinus rhythm restoration with ECV. Weight seems to affect more APP configuration, while height seems to impact more for the AAP. These findings have the potential to optimize ECV in clinical practice.
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Affiliation(s)
- Giulia Massaro
- Cardiology Unit, Cardio-Thoracic-Vascular Building, S.Orsola-Malpighi Policlinic, University of Bologna, Bologna
| | - Stefano Spagni
- Cardiology Unit, Cardio-Thoracic-Vascular Building, S.Orsola-Malpighi Policlinic, University of Bologna, Bologna
| | - Cristian Martignani
- Cardiology Unit, Cardio-Thoracic-Vascular Building, S.Orsola-Malpighi Policlinic, University of Bologna, Bologna
| | - Luca Bettazzoni
- Cardiology Unit, Cardio-Thoracic-Vascular Building, S.Orsola-Malpighi Policlinic, University of Bologna, Bologna
| | - Alberto Spadotto
- Cardiology Unit, Cardio-Thoracic-Vascular Building, S.Orsola-Malpighi Policlinic, University of Bologna, Bologna
| | - Matteo Ziacchi
- Cardiology Unit, Cardio-Thoracic-Vascular Building, S.Orsola-Malpighi Policlinic, University of Bologna, Bologna
| | - Mauro Biffi
- Cardiology Unit, Cardio-Thoracic-Vascular Building, S.Orsola-Malpighi Policlinic, University of Bologna, Bologna
| | - Nazzareno Galiè
- Cardiology Unit, Cardio-Thoracic-Vascular Building, S.Orsola-Malpighi Policlinic, University of Bologna, Bologna
| | - Giuseppe Boriani
- Cardiology Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Jessica Frisoni
- Cardiology Unit, Cardio-Thoracic-Vascular Building, S.Orsola-Malpighi Policlinic, University of Bologna, Bologna
| | - Igor Diemberger
- Cardiology Unit, Cardio-Thoracic-Vascular Building, S.Orsola-Malpighi Policlinic, University of Bologna, Bologna
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Roh SY, Ahn J, Lee KN, Baek YS, Kim DH, Lee DI, Shim J, Choi JI, Kim YH. The Impact of Personal Thoracic Impedance on Electrical Cardioversion in Patients with Atrial Arrhythmias. ACTA ACUST UNITED AC 2021; 57:medicina57060618. [PMID: 34199329 PMCID: PMC8231855 DOI: 10.3390/medicina57060618] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 05/31/2021] [Accepted: 06/11/2021] [Indexed: 11/30/2022]
Abstract
Background and Objectives: Direct current cardioversion (DCCV) is a safe and useful treatment for atrial tachyarrhythmias. In the past, the energy delivered in DCCV was decided upon empirically, based only on the type of tachyarrhythmia. This conventional method does not consider individual factors and may lead to unnecessary electrical damage. Materials and Methods: We performed DCCV in patients with atrial tachyarrhythmias. The impedance and electrical current at the moment of shock were measured. The human thoracic impedance between both defibrillator patches and the electric current that was used were measured. Results: A total of 683 DCCVs were performed on 466 atrial tachyarrhythmia patients. The average impedance was 64 ± 11 Ω and the average successful current was 23 ± 6 mA. The magnitude of the electrical current that was successful depended upon the human impedance (linear regression, B = −0.266, p < 0.001) and the left atrial diameter (B = 0.092, p < 0.001). Impedance was directly proportional to body mass index (BMI) (B = 1.598, p < 0.001) and was higher in females than in males (77 ± 15 Ω vs. 63 ± 11 Ω, p < 0.001). Notably, the high-impedance (>70 Ω) group had a higher BMI (27 ± 4 kg/m2 vs. 25 ± 3 kg/m2, p < 0.001) and a higher proportion of females (37% vs. 9%, p < 0.001) than the low-impedance group (<70 Ω). However, thoracic impedance was not an independent predictor for successful DCCV. Conclusions: Human thoracic impedance was one of the factors that impacted the level of electrical current required for successful DCCV in patients with atrial arrhythmias. In the future, it will be helpful to consider individual predictors, such as BMI and gender, to minimize electrical damage during DCCV.
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Affiliation(s)
- Seung-Young Roh
- Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine and Korea University Medical Center, Seoul 02841, Korea; (S.-Y.R.); (J.S.); (J.-I.C.)
| | - Jinhee Ahn
- Division of Cardiology, Department of Internal Medicine, Pusan National University Hsopital, Busan 49241, Korea;
| | - Kwang-No Lee
- Division of Cardiology, Department of Internal Medicine, Ajou University Hospital, Suwon 16499, Korea;
| | - Yong-Soo Baek
- Division of Cardiology, Department of Internal Medicine, Inha University hospital, Incheon 22332, Korea;
| | - Dong-Hyeok Kim
- Division of Cardiology, Department of Internal Medicine, Ewha University Hospital, Seoul 07804, Korea;
| | - Dae-In Lee
- Division of Cardiology, Department of Internal Medicine, Chungbuk National University Hospital, Chungju-si 28644, Korea;
| | - Jaemin Shim
- Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine and Korea University Medical Center, Seoul 02841, Korea; (S.-Y.R.); (J.S.); (J.-I.C.)
| | - Jong-Il Choi
- Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine and Korea University Medical Center, Seoul 02841, Korea; (S.-Y.R.); (J.S.); (J.-I.C.)
| | - Young-Hoon Kim
- Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine and Korea University Medical Center, Seoul 02841, Korea; (S.-Y.R.); (J.S.); (J.-I.C.)
- Correspondence:
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El Amrani A, Viñolas X, Arias MA, Bazan V, Valdovinos P, Alegret JM. Pharmacological Cardioversion after Pre-Treatment with Antiarrythmic Drugs Prior to Electrical Cardioversion in Persistent Atrial Fibrillation: Impact on Maintenance of Sinus Rhythm. J Clin Med 2021; 10:1029. [PMID: 33802253 PMCID: PMC7958960 DOI: 10.3390/jcm10051029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 02/19/2021] [Accepted: 02/22/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Antiarrhythmic drugs (AADs) are frequently initiated in patients with persistent atrial fibrillation (AF) prior to electrical cardioversion (ECV), achieving pharmacological cardioversion (PCV) in some cases. Little is known about the mode of cardioversion and the effect of the type of AAD used in the maintenance of sinus rhythm (SR). METHODS From three national surveys of patients with persistent AF referred for ECV, we selected those who were pre-treated with AADs (amiodarone or group Ic AADs). We analyzed the effect of the type of cardioversion (pharmacological vs. electrical) and the AAD used in the maintenance of SR at three months. RESULTS Among the 665 patients selected, 151 had a successful PCV prior to the planned ECV. In the remaining 514 patients, 460 had a successful ECV. A successful PCV was related to a higher rate of SR maintenance than a successful ECV (77.9% vs. 57.5%; p < 0.0001). After a successful PCV, the maintenance of SR was identical in those patients treated with amiodarone and those treated with group Ic AADs (77.4% vs. 77.5%; p = 0.99), whereas after a successful ECV, amiodarone was clearly superior to group Ic AADs (61.3% vs. 43.0%; p = 0.001). Considering patients with successful PCV and ECV together, PCV was an independent factor related to the maintenance of SR. CONCLUSIONS In patients with persistent AF, successful PCV selects a subgroup with a high probability of maintenance of SR. With regard to drugs, amiodarone was superior to group Ic AADs in patients with ECV, whereas in PCV, no differences were observed.
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Affiliation(s)
- Amine El Amrani
- Department of Cardiology, Hospital Universitari de Sant Joan, IISPV, Universitat Rovira i Virgili, 43204 Reus, Spain; (A.E.A.); (P.V.)
| | - Xavier Viñolas
- Department of Cardiology, Hospital de la Sta. Creu i St. Pau, 08026 Barcelona, Spain;
| | - Miguel Angel Arias
- Department of Cardiology, Hospital Virgen de la Salud, 45004 Toledo, Spain;
| | - Victor Bazan
- Department of Cardiology, Hospital Universitari Germans Trias i Pujol, 08916 Badalona, Spain;
| | - Pilar Valdovinos
- Department of Cardiology, Hospital Universitari de Sant Joan, IISPV, Universitat Rovira i Virgili, 43204 Reus, Spain; (A.E.A.); (P.V.)
| | - Josep M. Alegret
- Department of Cardiology, Hospital Universitari de Sant Joan, IISPV, Universitat Rovira i Virgili, 43204 Reus, Spain; (A.E.A.); (P.V.)
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Utility of Amiodarone Pre-Treatment as a Facilitator of the Acute Success of Electrical Cardioversion in Persistent Atrial Fibrillation. Cardiovasc Drugs Ther 2020; 34:89-94. [PMID: 32096001 DOI: 10.1007/s10557-019-06934-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
PURPOSE The usefulness and mechanisms of antiarrhythmic drug (AAD) pre-treatment as a facilitator of the acute success of electrical cardioversion (ECV) in atrial fibrillation (AF) remain controversial. We sought to analyze the role of AAD treatment with this purpose, differentiating its possible utility either facilitating the restoration of sinus rhythm (SR) or reducing immediate AF recurrences (IAFR). METHODS We analyzed 2962 consecutive patients with persistent AF undergoing ECV prospectively included in 3 national registries. The acute success of ECV was indicated by the reversion to SR without presenting an IAFR (< 2 h). RESULTS A total of 1410 patients (48%) received AAD treatment prior to ECV (80% amiodarone, 15% class Ic AAD, 2% other AAD). The rate of restoration of SR was similar between the patients treated with amiodarone (92%), class Ic AAD (91%) and who did not receive AAD pre-treatment (91%) (p = 0.92). However, those treated with amiodarone had fewer IAFR than those in the other two groups (amiodarone 3% vs class Ic 7% vs without treatment 6%; p = 0.002), so the ECV success rate was higher in the amiodarone group than in the other groups (amiodarone 89% vs Ic 84% vs without treatment 86%; p = 0.04). After adjusting for multiple variables, amiodarone remained as an independent predictor of a lower occurrence of IAFR (OR = 0.57; p = 0.01) and of a successful ECV (OR 1.37; p = 0.01). CONCLUSIONS For patients with persistent AF undergoing ECV, AAD has a neutral effect on the restoration of SR but amiodarone increases its effectiveness due to a lower incidence of IAFR.
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7
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Lüker J, Kuhr K, Sultan A, Nölker G, Omran H, Willems S, Andrié R, Schrickel JW, Winter S, Vollmann D, Tilz RR, Jobs A, Heeger CH, Metzner A, Meyer S, Mischke K, Napp A, Fahrig A, Steinhauser S, Brachmann J, Baldus S, Mahajan R, Sanders P, Steven D. Internal Versus External Electrical Cardioversion of Atrial Arrhythmia in Patients With Implantable Cardioverter-Defibrillator: A Randomized Clinical Trial. Circulation 2019; 140:1061-1069. [PMID: 31466479 DOI: 10.1161/circulationaha.119.041320] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Atrial arrhythmias are common in patients with implantable cardioverter-defibrillator (ICD). External shocks and internal cardioversion through commanded ICD shock for electrical cardioversion are used for rhythm-control. However, there is a paucity of data on efficacy of external versus internal cardioversion and on the risk of lead and device malfunction. We hypothesized that external cardioversion is noninferior to internal cardioversion for safety, and superior for successful restoration of sinus rhythm. METHODS Consecutive patients with ICD undergoing elective cardioversion for atrial arrhythmias at 13 centers were randomized in 1:1 fashion to either internal or external cardioversion. The primary safety end point was a composite of surrogate events of lead or device malfunction. Conversion of atrial arrhythmia to sinus rhythm was the primary efficacy end point. Myocardial damage was studied by measuring troponin release in both groups. RESULTS N=230 patients were randomized. Shock efficacy was 93% in the external cardioversion group and 65% in the internal cardioversion group (P<0.001). Clinically relevant adverse events caused by external or internal cardioversion were not observed. Three cases of pre-existing silent lead malfunction were unmasked by internal shock, resulting in lead failure. Troponin release did not differ between groups. CONCLUSIONS This is the first randomized trial on external vs internal cardioversion in patients with ICDs. External cardioversion was superior for the restoration of sinus rhythm. The unmasking of silent lead malfunction in the internal cardioversion group suggests that an internal shock attempt may be reasonable in selected ICD patients presenting for electrical cardioversion. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifier: NCT03247738.
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Affiliation(s)
- Jakob Lüker
- University of Cologne, University Hospital Cologne, Department of Electrophysiology (J.L., A.S., D.S.), Germany
| | - Kathrin Kuhr
- Institute of Medical Statistics and Computational Biology (IMSB) (K.K., S.S.), Germany
| | - Arian Sultan
- University of Cologne, University Hospital Cologne, Department of Electrophysiology (J.L., A.S., D.S.), Germany
| | - Georg Nölker
- Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Clinic for Electrophysiology, Bad Oeynhausen, Germany (G.N., H.O.)
| | - Hazem Omran
- Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Clinic for Electrophysiology, Bad Oeynhausen, Germany (G.N., H.O.)
| | - Stephan Willems
- Department of Electrophysiology, University Heart Center, Hamburg, Germany (S.W.)
| | - René Andrié
- Department of Internal Medicine II, University Hospital Bonn, Germany (R.A., J.W.S.)
| | - Jan W Schrickel
- Department of Internal Medicine II, University Hospital Bonn, Germany (R.A., J.W.S.)
| | | | | | - Roland R Tilz
- Department of Cardiology, University Hospital Lübeck, Germany (R.R.T., A.J., C.H.H.)
| | - Alexander Jobs
- Department of Cardiology, University Hospital Lübeck, Germany (R.R.T., A.J., C.H.H.).,Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Germany (A.J.)
| | - Christian-H Heeger
- Department of Cardiology, University Hospital Lübeck, Germany (R.R.T., A.J., C.H.H.)
| | - Andreas Metzner
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany (A.M.)
| | - Sven Meyer
- Department of Cardiology, Heart Center Oldenburg, European Medical School Oldenburg-Groningen, Germany (S.M.)
| | - Karl Mischke
- Medical Clinic I, Leopoldina Hospital, Schweinfurt, Germany (K.M.)
| | - Andreas Napp
- Department of Internal Medicine I, RWTH Aachen University Hospital, Germany (A.N.)
| | | | - Susanne Steinhauser
- Institute of Medical Statistics and Computational Biology (IMSB) (K.K., S.S.), Germany
| | | | | | - Rajiv Mahajan
- Center for Heart Rhythm Disorders, South Australian Health and Medical Research Institute (SAHMRI), University of Adelaide, Australia (R.M., P.S.)
| | - Prashanthan Sanders
- Center for Heart Rhythm Disorders, South Australian Health and Medical Research Institute (SAHMRI), University of Adelaide, Australia (R.M., P.S.)
| | - Daniel Steven
- University of Cologne, University Hospital Cologne, Department of Electrophysiology (J.L., A.S., D.S.), Germany
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Hellman T, Kiviniemi T, Nuotio I, Biancari F, Vasankari T, Hartikainen J, Lehto M, Airaksinen KE. Optimal timing for cardioversion in patients with atrial fibrillation. Clin Cardiol 2018; 41:966-971. [PMID: 29802625 DOI: 10.1002/clc.22986] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 04/25/2018] [Accepted: 05/24/2018] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Electrical cardioversion (CV) is essential in rhythm management of atrial fibrillation (AF). However, optimal timing of CV remains unknown. HYPOTHESIS Timing of CV in AF is associated with risk of adverse events. METHODS We analyzed the effect of AF episode duration on safety and efficacy of electrical CV in a multicenter, multicohort study exploring 4356 CVs in 2530 patients on oral anticoagulation. The composite adverse outcome included unsuccessful CV, acute arrhythmic complications, thromboembolic events, mortality, and AF recurrence within 30-day follow-up. RESULTS Study groups were stratified according to duration of index AF episode (<24 h, 24-48 h, 48 h-30d, and > 30d), consisting of 1767, 516, 632, and 1441 CVs, respectively. CVs were unsuccessful in 8.5% (<24 h), 5.4% (24-48 h), 11.1% (48 h-30d), and 13.9% (>30d), respectively (P < 0.01). Occurrence of thromboembolic events (0.1%), mortality (0.1%), and asystole >5 seconds (0.7%) within 30-day follow-up was infrequent and comparable in the study groups. AF recurrence within 30 days after initially successful CVs was 29.8% (<24 h), 26.5% (24-48 h), 37.3% (48 h-30d), and 30.3% (>30d), respectively (P < 0.01). Composite adverse outcome occurred in 1669 (38.4%) CVs, and index AF episode >48 hours was an independent predictor for the composite endpoint (OR: 1.49, 95% CI: 1.28-1.74, P < 0.01) in multivariate analysis. CONCLUSIONS Optimal timing of CV for AF showed a J-shaped curve, with fewest adverse outcomes in patients with CV performed 24 to 48 hours after onset of AF. In patients with rhythm-control strategy, delaying CV >48 hours is associated with increased risk for adverse outcomes.
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Affiliation(s)
- Tapio Hellman
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland.,Department of Medicine, Turku University Hospital and University of Turku, Turku, Finland
| | - Tuomas Kiviniemi
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Ilpo Nuotio
- Department of Medicine, Turku University Hospital and University of Turku, Turku, Finland
| | - Fausto Biancari
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland.,Department of Surgery, Turku University Hospital and University of Turku, Turku, Finland.,Department of Surgery, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Tuija Vasankari
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Juha Hartikainen
- Heart Center, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
| | - Mika Lehto
- Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Finland
| | - K E Airaksinen
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
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Hellman T, Kiviniemi T, Vasankari T, Nuotio I, Biancari F, Bah A, Hartikainen J, Mäkäräinen M, Airaksinen KEJ. Prediction of ineffective elective cardioversion of atrial fibrillation: a retrospective multi-center patient cohort study. BMC Cardiovasc Disord 2017; 17:33. [PMID: 28100174 PMCID: PMC5241921 DOI: 10.1186/s12872-017-0470-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 01/13/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Elective cardioversion (ECV) of atrial fibrillation (AF) is a standard procedure to restore sinus rhythm. However, predictors for ineffective ECV (failure of ECV or recurrence of AF within 30 days) are unknown. METHODS We investigated 1998 ECVs performed for AF lasting >48 h in 1,342 patients in a retrospective multi-center study. Follow-up data were collected from 30 days after ECV. RESULTS Median number of cardioversions was one per patient with a range of 1-10. Altogether 303/1998 (15.2%) ECVs failed. Long (>5 years) AF history and over 30 days duration of the index AF episode were independent predictors for ECV failure and low (<60/min) ventricular rate of AF predicted success of ECV. In patients with successful ECVs an early recurrence of AF was detected in 549 (32.4%) cases. Female gender, high (>60/min) ventricular rate, renal failure and antiarrhythmic agents at discharge were the independent predictors for recurrence. In total ECV was ineffective in 852 (42.6%) cases. Female gender (OR 1.44, CI95% 1.15-1.80, p < 0.01), young (<65 years) age (OR 1.31, CI95% 1.07-1.62, p = 0.01), ventricular rate >60/min (OR 1.92, CI95% 1.08-3.41, p = 0.03), antiarrhythmic medication at discharge (OR 1.48, CI95% 1.14-1.93, p < 0.01) and low (<60/ml/min) estimated glomerular filtration rate (OR 1.59, CI95% 1.08-2.33, p = 0.02) were predictors of ineffective ECV. CONCLUSIONS Female gender, use of antiarrhythmic drug therapy and renal failure predicted both recurrence of AF and the composite end point. For the first time in a large real-life study several clinical predictors for clinically ineffective ECV were identified.
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Affiliation(s)
- Tapio Hellman
- Department of Medicine, Turku University Hospital and University of Turku, Hämeentie 11, PO Box 52, 20521, Turku, Finland
| | - Tuomas Kiviniemi
- Heart Center, Turku University Hospital and University of Turku, Hämeentie 11, PO Box 52, 20521, Turku, Finland
| | - Tuija Vasankari
- Heart Center, Turku University Hospital and University of Turku, Hämeentie 11, PO Box 52, 20521, Turku, Finland
| | - Ilpo Nuotio
- Department of Medicine, Turku University Hospital and University of Turku, Hämeentie 11, PO Box 52, 20521, Turku, Finland
| | - Fausto Biancari
- Department of Surgery, Oulu University Hospital, Kajaanintie 50, PO Box 10, 90029 OYS, Oulu, Finland
| | - Aissa Bah
- Heart Center, Kuopio University Hospital and University of Eastern Finland, PO Box 100, Kuopio, 70029, Finland
| | - Juha Hartikainen
- Heart Center, Kuopio University Hospital and University of Eastern Finland, PO Box 100, Kuopio, 70029, Finland
| | - Marianne Mäkäräinen
- Heart Center, Turku University Hospital and University of Turku, Hämeentie 11, PO Box 52, 20521, Turku, Finland
| | - K E Juhani Airaksinen
- Heart Center, Turku University Hospital and University of Turku, Hämeentie 11, PO Box 52, 20521, Turku, Finland.
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Alegret JM, Viñolas X, Martínez-Rubio A, Pedrote A, Beiras X, García-Sacristán JF, Crespo-Mancebo F, Ruiz-Mateas F. Gender Differences in Patients with Atrial Fibrillation Undergoing Electrical Cardioversion. J Womens Health (Larchmt) 2015; 24:466-70. [PMID: 25978301 DOI: 10.1089/jwh.2014.5014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Current recommendations on the rhythm control strategy for treatment of atrial fibrillation (AF) are more restrictive than a decade ago. Gender may play a role in decisions on the management of AF, including application of electrical cardioversion. METHODS We analyzed clinical characteristics by gender in patients participating in the observational survey about stable patients underlying cardioversion in Spain (CARDIOVERSE) study (n=915), a survey of the practice of electrical cardioversion in 67 Spanish hospitals. We compared these data with those from a previous survey of electrical cardioversion in Spain (REVERSE study) performed 8 years previously. RESULTS Patients undergoing electrical cardioversion were mainly men (76%). This finding was observed in all age groups, independently of symptoms. Men were younger (62±10 years vs. 69±9 years; p<0.001), more frequently asymptomatic and had a lower prevalence of hypertension and a lower stroke risk. Among asymptomatic patients, the predominance of men was especially evident in older age groups (<65 years, men 76%, women 24%; ≥65 years, men 92%, women 8% (p<0.001). Compared with the REVERSE study, we observed a decrease in the percentage of women among patients undergoing electrical cardioversion (37% REVERSE vs. 24% CARDIOVERSE; p<0.001), mainly in older than 65 years. CONCLUSIONS Our results support the hypothesis that gender is a determinant in decisions on the most appropriate strategy for managing AF. We observed a decrease in the percentage of women undergoing electrical cardioversion during the last decade, especially in older asymptomatic patients.
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Affiliation(s)
- Josep M Alegret
- 1 Grup de Recerca Cardiovascular, Hospital Universitari de Sant Joan, IISPV, Universitat Rovira i Virgili , Reus, Spain
| | | | | | - Alonso Pedrote
- 4 Hospital Universitario Virgen del Rocío , Sevilla, Spain
| | - Xulio Beiras
- 5 Complejo Hospitalario Universitario de Vigo , Vigo, Spain
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A South Australian registry of biphasic cardioversions of atrial arrhythmias: efficacy and predictors of success. Heart Lung Circ 2014; 24:342-7. [PMID: 25465515 DOI: 10.1016/j.hlc.2014.10.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Accepted: 10/08/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Restoration of sinus rhythm by biphasic cardioversion is an established strategy for patients in atrial arrhythmias. This study aimed to investigate the real-life practice of cardioversions throughout a local hospital to determine frequency and predictors of success and use of high energy (> 200 joules). METHODS Prospective analysis of consecutive biphasic cardioversions from 2009-2013. Patient demographics, medical history and cardioversion data were collected. RESULTS 484 cardioversions from 379 patients were included in the final analysis. The majority (73%) of cardioversions were immediately successful after a single shock; overall success was 88% (1-5 shocks). Exploratory analyses revealed that single-shock success was significantly associated with lighter weight (OR 1.19, 95% CI 1.0-1.4, p<0.05). If a second shock was required, energy escalation was significantly associated with success (OR 3.11, 95% CI 1.43-6.77, p<0.05). Increasing weight was the strongest predictor of receiving high energy (10kg increase OR 1.43, 95% CI 1.13-1.81, p<0.05). CONCLUSIONS This prospective analysis reflects the real-life heterogeneous practice of biphasic cardioversions of atrial arrhythmias throughout a local hospital. These findings highlight the importance of first shock energy selection with careful consideration of patient weight. We emphasise the recommendation to escalate energy, highlighting the need for high-energy defibrillators in 'hard-to-cardiovert' patients.
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Abstract
Cardiac arrhythmias comprise of a heterogeneous group of disorders which manifest in a wide range of clinical presentations. They can be associated with underlying cardiac disease and portend a grave prognosis, with some arrhythmias being rapidly fatal. Other arrhythmias, however are relatively benign and can be asymptomatic or may be a mere inconvenience for the patient. All primary care physicians can expect to encounter some forms of arrhythmias during the course of their practice. This review article provides a brief overview of the commonly seen tachyarrhythmias for the general practitioner and provides relevant updates on the recent developments in our understanding of their mechanisms and management.
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Affiliation(s)
- Ramil Goel
- Department of Cardiovascular Disease, Mayo Clinic, 13400 East Shea Boulevard, Scottsdale, AZ 85259, USA
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13
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Factores predictivos de reversión a ritmo sinusal precardioversión eléctrica en pacientes con fibrilación auricular persistente tratados con antiarrítmicos. Med Clin (Barc) 2013; 140:351-5. [DOI: 10.1016/j.medcli.2012.02.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2011] [Revised: 02/09/2012] [Accepted: 02/16/2012] [Indexed: 11/17/2022]
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Alegret JM, Aragonès G, Elosua R, Beltrán-Debón R, Hernández-Aguilera A, Romero-Menor C, Camps J, Joven J. The relevance of the association between inflammation and atrial fibrillation. Eur J Clin Invest 2013; 43:324-31. [PMID: 23397981 DOI: 10.1111/eci.12047] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2012] [Accepted: 12/20/2012] [Indexed: 01/17/2023]
Abstract
BACKGROUND The relevance of the association between inflammation and atrial fibrillation (AF) is not firmly established. The clinical importance is considerable because inflammation is usually not targeted as a treatment option, minimizing a probable benefit. MATERIALS AND METHODS We have used a case-control study with a Mendelian randomization rationale to assess whether proposed risk factors that have a genetic component and are readily detected in circulating blood are causally related to AF. The studied variables were C-reactive protein (CRP) and a representative of the chemokine system, the monocyte chemoattractant protein-1 (CCL2). RESULTS Plasma CRP and CCL2 concentrations were significantly higher in AF patients than in the unaffected population. However, when segregated between paroxysmal and permanent, the difference for CRP was only observed in patients with a permanent condition. Plasma CCL2 was raised in both subgroups. Confounding factors were carefully considered, and multivariable analyses revealed that circulating CCL2 was significant and CRP was negligible to explain the presence of AF. The duration of the episode also bore a significant predictive value. Odd ratios for AF as a function of genotype did not differ from 1·0 for any of the individual CRP and CCL2 polymorphisms, or any combinations. CONCLUSIONS Elevated plasma CRP concentration per se does not increase atrial fibrillation risk. Values obtained for CCL2 suggest that inflammation is probably a consequence of AF. Our data also suggest that the effect of the duration of the episode should be further studied in the assessment of the actual role of inflammation.
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Affiliation(s)
- Josep M Alegret
- Secció de Cardiologia, Hospital Universitari de Sant Joan, IISPV, Universitat Rovira i Virgili, Reus, Spain.
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15
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Alegret JM, Viñolas X, Romero-Menor C, Pons S, Villuendas R, Calvo N, Pérez-Rodon J, Sabaté X. Trends in the use of electrical cardioversion for atrial fibrillation: influence of major trials and guidelines on clinical practice. BMC Cardiovasc Disord 2012; 12:42. [PMID: 22708978 PMCID: PMC3441848 DOI: 10.1186/1471-2261-12-42] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2012] [Accepted: 05/31/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The purpose of the present study was to assess the trends in the use of ECV following published studies that had compared rhythm and rate control strategies on atrial fibrillation (AF), and the recommendations included in the current clinical practice guidelines. METHODS The REVERCAT is a population-based assessment of the use of electrical cardioversion (ECV) in treating persistent AF in Catalonia (Spain). The initial survey was conducted in 2003 and the follow-up in 2010. RESULTS We observed a decrease of 9% in the absolute numbers of ECV performed (436 in 2003 vs. 397 in 2010). This is equivalent to 27% when considering population increases over this period. The patients treated with ECV in 2010 were younger, had a lower prevalence of previous embolism, a higher prevalence of diabetes, and increased body weight. Underlying heart disease factors indicated, in 2010, a higher proportion of NYHA ≥ II and left ventricular ejection fraction <30%. We observed a reduction in the number of ECV performed in 16 of the 27 (67%) participating hospitals. However, there was an increase of 14% in the number of procedures performed in tertiary hospitals, and was related to the increasing use of ECV as a bridge to AF ablation. Considering the initial number of patients treated with ECV, the rate of sinus rhythm at 3 months was almost unchanged (58% in 2003 vs. 57% in 2010; p=0.9) despite the greater use of biphasic energy in 2010 and a similar prescription of anti-arrhythmic drugs. CONCLUSIONS Although we observed a decrease in the number of ECVs performed over the 7 year period between the two studies, this technique remains a common option for treating patients with persistent AF. The change in the characteristics of candidate patients did not translate into better outcomes.
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Affiliation(s)
- Josep M Alegret
- Secció de Cardiologia, Hospital Universitari de Sant Joan, Institut d’Investigacions Sanitàries Pere Virgili, Universitat Rovira i Virgili, C/Dr. Laporte, s/n, Reus, 43205, Spain
| | | | | | | | | | | | | | - Xavier Sabaté
- Hospital de Bellvitge, Hospitalet de Llobregat, Spain
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Reiffel JA. Cardioversion for atrial fibrillation: treatment options and advances. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2009; 32:1073-84. [PMID: 19659629 DOI: 10.1111/j.1540-8159.2009.02441.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Atrial fibrillation (AF) is associated with significant morbidity and mortality. There are two basic approaches to managing AF: slowing the ventricular rate, while allowing the arrhythmia to continue (the rate-control approach), and restoring and maintaining sinus rhythm (the rhythm-control approach) with antiarrhythmic drugs (AADs) and/or ablation, electrical cardioversion (CV), if needed, or both. Strategy trials comparing rate and rhythm control have found no survival advantage of one approach over the other, but other considerations, such as symptom reduction, often necessitate pursuit of rhythm control. Electrical, or direct current, CV is a widely used and effective method for termination of nonparoxysmal AF, although its success can be affected by patient- and technique-related variables. Pharmacological CV options also exist and are preferable in specific circumstances. Both pharmacological and electrical CV are associated with the risk of proarrhythmia. Many AADs are under development for both CV and maintenance of sinus rhythm. Some are atrioselective, such as vernakalant, and target ion channels in the atria, with little or no effects in the ventricle. Vernakalant, currently under Food and Drug Administration review, appears to offer a safer profile than current CV agents and is likely to expand the role of pharmacological CV. Other new AADs that provide increased efficacy or safety while maintaining normal sinus rhythm may also be better than current drugs; if so, rate-rhythm comparisons will differ from those of previous studies. In conclusion, further trials should clarify the long-term safety profiles of new atrioselective agents and other investigational drugs and define their role in the treatment of AF.
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Affiliation(s)
- James A Reiffel
- Department of Medicine, Division of Cardiology, Section of Electrophysiology, Columbia University, New York, New York 10032, USA.
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Alegret JM, Viñolas X, Grande A, Castellanos E, Asso A, Tercedor L, Carmona JR, Medina O, Alberola AG, Fidalgo ML, Pérez-Alvarez L, Sabaté X. Clinical effectiveness of antiarrhythmic treatment after electrical cardioversion in patients without structural heart disease. Rev Esp Cardiol 2009; 61:1274-9. [PMID: 19080966 DOI: 10.1016/s1885-5857(09)60055-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION AND OBJECTIVES The aim was to investigate the clinical effectiveness of using antiarrhythmic drugs after electrical cardioversion in patients without structural heart disease, including their effect on the maintenance of sinus rhythm. METHODS In total, 528 patients with persistent atrial fibrillation but without significant structural heart disease who underwent successful electrical cardioversion at 96 Spanish hospitals were followed up for 1 year. Patients were assessed at 1, 3, 6 and 12 months. The use and effectiveness of antiarrhythmic drugs for preventing the recurrence of persistent atrial fibrillation was evaluated. RESULTS Some 80% of patients were receiving antiarrhythmic drugs at discharge, most frequently amiodarone. No specific clinical factor was associated with greater use of antiarrhythmics. Overall, 37% of patients were in sinus rhythm at all follow-up assessments. At the 1-year assessment, 59% of patients who remained in sinus rhythm were still taking antiarrhythmic drugs. Multivariate Cox regression analysis identified weight (hazard ratio [HR]=1.01 per kg; P=.04) and no antiarrhythmic treatment (HR=1.59; P=.001) as being independently associated with the recurrence of persistent atrial fibrillation. Amiodarone tended to be better than other antiarrhythmic drugs. CONCLUSIONS In routine clinical practice, the large majority of patients without structural heart disease received antiarrhythmic drugs, most frequently amiodarone, after successful electrical cardioversion. Drug use was the principal factor associated with the maintenance of sinus rhythm at 1 year.
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Affiliation(s)
- Josep Maria Alegret
- Servicio de Cardiología, Hospital de Sant Joan de Reus, Reus, Tarragona, Spain.
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Utilidad en la práctica clínica del tratamiento antiarrítmico tras cardioversión eléctrica en pacientes sin cardiopatía estructural. Rev Esp Cardiol 2008. [DOI: 10.1016/s0300-8932(08)75735-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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