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Tubeeckx MRL, De Keulenaer GW, Heidbuchel H, Segers VFM. Pathophysiology and clinical relevance of atrial myopathy. Basic Res Cardiol 2024; 119:215-242. [PMID: 38472506 DOI: 10.1007/s00395-024-01038-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 02/01/2024] [Accepted: 02/02/2024] [Indexed: 03/14/2024]
Abstract
Atrial myopathy is a condition that consists of electrical, structural, contractile, and autonomic remodeling of the atria and is the substrate for development of atrial fibrillation, the most common arrhythmia. Pathophysiologic mechanisms driving atrial myopathy are inflammation, oxidative stress, atrial stretch, and neurohormonal signals, e.g., angiotensin-II and aldosterone. These mechanisms initiate the structural and functional remodeling of the atrial myocardium. Novel therapeutic strategies are being developed that target the pathophysiologic mechanisms of atrial myopathy. In this review, we will discuss the pathophysiology of atrial myopathy, as well as diagnostic and therapeutic strategies.
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Affiliation(s)
- Michiel R L Tubeeckx
- Laboratory of Physiopharmacology, Universiteitsplein 1, Building T (2nd Floor), 2610, Antwerp, Belgium.
| | - Gilles W De Keulenaer
- Laboratory of Physiopharmacology, Universiteitsplein 1, Building T (2nd Floor), 2610, Antwerp, Belgium
- Department of Cardiology, ZNA Middelheim Hospital Antwerp, Antwerp, Belgium
| | - Hein Heidbuchel
- Research Group Cardiovascular Diseases, GENCOR, University of Antwerp, Antwerp, Belgium
- Department of Cardiology, University Hospital Antwerp, Antwerp, Belgium
| | - Vincent F M Segers
- Laboratory of Physiopharmacology, Universiteitsplein 1, Building T (2nd Floor), 2610, Antwerp, Belgium
- Department of Cardiology, University Hospital Antwerp, Antwerp, Belgium
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2
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Karwowski J, Wrzosek K, Rekosz J, Tymoszuk K, Wiktorska A, Szmarowska K, Solecki M, Dłużniewski M. Electric Cardioversion in Older Adults. Is Sedation Using Propofol Safe in the Absence of the Direct Anesthetist's Assistance? J Cardiovasc Pharmacol Ther 2024; 29:10742484231221929. [PMID: 38291723 DOI: 10.1177/10742484231221929] [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: 02/01/2024]
Abstract
Aims: This study aimed to assess the safety of electric cardioversion in the absence of anesthetists assistance. We also evaluated the efficacy and safety of this procedure in older adults (≥80 years) compared to younger populations. Methods: We retrospectively analyzed the data of patients who underwent electric cardioversion at our cardiology department. Patients were divided into 2 groups according to age: ≥ 80 years and <80 years old. Results: The study included 218 participants, 73 were aged 80 years or more (mean age: 84.8 years), and 145 were younger than 80 years (mean age: 66.7 years). Electric cardioversion was effective in 97.3% of older patients and 96.5% of younger patients (P = 1.00). No thromboembolic complications were observed in either of the groups. Asystole >5 s occurred immediately after shock in 4.1% of older and 2.1% of younger patients (P = .405). Propofol was used as a sedative, with a mean dose of 0.83 mg/kg versus 0.93 mg/kg, in older and younger patients, respectively. Intubation, medical intervention, or other advanced resuscitation techniques were not required. During hospitalization, arrhythmia recurred in 9.6% and 12.4% of the older and younger patients, respectively (P = .537). Conclusions: Electrical cardioversion is an effective and safe procedure regardless of patient age. Sedation with propofol administered by cardiologists was safe. Adverse events were not considered serious or reversible.
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Affiliation(s)
- Jarosław Karwowski
- Department of Heart Diseases, Medical Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Karol Wrzosek
- Department of Heart Diseases, Medical Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Jerzy Rekosz
- II Department of Cardiology, Masovian Brodnowski Hospital, Warsaw, Poland
| | - Katarzyna Tymoszuk
- II Department of Cardiology, Masovian Brodnowski Hospital, Warsaw, Poland
| | - Anna Wiktorska
- II Department of Cardiology, Masovian Brodnowski Hospital, Warsaw, Poland
| | | | - Mateusz Solecki
- II Department of Cardiology, Masovian Brodnowski Hospital, Warsaw, Poland
| | - Mirosław Dłużniewski
- Department of Heart Diseases, Medical Centre of Postgraduate Medical Education, Warsaw, Poland
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3
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Meng XS, Chen T, Wang XY, Lu X, Hu J, Shen J, Guo J. Feasibility and safety of the direct current cardioversion at the time of left atrial appendage occlusion for patients with atrial fibrillation. Front Cardiovasc Med 2023; 10:1219611. [PMID: 37745133 PMCID: PMC10514907 DOI: 10.3389/fcvm.2023.1219611] [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: 05/09/2023] [Accepted: 08/28/2023] [Indexed: 09/26/2023] Open
Abstract
Background With an increasing number of patients undergoing left atrial appendage occlusion (LAAO), more attention is being paid to relieving clinical symptoms and improving the quality of life of these patients. For patients with atrial fibrillation (AF), direct current cardioversion (DCCV) is an alternate, nonpharmacological choice to restore sinus rhythm and relieve clinical symptoms. Objectives The purpose of this study was to assess the feasibility and safety of the DCCV at the time of LAAO for patients with AF. Methods Forty patients were enrolled in the DCCV group undergoing the DCCV at the time of LAAO. The control group undergoing LAAO alone was formed by 1:1 matching. Results In the DCCV group, cardioversion was immediately successful in 30 (75%) patients, of which 12 (40%) had AF recurrence at the three-month follow-up. The failed-DCCV group was older (73.70 ± 4.74 vs. 62.20 ± 9.01 years old, P = 0.000), had a faster postcardioversion heart rate (88.80 ± 16.58 vs. 70.97 ± 14.73 times, P = 0.03), and had a higher mean HAS-BLED score (4.00 vs. 3.00, P = 0.01) than the successful-DCCV group. No patients experienced periprocedural pericardial effusion, occluder displacement, device embolism, or >5 mm peridevice leakage. One patient experienced a transient ischemic attack (TIA) in the DCCV group during the follow-up. Conclusions The DCCV at the time of LAAO is feasible and safe for AF patients with contraindications for catheter ablation or AF recurrence after previous catheter ablation to restore the sinus rhythm and relieve clinical symptoms. The DCCV at the time of LAAO is more likely to succeed for younger patients and patients with lower HAS-BLED scores.
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Affiliation(s)
| | | | | | | | | | | | - Jun Guo
- Department of Cardiovascular, The Sixth Medical Center of Chinese PLA General Hospital, Beijing, China
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4
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Cunha PS, Laranjo S, Heijman J, Oliveira MM. The Atrium in Atrial Fibrillation - A Clinical Review on How to Manage Atrial Fibrotic Substrates. Front Cardiovasc Med 2022; 9:879984. [PMID: 35859594 PMCID: PMC9289204 DOI: 10.3389/fcvm.2022.879984] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 06/03/2022] [Indexed: 12/27/2022] Open
Abstract
Atrial fibrillation (AF) is the most common sustained arrhythmia in the population and is associated with a significant clinical and economic burden. Rigorous assessment of the presence and degree of an atrial arrhythmic substrate is essential for determining treatment options, predicting long-term success after catheter ablation, and as a substrate critical in the pathophysiology of atrial thrombogenesis. Catheter ablation of AF has developed into an essential rhythm-control strategy. Nowadays is one of the most common cardiac ablation procedures performed worldwide, with its success inversely related to the extent of atrial structural disease. Although atrial substrate evaluation remains complex, several diagnostic resources allow for a more comprehensive assessment and quantification of the extent of left atrial structural remodeling and the presence of atrial fibrosis. In this review, we summarize the current knowledge on the pathophysiology, etiology, and electrophysiological aspects of atrial substrates promoting the development of AF. We also describe the risk factors for its development and how to diagnose its presence using imaging, electrocardiograms, and electroanatomic voltage mapping. Finally, we discuss recent data regarding fibrosis biomarkers that could help diagnose atrial fibrotic substrates.
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Affiliation(s)
- Pedro Silva Cunha
- Arrhythmology, Pacing and Electrophysiology Unit, Cardiology Service, Santa Marta Hospital, Central Lisbon Hospital University Center, Lisbon, Portugal
- Lisbon School of Medicine, Universidade de Lisboa, Lisbon, Portugal
- Comprehensive Health Research Center, Universidade NOVA de Lisboa, Lisbon, Portugal
| | - Sérgio Laranjo
- Arrhythmology, Pacing and Electrophysiology Unit, Cardiology Service, Santa Marta Hospital, Central Lisbon Hospital University Center, Lisbon, Portugal
- Lisbon School of Medicine, Universidade de Lisboa, Lisbon, Portugal
- Comprehensive Health Research Center, Universidade NOVA de Lisboa, Lisbon, Portugal
| | - Jordi Heijman
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
| | - Mário Martins Oliveira
- Arrhythmology, Pacing and Electrophysiology Unit, Cardiology Service, Santa Marta Hospital, Central Lisbon Hospital University Center, Lisbon, Portugal
- Lisbon School of Medicine, Universidade de Lisboa, Lisbon, Portugal
- Comprehensive Health Research Center, Universidade NOVA de Lisboa, Lisbon, Portugal
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5
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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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6
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Alexandre J, Dolladille C, Douesnel L, Font J, Dabrowski R, Shavit L, Legallois D, Funck-Brentano C, Champ-Rigot L, Ollitrault P, Beygui F, Bejan-Angoulvant T, Parienti JJ, Milliez P. Effects of Mineralocorticoid Receptor Antagonists on Atrial Fibrillation Occurrence: A Systematic Review, Meta-Analysis, and Meta-Regression to Identify Modifying Factors. J Am Heart Assoc 2019; 8:e013267. [PMID: 31711383 PMCID: PMC6915291 DOI: 10.1161/jaha.119.013267] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Background Mineralocorticoid receptor antagonists (MRAs) have emerged as potential atrial fibrillation (AF) preventive therapy, but inconsistent results have been reported. We aimed to examine the effects of MRAs on AF occurrence and explore factors that could influence the magnitude of the effect size. Methods and Results PubMed, Embase, and Cochrane Central databases were used to search for randomized clinical trials and observational studies addressing the effect of MRAs on AF occurrence from database inception through April 03, 2018. We performed a systematic review and random effects meta‐analyses to compute odds ratios with 95% CIs. Meta‐regression was then applied to explore the sources of between‐study heterogeneity. We included 24 studies, 11 randomized clinical trials and 13 observational cohorts, representing a total number of 7914 patients (median age: 64.2 years; median left ventricular ejection fraction: 49.7%; median follow‐up: 12.0 months), 2843 (35.9%) of whom received MRA therapy. Meta‐analyses showed a significant overall reduction in AF occurrence in the MRA‐treated patients versus the control groups (15.0% versus 32.2%; odds ratio, 0.55; 95% CI, 0.44–0.70 [P<0.00001]), with the greatest benefit regarding recurrent AF episodes (odds ratio, 0.42; 95% CI, 0.31–0.59 [P<0.00001]) and with significant heterogeneity among the included studies (I2=54%; P=0.0008). Meta‐regression analyses showed that effect size was significantly associated with older studies and higher AF occurrence rate in the control groups. Conclusions MRAs seem to be effective in AF prevention, especially regarding recurrent AF episodes.
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Affiliation(s)
- Joachim Alexandre
- Department of Pharmacology CHU Caen France.,UNICAEN, CHU Caen Medical School Université Caen Normandie Caen France.,Signalisation, électrophysiologie et imagerie des lésions d'ischémie-reperfusion myocardique Caen France
| | - Charles Dolladille
- Department of Pharmacology CHU Caen France.,Department of Cardiology CHU Caen France
| | | | - Jonaz Font
- Department of Pharmacology CHU Caen France
| | | | - Linda Shavit
- Adult Nephrology Unit Shaare Zedek Medical Center Jerusalem Israel
| | - Damien Legallois
- UNICAEN, CHU Caen Medical School Université Caen Normandie Caen France.,Signalisation, électrophysiologie et imagerie des lésions d'ischémie-reperfusion myocardique Caen France.,Department of Cardiology CHU Caen France
| | - Christian Funck-Brentano
- Department of Pharmacology AP-HP Pitié-Salpêtrière Hospital Paris France.,INSERM UMR ICAN 1166 Paris France.,Faculty of Medicine UPMC Univ Paris 06 Sorbonne Universités Paris France.,Institute of Cardiometabolism and Nutrition Paris France
| | - Laure Champ-Rigot
- UNICAEN, CHU Caen Medical School Université Caen Normandie Caen France.,Signalisation, électrophysiologie et imagerie des lésions d'ischémie-reperfusion myocardique Caen France.,Department of Cardiology CHU Caen France
| | | | - Farzin Beygui
- UNICAEN, CHU Caen Medical School Université Caen Normandie Caen France.,Signalisation, électrophysiologie et imagerie des lésions d'ischémie-reperfusion myocardique Caen France.,Department of Cardiology CHU Caen France
| | | | - Jean-Jacques Parienti
- Department of Biostatistics and Clinical Research CHU Caen France.,EA2656 Groupe de Recherche sur l'Adaptation Microbienne (GRAM 2.0) UNICAEN, CHU Caen Medical School Université Caen Normandie Caen France
| | - Paul Milliez
- UNICAEN, CHU Caen Medical School Université Caen Normandie Caen France.,Signalisation, électrophysiologie et imagerie des lésions d'ischémie-reperfusion myocardique Caen France.,Department of Cardiology CHU Caen France
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7
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Oikonomou E, Zografos T, Papamikroulis GA, Siasos G, Vogiatzi G, Theofilis P, Briasoulis A, Papaioannou S, Vavuranakis M, Gennimata V, Tousoulis D. Biomarkers in Atrial Fibrillation and Heart Failure. Curr Med Chem 2019; 26:873-887. [PMID: 28875838 DOI: 10.2174/0929867324666170830100424] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Revised: 10/25/2016] [Accepted: 11/11/2016] [Indexed: 02/07/2023]
Abstract
Atrial fibrillation (AF) is the most common sustained arrhythmia encountered in clinical practice and an important contributor to cardiovascular morbidity and mortality. Although the exact mechanisms behind AF are not completely elucidated, the underlying pathophysiological changes have been well described. Predisposal factors for AF include the older age, the increased left atrial size, the decreased left atrial function, the presence of heart failure and left ventricular systolic dysfunction and the presence of coronary heart disease or pulmonary or mitral valve disease. In addition to these factors, emerging evidence demonstrate that myocardial strain, fibrosis and inflammation, are associated with AF as well as the pathogenesis of the arrhythmia. The natruretic peptide system including Atrial Natriuretic Peptide (ANP), Brain Natriuretic Peptide (BNP) and C-type Natriuretic Peptide (CNP) is indicative of the level of myocardial strain which may predispose to AF. As a result, the aforementioned peptides are increased in AF patients. The levels of myocardial fibrosis biomarkers, such as ST2 and Galectin-3, are elevated suggesting atrial structural abnormalities, while the increased levels of CRP and Interleukin-6 supplement the inflammatory profile of AF patients. Emerging data for the aforementioned biomarkers are discussed in the present review.
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Affiliation(s)
- Evangelos Oikonomou
- 1st Department of Cardiology, 'Hippokration' Hospital, University of Athens Medical School, Athens, Greece
| | - Theodoros Zografos
- 1st Department of Cardiology, 'Hippokration' Hospital, University of Athens Medical School, Athens, Greece
| | | | - Gerasimos Siasos
- 1st Department of Cardiology, 'Hippokration' Hospital, University of Athens Medical School, Athens, Greece
| | - Georgia Vogiatzi
- 1st Department of Cardiology, 'Hippokration' Hospital, University of Athens Medical School, Athens, Greece
| | - Panagiotis Theofilis
- 1st Department of Cardiology, 'Hippokration' Hospital, University of Athens Medical School, Athens, Greece
| | - Alexandros Briasoulis
- 1st Department of Cardiology, 'Hippokration' Hospital, University of Athens Medical School, Athens, Greece
| | - Spyridon Papaioannou
- 1st Department of Cardiology, 'Hippokration' Hospital, University of Athens Medical School, Athens, Greece
| | - Manolis Vavuranakis
- 1st Department of Cardiology, 'Hippokration' Hospital, University of Athens Medical School, Athens, Greece
| | - Vasiliki Gennimata
- 1st Department of Cardiology, 'Hippokration' Hospital, University of Athens Medical School, Athens, Greece
| | - Dimitris Tousoulis
- 1st Department of Cardiology, 'Hippokration' Hospital, University of Athens Medical School, Athens, Greece
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8
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Dilaveris P, Antoniou CK, Manolakou P, Tsiamis E, Gatzoulis K, Tousoulis D. Biomarkers Associated with Atrial Fibrosis and Remodeling. Curr Med Chem 2019; 26:780-802. [PMID: 28925871 DOI: 10.2174/0929867324666170918122502] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 12/16/2016] [Accepted: 12/23/2016] [Indexed: 12/22/2022]
Abstract
Atrial fibrillation is the most common rhythm disturbance encountered in clinical practice. Although often considered as solely arrhythmic in nature, current evidence has established that atrial myopathy constitutes both the substrate and the outcome of atrial fibrillation, thus initiating a vicious, self-perpetuating cycle. This myopathy is triggered by stress-induced (including pressure/volume overload, inflammation, oxidative stress) responses of atrial tissue, which in the long term become maladaptive, and combine elements of both structural, especially fibrosis, and electrical remodeling, with contemporary approaches yielding potentially useful biomarkers of these processes. Biomarker value becomes greater given the fact that they can both predict atrial fibrillation occurrence and treatment outcome. This mini-review will focus on the biomarkers of atrial remodeling (both electrical and structural) and fibrosis that have been validated in human studies, including biochemical, histological and imaging approaches.
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Affiliation(s)
- Polychronis Dilaveris
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Panagiota Manolakou
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Eleftherios Tsiamis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantinos Gatzoulis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitris Tousoulis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
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9
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Left atrial longitudinal strain by speckle tracking as independent predictor of recurrence after electrical cardioversion in persistent and long standing persistent non-valvular atrial fibrillation. Int J Cardiovasc Imaging 2019; 35:1587-1596. [PMID: 30993507 PMCID: PMC6700045 DOI: 10.1007/s10554-019-01597-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Accepted: 04/03/2019] [Indexed: 11/01/2022]
Abstract
Atrial fibrillation (AF) is the most common arrhythmia in humans. After successful cardioversion, there is a recurrence of 60% due to atrial remodeling, and it has been shown that the global peak atrial longitudinal strain (GPALS) is decreased in these subjects. The aim of this study was to evaluate the predictive value of GPALS for AF recurrence. A prospective cohort of patients with persistent (PnVAF) and long standing persistent non-valvular AF (LSPnVAF) which underwent electrical cardioversion was evaluated with standard echocardiographic variables and GPALS quantification. The primary endpoint was AF recurrence at 6 months. We included PnVAF (n = 50, aged 68.4 ± 10.2 years, female 46%, lasted AF 6 months) and LSPnVAF (n = 81, aged 66.5 ± 13.1 years, female 36%, lasted AF 18 months). At 6 months there were a 68% of recurrence of AF in PnVAF and 53% in LSPnVAF group. GPALS was lower in recurrence 7.8 ± 2.0% versus 21.2 ± 8.9% (p < 0.001) for PnVAF and 7.3 ± 2.7% versus 20.7 ± 7.6% (p < 0.001) in LSPnVAF. GPALS ≤ 10.75% discriminates recurrence at 6 months with a sensitivity of 85%, specificity 99%, PPV 85%, NPV 90%, LR + 8.5 and LR- 0.17. The independent predictors of recurrence in PnVAF were GPALS ≤ 10.75% HR 8.89 [(2.2-35.7), p < 0.01] meanwhile in LSPnVAF were age HR 1.039 [(1.007-1.071), p = 0.01], and GPALS ≤ 10.75% HR 28.1 [(7.2-109.1), p < 0.001]. In subjects with PnVAF and LSPnVAF with successful electrical cardioversion, GPALS ≤ 10.75% predicts arrhythmia recurrence at 6-month follow-up.
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10
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Park HS, Jeong DS, Yu HT, Pak HN, Shim J, Kim JY, Kim J, Lee JM, Kim KH, Roh SY, Cho YJ, Kim YH, Yoon NS. 2018 Korean Guidelines for Catheter Ablation of Atrial Fibrillation: Part I. INTERNATIONAL JOURNAL OF ARRHYTHMIA 2018. [DOI: 10.18501/arrhythmia.2018.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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11
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Kornej J, Schumacher K, Husser D, Hindricks G. [Biomarkers and atrial fibrillation : Prediction of recurrences and thromboembolic events after rhythm control management]. Herzschrittmacherther Elektrophysiol 2018; 29:219-227. [PMID: 29761335 DOI: 10.1007/s00399-018-0558-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 04/03/2018] [Indexed: 06/08/2023]
Abstract
Atrial fibrillation (AF) is the most common arrhythmia in clinical praxis and is associated with an increased risk for cardio- and cerebrovascular complications leading to an increased mortality. Catheter ablation represents one of the most important and efficient therapy strategies in AF patients. Nevertheless, the high incidence of arrhythmia recurrences after catheter ablation leads to repeated procedures and higher treatment costs. Recently, several scores had been developed to predict rhythm outcomes after catheter ablation. Biomarker research is also of enormous interest. There are many clinical and blood biomarkers pathophysiologically associated with AF occurrence, progression and recurrences. These biomarkers-including different markers in blood (e. g. von Willebrand factor, D‑dimer, natriuretic peptides) or urine (proteins, epidermal grown factor receptor) but also cardiac imaging (echocardiography, computed tomography, magnetic resonance imaging)-could help to improve clinical scores and be useful for individualized AF management and optimized patients' selection for different AF treatment strategies. In this review, the role of diverse biomarkers and their predictive value related to AF-associated complications are discussed.
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Affiliation(s)
- Jelena Kornej
- Abteilung für Rhythmologie, Herzzentrum Leipzig, HELIOS Kliniken GmbH, Strümpellstraße 39, 04289, Leipzig, Deutschland.
| | - Katja Schumacher
- Abteilung für Rhythmologie, Herzzentrum Leipzig, HELIOS Kliniken GmbH, Strümpellstraße 39, 04289, Leipzig, Deutschland
| | - Daniela Husser
- Abteilung für Rhythmologie, Herzzentrum Leipzig, HELIOS Kliniken GmbH, Strümpellstraße 39, 04289, Leipzig, Deutschland
| | - Gerhard Hindricks
- Abteilung für Rhythmologie, Herzzentrum Leipzig, HELIOS Kliniken GmbH, Strümpellstraße 39, 04289, Leipzig, Deutschland
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Gwag HB, Chun KJ, Hwang JK, Park SJ, Kim JS, Park KM, On YK. Which antiarrhythmic drug to choose after electrical cardioversion: A study on non-valvular atrial fibrillation patients. PLoS One 2018; 13:e0197352. [PMID: 29787592 PMCID: PMC5963785 DOI: 10.1371/journal.pone.0197352] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 05/01/2018] [Indexed: 11/24/2022] Open
Abstract
The relative efficacy of antiarrhythmic drugs (AADs) after electrical cardioversion are not well established. This study aimed to investigate the efficacies of different AADs for maintaining sinus rhythm (SR) after electrical cardioversion for atrial fibrillation (AF). We selected patients from a retrospective registry including patients admitted for cardioversion between January 2012 and June 2016. The primary outcome was time to AF recurrence during the first year after cardioversion. The secondary outcomes included AF recurrence within 1 month, and first readmission due to heart failure, stroke, or additional non-pharmacological rhythm control. A total of 265 patients were divided into the 4 groups according to AAD type: flecainide (n = 33), propafenone (n = 64), amiodarone (n = 128), and dronedarone (n = 40). During the first year after cardioversion, the AF recurrence-free survival was similar between all AAD groups (69.7% vs. 67.2% vs. 71.9% vs. 80.0%, p = 0.439). About half of all recurrences occurred during the first month. There was no difference in any of the secondary outcomes, although the amiodarone group showed a trend toward more non-pharmacological rhythm control. AAD type was not associated with recurrence in multivariate analysis. In this study, half of all patients received amiodarone after electrical cardioversion. Flecainide, propafenone, amiodarone, and dronedarone showed similar efficacies for maintaining SR after electrical cardioversion. Thus, it might be reasonable to reconsider amiodarone use after cardioversion, since it did not show superior efficacy to the other drugs considered and is associated with potential side effects.
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Affiliation(s)
- Hye Bin Gwag
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kwang Jin Chun
- Division of Cardiology, Department of Medicine, Kangnam Sacred Heart Hospital, Hallym University Medical Center, Seoul, Korea
| | - Jin Kyung Hwang
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Seung-Jung Park
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - June Soo Kim
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kyoung-Min Park
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Young Keun On
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- * E-mail:
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Fudim M, Liu PR, Shrader P, Blanco RG, Allen LA, Fonarow GC, Gersh BJ, Kowey PR, Mahaffey KW, Hylek E, Go AS, Thomas L, Peterson ED, Piccini JP. Mineralocorticoid Receptor Antagonism in Patients With Atrial Fibrillation: Findings From the ORBIT-AF (Outcomes Registry for Better Informed Treatment of Atrial Fibrillation) Registry. J Am Heart Assoc 2018; 7:JAHA.117.007987. [PMID: 29654203 PMCID: PMC6015424 DOI: 10.1161/jaha.117.007987] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background Mineralocorticoid receptor antagonist (MRA) therapy may be beneficial to patients with atrial fibrillation (AF), but little is known about their use in patients with AF and subsequent outcomes. Methods and Results In order to better understand MRA use and subsequent outcomes, we performed a retrospective cohort study of the contemporary ORBIT‐AF (Outcomes Registry for Better Informed Treatment of Atrial Fibrillation) registry. AF progression and cardiovascular outcomes were compared using propensity‐matched Cox proportional hazards modeling according to MRA use at baseline and new MRA use at follow‐up versus patients with no MRA use. Among 7012 patients with nonpermanent AF, 320 patients were taking MRA at enrollment, and 416 patients initiated MRA use during follow‐up. The mean patient age was 72.5 years, 56.3% were men, and 70.4% had paroxysmal AF. Among all patients taking MRAs, 434 (59.0%) had heart failure, 655 (89.0%) had hypertension, and 380 (51.6%) had both. After adjustment, new MRA use was not associated with reduced AF progression (hazard ratio, 1.18; 95% confidence interval, 0.88–1.58; P=0.27) but showed a trend towards lower risk of stroke, transient ischemic attack, or systemic embolism (hazard ratio, 0.17; 95% confidence interval, 0.02–1.23; P=0.08). Results were similar for a comparison of new MRA users and baseline MRA users compared with nonusers. Conclusions In community‐based outpatients with AF, the majority of MRA use was for heart failure and hypertension. MRA use also trended towards lower adjusted stroke risk. Future studies should test the hypothesis that MRA use may decrease the risk of stroke in patients with AF.
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Affiliation(s)
- Marat Fudim
- Division of Cardiology, Duke Clinical Research Institute, Durham, NC
| | - Peter R Liu
- Division of Cardiology, Duke Clinical Research Institute, Durham, NC
| | - Peter Shrader
- Division of Cardiology, Duke Clinical Research Institute, Durham, NC
| | - Rosalia G Blanco
- Division of Cardiology, Duke Clinical Research Institute, Durham, NC
| | - Larry A Allen
- University of Colorado School of Medicine, Aurora, CO
| | | | | | - Peter R Kowey
- Lankenau Institute for Medical Research, Wynnewood, PA
| | | | - Elaine Hylek
- Boston University School of Medicine, Boston, MA
| | - Alan S Go
- Kaiser Permanente Northern California, Oakland, CA
| | - Laine Thomas
- Division of Cardiology, Duke Clinical Research Institute, Durham, NC
| | - Eric D Peterson
- Division of Cardiology, Duke Clinical Research Institute, Durham, NC
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14
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Weijs B, Limantoro I, Delhaas T, de Vos CB, Blaauw Y, Houben RPM, Verheule S, Pisters R, Crijns HJGM. Cardioversion of persistent atrial fibrillation is associated with a 24-hour relapse gap: Observations from prolonged postcardioversion rhythm monitoring. Clin Cardiol 2018; 41:366-371. [PMID: 29569353 DOI: 10.1002/clc.22877] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Revised: 12/12/2017] [Accepted: 12/19/2017] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Many recurrences occur after electrical cardioversion (ECV) of atrial fibrillation (AF). Assessment of extent of remodeling and continuous prolonged rhythm monitoring might reveal actionable recurrence mechanisms. HYPOTHESIS After ECV of AF specific patterns of arrhythmia recurrence can be distinguished. METHODS All patients who underwent successful ECV due to persistent AF were included. Tissue velocity echocardiography during AF was performed before ECV to study atrial fibrillatory cycle length and fibrillatory velocity. After ECV, the heart rhythm of all patients was monitored 3 times daily during 4 weeks, and timing of recurrence was noted. RESULTS In total, 50 patients (68% male) were included; mean age was 68 ± 9 years. Median duration of the current AF episode was 102 (range, 74-152) days. Twenty-one (42%) patients showed recurrence of persistent AF. No recurrences occurred during the first 24 hours. There were no differences in clinical characteristics between patients with or without recurrence of AF. However, patients with early recurrence of AF had significantly higher precardioversion wall-motion velocity compared with patients who remained in sinus rhythm (2.8 [1.6-3.6] vs 1.4 [0.9-3.3] cm/s; P = 0.017), whereas atrial fibrillatory cycle length did not differ. CONCLUSIONS In this study on 50 patients successfully cardioverted for persistent AF, there was a relapse gap of ≥24 hours. This phenomenon has not been well appreciated before and offers an AF-free window of opportunity for electrocardiographically triggered cardiac imaging or complex electrophysiological procedures. Echocardiographic tissue velocity imaging may visualize atrial remodeling relevant to AF recurrence.
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Affiliation(s)
- Bob Weijs
- Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands
| | - Ione Limantoro
- Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands
| | - Tammo Delhaas
- Department of Physiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands
| | - Cees B de Vos
- Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands
| | - Yuri Blaauw
- Department of Cardiology, University Medical Center Groningen, Groningen, the Netherlands
| | - Richard P M Houben
- Medtronic Bakken Research Center Maastricht, Maastricht, the Netherlands
| | - Sander Verheule
- Department of Physiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands
| | - Ronny Pisters
- Department of Cardiology, Rijnstate Hospital Arnhem, Arnhem, the Netherlands
| | - Harry J G M Crijns
- Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands
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Dentali F, Gianni M, Squizzato A, Ageno W, Castiglioni L, Maroni L, Hylek EM, Grandi AM, Cazzani E, Venco A, Guasti L. Use of statins and recurrence of atrial fibrillation after catheter ablation or electrical cardioversion. Thromb Haemost 2017; 106:363-70. [DOI: 10.1160/th10-10-0660] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2010] [Accepted: 04/29/2011] [Indexed: 11/05/2022]
Abstract
SummaryStatins have important pleiotropic effects and have been shown to reduce vascular inflammation. Some evidence suggests that statins may have a role in the primary prevention of atrial fibrillation (AF), whereas little is know on the role of statins in patients with existing AF. We performed a meta-analysis of the literature to assess the effect of statins on the recurrence of AF after electrical cardioversion or ablation. MEDLINE and EMBASE databases were searched up to January 2010. Relative risks (RR) and 95% confidence intervals (CIs) were then calculated and pooled using a random-effects model. Statistical heterogeneity was evaluated through the use of I2 statistics. Sixteen studies were included in our systematic review. Statins did not reduce the risk of AF recurrence after ablation (four studies including 750 patients; RR, 1.04; 95% CI, 0.85–1.28, p=0.71; I2 = 34%). Conversely, the use of statins was associated with a significantly reduced risk of AF recurrence after electrical cardioversion (12 studies including 1790 patients; RR, 0.78; 95% CI, 0.67–0.90, p=0.0003; I2 = 34%). This reduction was not statistically significant when the analysis was restricted to randomised controlled trials (RCTs) only (five studies, 458 patients, RR, 0.76; 95% CI, 0.48–1.20). In conclusion, statins may lower the risk of AF recurrence after electrical cardioversion, but not ablation. However, this finding should be considered with caution, and larger RCTs are warranted to confirm our preliminary results.
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Aldosterone Pathway Blockade to Prevent Atrial Fibrillation: A Systematic Review and Meta-Analysis. Int J Cardiol 2017; 231:155-161. [DOI: 10.1016/j.ijcard.2016.12.029] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 11/25/2016] [Accepted: 12/10/2016] [Indexed: 11/19/2022]
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Abstract
Postoperative atrial fibrillation (PoAF), a common complication of cardiac surgery, contributes significantly to morbidity, mortality, and increasing healthcare costs. Despite advances in surgical and medical management, the overall incidence of PoAF has not changed significantly, partly because of the limited understanding of mechanisms underlying acute surgery-related factors, such as myocardial injury, inflammation, sympathetic activation, and oxidative stress, which play an important role in the initiation of PoAF, whereas a preexisting atrial substrate appears to be more important in the maintenance of this dysrhythmia. Thus, in a majority of patients, PoAF becomes a manifestation of an underlying arrhythmogenic substrate that is unmasked after acute surgical stress. As such, the ability to identify which patients have this proarrhythmic substrate and are, therefore, at high risk for developing AF postoperatively, is important for the improved selection for prophylactic interventions, closer monitoring for complications, and establishing the probability of AF in the long term. This review highlights the role of the underlying substrate in promoting PoAF, proposed mechanisms, and the potential role of serum biomarkers to identify patients at risk for PoAF.
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18
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Begg GA, Holden AV, Lip GY, Plein S, Tayebjee MH. Assessment of atrial fibrosis for the rhythm control of atrial fibrillation. Int J Cardiol 2016; 220:155-61. [DOI: 10.1016/j.ijcard.2016.06.144] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 06/11/2016] [Accepted: 06/24/2016] [Indexed: 01/26/2023]
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Circulating biomarkers of fibrosis and cardioversion of atrial fibrillation: A prospective, controlled cohort study. Clin Biochem 2016; 50:11-15. [PMID: 27622867 DOI: 10.1016/j.clinbiochem.2016.09.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 08/31/2016] [Accepted: 09/08/2016] [Indexed: 02/05/2023]
Abstract
INTRODUCTION External direct current cardioversion (DCCV) is an established treatment for AF but is associated with procedural risk and high AF recurrence rates. Cardiac fibrosis has been associated with AF, and circulating biomarkers have been suggested as a method of its assessment, but which biomarkers are suitable is yet to be determined. This study examines the differences between levels of procollagen type III N terminal peptide (PIIINP), type I collagen carboxyl telopeptide (ICTP), galectin-3 (gal-3) and fibroblast growth factor 23 (FGF-23) in DCCV patients, and disease-and-age-matched controls. Their predictive value for AF recurrence was analysed. METHODS 79 patients undergoing DCCV and 40 age-and-disease-matched controls were included. Biomarkers were analysed using ELISA. Linear regression was used to examine relationships between biomarker levels and baseline characteristics, including echocardiographic measurements. Cox regression was used to assess relationships between baseline characteristics, including biomarker levels, and AF recurrence. RESULTS There was no statistically significant difference between biomarker levels in the DCCV and control groups. Diabetes mellitus was related to higher FGF-23 (p=0.007) and PIIINP (p=0.027). Female sex (p=0.014), hypertension (p=0.001), and higher body mass index (p≤0.001) were related to higher gal-3 levels. FGF-23 was weakly predictive of AF recurrence (HR 1.003 p=0.012). CONCLUSION PIIINP, ICTP, and Gal-3 are not predictive of AF recurrence after DCCV. FGF-23 may be associated with arrhythmia recurrence, but further work is required to clarify this. The presence of AF has no effect on levels of these biomarkers when compared to age and disease-matched controls.
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Li J, Yang Y, Ng CY, Zhang Z, Liu T, Li G. Association of Plasma Transforming Growth Factor-β1 Levels and the Risk of Atrial Fibrillation: A Meta-Analysis. PLoS One 2016; 11:e0155275. [PMID: 27171383 PMCID: PMC4865111 DOI: 10.1371/journal.pone.0155275] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 04/26/2016] [Indexed: 11/30/2022] Open
Abstract
Introduction Numerous studies have demonstrated that plasma transforming growth factor-β1 (TGF-β1) may be involved in the pathogenesis of atrial fibrillation (AF), but some discrepancy remained. We performed a meta-analysis to evaluate the association between the plasma level of TGF-β1 and the risk of AF. Methods Published clinical studies evaluating the association between the plasma level of TGF-β1 and the risk of AF were retrieved from PubMed and EMBASE databases. Two reviewers independently evaluated the quality of the included studies and extracted study data. Subgroup analysis and sensitivity analysis were performed to evaluate for heterogeneity between studies. Results Of the 395 studies identified initially, 13 studies were included into our analysis, with a total of 3354 patients. Higher plasma level of TGF-β1 was associated with increased risk of AF when evaluated as both a continuous variable (SMD 0.67; 95%CI 0.29–1.05) and a categorical variable (OR 1.01, 95% CI 1.01–1.02). Conclusions This meta-analysis suggests an association between elevated plasma TGF-β1 and new onset AF. Additional studies with larger sample sizes are needed to further investigate the relationship between plasma TGF-β1 and the occurrence of AF.
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Affiliation(s)
- Jiao Li
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, 300211, People’s Republic of China
| | - Yajuan Yang
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, 300211, People’s Republic of China
| | - Chee Yuan Ng
- Cardiac Arrhythmia Service, Massachusetts General Hospital, 55 Fruit St., Boston, Massachusetts, 02114, United States of America
| | - Zhiwei Zhang
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, 300211, People’s Republic of China
| | - Tong Liu
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, 300211, People’s Republic of China
- * E-mail: (TL); (GL)
| | - Guangping Li
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, 300211, People’s Republic of China
- * E-mail: (TL); (GL)
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Jaakkola J, Hartikainen JEK, Kiviniemi T, Nuotio I, Nammas W, Grönberg T, Karmi A, Ylitalo A, Airaksinen KEJ. Ventricular rate during acute atrial fibrillation and outcome of electrical cardioversion: The FinCV Study. Ann Med 2015; 47:341-5. [PMID: 25943162 DOI: 10.3109/07853890.2015.1031821] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION The impact of ventricular rate (VR) on the outcome of electrical cardioversion (ECV) of acute atrial fibrillation (AF) is currently unknown. We aimed to determine the effect of VR during acute AF on the success of ECV, recurrence of AF, and occurrence of post-cardioversion complications in 30 days of follow-up. METHODS A total of 6,624 ECVs were performed in 2,821 consecutive patients with AF lasting < 48 hours. VR ≤ 60 bpm was defined low, and VR ≥ 160 bpm high. RESULTS The median VR before ECV was 109 bpm. The success rate of ECV was 94.2%. Bradycardia occurred in 62 (0.9%) and thromboembolic complications in 39 (0.6%) ECVs. Low VR was observed before 75 (1.1%) ECVs, and male sex was its only independent predictor. High VR was observed in 165 (2.5%) ECVs. The independent predictors of high VR were younger age, < 12 h episode duration, no previous history of AF, and alcohol abuse. Low or high VR were not related to the success of ECV, incidence of thromboembolic or bradycardic complications, or recurrence of AF, although VR was significantly (P < 0.001) lower in the patients in whom AF recurred. CONCLUSION VR during acute AF does not affect the efficacy or safety of ECV.
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Affiliation(s)
- Jussi Jaakkola
- Heart Center, Turku University Hospital and University of Turku , Finland
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Circulating fibrosis biomarkers and risk of atrial fibrillation: The Cardiovascular Health Study (CHS). Am Heart J 2014; 167:723-8.e2. [PMID: 24766983 DOI: 10.1016/j.ahj.2014.01.010] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Accepted: 01/27/2014] [Indexed: 01/15/2023]
Abstract
BACKGROUND Cardiac fibrosis is thought to play a central role in the pathogenesis of atrial fibrillation (AF). Retrospective studies have suggested that circulating fibrosis biomarkers are associated with AF, but prospective studies are limited. METHODS We measured circulating levels of 2 fibrosis biomarkers, procollagen type III, N-terminal propeptide (PIIINP) and transforming growth factor β1 among participants of the CHS, a population-based study of older Americans. We used Cox proportional hazards and competing risks models to examine adjusted risk of incident AF over a median follow-up of 8.8 years. RESULTS Levels of PIIINP were assessed in 2,935 participants, of whom 767 developed AF. Compared with the median PIIINP level (4.45 μg/L), adjusted hazard ratios (95% CIs) were 0.85 (0.72-1.00) at the 10th percentile, 0.93 (0.88-0.99) at the 25th percentile, 1.04 (0.95-1.04) at the 75th percentile, and 1.07 (0.90-1.26) at the 90th. Transforming growth factor β1 levels, assessed in 1,538 participants with 408 cases of incident AF, were not associated with AF risk. CONCLUSION In older adults, PIIINP levels were associated with risk of incident AF in a complex manner, with an association that appeared to be positive up to median levels but with little relationship beyond that. Further studies are required to confirm and possibly delineate the mechanism for this relationship.
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Doruchowska A, Wita K, Bochenek T, Szydło K, Filipecki A, Staroń A, Wróbel W, Krzych Ł, Trusz-Gluza M. Role of left atrial speckle tracking echocardiography in predicting persistent atrial fibrillation electrical cardioversion success and sinus rhythm maintenance at 6 months. Adv Med Sci 2014; 59:120-5. [PMID: 24797987 DOI: 10.1016/j.advms.2013.10.003] [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: 04/13/2013] [Accepted: 10/02/2013] [Indexed: 11/26/2022]
Abstract
PURPOSE We assessed the value of left atrium speckle tracking imaging (STI) indices, and clinical and other echocardiographic parameters in persistent atrial fibrillation (AF) patients to predict the efficacy of electrical cardioversion (EC) and sinus rhythm (SR) maintenance at 6 months. MATERIAL/METHODS Eighty persistent AF patients planned to receive EC, underwent echocardiography including STI. After 24h, patients with successful EC were examined to predict SR maintenance. After 6 months patients with no AF recurrence in electrocardiogram (ECG) underwent 7-day ECG to exclude silent AF. Every AF>1 min was a recurrence. RESULTS SR restored in 61 patients, 19 unsuccessful. Prior use of statins (68.8% vs. 42.1%, p=0.03) was the only factor, determined later by univariate analysis to be a significant EC success predictor (OR=1.09, CL ± 95% 1.001-1.019, p<0.03). Both groups received similar antiarrhythmics and had similar echocardiographic parameters. After 6 months, SR was maintained in 19 patients (31.1%, Group I); AF recurrences were registered in 42 patients (68.8%, Group II). In Group I, only the mitral valve deceleration time (MVDT) 224.18 ± 88.13 vs. 181.6 ± 60.6 in Group II, p=0.04) and the dispersion of time to peak longitudinal strain (dTPLS) (86.0 ± 68.3 vs. 151.8 ± 89.6, p=0.03) differed significantly. The univariate analysis revealed dTPLS as a significant predictor of SR maintenance. CONCLUSION High EC efficacy and frequent AF recurrences were observed. The dispersion of time to the maximal longitudinal strain (LS) of left atrial segments facilitated prediction of SR maintenance. The value of 7-day ECG monitoring for detection of arrhythmia after 6 months was limited.
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Zografos TA, Katritsis DG. Natriuretic Peptides as Predictors of Atrial Fibrillation Recurrences Following Electrical Cardioversion. Arrhythm Electrophysiol Rev 2013; 2:109-14. [PMID: 26835050 DOI: 10.15420/aer.2013.2.2.109] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2013] [Accepted: 11/04/2013] [Indexed: 11/04/2022] Open
Abstract
Electrical cardioversion (ECV) can be effective in restoring sinus rhythm (SR) in the majority of patients with atrial fibrillation (AF). Several factors that predispose to AF recurrences, such as age, AF duration and left atrial size have been used to guide a decision for cardioversion, but increasing evidence suggests that they may be rather poor markers of left atrial structural remodeling that determines the long-term success of a rhythm control strategy. In this context, the use of easily obtainable biomarkers, such as the levels of atrial natriuretic peptide (ANP) and B-type natriuretic peptide (BNP), to predict AF recurrences may be preferable. Since ANP production is associated with the extent of functional atrial myocardium, and both ANP and BNP reflect atrial pressure and mechanical stretching, these peptides are good candidate biomarkers to assess predisposition to AF recurrences. In this review we focus on the pathophysiological mechanisms and the available clinical evidence regarding the prediction of AF recurrences following successful ECV from pre-procedural ANP and BNP levels.
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Affiliation(s)
- Theodoros A Zografos
- Athens Euroclinic, Department of Cardiology, Department of Cardiology, Athens, Greece
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Kornej J, Husser D, Bollmann A, Lip GYH. Rhythm outcomes after catheter ablation of atrial fibrillation. Clinical implication of biomarkers. Hamostaseologie 2013; 34:9-19. [PMID: 24166596 DOI: 10.5482/hamo-13-09-0051] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Accepted: 10/21/2013] [Indexed: 12/13/2022] Open
Abstract
Atrial fibrillation (AF) occurs as the result of numerous complex physiological processes in the atria leading to AF promotion and maintenance. Improved diagnostic techniques have identified various biomarkers which may play an important role in the prediction of AF related outcomes (cardio- and cerebrovascular events, as well as mortality and rhythm outcomes). Biomarkers refer to 'biological markers' and biomarkers in blood, urine as well as imaging marker (eg, dimensions (left atrial diameter and volume), anatomical features (left appendage and pulmonary vein anatomy), and physiological pattern (LAA flow velocity)) may play important role(s) as clinically important indices in relation to outcomes after different therapeutic strategies. However, the main domain in the biomarker field has focused on blood-based biomarkers, which are widely used to predict therapeutic success regarding underlying pathophysiological mechanism, such as inflammation, fibrosis, endothelial damage. This review provides an update of the role of clinically relevant biomarkers in AF, with particular focus on AF rhythm outcomes.
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Affiliation(s)
| | | | | | - G Y H Lip
- Prof. Gregory Y. H. Lip, Centre for Cardiovascular Sciences, University of Birmingham City Hospital, Birmingham, United Kingdom, E-mail:
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Low efficacy of cardioversion of persistent atrial fibrillation with the implantable cardioverter-defibrillator. Neth Heart J 2013; 21:548-53. [PMID: 24092363 PMCID: PMC3833915 DOI: 10.1007/s12471-013-0474-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
AIMS Atrial fibrillation (AF) and heart failure are conditions that often coexist. Consequently, many patients with an implantable cardioverter-defibrillator (ICD) present with AF. We evaluated the effectiveness of internal cardioversion of AF in patients with an ICD. METHODS Retrospectively, we included 27 consecutive ICD patients with persistent AF who underwent internal cardioversion using the ICD. When ICD cardioversion failed, external cardioversion was performed. RESULTS Patients were predominantly male (89 %) with a mean (SD) age of 65 ± 9 years and left ventricular ejection fraction of 36 ± 17 %. Only nine (33 %) patients had successful internal cardioversion after one, two or three shocks. The remaining 18 patients underwent external cardioversion after they failed internal cardioversion, which resulted in sinus rhythm in all. A smaller left atrial volume (99 ± 36 ml vs. 146 ± 44 ml; p = 0.019), a longer right atrial cycle length (227 (186-255) vs. 169 (152-183) ms, p = 0.030), a shorter total AF history (2 (0-17) months vs. 40 (5-75) months, p = 0.025) and dual-coil ICD shock (75 % vs. 26 %, p = 0.093) were associated with successful ICD cardioversion. CONCLUSION Internal cardioversion of AF in ICD patients has a low success rate but may be attempted in those with small atria, a long right atrial fibrillatory cycle length and a short total AF history, especially when a dual-coil ICD is present. Otherwise, it seems reasonable to prefer external over internal cardioversion when it comes to termination of persistent AF.
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Association of inflammatory factors with occurrence and recurrence of atrial fibrillation: A meta-analysis. Int J Cardiol 2013; 169:62-72. [DOI: 10.1016/j.ijcard.2013.08.078] [Citation(s) in RCA: 136] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2013] [Revised: 07/21/2013] [Accepted: 08/28/2013] [Indexed: 11/20/2022]
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Kornej J, Apostolakis S, Bollmann A, Lip GY. The Emerging Role of Biomarkers in Atrial Fibrillation. Can J Cardiol 2013; 29:1181-93. [DOI: 10.1016/j.cjca.2013.04.016] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Revised: 04/18/2013] [Accepted: 04/18/2013] [Indexed: 10/26/2022] Open
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Velagapudi P, Turagam MK, Leal MA, Kocheril AG. Atrial fibrosis: a risk stratifier for atrial fibrillation. Expert Rev Cardiovasc Ther 2013; 11:155-60. [PMID: 23405837 DOI: 10.1586/erc.12.174] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Atrial fibrillation (AF), especially persistent and long-standing persistent AF, may result in electro-anatomical changes in the left atrium, resulting in remodeling and deposition of fibrous tissue. There are emerging data that atrial substrate modification may increase the risk of thromboembolic complications, including stroke. Several studies have reported that atrial fibrosis is due to complex interactions among several cellular and neurohumoral mediators. Late gadolinium enhancement MRI has been reported to allow quantitative assessment of myocardial fibrosis in patients at risk of developing a stroke. Current stroke risk stratification criteria for AF do not utilize atrial fibrosis as an independent risk factor despite its association with AF and stroke. Further research is required in developing adequate risk stratification tools for predicting the stroke risk and catheter ablation outcomes in AF.
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Affiliation(s)
- Poonam Velagapudi
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI 53705, USA
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Rahmutula D, Marcus GM, Wilson EE, Ding CH, Xiao Y, Paquet AC, Barbeau R, Barczak AJ, Erle DJ, Olgin JE. Molecular basis of selective atrial fibrosis due to overexpression of transforming growth factor-β1. Cardiovasc Res 2013; 99:769-79. [PMID: 23612580 DOI: 10.1093/cvr/cvt074] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
AIMS Animal studies show that transforming growth factor-β1 (TGF-β1) is an important mediator of atrial fibrosis and atrial fibrillation (AF). This study investigated the role of TGF-β1 in human AF and the mechanism of atrial-selective fibrosis. METHODS AND RESULTS Atrial specimens from 17 open heart surgery patients and left atrial and ventricular specimens from 17 explanted hearts were collected to assess the relationship between TGF-β1, AF, and differential atrial vs. ventricular TGF-β1 levels. A transgenic mouse model overexpressing active TGF-β1 was used to study the mechanisms underlying the resultant atrial-selective fibrosis. Higher right atrial total TGF-β1 levels (2.58 ± 0.16-fold, P < 0.0001) and active TGF-β1 (3.7 ± 0.7-fold, P = 0.013) were observed in those that developed post-operative AF. Although no ventricular differences were observed, 11 explanted heart failure hearts exhibited higher atrial TGF-β1 levels than 6 non-failing hearts (2.30 ± 0.87 fold higher, P < 0.001). In the transgenic mouse, TGF-β1 receptor-1 kinase blockade resulted in decreased atrial expression of fibrosis-related genes. By RNA microarray analyses in that model, 80 genes in the atria and only 2 genes in the ventricle were differentially expressed. Although these mice atria, but not the ventricles, exhibited increased expression of fibrosis-related genes and phosphorylation of Smad2, there were no differences in TGF-β1 receptor levels or Smads in the atria compared with the ventricles. CONCLUSIONS TGF-β1 mediates selective atrial fibrosis in AF that occurs via TGF-β Receptor 1/2 and the classical Smad pathway. The differential atrial vs. ventricular fibrotic response occurs at the level of TGF-β1 receptor binding or phosphorylation.
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Affiliation(s)
- Dolkun Rahmutula
- Division of Cardiology, University of California, San Francisco, CA 94143, USA
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Smit MD, Maass AH, De Jong AM, Muller Kobold AC, Van Veldhuisen DJ, Van Gelder IC. Role of inflammation in early atrial fibrillation recurrence. Europace 2012; 14:810-7. [PMID: 22237586 DOI: 10.1093/europace/eur402] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
AIMS Outcome of rhythm control in atrial fibrillation (AF) is still poor due to various mechanisms involved in the initiation and perpetuation of AF. Differences in timing of AF recurrence may depend on different types of mechanisms. The aim of this study was to assess the mechanisms involved in early AF recurrence in patients with short-lasting AF. METHODS AND RESULTS Patients with short-lasting persistent AF undergoing rhythm control (n= 100) were included. Markers of mechanisms involved in the initiation and perpetuation of AF were assessed, including clinical factors, echocardiographic parameters, and biomarkers. Primary endpoint was early AF recurrence (recurrence <1 month). Secondary endpoint was progression to permanent AF. Median total AF history was short: 4.2 months. Early AF recurrences occurred in 30 patients (30%) after a median of 6 (inter-quartile range 2-14) days. Baseline log(2) interleukin (IL)-6 [adjusted hazard ratio (HR) 1.3, 95% confidence interval (CI) 1.0-1.7, P= 0.02] and present or previous smoking (adjusted HR 3.6, 95% CI 1.2-10.9, P= 0.03) were independently associated with early AF recurrence, suggesting that inflammation played an important role in early recurrences. Atrial fibrillation became permanent in 29 patients (29%). Baseline transforming growth factor-β1, left ventricular ejection fraction, and early AF recurrence were independently associated with progression to permanent AF. CONCLUSION In patients with short-lasting AF, early AF recurrence seemed to be associated with inflammation as represented by IL-6. Treatment aimed against inflammation may therefore prevent early AF recurrences, which can improve rhythm control outcome.
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Affiliation(s)
- Marcelle D Smit
- Department of Cardiology, Thoraxcenter, University Medical Center Groningen, University of Groningen, PO Box 30.001, 9700 RB Groningen, The Netherlands.
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Sultan A, Steven D, Rostock T, Hoffmann B, Müllerleile K, Servatius H, Drewitz I, Lüker J, Meyer P, Salukhe T, Willems S. Intravenous administration of magnesium and potassium solution lowers energy levels and increases success rates electrically cardioverting atrial fibrillation. J Cardiovasc Electrophysiol 2011; 23:54-9. [PMID: 21815963 DOI: 10.1111/j.1540-8167.2011.02146.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND External biphasic electrical cardioversion (CV) is a standard treatment option for patients suffering from acute symptoms of atrial fibrillation (AF). Nevertheless, CV is not always successful, and thus strategies to increase the success rate are desirable. OBJECTIVE The purpose of this study was to evaluate the effect of intravenously administered K/Mg solution on the biphasic CV energy threshold and success rate to restore sinus rhythm (SR) in patients with AF. METHODS The study consisted of 170 patients with persistent AF. The patients were randomly assigned to undergo biphasic CV either with (n = 84) or without (n = 86) pretreatment with K/Mg solution. An energy step-up protocol of 75, 100, and 150 W (J) was used. RESULTS Biphasic CV of AF was effective in 81 (96.4%) patients in the pretreatment and 74 (86.0%) patients in the control group (P = 0.005). The effective energy level required to achieve SR was significantly lower in the pretreated group (140.8 ± 26.9 J vs 182.5 ± 52.2 J, P = 0.02). No K/Mg-solution-associated side effects such as hypotension or bradycardia were observed. CONCLUSION Administration of K/Mg solution positively influences the success rate of CV in patients with persistent AF. Furthermore, significantly less energy is required to successfully restore SR and therefore K/Mg pretreatment may facilitate SR restoration in patients undergoing CV for AF.
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Affiliation(s)
- Arian Sultan
- Cardiac Electrophysiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany.
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Yeh YH, Kuo CT, Chan TH, Chang GJ, Qi XY, Tsai F, Nattel S, Chen WJ. Transforming growth factor-β and oxidative stress mediate tachycardia-induced cellular remodelling in cultured atrial-derived myocytes. Cardiovasc Res 2011; 91:62-70. [PMID: 21289011 DOI: 10.1093/cvr/cvr041] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIMS Atrial fibrillation (AF), a common tachyarrhythmia in clinical practice, is associated with increased oxidative stress. Structural remodelling in atrial myocytes, including myofibril degradation, is an important characteristic of AF. However, the mechanism underlying AF-induced cellular structural remodelling remains unclear. The aim of this study was to investigate the role of oxidative stress and related factors in tachycardia-induced atrial structural remodelling. METHODS AND RESULTS Cultured atrial-derived myocytes (HL-1 cell line) were subjected to electrical stimulation. Immunofluorescence and immunoblotting were used to evaluate oxidative stress, myofibril degradation, and transforming growth factor-β (TGF-β) expression. Tachypacing in HL-1 cells induced TGF-β expression, pronounced oxidative stress including up-regulation of NADPH oxidases (Nox2/4), and myofibril degradation. Oxidative stress scavenger, NADPH oxidase inhibitors, and small-interfering RNAs for Nox2/4 blocked tachypacing-induced myofibril degradation, suggesting that Nox-derived oxidative stress may lead to tachycardia-induced myofibril degradation. Blockade of TGF-β signalling by neutralizing TGF-β antibodies attenuated myofibril loss in response to tachypacing, implicating autocrine and/or paracrine roles for TGF-β in such effects. Tachypacing also induced the activation of p-Smad3 (an effective mediator of TGF-β) and small-interfering RNAs for Nox2/4 attenuated its activation, supporting a crosstalk between both signalling pathways. Furthermore, TGF-β expression, oxidative stress, and myofibril loss were greater in the atria of patients with AF than those with sinus rhythm. CONCLUSIONS Rapid activation in atrial myocytes promotes myofibril degradation through autocrine/paracrine TGF-β signalling and increased oxidative stress. These findings provide an important mechanistic insight into AF-related structural remodelling.
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Affiliation(s)
- Yung-Hsin Yeh
- First Cardiovascular Division, Chang-Gung Memorial Hospital, Chang-Gung University College of Medicine, Fu-Shin Road no 5, Kwei-Shan, Tao-Yuan 333, Taiwan
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Kim SK, Park JH, Kim JY, Choi JI, Joung B, Lee MH, Kim SS, Kim YH, Pak HN. High Plasma Concentrations of Transforming Growth Factor-.BETA. and Tissue Inhibitor of Metalloproteinase-1 - Potential Non-Invasive Predictors for Electroanatomical Remodeling of Atrium in Patients With Non-Valvular Atrial Fibrillation -. Circ J 2011; 75:557-64. [DOI: 10.1253/circj.cj-10-0758] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Siu CW, Tse HF. Predicting recurrence of atrial fibrillation after electrical cardioversion: gauging atrial damage. Europace 2010; 12:764-5. [DOI: 10.1093/europace/eup436] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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