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Okhotin A, Osipov M, Osipov V, Barchuk A. Atrial fibrillation: real-life experience of a rhythm control with electrical cardioversion in a community hospital. BMC Cardiovasc Disord 2024; 24:213. [PMID: 38632510 PMCID: PMC11022487 DOI: 10.1186/s12872-024-03885-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 04/09/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Atrial fibrillation is the most prevalent sustained cardiac arrhythmia. Electrical cardioversion, a well-established part of the rhythm control strategy, is probably underused in community settings. Here, we describe its use, safety, and effectiveness in a cohort of patients with atrial fibrillation treated in rural settings. METHODS It is a retrospective cohort study. Data on all procedures from January 1, 2016, till December 1, 2022, in Tarusa Hospital, serving mostly a rural population of 15,000 people, were extracted from electronic health records. Data on the procedure's success, age, gender, body mass index, comorbidities, previous procedures, echocardiographic parameters, type and duration of arrhythmia, anticoagulation, antiarrhythmic drugs, transesophageal echocardiography, and settings were available. RESULTS Altogether, 1,272 procedures in 435 patients were performed during the study period. The overall effectiveness of the procedure was 92%. Effectiveness was similar across all prespecified subgroups. Electrical cardioversion was less effective in patients undergoing the procedure for the first time (86%, 95% CI: 82-90) compared to repeated procedures (95%, 95% CI: 93-96), OR 0.39 (95% CI: 0.26-0.59). Complications were encountered in 13 (1.02%) procedures but were not serious. CONCLUSIONS Electrical cardioversion is an immediately effective procedure that can be safely performed in community hospitals, both in inpatient and outpatient settings. Further studies with longer follow-up are needed to investigate the rate of sinus rhythm maintenance in these patients.
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Affiliation(s)
- Artemiy Okhotin
- ITMO University, Kronverkskiy Prospekt, 49, 197101, St. Petersburg, Russia.
- Tarusa Hospital, K. Libknekhta ulitsa, 16, 249100, Tarusa, Russia.
| | - Maxim Osipov
- Tarusa Hospital, K. Libknekhta ulitsa, 16, 249100, Tarusa, Russia
| | - Vasilij Osipov
- Tarusa Hospital, K. Libknekhta ulitsa, 16, 249100, Tarusa, Russia
| | - Anton Barchuk
- ITMO University, Kronverkskiy Prospekt, 49, 197101, St. Petersburg, Russia
- Institute for Interdisciplinary Health Research, European University at St. Petersburg, Shpalernaya Ulitsa 1, 191187, St. Petersburg, Russia
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Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2024; 149:e1-e156. [PMID: 38033089 PMCID: PMC11095842 DOI: 10.1161/cir.0000000000001193] [Citation(s) in RCA: 145] [Impact Index Per Article: 145.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
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Affiliation(s)
| | | | | | | | | | | | - Anita Deswal
- ACC/AHA Joint Committee on Clinical Practice Guidelines liaison
| | | | | | | | | | - Paul L Hess
- ACC/AHA Joint Committee on Performance Measures liaison
| | | | | | | | | | - Kazuhiko Kido
- American College of Clinical Pharmacy representative
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3
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Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2024; 83:109-279. [PMID: 38043043 PMCID: PMC11104284 DOI: 10.1016/j.jacc.2023.08.017] [Citation(s) in RCA: 42] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Patients With Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
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4
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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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5
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Velliou M, Sanidas E, Diakantonis A, Ventoulis I, Parissis J, Polyzogopoulou E. The Optimal Management of Patients with Atrial Fibrillation and Acute Heart Failure in the Emergency Department. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:2113. [PMID: 38138216 PMCID: PMC10744575 DOI: 10.3390/medicina59122113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 11/29/2023] [Accepted: 11/30/2023] [Indexed: 12/24/2023]
Abstract
Atrial fibrillation (AF) and acute heart failure (AHF) are two closely interrelated conditions that frequently coexist in a manifold manner, with AF serving either as the causative factor or as the consequence or even as an innocent bystander. The interplay between these two clinical conditions is complex, given that they share common pathophysiological pathways and they can reciprocally exacerbate each other, thus triggering a vicious cycle that worsens the prognosis and increases the thromboembolic risk. The optimal management of AF in the context of AHF in the emergency department remains a challenge depending on the time onset, as well as the nature and the severity of the associated symptoms. Acute rate control, along with early rhythm control, when indicated, and anticoagulation represent the main pillars of the therapeutic intervention. The purpose of this review is to elucidate the pathophysiological link between AF and AHF and accordingly present a stepwise algorithmic approach for the management of AF in AHF patients in the emergency setting.
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Affiliation(s)
- Maria Velliou
- Emergency Medicine Department, Attikon University Hospital, 12462 Athens, Greece; (M.V.); (A.D.); (J.P.)
| | - Elias Sanidas
- Department of Cardiology, Laiko General Hospital, 11527 Athens, Greece;
| | - Antonis Diakantonis
- Emergency Medicine Department, Attikon University Hospital, 12462 Athens, Greece; (M.V.); (A.D.); (J.P.)
| | - Ioannis Ventoulis
- Department of Occupational Therapy, University of Western Macedonia, 50200 Ptolemaida, Greece;
| | - John Parissis
- Emergency Medicine Department, Attikon University Hospital, 12462 Athens, Greece; (M.V.); (A.D.); (J.P.)
| | - Effie Polyzogopoulou
- Emergency Medicine Department, Attikon University Hospital, 12462 Athens, Greece; (M.V.); (A.D.); (J.P.)
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Reiffel JA, Blomström-Lundqvist C, Boriani G, Goette A, Kowey PR, Merino JL, Piccini JP, Saksena S, Camm AJ. Real-world utilization of the pill-in-the-pocket method for terminating episodes of atrial fibrillation: data from the multinational Antiarrhythmic Interventions for Managing Atrial Fibrillation (AIM-AF) survey. Europace 2023; 25:euad162. [PMID: 37354453 PMCID: PMC10290490 DOI: 10.1093/europace/euad162] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 06/02/2023] [Indexed: 06/26/2023] Open
Abstract
AIMS Atrial fibrillation (AF) is the most common sustained arrhythmia encountered in clinical practice. Episodes may stop spontaneously (paroxysmal AF); may terminate only via intervention (persistent AF); or may persist indefinitely (permanent AF) (see European and American guidelines, referenced below, for more precise definitions). Recently, there has been renewed interest in an approach to terminate AF acutely referred to as 'pill-in-the-pocket' (PITP). The PITP is recognized in both the US and European guidelines as an effective option using an oral antiarrhythmic drug for acute conversion of acute/recent-onset AF. However, how PITP is currently used has not been systematically evaluated. METHODS AND RESULTS The recently published Antiarrhythmic Interventions for Managing Atrial Fibrillation (AIM-AF) survey included questions regarding current PITP usage, stratified by US vs. European countries surveyed, by representative countries within Europe, and by cardiologists vs. electrophysiologists. This manuscript presents the data from this planned sub-study. Our survey revealed that clinicians in both the USA and Europe consider PITP in about a quarter of their patients, mostly for recent-onset AF with minimal or no structural heart disease (guideline appropriate). However, significant deviations exist. See the Graphical abstract for a summary of the data. CONCLUSION Our findings highlight the frequent use of PITP and the need for further physician education about appropriate and optimal use of this strategy.
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Affiliation(s)
- James A Reiffel
- Department of Medicine, Division of Cardiology, Columbia University Vagelos College of Physicians & Surgeons, c/o 202 Birkdale Lane, New York, NY 33458, USA
| | - Carina Blomström-Lundqvist
- Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- Department of Medical Science, Uppsala University, akademiska sjukhuset, ingang 35, 2tr 751 85 Uppsala, Sweden
| | - Giuseppe Boriani
- Division of Cardiology, Department of Biomedical, Metabolic, and Neural Sciences, University of Modena and Reggio Emilia, Via Del Pozzo71, 41124 Moderna, Italy
| | - Andreas Goette
- St. Vincenz Hospital, Am Busdorf 2 33098, Paderborn, Germany
| | - Peter R Kowey
- Sidney Kimmel Medical College at Thomas Jefferson University, 1015 Walnut Street, Philadelphia, PA 19107, USA
- Lankenau Heart Institute, 100 East Lancaster, Ave, Wynnewood, PA 19096, USA
| | - Jose L Merino
- Chief, Arrhythmia & Robotic EP Unit, La Paz University Hospital, and Professor of Cardiology, Universidad Autonoma, IDIPAZ, Madrid, Spain
- La Paz University Hospital, Castellana Avenue, 261, 28046 Madrid, Spain
| | - Jonathan P Piccini
- Duke University, Duke Clinical Research Institute, 300 West Morgan Street, Durham, NC 27701, USA
| | - Sanjeev Saksena
- Rutgers Robert Wood Johnson Medical School, Piscataway, NJ, USA
- Medical Director and Trustee, Electrophysiologiy Research Foundation, 161 Washington Valley Road, Warren, NJ 07059, USA
| | - A John Camm
- St George’s University Hospitals, Blackshaw Road, Tooting London SW17 0QT, UK
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7
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Chyou JY, Barkoudah E, Dukes JW, Goldstein LB, Joglar JA, Lee AM, Lubitz SA, Marill KA, Sneed KB, Streur MM, Wong GC, Gopinathannair R. Atrial Fibrillation Occurring During Acute Hospitalization: A Scientific Statement From the American Heart Association. Circulation 2023; 147:e676-e698. [PMID: 36912134 DOI: 10.1161/cir.0000000000001133] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
Acute atrial fibrillation is defined as atrial fibrillation detected in the setting of acute care or acute illness; atrial fibrillation may be detected or managed for the first time during acute hospitalization for another condition. Atrial fibrillation after cardiothoracic surgery is a distinct type of acute atrial fibrillation. Acute atrial fibrillation is associated with high risk of long-term atrial fibrillation recurrence, warranting clinical attention during acute hospitalization and over long-term follow-up. A framework of substrates and triggers can be useful for evaluating and managing acute atrial fibrillation. Acute management requires a multipronged approach with interdisciplinary care collaboration, tailoring treatments to the patient's underlying substrate and acute condition. Key components of acute management include identification and treatment of triggers, selection and implementation of rate/rhythm control, and management of anticoagulation. Acute rate or rhythm control strategy should be individualized with consideration of the patient's capacity to tolerate rapid rates or atrioventricular dyssynchrony, and the patient's ability to tolerate the risk of the therapeutic strategy. Given the high risks of atrial fibrillation recurrence in patients with acute atrial fibrillation, clinical follow-up and heart rhythm monitoring are warranted. Long-term management is guided by patient substrate, with implications for intensity of heart rhythm monitoring, anticoagulation, and considerations for rhythm management strategies. Overall management of acute atrial fibrillation addresses substrates and triggers. The 3As of acute management are acute triggers, atrial fibrillation rate/rhythm management, and anticoagulation. The 2As and 2Ms of long-term management include monitoring of heart rhythm and modification of lifestyle and risk factors, in addition to considerations for atrial fibrillation rate/rhythm management and anticoagulation. Several gaps in knowledge related to acute atrial fibrillation exist and warrant future research.
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8
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Beaty EH, Fernando RJ, Jacobs ML, Winter GG, Bulla C, Singleton MJ, Patel NJ, Bradford NS, Bhave PD, Royster RL. Comparison of Bolus Dosing of Methohexital and Propofol in Elective Direct Current Cardioversion. J Am Heart Assoc 2022; 11:e026198. [PMID: 36129031 DOI: 10.1161/jaha.122.026198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Methohexital and propofol can both be used as sedation for direct current cardioversion (DCCV). However, there are limited data comparing these medications in this setting. We hypothesized that patients receiving methohexital for elective DCCV would be sedated more quickly, recover from sedation faster, and experience less adverse effects. Methods and Results This was a prospective, blinded randomized controlled trial conducted at a single academic medical center. Eligible participants were randomly assigned to receive either methohexital (0.5 mg/kg) or propofol (0.8 mg/kg) as a bolus for elective DCCV. The times from bolus of the medication to achieving a Ramsay Sedation Scale score of 5 to 6, first shock, eyes opening on command, and when the patient could state their age and name were obtained. The need for additional medication dosing, airway intervention, vital signs, and medication side effects were also recorded. Seventy patients who were randomized to receive methohexital (n=37) or propofol (n=33) were included for analysis. The average doses of methohexital and propofol were 0.51 mg/kg and 0.84 mg/kg, respectively. There were no significant differences between methohexital and propofol in the time from end of injection to loss of conscious (1.4±1.8 versus 1.1±0.5 minutes; P=0.33) or the time to first shock (1.7±1.9 versus 1.4±0.5 minutes; P=0.31). Time intervals were significantly lower for methohexital compared with propofol in the time to eyes opening on command (5.1±2.5 versus 7.8±3.7 minutes; P=0.0005) as well as at the time to the ability to answer simple questions of age and name (6.0±2.6 versus 8.6±4.0 minutes; P=0.001). The methohexital group experienced less hypotension (8.1% versus 42.4%; P<0.001) and less hypoxemia (0.0% versus 15.2%; P=0.005), had lower need for jaw thrust/chin lift (16.2% versus 42.4%; P=0.015), and had less pain on injection compared with propofol using the visual analog scale (7.2±9.7 versus 22.4±28.1; P=0.003). Conclusions In this model of fixed bolus dosing, methohexital was associated with faster recovery, more stable hemodynamics, and less hypoxemia after elective DCCV compared with propofol. It can be considered as a preferred agent for sedation for DCCV. Registration URL: https://www.clinicaltrials.gov/ct; Unique identifier: NCT04187196.
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Affiliation(s)
- Elijah H Beaty
- Section on Cardiovascular Medicine, Department of Internal Medicine Wake Forest School of Medicine Winston-Salem NC
| | - Rohesh J Fernando
- Department of Anesthesiology Wake Forest School of Medicine Winston-Salem NC
| | | | - Gillian G Winter
- Section on Cardiovascular Medicine, Department of Internal Medicine Wake Forest School of Medicine Winston-Salem NC
| | - Catalina Bulla
- Hospital Medicine Cleveland Clinic Florida, Indian River Hospital Vero Beach FL
| | | | - Neel J Patel
- Section on Cardiovascular Medicine, Department of Internal Medicine Wake Forest School of Medicine Winston-Salem NC
| | - Natalie S Bradford
- Section on Cardiovascular Medicine, Department of Internal Medicine Wake Forest School of Medicine Winston-Salem NC
| | - Prashant D Bhave
- Section on Cardiovascular Medicine, Department of Internal Medicine Wake Forest School of Medicine Winston-Salem NC
| | - Roger L Royster
- Department of Anesthesiology Wake Forest School of Medicine Winston-Salem NC
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9
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Brandes A, Crijns HJGM, Rienstra M, Kirchhof P, Grove EL, Pedersen KB, Van Gelder IC. Cardioversion of atrial fibrillation and atrial flutter revisited: current evidence and practical guidance for a common procedure. Europace 2021; 22:1149-1161. [PMID: 32337542 PMCID: PMC7399700 DOI: 10.1093/europace/euaa057] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 02/25/2020] [Indexed: 12/17/2022] Open
Abstract
Cardioversion is widely used in patients with atrial fibrillation (AF) and atrial flutter when a rhythm control strategy is pursued. We sought to summarize the current evidence on this important area of clinical management of patients with AF including electrical and pharmacological cardioversion, peri-procedural anticoagulation and thromboembolic complications, success rate, and risk factors for recurrence to give practical guidance.
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Affiliation(s)
- Axel Brandes
- Department of Cardiology, Odense University Hospital, J.B. Winsløws Vej 4, 5000 Odense C, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Corresponding author. Tel: +45 30 43 36 50. E-mail address:
| | - Harry J G M Crijns
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Michiel Rienstra
- Department of Cardiology, University of Groningen, University Medical Centre, Groningen, The Netherlands
| | - Paulus Kirchhof
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, UHB and Sandwell & West Birmingham Hospitals, NHS Trusts, Birmingham, UK
| | - Erik L Grove
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Kenneth Bruun Pedersen
- Department of Cardiology, Odense University Hospital, J.B. Winsløws Vej 4, 5000 Odense C, Denmark
| | - Isabelle C Van Gelder
- Department of Cardiology, Odense University Hospital, J.B. Winsløws Vej 4, 5000 Odense C, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Department of Cardiology, University of Groningen, University Medical Centre, Groningen, The Netherlands
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10
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Ramirez FD, Sadek MM, Boileau I, Cleland M, Nery PB, Nair GM, Redpath CJ, Green MS, Davis DR, Charron K, Henne J, Zakutney T, Beanlands RSB, Hibbert B, Wells GA, Birnie DH. Evaluation of a novel cardioversion intervention for atrial fibrillation: the Ottawa AF cardioversion protocol. Europace 2020; 21:708-715. [PMID: 30535367 DOI: 10.1093/europace/euy285] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 11/23/2018] [Indexed: 12/15/2022] Open
Abstract
AIMS Electrical cardioversion is commonly performed to restore sinus rhythm in patients with atrial fibrillation (AF), but it is unsuccessful in 10-12% of attempts. We sought to evaluate the effectiveness and safety of a novel cardioversion protocol for this arrhythmia. METHODS AND RESULTS Consecutive elective cardioversion attempts for AF between October 2012 and July 2017 at a tertiary cardiovascular centre before (Phase I) and after (Phase II) implementing the Ottawa AF cardioversion protocol (OAFCP) as an institutional initiative in July 2015 were evaluated. The primary outcome was cardioversion success, defined as ≥2 consecutive sinus beats or atrial-paced beats in patients with implanted cardiac devices. Secondary outcomes were first shock success, sustained success (sinus or atrial-paced rhythm on 12-lead electrocardiogram prior to discharge from hospital), and procedural complications. Cardioversion was successful in 459/500 (91.8%) in Phase I compared with 386/389 (99.2%) in Phase II (P < 0.001). This improvement persisted after adjusting for age, body mass index, amiodarone use, and transthoracic impedance using modified Poisson regression [adjusted relative risk 1.08, 95% confidence interval (CI) 1.05-1.11; P < 0.001] and when analysed as an interrupted time series (change in level +9.5%, 95% CI 6.8-12.1%; P < 0.001). The OAFCP was also associated with greater first shock success (88.4% vs. 79.2%; P < 0.001) and sustained success (91.6% vs 84.7%; P=0.002). No serious complications occurred. CONCLUSION Implementing the OAFCP was associated with a 7.4% absolute increase in cardioversion success and increases in first shock and sustained success without serious procedural complications. Its use could safely improve cardioversion success in patients with AF. CLINICAL TRIAL NUMBER www.clinicaltrials.gov ID: NCT02192957.
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Affiliation(s)
- F Daniel Ramirez
- Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, Ontario, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Mouhannad M Sadek
- Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, Ontario, Canada
| | - Isabelle Boileau
- Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, Ontario, Canada
| | - Mark Cleland
- Biomedical Engineering, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Pablo B Nery
- Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, Ontario, Canada
| | - Girish M Nair
- Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, Ontario, Canada
| | - Calum J Redpath
- Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, Ontario, Canada
| | - Martin S Green
- Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, Ontario, Canada
| | - Darryl R Davis
- Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, Ontario, Canada.,Department of Cellular and Molecular Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Karen Charron
- Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, Ontario, Canada
| | - Joshua Henne
- Biomedical Engineering, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Timothy Zakutney
- Biomedical Engineering, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Rob S B Beanlands
- Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, Ontario, Canada
| | - Benjamin Hibbert
- Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, Ontario, Canada.,Department of Cellular and Molecular Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - George A Wells
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada.,Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - David H Birnie
- Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, Ontario, Canada
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11
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Khatami M, Pope MK, Le Page S, Radic P, Schirripa V, Grundvold I, Atar D. Cardioversion Safety - Are We Doing Enough? Cardiology 2020; 145:740-745. [PMID: 32898849 DOI: 10.1159/000509343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 06/06/2020] [Indexed: 11/19/2022]
Abstract
There is a considerable periprocedural risk of thromboembolic events in atrial fibrillation patients undergoing cardioversion, and treatment with anticoagulants is therefore a hallmark of cardioversion safety. Based on retrospective subgroup analyses and prospective studies, non-vitamin K anticoagulants are at least as efficient as vitamin K-antagonists in preventing thromboembolic complications after cardioversion. The risk of thromboembolic complications after cardioversion very much depends on the comorbidities in a given patient, and especially heart failure, diabetes, and age >75 years carry a markedly increased risk. Cardioversion has been considered safe within a 48-h time window after onset of atrial fibrillation without prior treatment with anticoagulants, but recent studies have set this practice into question based on e.g. erratic debut assessment of atrial fibrillation. Therefore, a simple and more practical approach is here suggested, where early cardioversion is performed only in hemodynamically unstable patients.
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Affiliation(s)
- Mohsen Khatami
- Department of Cardiology, Akershus University Hospital, Lørenskog, Norway,
| | - Marita Knudsen Pope
- Department of Cardiology, Oslo University Hospital, Oslo, Norway.,Department of Internal Medicine, Hamar Hospital, Innlandet Hospital Trust, Hamar, Norway
| | - Sophie Le Page
- Department of Cardiology, Angers University Hospital, Angers, France
| | - Petra Radic
- Department of Cardiology, University Hospital Sisters of Charity, Zagreb, Croatia
| | | | - Irene Grundvold
- Department of Cardiology, Akershus University Hospital, Lørenskog, Norway
| | - Dan Atar
- Department of Cardiology, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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12
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Sless RT, Allen G, Hayward NE, Fahy G. Characterization of troponin I levels post synchronized direct current cardioversion of atrial arrhythmias in patients with and without cardiomyopathy. J Interv Card Electrophysiol 2020; 60:329-335. [PMID: 32621213 DOI: 10.1007/s10840-020-00814-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 06/29/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Cardiac-specific markers of myocardial injury, such as troponin I (TnI), are often elevated following procedures that stimulate the myocardium. This study aimed to determine the effect of synchronized direct current (DC) cardioversion of atrial arrhythmias on myocardial injury 6-h post-procedure, as measured by cardiac TnI in patients with and without cardiomyopathy. METHODS Seventy-three individuals (59 M:14 F) participated in this study. Inclusion criteria were subjects 18 and older undergoing DC cardioversion for an atrial arrhythmia, including elective and non-elective admissions. Exclusion criteria included MI or CABG within the past month, cardioversion for a ventricular arrhythmia, or recent shock by implantable internal cardioverter defibrillator. Patients underwent standard DC cardioversion procedure with blood work (TnI and CRP) prior to and 6-h post-cardioversion. Primary outcome was change in TnI. Secondary outcomes included changes in CRP, correlation of TnI with cumulative energy and LVM, and a sub-group analysis in patients with cardiomyopathy. RESULTS There was no significant change in TnI following cardioversion (20.4 ± 7.9 vs. 17.5 ± 6.5 ng/L, F(1,72) = 2.651, p = 0.108). When stratified by cardiomyopathy status, there was a statistically significant reduction in TnI following cardioversion in the non-cardiomyopathy group (6.7 ± 3.7 ng/L vs. 6.2 ± 3.2 ng/L, F(1,58) = 6.481, p = 0.014) and a clinically significant reduction in the cardiomyopathy group (74.4 ± 136.7 ng/L vs. 54.6 ± 104.3 ng/L, F(1,13) = 3.676, p = 0.07). There was no significant relationship between change in TnI and cumulative energy or LVM (r = 0.137, p = 0.306 and r = 0.125, p = 0.412 respectively). CONCLUSIONS Synchronized DC cardioversion of an atrial arrhythmia did not cause myocardial injury 6-h post-cardioversion. Sub-group analysis suggests that cardioversion of patients with cardiomyopathy may result in normalization of TnI levels.
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Affiliation(s)
- Ryan T Sless
- School of Medicine, University College Cork, Cork, Ireland.
| | - Gerry Allen
- Department of Cardiology, Cork University Hospital, Cork, Ireland
| | | | - Gerry Fahy
- Department of Cardiology, Cork University Hospital, Cork, Ireland
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13
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Ramirez FD, Sadek MM, Birnie DH. Improving first shock success in patients with atrial fibrillation undergoing electrical cardioversion: Authors’ reply. Europace 2019; 21:833-834. [DOI: 10.1093/europace/euz048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- F Daniel Ramirez
- Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, H-1285A, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Mouhannad M Sadek
- Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, H-1285A, Ottawa, Ontario, Canada
| | - David H Birnie
- Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, H-1285A, Ottawa, Ontario, Canada
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14
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Maciag A, Farkowski MM, Chwyczko T, Beckowski M, Syska P, Kowalik I, Pytkowski M, Wozniak J, Dabrowski R, Szwed H. Efficacy and safety of antazoline in the rapid cardioversion of paroxysmal atrial fibrillation (the AnPAF Study). Europace 2018; 19:1637-1642. [PMID: 28339554 DOI: 10.1093/europace/euw384] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2016] [Accepted: 11/02/2016] [Indexed: 11/14/2022] Open
Abstract
Aims The aim of the study was to assess the clinical efficacy of antazoline, a first-generation anti-histaminic agent, in the rapid conversion of paroxysmal non-valvular atrial fibrillation (AF) to sinus rhythm in patients without heart failure. Methods and results This study was a single center, randomized, double blind, placebo-controlled, superiority clinical trial. We enrolled patients with an AF episode lasting less than 43 h, in stable cardiopulmonary condition. Subjects who fulfilled the selection criteria were randomly assigned to receive intravenously either a placebo or up to 250 mg of antazoline. The primary end point was the conversion of AF to sinus rhythm confirmed in electrocardiogram (ECG). We enrolled 74 patients: 36 (48.6%) in the antazoline group and 38 (51.4%) in the control group. The mean age was 68 ± 12 years (range 31-90 years), 39 (53.3%) patients were male. The successful conversion of AF to sinus rhythm during the observation period was achieved in 26 (72.2%) patients treated with antazoline and 4 (10.5%) in the control group: RR 6.86 (95% CI: 2.66-17.72, P < 0.0001). Median time to conversion was 16.0 min in antazoline and 72.5 min in the control group (P = 0.0246). There were no cases of atrial tachycardia/flutter in the antazoline group. Conclusion Intravenous antazoline was effective and safe in the rapid conversion of non-valvular paroxysmal atrial fibrillation to sinus rhythm in patients without heart failure. Clinical Trial Registration number: NCT01527279.
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Affiliation(s)
- Aleksander Maciag
- The 2nd Department of Coronary Artery Disease, Institute of Cardiology, Spartanska 1, 02-637 Warsaw, Poland
| | - Michal M Farkowski
- The 2nd Department of Coronary Artery Disease, Institute of Cardiology, Spartanska 1, 02-637 Warsaw, Poland
| | - Tomasz Chwyczko
- The 2nd Department of Coronary Artery Disease, Institute of Cardiology, Spartanska 1, 02-637 Warsaw, Poland
| | - Maciej Beckowski
- The 2nd Department of Coronary Artery Disease, Institute of Cardiology, Spartanska 1, 02-637 Warsaw, Poland
| | - Pawel Syska
- The 2nd Department of Coronary Artery Disease, Institute of Cardiology, Spartanska 1, 02-637 Warsaw, Poland
| | - Ilona Kowalik
- The 2nd Department of Coronary Artery Disease, Institute of Cardiology, Spartanska 1, 02-637 Warsaw, Poland
| | - Mariusz Pytkowski
- The 2nd Department of Coronary Artery Disease, Institute of Cardiology, Spartanska 1, 02-637 Warsaw, Poland
| | - Jacek Wozniak
- The 2nd Department of Coronary Artery Disease, Institute of Cardiology, Spartanska 1, 02-637 Warsaw, Poland
| | - Rafal Dabrowski
- The 2nd Department of Coronary Artery Disease, Institute of Cardiology, Spartanska 1, 02-637 Warsaw, Poland
| | - Hanna Szwed
- The 2nd Department of Coronary Artery Disease, Institute of Cardiology, Spartanska 1, 02-637 Warsaw, Poland
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15
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Sadek MM, Chaugai V, Cleland MJ, Zakutney TJ, Birnie DH, Ramirez FD. Association between transthoracic impedance and electrical cardioversion success with biphasic defibrillators: An analysis of 1055 shocks for atrial fibrillation and flutter. Clin Cardiol 2018. [PMID: 29532491 DOI: 10.1002/clc.22947] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The relevance of transthoracic impedance (TTI) to electrical cardioversion (ECV) success for atrial tachyarrhythmias when using biphasic waveform defibrillators is unknown. HYPOTHESIS TTI is predictive of ECV success with contemporary defibrillators. METHODS De-identified data stored in biphasic defibrillator memory cards from ECV attempts for atrial fibrillation (AF) or atrial flutter (AFL) over a 2-year period at our center were evaluated. ECV success, defined as arrhythmia termination and ≥ 1 sinus beat, was adjudicated by 2 blinded cardiac electrophysiologists. The association between TTI and ECV success was assessed via Cochrane-Armitage trend and Spearman rank correlation tests, as well as simple and multivariable logistic regression. The influence of TTI on the number of shocks and on cumulative energy delivered per patient was also examined. RESULTS 703 patients (593 with AF, 110 with AFL) receiving 1055 shocks were included. Last shock success was achieved in 88.0% and 98.2% of patients with AF and AFL, respectively. In patients with AF, TTI was positively associated with last shock failure (Ptrend =0.019), the need for multiple shocks (Ptrend <0.001), and cumulative energy delivered (ρ = 0.348; P < 0.001). After adjusting for first shock energy, 10-Ω increments in TTI were associated with odds ratios of 1.36 (95% CI: 1.24-1.49) and 1.22 (95% CI: 1.09-1.37) for first and last shock failure, respectively (P < 0.001 for both). CONCLUSIONS Although contemporary defibrillators are designed to compensate for TTI, this variable continues to be associated with ECV failure in patients with AF. Strategies to lower TTI during ECV for AF may improve procedural success.
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Affiliation(s)
- Mouhannad M Sadek
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Varsha Chaugai
- Biomedical Engineering, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Mark J Cleland
- Biomedical Engineering, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Timothy J Zakutney
- Biomedical Engineering, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - David H Birnie
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - F Daniel Ramirez
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
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16
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van Vugt SPG, Brouwer MA. Periprocedural anticoagulation in atrial fibrillation: Update on electrical cardioversion and ablation. Neth Heart J 2018; 26:352-360. [PMID: 29744816 PMCID: PMC5968006 DOI: 10.1007/s12471-018-1119-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
In this manuscript, we discuss the most important changes in the field of anticoagulant treatment in patients with atrial fibrillation in the setting of electrical cardioversion or catheter ablation. Moreover, we provide practical guidance as well as information on daily practice.
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Affiliation(s)
- S. P. G. van Vugt
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - M. A. Brouwer
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
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Abstract
INTRODUCTION Procedural sedation is of paramount importance for a plethora of electrophysiological procedures. From electrical cardioversion to electrophysiology studies, device implantations, and catheter ablations, intraprocedural sedation and anesthesia have a pivotal role in allowing procedural success while ensuring patient safety and avoiding discomfort. Areas covered: The present review will discuss the current state-of-the-art in sedation and anesthesia during electrical cardioversion, cardiac implantable electronic device implantation, catheter ablation and electrophysiology studies. Specific information will be provided for each procedure in order to reach the core of this important clinical issue, and specific protocols will be compared. The main pro-arrhythmic and anti-arrhythmic effects of the most commonly used sedatives will also be discussed. Expert commentary: According to much recent evidence, the cardiologist can be the only person responsible for sedation administration in many settings, highlighting few safety issues associated with the absence of a dedicated anesthesiologist thus a concomitant reduction in costs. However, many concerns have been raised in allowing non-anesthesiologists to manage sedatives, as adverse events, while rare, could have catastrophic consequences. The present paper will highlight when a cardiologist-directed sedation is considered safe, how it should be performed, and the pros and cons related to this strategy.
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Affiliation(s)
- Federico Guerra
- a Cardiology and Arrhythmology Clinic , Marche Polytechnic University, University Hospital "Ospedali Riuniti" , Ancona , Italy
| | | | - Alessandro Capucci
- a Cardiology and Arrhythmology Clinic , Marche Polytechnic University, University Hospital "Ospedali Riuniti" , Ancona , Italy
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19
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Pokorney SD, Kim S, Thomas L, Fonarow GC, Kowey PR, Gersh BJ, Mahaffey KW, Peterson ED, Piccini JP. Cardioversion and subsequent quality of life and natural history of atrial fibrillation. Am Heart J 2017; 185:59-66. [PMID: 28267476 DOI: 10.1016/j.ahj.2016.10.018] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Accepted: 10/25/2016] [Indexed: 11/27/2022]
Abstract
Cardioversion is a class I procedure for patients with symptomatic atrial fibrillation (AF) pursuing rhythm control. There are few contemporary reports on quality of life and outcomes after cardioversion. METHODS Using the nationwide prospective ORBIT-AF registry, cardioversion patients were propensity matched 3:1 to noncardioverted patients and Cox proportional hazards modeling evaluated hospitalization at 1 year in those with and without cardioversion. Cardiovascular outcomes, AF progression, and quality of life were evaluated for the matched cohorts with and without cardioversion. RESULTS Among 9,642 patients, 817 patients (8%) underwent 906 cardioversions during a median follow-up of 12 (interquartile range 6-18) months. Among matched cardioverted and noncardioverted patients, 1-year cardiovascular hospitalization rates were 43% vs 21% (adjusted hazard ratio 2.2, 95% CI 1.8-2.8, P<.001), and sinus rhythm at both first and second follow-ups was 36% vs 27% (P=.042), respectively. Findings were similar among first-time cardioversion patients. Matched cardioversion patients did not exhibit greater symptom improvement (34% vs 42%) or less symptomatic progression (15% vs 4%) by European Heart Rhythm Association scores. Cardioversion was associated with AF progression with an odds ratio of 1.6 (95% CI 1.2-2.2, P=.001) after cardioversion and 2.7 (P<.001) after first cardioversion vs matched noncardioversion patients. After cardioversion, only 18% of patients not previously on an antiarrhythmic started one, less than 5% underwent ablation, and 22% stopped their antiarrhythmic. CONCLUSIONS Cardioversion was not associated with improved AF-related quality of life or less progression. Many patients who undergo cardioversion do not receive adjunctive rhythm control therapies. These findings may help to better inform therapeutic decision making.
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Goette A, Heidbuchel H. Practical Implementation of Anticoagulation Strategy for Patients Undergoing Cardioversion of Atrial Fibrillation. Arrhythm Electrophysiol Rev 2017; 6:50-54. [PMID: 28835835 DOI: 10.15420/aer.2017:3:2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Anticoagulation is routinely prescribed to patients with persistent AF before cardioversion to reduce the risk of thromboembolic events. As direct oral anticoagulants (DOACs) have a rapid onset of action, a consistent anticoagulant effect, if taken correctly, and do not need monitoring or dose adjustments, there is considerable interest in their use for patients with AF undergoing cardioversion. Post-hoc analyses show that DOACs are safe to use prior to and following cardioversion. In addition, two randomised controlled trials, X-VeRT and ENSURE-AF, have demonstrated the efficacy and safety of the DOACs rivaroxaban and edoxaban, respectively, in this setting. The use of DOACs allows cardioversions to be performed promptly and reduces the number of cancelled procedures compared with the use of warfarin.
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Affiliation(s)
| | - Hein Heidbuchel
- Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
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21
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Chiang CE, Wu TJ, Ueng KC, Chao TF, Chang KC, Wang CC, Lin YJ, Yin WH, Kuo JY, Lin WS, Tsai CT, Liu YB, Lee KT, Lin LJ, Lin LY, Wang KL, Chen YJ, Chen MC, Cheng CC, Wen MS, Chen WJ, Chen JH, Lai WT, Chiou CW, Lin JL, Yeh SJ, Chen SA. 2016 Guidelines of the Taiwan Heart Rhythm Society and the Taiwan Society of Cardiology for the management of atrial fibrillation. J Formos Med Assoc 2016; 115:893-952. [PMID: 27890386 DOI: 10.1016/j.jfma.2016.10.005] [Citation(s) in RCA: 92] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Revised: 08/24/2016] [Accepted: 10/10/2016] [Indexed: 12/21/2022] Open
Abstract
Atrial fibrillation (AF) is the most common sustained arrhythmia. Both the incidence and prevalence of AF are increasing, and the burden of AF is becoming huge. Many innovative advances have emerged in the past decade for the diagnosis and management of AF, including a new scoring system for the prediction of stroke and bleeding events, the introduction of non-vitamin K antagonist oral anticoagulants and their special benefits in Asians, new rhythm- and rate-control concepts, optimal endpoints of rate control, upstream therapy, life-style modification to prevent AF recurrence, and new ablation techniques. The Taiwan Heart Rhythm Society and the Taiwan Society of Cardiology aimed to update the information and have appointed a jointed writing committee for new AF guidelines. The writing committee members comprehensively reviewed and summarized the literature, and completed the 2016 Guidelines of the Taiwan Heart Rhythm Society and the Taiwan Society of Cardiology for the Management of Atrial Fibrillation. This guideline presents the details of the updated recommendations, along with their background and rationale, focusing on data unique for Asians. The guidelines are not mandatory, and members of the writing committee fully realize that treatment of AF should be individualized. The physician's decision remains most important in AF management.
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Affiliation(s)
- Chern-En Chiang
- General Clinical Research Center, Division of Cardiology, Taipei Veterans General Hospital and National Yang-Ming University, Taipei, Taiwan.
| | - Tsu-Juey Wu
- Cardiovascular Center, Department of Internal Medicine, Taichung Veterans General Hospital and National Yang-Ming University, Taipei, Taiwan
| | - Kwo-Chang Ueng
- Department of Internal Medicine, School of Medicine, Chung-Shan Medical University (Hospital), Taichung, Taiwan
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Kuan-Cheng Chang
- Division of Cardiology, Department of Medicine, China Medical University Hospital, Taichung, Taiwan; Graduate Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan
| | - Chun-Chieh Wang
- Department of Internal Medicine, Section of Cardiology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yenn-Jiang Lin
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Wei-Hsian Yin
- Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan; Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Jen-Yuan Kuo
- Division of Cardiology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan; Department of Medicine, Mackay Medical College, Taipei, Taiwan
| | - Wei-Shiang Lin
- Division of Cardiology, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan
| | - Chia-Ti Tsai
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan
| | - Yen-Bin Liu
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan; Division of Cardiology, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Kun-Tai Lee
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Department of Internal Medicine, Faculty of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Li-Jen Lin
- Department of Internal Medicine, National Cheng Kung University College of Medicine and Hospital, Tainan, Taiwan
| | - Lian-Yu Lin
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan
| | - Kang-Ling Wang
- General Clinical Research Center, Division of Cardiology, Taipei Veterans General Hospital and National Yang-Ming University, Taipei, Taiwan
| | - Yi-Jen Chen
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Division of Cardiovascular Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Mien-Cheng Chen
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | | | - Ming-Shien Wen
- Department of Internal Medicine, Section of Cardiology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Wen-Jone Chen
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan; Division of Cardiology, Poh-Ai Hospital, Yilan, Taiwan
| | - Jyh-Hong Chen
- Department of Internal Medicine, National Cheng Kung University College of Medicine and Hospital, Tainan, Taiwan; College of Medicine, China Medical University, Taichung, Taiwan
| | - Wen-Ter Lai
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Department of Internal Medicine, Faculty of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chuen-Wang Chiou
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Jiunn-Lee Lin
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan
| | - San-Jou Yeh
- Department of Internal Medicine, Section of Cardiology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan.
| | - Shih-Ann Chen
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan.
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Guerra F, Stronati G, Mariotti G, Capucci A. Safety and tolerability of a cardiologist-only approach to sedation for electrical cardioversion in the Emergency Department: The INSTEAD pilot trial. Int J Cardiol 2016; 223:766-767. [DOI: 10.1016/j.ijcard.2016.08.291] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Accepted: 08/18/2016] [Indexed: 10/21/2022]
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RAMIREZ FDANIEL, FISET SANDRAL, CLELAND MARKJ, ZAKUTNEY TIMOTHYJ, NERY PABLOB, NAIR GIRISHM, REDPATH CALUMJ, SADEK MOUHANNADM, BIRNIE DAVIDH. Effect of Applying Force to Self-Adhesive Electrodes on Transthoracic Impedance: Implications for Electrical Cardioversion. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2016; 39:1141-1147. [DOI: 10.1111/pace.12937] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Revised: 07/20/2016] [Accepted: 08/18/2016] [Indexed: 11/28/2022]
Affiliation(s)
- F. DANIEL RAMIREZ
- Arrhythmia Service; University of Ottawa Heart Institute; Ottawa Ontario Canada
| | - SANDRA L. FISET
- Biomedical Engineering; University of Ottawa Heart Institute; Ottawa Ontario Canada
| | - MARK J. CLELAND
- Biomedical Engineering; University of Ottawa Heart Institute; Ottawa Ontario Canada
| | - TIMOTHY J. ZAKUTNEY
- Biomedical Engineering; University of Ottawa Heart Institute; Ottawa Ontario Canada
| | - PABLO B. NERY
- Arrhythmia Service; University of Ottawa Heart Institute; Ottawa Ontario Canada
| | - GIRISH M. NAIR
- Arrhythmia Service; University of Ottawa Heart Institute; Ottawa Ontario Canada
| | - CALUM J. REDPATH
- Arrhythmia Service; University of Ottawa Heart Institute; Ottawa Ontario Canada
| | - MOUHANNAD M. SADEK
- Arrhythmia Service; University of Ottawa Heart Institute; Ottawa Ontario Canada
| | - DAVID H. BIRNIE
- Arrhythmia Service; University of Ottawa Heart Institute; Ottawa Ontario Canada
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Klein HH, Trappe HJ. Cardioversion in Non-Valvular Atrial Fibrillation. DEUTSCHES ARZTEBLATT INTERNATIONAL 2015; 112:856-62. [PMID: 26763380 DOI: 10.3238/arztebl.2015.0856] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Revised: 06/01/2015] [Accepted: 06/01/2015] [Indexed: 01/18/2023]
Abstract
BACKGROUND Atrial fibrillation is the most common type of cardiac arrhythmia and is associated with elevated rates of stroke, heart failure, hospital admission, and death. Its prevalence in the overall population is 1.5% to 2%. To convert atrial fibrillation to sinus rhythm, cardioversion is needed. METHODS This review is based on pertinent articles published from 2004 to December 2014 that were retrieved by a selective PubMed search employing the terms "atrial fibrillation" and "cardioversion." RESULTS In electrical cardioversion, a defibrillator is used to pass a pulse of current between two electrodes. In pharmacological cardioversion, antiarrhythmic drugs are given intravenously or orally. Electrical cardioversion results in sinus rhythm in more than 85% of patients; pharmacological cardioversion results in sinus rhythm in about 70% of patients with recent-onset atrial fibrillation. As a rule, cardioversion should be carried out only under effective therapeutic anticoagulation with heparin, a vitamin K antagonist, or a new oral anticoagulant drug. If atrial fibrillation has been present for more than 48 hours, cardioversion must be preceded by transesophageal echocardiography to rule out blood clot in the left atrium, or else the patient is pretreated with an anticoagulant drug for at least 3 weeks. As cardioversion can transiently impair left atrial pumping function, anticoagulation is usually maintained for 4 weeks after the procedure. The decision whether to continue anticoagulation beyond this point is based on the risk of stroke, as assessed with the CHA2DS2-VASc score. CONCLUSION The main risks of cardioversion-thrombo--embolism and clinically significant hemorrhage--occur in 1% of cases or less (in the first 30 days after treatment) if the procedure is carried out as recommended in therapeutic guidelines. Serious complications still occur, but they are rare.
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Bongiorni MG, Chen J, Dagres N, Estner H, Hernandez-Madrid A, Hocini M, Larsen TB, Pison L, Potpara T, Proclemer A, Sciaraffia E, Todd D, Blomstrom-Lundqvist C. EHRA research network surveys: 6 years of EP wires activity. Europace 2015; 17:1733-8. [PMID: 26589904 DOI: 10.1093/europace/euv371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Clinical practice should follow guidelines and recommendations mainly based on the results of controlled trials, which are often conducted in selected populations and special conditions, whereas clinical practice may be influenced by factors different from controlled scientific studies. Hence, the real-world setting is better assessed by the observational registries enrolling patients for longer periods of time. However, this may be difficult, expensive, and time-consuming. In 2009, the Scientific Initiatives Committee of the European Heart Rhythm Association (EHRA) has instigated a series of surveys covering the controversial issues in clinical electrophysiology (EP). With this in mind, an EHRA EP research network has been created, which included EP centres in Europe among which the surveys on 'hot topic' were circulated. This review summarizes the overall experience conducting EP wires over the past 6 years, categorizing and assessing the topics regarding clinical EP, and evaluating the acceptance and feedback from the responding centres, in order to improve participation in the surveys and better address the research needs and aspirations of the European EP community.
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Affiliation(s)
| | - Jian Chen
- Department of Clinical Science, Haukeland University Hospital, University of Bergen, Bergen, Norway
| | - Nikolaos Dagres
- Second Cardiology Department, Attikon University Hospital, University of Athens, Athens, Greece
| | - Heidi Estner
- Department of Cardiology Medizinische Klinik und Poliklinik I, LMU Klinikum der Universität München, München, Germany
| | - Antonio Hernandez-Madrid
- Cardiology Department, Ramon y Cajal Hospital, Alcalá University, CarreteraColmenar Viejo, Madrid 28034, Spain
| | - Meleze Hocini
- HôpitalCardiologique du Haut Lévêque Université Victor Segalen Bordeaux II, Bordeaux, Pessac 33604, France
| | - Torben Bjerregaard Larsen
- Department of Cardiology, Cardiovascular Research Centre, Aalborg University Hospital, Aalborg, Denmark
| | - Laurent Pison
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Tatjana Potpara
- School of Medicine, University of Belgrade, Serbia and Cardiology Clinic, Clinical Center of Serbia, Belgrade, Serbia
| | - Alessandro Proclemer
- Division of Cardiology, University Hospital S. Maria della Misericordia, IRCAB Foundation Udine, Udine, Italy
| | - Elena Sciaraffia
- Department of Cardiology, Institution of Medical Science, Uppsala University, Uppsala 75185, Sweden
| | - Derick Todd
- Institute of Cardiovascular Medicine and Science Liverpool Heart & Chest Hospital, UK
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Stoschitzky K, Stoschitzky G, Lercher P, Brussee H, Lamprecht G, Lindner W. Propafenone shows class Ic and class II antiarrhythmic effects. Europace 2015; 18:568-71. [DOI: 10.1093/europace/euv195] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Accepted: 05/08/2015] [Indexed: 11/14/2022] Open
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Abstract
Atrial fibrillation is the most common form of cardiac arrhythmia, occurring in 1-2 % of the population and due to an increased life expectancy the prevalence will increase further. Pharmacological treatment of atrial fibrillation is an important component of basic initial therapeutic options for patients with atrial fibrillation. Independent of an individually adjusted prevention of thromboembolism, rate and rhythm management can also be carried out. While rate control mainly applies to all patients, rhythm control is only indicated in patients who remain clinically symptomatic despite sufficient rate control. Profound knowledge about antiarrhythmic drugs including specific interactions is necessary due to the variable individual effects and sometimes severe side effects.
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Guerra F, Pavoni I, Romandini A, Baldetti L, Matassini MV, Brambatti M, Luzi M, Pupita G, Capucci A. Feasibility of a cardiologist-only approach to sedation for electrical cardioversion of atrial fibrillation: A randomized, open-blinded, prospective study. Int J Cardiol 2014; 176:930-5. [DOI: 10.1016/j.ijcard.2014.08.050] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Revised: 08/05/2014] [Accepted: 08/09/2014] [Indexed: 11/28/2022]
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Hansen ML, Jepsen RMH, Olesen JB, Ruwald MH, Karasoy D, Gislason GH, Hansen J, Køber L, Husted S, Torp-Pedersen C. Thromboembolic risk in 16 274 atrial fibrillation patients undergoing direct current cardioversion with and without oral anticoagulant therapy. ACTA ACUST UNITED AC 2014; 17:18-23. [DOI: 10.1093/europace/euu189] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Załęska-Kocięcka M, Stępińska J. Letter to the editor concerning the rationale and design of the X-VERT trial by Ezekowitz et al. Am Heart J 2014; 168:e1. [PMID: 24952870 DOI: 10.1016/j.ahj.2014.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Affiliation(s)
| | - Jannina Stępińska
- Cardica Intensive Care Unit, Institute of Cardiology, Warsaw, Poland
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Brown RA, Lau YC, Lip GYH. Vernakalant hydrochloride to treat atrial fibrillation. Expert Opin Pharmacother 2014; 15:865-72. [DOI: 10.1517/14656566.2014.898751] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Koskinas KC, Fragakis N, Katritsis D, Skeberis V, Vassilikos V. Ranolazine enhances the efficacy of amiodarone for conversion of recent-onset atrial fibrillation. Europace 2014; 16:973-9. [DOI: 10.1093/europace/eut407] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
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Savelieva I, Graydon R, Camm AJ. Pharmacological cardioversion of atrial fibrillation with vernakalant: evidence in support of the ESC Guidelines. Europace 2013; 16:162-73. [DOI: 10.1093/europace/eut274] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Rosenqvist M. Acute direct current cardioversion: how 'dangerous' is it? Europace 2013; 15:1387-8. [DOI: 10.1093/europace/eut221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Abstract
DNA methylation is a stable but not irreversible epigenetic signal that silences gene expression. It has a variety of important functions in mammals, including control of gene expression, cellular differentiation and development, preservation of chromosomal integrity, parental imprinting and X-chromosome inactivation. In addition, it has been implicated in brain function and the development of the immune system. Somatic alterations in genomic methylation patterns contribute to the etiology of human cancers and ageing. It is tightly interwoven with the modification of histone tails and other epigenetic signals. Here we review our current understanding of the molecular enzymology of the mammalian DNA methyltransferases Dnmt1, Dnmt3a, Dnmt3b and Dnmt2 and the roles of the enzymes in the above-mentioned biological processes.
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Affiliation(s)
- A Hermann
- Institut für Biochemie, FB 8, Justus-Liebig-Universität, Heinrich-Buff-Ring 58, 35392, Giessen, Germany
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