Controlling persistent atrial fibrillation

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

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.

WITHDRAWN: Electrical cardioversion for atrial fibrillation and flutter

BACKGROUND

Atrial fibrillation increases stroke risk and adversely affects cardiovascular haemodynamics. Electrical cardioversion may, by restoring sinus rhythm, improve cardiovascular haemodynamics, reduce the risk of stroke, and obviate the need for long-term anticoagulation.

OBJECTIVES

To assess the effects of electrical cardioversion of atrial fibrillation or flutter on the risk of thromboembolic events, strokes and mortality (primary outcomes), the rate of cognitive decline, quality of life, the use of anticoagulants and the risk of re-hospitalisation (secondary outcomes) in adults (>18 years).

SEARCH METHODS

We searched the Cochrane CENTRAL Register of Controlled Trials (1967 to May 2004), MEDLINE (1966 to May 2004), Embase (1980 to May 2004), CINAHL (1982 to May 2004), proceedings of the American College of Cardiology (published in Journal of the American College of Cardiology 1983 to 2003), www.trialscentral.org, www.controlled-trials.com and reference lists of articles. We hand-searched the indexes of the Proceedings of the British Cardiac Society published in British Heart Journal (1980 to 1995) and in Heart (1995 to 2002); proceedings of the European Congress of Cardiology and meetings of the Joint Working Groups of the European Society of Cardiology (published in European Heart Journal 1983-2003); scientific sessions of the American Heart Association (published in Circulation 1990-2003). Personal contact was made with experts.

SELECTION CRITERIA

Randomised controlled trial or controlled clinical trials of electrical cardioversion plus 'usual care' versus 'usual care' only, where 'usual care' included any combination of anticoagulants, antiplatelet drugs and drugs for 'rate control'. We excluded trials which used pharmacological cardioversion as the first intervention, and trials of new onset atrial fibrillation after cardiac surgery. There were no language restrictions.

DATA COLLECTION AND ANALYSIS

For dichotomous data, odds ratios were calculated; and for continuous data, the weighted mean difference was calculated.

MAIN RESULTS

We found three completed trials of electrical cardioversion (rhythm control) versus rate control, recruiting a total of 927 participants (Hot Cafe; RACE; STAF) and one ongoing trial (J-RHYTHM). There was no difference in mortality between the two strategies (OR 0.83; CI 0.48 to 1.43). There was a trend towards more strokes in the rhythm control group (OR 1.9; 95% CI 0.99 to 3.64). At follow up, three domains of quality of life (physical functioning, physical role function and vitality) were significantly better in the rhythm control group (RACE 2002; STAF 2003).

AUTHORS' CONCLUSIONS

Electrical cardioversion (rhythm control) led to a non-significant increase in stroke risk but improved three domains of quality of life.

Electrical cardioversion for atrial fibrillation and flutter

BACKGROUND

Atrial fibrillation increases stroke risk and adversely affects cardiovascular haemodynamics. Electrical cardioversion may, by restoring sinus rhythm, improve cardiovascular haemodynamics, reduce the risk of stroke, and obviate the need for long-term anticoagulation.

OBJECTIVES

To assess the effects of electrical cardioversion of atrial fibrillation or flutter on the risk of thromboembolic events, strokes and mortality (primary outcomes), the rate of cognitive decline, quality of life, the use of anticoagulants and the risk of re-hospitalisation (secondary outcomes) in adults (>18 years).

SEARCH STRATEGY

We searched the Cochrane CENTRAL Register of Controlled Trials (1967 to May 2004), MEDLINE (1966 to May 2004), Embase (1980 to May 2004), CINAHL (1982 to May 2004), proceedings of the American College of Cardiology (published in Journal of the American College of Cardiology 1983 to 2003), www.trialscentral.org, www.controlled-trials.com and reference lists of articles. We hand-searched the indexes of the Proceedings of the British Cardiac Society published in British Heart Journal (1980 to 1995) and in Heart (1995 to 2002); proceedings of the European Congress of Cardiology and meetings of the Joint Working Groups of the European Society of Cardiology (published in European Heart Journal 1983-2003); scientific sessions of the American Heart Association (published in Circulation 1990-2003). Personal contact was made with experts.

SELECTION CRITERIA

Randomised controlled trial or controlled clinical trials of electrical cardioversion plus 'usual care' versus 'usual care' only, where 'usual care' included any combination of anticoagulants, antiplatelet drugs and drugs for 'rate control'. We excluded trials which used pharmacological cardioversion as the first intervention, and trials of new onset atrial fibrillation after cardiac surgery. There were no language restrictions.

DATA COLLECTION AND ANALYSIS

For dichotomous data, odds ratios were calculated; and for continuous data, the weighted mean difference was calculated.

MAIN RESULTS

We found three completed trials of electrical cardioversion (rhythm control) versus rate control, recruiting a total of 927 participants (Hot Cafe; RACE; STAF) and one ongoing trial (J-RHYTHM). There was no difference in mortality between the two strategies (OR 0.83; CI 0.48 to 1.43). There was a trend towards more strokes in the rhythm control group (OR 1.9; 95% CI 0.99 to 3.64). At follow up, three domains of quality of life (physical functioning, physical role function and vitality) were significantly better in the rhythm control group (RACE 2002; STAF 2003).

AUTHORS' CONCLUSIONS

Electrical cardioversion (rhythm control) led to a non-significant increase in stroke risk but improved three domains of quality of life.