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Wong CX, Buch EF, Beygui R, Lee RJ. Hybrid Endo-Epicardial Therapies for Advanced Atrial Fibrillation. J Clin Med 2024; 13:679. [PMID: 38337373 PMCID: PMC10856493 DOI: 10.3390/jcm13030679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 12/27/2023] [Accepted: 01/17/2024] [Indexed: 02/12/2024] Open
Abstract
Atrial fibrillation (AF) is a growing health problem that increases morbidity and mortality, and in most patients progresses to more advanced diseases over time. Recent research has examined the underlying mechanisms, risk factors, and progression of AF, leading to updated AF disease classification schemes. Although endocardial catheter ablation is effective for early-stage paroxysmal AF, it consistently achieves suboptimal outcomes in patients with advanced AF. Identification of the factors that lead to the increased risk of treatment failure in advanced AF has spurred the development and adoption of hybrid ablation therapies and collaborative heart care teams that result in higher long-term arrhythmia-free survival. Patients with non-paroxysmal AF, atrial remodeling, comorbidities, or AF otherwise deemed difficult to treat may find hybrid treatment to be the most effective option. Future research of hybrid therapies in advanced AF patient populations, including those with dual diagnoses, may provide further evidence establishing the safety and efficacy of hybrid endo-epicardial ablation as a first line treatment.
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Affiliation(s)
- Christopher X. Wong
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide 5001, Australia
- Cardiac Electrophysiology, University of California San Francisco, San Francisco, CA 94143, USA
| | - Eric F. Buch
- Cardiac Arrhythmia Center, University of California Los Angeles, Los Angeles, CA 90095, USA
| | - Ramin Beygui
- Cardiothoracic Surgery, University of California San Francisco, San Francisco, CA 94143, USA
| | - Randall J. Lee
- Cardiac Electrophysiology, University of California San Francisco, San Francisco, CA 94143, USA
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2
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Bai J, Lu Y, Wang H, Zhao J. How synergy between mechanistic and statistical models is impacting research in atrial fibrillation. Front Physiol 2022; 13:957604. [PMID: 36111152 PMCID: PMC9468674 DOI: 10.3389/fphys.2022.957604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 08/08/2022] [Indexed: 11/13/2022] Open
Abstract
Atrial fibrillation (AF) with multiple complications, high morbidity and mortality, and low cure rates, has become a global public health problem. Although significant progress has been made in the treatment methods represented by anti-AF drugs and radiofrequency ablation, the therapeutic effect is not as good as expected. The reason is mainly because of our lack of understanding of AF mechanisms. This field has benefited from mechanistic and (or) statistical methodologies. Recent renewed interest in digital twin techniques by synergizing between mechanistic and statistical models has opened new frontiers in AF analysis. In the review, we briefly present findings that gave rise to the AF pathophysiology and current therapeutic modalities. We then summarize the achievements of digital twin technologies in three aspects: understanding AF mechanisms, screening anti-AF drugs and optimizing ablation strategies. Finally, we discuss the challenges that hinder the clinical application of the digital twin heart. With the rapid progress in data reuse and sharing, we expect their application to realize the transition from AF description to response prediction.
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Affiliation(s)
- Jieyun Bai
- Guangdong Provincial Key Laboratory of Traditional Chinese Medicine Information Technology, Jinan University, Guangzhou, China
- College of Information Science and Technology, Jinan University, Guangzhou, China
- *Correspondence: Jieyun Bai, ; Jichao Zhao,
| | - Yaosheng Lu
- Guangdong Provincial Key Laboratory of Traditional Chinese Medicine Information Technology, Jinan University, Guangzhou, China
- College of Information Science and Technology, Jinan University, Guangzhou, China
| | - Huijin Wang
- College of Information Science and Technology, Jinan University, Guangzhou, China
| | - Jichao Zhao
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
- *Correspondence: Jieyun Bai, ; Jichao Zhao,
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Maj R, De Ceglia S, Piazzi E, Pozzi M, Montemerlo E, Casiraghi M, Fienga M, Gressoni S, Rovaris G. Cryoballoon ablation for paroxysmal atrial fibrillation: mid-term outcome evaluated by ECG monitoring with an implantable loop recorder. J Cardiovasc Electrophysiol 2021; 32:933-940. [PMID: 33694210 DOI: 10.1111/jce.14998] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Revised: 02/11/2021] [Accepted: 02/21/2021] [Indexed: 01/28/2023]
Abstract
BACKGROUND The success rate after cryoballoon ablation (CB-A) performed for paroxysmal atrial fibrillation (PAF) might be overestimated by traditional noninvasive monitoring techniques. The purpose of this study was to evaluate the mid-term outcome of CB-A in patients with PAF implanted with an implantable loop recorder (ILR) after the procedure. METHODS Between January 2017 and March 2019, all patients who underwent CB-A for PAF and who were subsequently implanted with an ILR were retrospectively included. All devices were equipped with remote monitoring. All ILR-documented atrial tachycardia (AT) or AF episodes ≥ 6 min were considered as recurrence; both true and false episodes were collected. A 3-month post-procedural blanking period (BP) was applied. RESULTS A total of 102 patients (77 men, mean age 60.6 ± 9.6 years) who underwent pulmonary vein isolation (PVI) by CB-A were included; mean time from first diagnosis of AF to PVI was 51.5 ± 46.9 months. Mean follow-up was 29.3 ± 8.1 months; at 12-month follow-up, the success rate was 65.7%, while at 2-year follow-up, freedom from AT/AF recurrences was achieved in 59.3% of the patients. In the follow-up, a total of 4987 ECG strips were analyzed; true-positive episodes were confirmed in 2026 cases (40.6%), whereas 2961 episodes (59.4%) were considered false-positive. CONCLUSION In patients with PAF implanted with an ILR, CB-A results in freedom from any AT/AF recurrence in 65.7% of patients at 12-month follow-up and in 59.3% of patients when evaluated at 2-year. Careful adjudication of all ILR-documented AF episodes is required to avoid misdiagnosis.
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Affiliation(s)
- Riccardo Maj
- Cardiovascular Department, San Gerardo Hospital, ASST-Monza, Monza, Italy
| | - Sergio De Ceglia
- Cardiovascular Department, San Gerardo Hospital, ASST-Monza, Monza, Italy
| | - Elena Piazzi
- Cardiovascular Department, San Gerardo Hospital, ASST-Monza, Monza, Italy
| | - Mattia Pozzi
- Cardiovascular Department, San Gerardo Hospital, ASST-Monza, Monza, Italy
| | | | - Mirko Casiraghi
- Cardiovascular Department, San Gerardo Hospital, ASST-Monza, Monza, Italy
| | - Marianna Fienga
- Cardiovascular Department, San Gerardo Hospital, ASST-Monza, Monza, Italy
| | - Sara Gressoni
- Cardiovascular Department, San Gerardo Hospital, ASST-Monza, Monza, Italy
| | - Giovanni Rovaris
- Cardiovascular Department, San Gerardo Hospital, ASST-Monza, Monza, Italy
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Fernando SM, Mathew R, Hibbert B, Rochwerg B, Munshi L, Walkey AJ, Møller MH, Simard T, Di Santo P, Ramirez FD, Tanuseputro P, Kyeremanteng K. New-onset atrial fibrillation and associated outcomes and resource use among critically ill adults-a multicenter retrospective cohort study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:15. [PMID: 31931845 PMCID: PMC6958729 DOI: 10.1186/s13054-020-2730-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 01/05/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND New-onset atrial fibrillation (NOAF) is commonly encountered in critically ill adults. Evidence evaluating the association between NOAF and patient-important outcomes in this population is conflicting. Furthermore, little is known regarding the association between NOAF and resource use or hospital costs. METHODS Retrospective analysis (2011-2016) of a prospectively collected registry from two Canadian hospitals of consecutive ICU patients aged ≥ 18 years. We excluded patients with a known history of AF prior to hospital admission. Any occurrence of atrial fibrillation (AF) was prospectively recorded by bedside nurses. The primary outcome was hospital mortality, and we used multivariable logistic regression to adjust for confounders. We used a generalized linear model to evaluate contributors to total cost. RESULTS We included 15,014 patients, and 1541 (10.3%) had NOAF during their ICU admission. While NOAF was not associated with increased odds of hospital death among the entire cohort (adjusted odds ratio [aOR] 1.02 [95% confidence interval [CI] 0.97-1.08]), an interaction was noted between NOAF and sepsis, and the presence of both was associated with higher odds of hospital mortality (aOR 1.28 [95% CI 1.09-1.36]) than either alone. Patients with NOAF had higher total costs (cost ratio [CR] 1.09 [95% CI 1.02-1.20]). Among patients with NOAF, treatment with a rhythm-control strategy was associated with higher costs (CR 1.24 [95% CI 1.07-1.40]). CONCLUSIONS While NOAF was not associated with death or requiring discharge to long-term care among critically ill patients, it was associated with increased length of stay in ICU and increased total costs.
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Affiliation(s)
- Shannon M Fernando
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada. .,Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.
| | - Rebecca Mathew
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Benjamin Hibbert
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Bram Rochwerg
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Laveena Munshi
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Department of Medicine, Sinai Health System, Toronto, ON, Canada
| | - Allan J Walkey
- Department of Medicine, The Pulmonary Center, Boston University School of Medicine, Boston, MA, USA.,Center for Implementation and Improvement Sciences, Boston University School of Medicine, Boston, MA, USA
| | - Morten Hylander Møller
- Department of Intensive Care, Copenhagen University Hospital Righospitalet, Copenhagen, Denmark
| | - Trevor Simard
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Pietro Di Santo
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - F Daniel Ramirez
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada.,Electrophysiology Service, Hôpital Cardiologique du Haut-Lévêque, Centre Hospitalier Universitaire de Bordeaux, Bordeaux-Pessac, France.,L'Institut de Rythmologie et Modélisation Cardiaque, Université de Bordeaux, Bordeaux-Pessac, France
| | - Peter Tanuseputro
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Bruyere Research Institute, Ottawa, ON, Canada.,Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Kwadwo Kyeremanteng
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Institut du Savoir Montfort, Ottawa, ON, Canada
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Valembois L, Audureau E, Takeda A, Jarzebowski W, Belmin J, Lafuente‐Lafuente C. Antiarrhythmics for maintaining sinus rhythm after cardioversion of atrial fibrillation. Cochrane Database Syst Rev 2019; 9:CD005049. [PMID: 31483500 PMCID: PMC6738133 DOI: 10.1002/14651858.cd005049.pub5] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Atrial fibrillation is the most frequent sustained arrhythmia. Atrial fibrillation often recurs after restoration of normal sinus rhythm. Antiarrhythmic drugs have been widely used to prevent recurrence. This is an update of a review previously published in 2006, 2012 and 2015. OBJECTIVES To determine the effects of long-term treatment with antiarrhythmic drugs on death, stroke, drug adverse effects and recurrence of atrial fibrillation in people who had recovered sinus rhythm after having atrial fibrillation. SEARCH METHODS We updated the searches of CENTRAL, MEDLINE and Embase in January 2019, and ClinicalTrials.gov and WHO ICTRP in February 2019. We checked the reference lists of retrieved articles, recent reviews and meta-analyses. SELECTION CRITERIA Two authors independently selected randomised controlled trials (RCTs) comparing any antiarrhythmic drug with a control (no treatment, placebo, drugs for rate control) or with another antiarrhythmic drug in adults who had atrial fibrillation and in whom sinus rhythm was restored, spontaneously or by any intervention. We excluded postoperative atrial fibrillation. DATA COLLECTION AND ANALYSIS Two authors independently assessed quality and extracted data. We pooled studies, if appropriate, using Mantel-Haenszel risk ratios (RR), with 95% confidence intervals (CI). All results were calculated at one year of follow-up or the nearest time point. MAIN RESULTS This update included one new study (100 participants) and excluded one previously included study because of double publication. Finally, we included 59 RCTs comprising 20,981 participants studying quinidine, disopyramide, propafenone, flecainide, metoprolol, amiodarone, dofetilide, dronedarone and sotalol. Overall, mean follow-up was 10.2 months.All-cause mortalityHigh-certainty evidence from five RCTs indicated that treatment with sotalol was associated with a higher all-cause mortality rate compared with placebo or no treatment (RR 2.23, 95% CI 1.03 to 4.81; participants = 1882). The number need to treat for an additional harmful outcome (NNTH) for sotalol was 102 participants treated for one year to have one additional death. Low-certainty evidence from six RCTs suggested that risk of mortality may be higher in people taking quinidine (RR 2.01, 95% CI 0.84 to 4.77; participants = 1646). Moderate-certainty evidence showed increased RR for mortality but with very wide CIs for metoprolol (RR 2.02, 95% CI 0.37 to 11.05, 2 RCTs, participants = 562) and amiodarone (RR 1.66, 95% CI 0.55 to 4.99, 2 RCTs, participants = 444), compared with placebo.We found little or no difference in mortality with dofetilide (RR 0.98, 95% CI 0.76 to 1.27; moderate-certainty evidence) or dronedarone (RR 0.86, 95% CI 0.68 to 1.09; high-certainty evidence) compared to placebo/no treatment. There were few data on mortality for disopyramide, flecainide and propafenone, making impossible a reliable estimation for those drugs.Withdrawals due to adverse eventsAll analysed drugs increased withdrawals due to adverse effects compared to placebo or no treatment (quinidine: RR 1.56, 95% CI 0.87 to 2.78; disopyramide: RR 3.68, 95% CI 0.95 to 14.24; propafenone: RR 1.62, 95% CI 1.07 to 2.46; flecainide: RR 15.41, 95% CI 0.91 to 260.19; metoprolol: RR 3.47, 95% CI 1.48 to 8.15; amiodarone: RR 6.70, 95% CI 1.91 to 23.45; dofetilide: RR 1.77, 95% CI 0.75 to 4.18; dronedarone: RR 1.58, 95% CI 1.34 to 1.85; sotalol: RR 1.95, 95% CI 1.23 to 3.11). Certainty of the evidence for this outcome was low for disopyramide, amiodarone, dofetilide and flecainide; moderate to high for the remaining drugs.ProarrhythmiaVirtually all studied antiarrhythmics showed increased proarrhythmic effects (counting both tachyarrhythmias and bradyarrhythmias attributable to treatment) (quinidine: RR 2.05, 95% CI 0.95 to 4.41; disopyramide: no data; flecainide: RR 4.80, 95% CI 1.30 to 17.77; metoprolol: RR 18.14, 95% CI 2.42 to 135.66; amiodarone: RR 2.22, 95% CI 0.71 to 6.96; dofetilide: RR 5.50, 95% CI 1.33 to 22.76; dronedarone: RR 1.95, 95% CI 0.77 to 4.98; sotalol: RR 3.55, 95% CI 2.16 to 5.83); with the exception of propafenone (RR 1.32, 95% CI 0.39 to 4.47) for which the certainty of evidence was very low and we were uncertain about the effect. Certainty of the evidence for this outcome for the other drugs was moderate to high.StrokeEleven studies reported stroke outcomes with quinidine, disopyramide, flecainide, amiodarone, dronedarone and sotalol. High-certainty evidence from two RCTs suggested that dronedarone may be associated with reduced risk of stroke (RR 0.66, 95% CI 0.47 to 0.95; participants = 5872). This result is attributed to one study dominating the meta-analysis and has yet to be reproduced in other studies. There was no apparent effect on stroke rates with the other antiarrhythmics.Recurrence of atrial fibrillationModerate- to high-certainty evidence, with the exception of disopyramide which was low-certainty evidence, showed that all analysed drugs, including metoprolol, reduced recurrence of atrial fibrillation (quinidine: RR 0.83, 95% CI 0.78 to 0.88; disopyramide: RR 0.77, 95% CI 0.59 to 1.01; propafenone: RR 0.67, 95% CI 0.61 to 0.74; flecainide: RR 0.65, 95% CI 0.55 to 0.77; metoprolol: RR 0.83 95% CI 0.68 to 1.02; amiodarone: RR 0.52, 95% CI 0.46 to 0.58; dofetilide: RR 0.72, 95% CI 0.61 to 0.85; dronedarone: RR 0.85, 95% CI 0.80 to 0.91; sotalol: RR 0.83, 95% CI 0.80 to 0.87). Despite this reduction, atrial fibrillation still recurred in 43% to 67% of people treated with antiarrhythmics. AUTHORS' CONCLUSIONS There is high-certainty evidence of increased mortality associated with sotalol treatment, and low-certainty evidence suggesting increased mortality with quinidine, when used for maintaining sinus rhythm in people with atrial fibrillation. We found few data on mortality in people taking disopyramide, flecainide and propafenone, so it was not possible to make a reliable estimation of the mortality risk for these drugs. However, we did find moderate-certainty evidence of marked increases in proarrhythmia and adverse effects with flecainide.Overall, there is evidence showing that antiarrhythmic drugs increase adverse events, increase proarrhythmic events and some antiarrhythmics may increase mortality. Conversely, although they reduce recurrences of atrial fibrillation, there is no evidence of any benefit on other clinical outcomes, compared with placebo or no treatment.
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Affiliation(s)
- Lucie Valembois
- Groupe Hospitalier Pitié‐Salpêtrière‐Charles Foix, AP‐HP, Université Pierre et Marie CurieService de Gériatrie à Orientation Cardiologique et Neurologique7 avenue de la RépubliqueIvry‐sur‐SeineFrance94200
| | - Etienne Audureau
- Hôpital Henri‐Mondor, APHP, Université Paris 12 UPECService de Santé Publique51 Avenue du Maréchal de Lattre de TassignyCréteilFrance94010
| | - Andrea Takeda
- University College LondonInstitute of Health Informatics ResearchLondonUK
| | | | - Joël Belmin
- Université Pierre et Marie Curie (Paris 6)La Triade ‐ Service Hospitalo‐Universitaire de GérontologieGroup Hospitalier Pitié‐Salpêtrière‐Charles Foix7, Avenue de la République, 94 Ivry‐sur‐SeineParisFrance
| | - Carmelo Lafuente‐Lafuente
- Groupe Hospitalier Pitié‐Salpêtrière‐Charles Foix, AP‐HP, Université Pierre et Marie CurieService de Gériatrie à Orientation Cardiologique et Neurologique7 avenue de la RépubliqueIvry‐sur‐SeineFrance94200
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Limbaugh DG. The harm of medical disorder as harm in the damage sense. THEORETICAL MEDICINE AND BIOETHICS 2019; 40:1-19. [PMID: 30826976 DOI: 10.1007/s11017-019-09483-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Jerome Wakefield has argued that a disorder is a harmful dysfunction. This paper develops how Wakefield should construe harmful in his harmful dysfunction analysis (HDA). Recently, Neil Feit has argued that classic puzzles involved in analyzing harm render Wakefield's HDA better off without harm as a necessary condition. Whether or not one conceives of harm as comparative or non-comparative, the concern is that the HDA forces people to classify as mere dysfunction what they know to be a disorder. For instance, one can conceive of cases where simultaneous disorders prevent each other from being, in any traditional sense, actually harmful; in such cases, according to the HDA, neither would be a disorder. I argue that the sense of harm that Wakefield should employ in the HDA is dispositional, similar to the sense of harm used when describing a vile of poison: "Be careful! That's poison. It's harmful." I call this harm in the damage sense. Using this sense of harm enables the HDA to avoid Feit's arguments, and thus it should be preferred to other senses when analyzing harmful dysfunction.
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Affiliation(s)
- David G Limbaugh
- Department of Philosophy, State University of New York at Buffalo, Buffalo, NY, USA.
- Romanell Center for Clinical Ethics and the Philosophy of Medicine, State University of New York at Buffalo, Buffalo, NY, USA.
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7
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Rat atrial engineered heart tissue: a new in vitro model to study atrial biology. Basic Res Cardiol 2018; 113:41. [DOI: 10.1007/s00395-018-0701-2] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 08/27/2018] [Indexed: 10/28/2022]
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8
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Dilaveris PE, Kennedy HL. Silent atrial fibrillation: epidemiology, diagnosis, and clinical impact. Clin Cardiol 2017; 40:413-418. [PMID: 28273368 DOI: 10.1002/clc.22667] [Citation(s) in RCA: 102] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Accepted: 11/23/2016] [Indexed: 11/05/2022] Open
Abstract
Silent or subclinical asymptomatic atrial fibrillation (SAF) has currently gained wide interest in the epidemiologic, neurologic, and cardiovascular communities. It is well known that the electrophysiological and mechanical effects of symptomatic and silent atrial fibrillation (AF) are the same. It is probable that because "AF begets AF," progression from paroxysmal to persistent or permanent AF might be more rapid in patients with long-term unrecognized and untreated SAF, because no treatment is sought by or provided to such patients. Moreover, SAF is common and has significant clinical implications. The clinical consequences of SAF, which include emboli (silent or symptomatic), heart failure, and early mortality, are of paramount importance. Consequently, SAF should be considered in estimating the prevalence of the disease and its impact on morbidity, mortality, and quality of life. Several diagnostic methods of arrhythmia detection utilizing the surface electrocardiogram (ECG), subcutaneous ECG, or intracardiac devices have been utilized to seek meaningful arrhythmic markers of SAF. Whereas a wide range of clinical risk factors of SAF have been validated in the literature, there is an ongoing search for those arrhythmic risk factors that precisely identify and prognosticate outcome events in diverse populations at risk of SAF. Modern diagnostic modalities for the identification of SAF exist, but should be further explored, validated, and tailored to each patient needs. The scientific community should undertake the clinical challenge of identifying and treating SAF.
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Affiliation(s)
| | - Harold L Kennedy
- Department of Medicine & Cardiovascular Diseases, University of Missouri, Columbia, Missouri.,The Cardiovascular Research Foundation, St. Louis, Missouri
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9
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Preuss R, Chenot JF, Angelow A. Quality of care in patients with atrial fibrillation in primary care: a cross-sectional study comparing clinical and claims data. GERMAN MEDICAL SCIENCE : GMS E-JOURNAL 2016; 14:Doc13. [PMID: 27980520 PMCID: PMC5124766 DOI: 10.3205/000240] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Revised: 10/19/2016] [Indexed: 01/26/2023]
Abstract
Objectives: Atrial fibrillation (AF) is a common cardiac arrhythmia with increased risk of thromboembolic stroke. Oral anticoagulation (OAC) reduces stroke risk by up to 68%. The aim of our study was to evaluate quality of care in patients with AF in a primary health care setting with a focus on physician guideline adherence for OAC prescription and heart rate- and rhythm management. In a second step we aimed to compare OAC rates based on primary care data with rates based on claims data. Methods: We included all GP practices in the region Vorpommern-Greifswald, Germany, which were willing to participate (N=29/182, response rate 16%). Claims data was derived from the regional association of statutory health insurance physicians. Patients with a documented AF diagnosis (ICD-10-GM-Code ICD I48.-) from 07/2011–06/2012 were identified using electronic medical records (EMR) and claims data. Stroke and bleeding risk were calculated using the CHA2DS2-VASc and HAS-BLED scores. We calculated crude treatment rates for OAC, rate and rhythm control medications and adjusted OAC treatment rates based on practice and claims data. Adjusted rates were calculated including the CHA2DS2-VASc and HAS-BLED scores and individual factors affecting guideline based treatment. Results: We identified 927 patients based on EMR and 1,247 patients based on claims data. The crude total OAC treatment rate was 69% based on EMR and 61% based on claims data. The adjusted OAC treatment rates were 90% for patients based on EMR and 63% based on claims data. 82% of the AF patients received a treatment for rate control and 12% a treatment for rhythm control. The most common reasons for non-prescription of OAC were an increased risk of falling, dementia and increased bleeding risk. Conclusion: Our results suggest that a high rate of AF patients receive a drug therapy according to guidelines. There is a large difference between crude and adjusted OAC treatment rates. This is due to individual contraindications and comorbidities which cannot be documented using ICD coding. Therefore, quality indicators based on crude EMR data or claims data would lead to a systematic underestimation of the quality of care. A possible overtreatment of low-risk patients cannot be ruled out.
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Affiliation(s)
- Rebekka Preuss
- Department of Family Medicine, Institute for Community Medicine, University Medicine Greifswald, Germany
| | - Jean-François Chenot
- Department of Family Medicine, Institute for Community Medicine, University Medicine Greifswald, Germany
| | - Aniela Angelow
- Department of Family Medicine, Institute for Community Medicine, University Medicine Greifswald, Germany
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10
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Incidence and Predictors of New-Onset Atrial Fibrillation in Septic Shock Patients in a Medical ICU: Data from 7-Day Holter ECG Monitoring. PLoS One 2015; 10:e0127168. [PMID: 25965915 PMCID: PMC4428753 DOI: 10.1371/journal.pone.0127168] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2014] [Accepted: 02/19/2015] [Indexed: 11/20/2022] Open
Abstract
Purpose We investigated incidence, risk factors for new-onset atrial fibrillation (NAF), and prognostic impact during septic shock in medical Intensive Care Unit (ICU) patients. Methods Prospective, observational study in a university hospital. Consecutive patients from 03/2011 to 05/2013 with septic shock were eligible. Exclusion criteria were age <18 years, history of AF, transfer with prior septic shock. Included patients were equipped with long-duration (7 days) Holter ECG monitoring. NAF was defined as an AF episode lasting >30 seconds. Patient characteristics, infection criteria, cardiovascular parameters, severity of illness, support therapies were recorded. Results Among 66 patients, 29(44%) developed NAF; 10 (34%) would not have been diagnosed without Holter ECG monitoring. NAF patients were older, with more markers of heart failure (troponin and NT-pro-BNP), lower left ventricular ejection fraction (LVEF), longer QRS duration and more nonsustained supra ventricular arrhythmias (<30s) on day 1 than patients who maintained sinus rhythm. By multivariate analysis, age (OR: 1.06; p = 0.01) and LVEF<45% (OR: 13.01, p = 0.03) were associated with NAF. NAF did not predict 28 or 90 day mortality. Conclusions NAF is common, especially in older patients, and is associated with low ejection fraction. We did not find NAF to be independently associated with higher mortality.
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11
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Lafuente-Lafuente C, Valembois L, Bergmann JF, Belmin J. Antiarrhythmics for maintaining sinus rhythm after cardioversion of atrial fibrillation. Cochrane Database Syst Rev 2015:CD005049. [PMID: 25820938 DOI: 10.1002/14651858.cd005049.pub4] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Atrial fibrillation is the most frequent sustained arrhythmia. Atrial fibrillation frequently recurs after restoration of normal sinus rhythm. Antiarrhythmic drugs have been widely used to prevent recurrence, but the effect of these drugs on mortality and other clinical outcomes is unclear. This is an update of a review previously published in 2008 and 2012. OBJECTIVES To determine in patients who have recovered sinus rhythm after having atrial fibrillation, the effects of long-term treatment with antiarrhythmic drugs on death, stroke, embolism, drug adverse effects and recurrence of atrial fibrillation. SEARCH METHODS We updated the searches of CENTRAL in The Cochrane Library (2013, Issue 12 of 12), MEDLINE (to January 2014) and EMBASE (to January 2014). The reference lists of retrieved articles, recent reviews and meta-analyses were checked. SELECTION CRITERIA Two independent authors selected randomised controlled trials comparing any antiarrhythmic drug with a control (no treatment, placebo, drugs for rate control) or with another antiarrhythmic drug in adults who had atrial fibrillation and in whom sinus rhythm was restored. Post-operative atrial fibrillation was excluded. DATA COLLECTION AND ANALYSIS Two authors independently assessed quality and extracted data. Studies were pooled, if appropriate, using Peto odds ratio (OR). All results were calculated at one year of follow-up. MAIN RESULTS In this update three new studies, with 534 patients, were included making a total of 59 included studies comprising 21,305 patients. All included studies were randomised controlled trials. Allocation concealment was adequate in 17 trials, it was unclear in the remaining 42 trials. Risk of bias was assessed in all domains only in the trials included in this update.Compared with controls, class IA drugs quinidine and disopyramide (OR 2.39, 95% confidence interval (95% CI) 1.03 to 5.59, number needed to treat to harm (NNTH) 109, 95% CI 34 to 4985) and sotalol (OR 2.23, 95% CI 1.1 to 4.50, NNTH 169, 95% CI 60 to 2068) were associated with increased all-cause mortality. Other antiarrhythmics did not seem to modify mortality, but our data could be underpowered to detect mild increases in mortality for several of the drugs studied.Several class IA (disopyramide, quinidine), IC (flecainide, propafenone) and III (amiodarone, dofetilide, dronedarone, sotalol) drugs significantly reduced recurrence of atrial fibrillation (OR 0.19 to 0.70, number needed to treat to beneft (NNTB) 3 to 16). Beta-blockers (metoprolol) also significantly reduced atrial fibrillation recurrences (OR 0.62, 95% CI 0.44 to 0.88, NNTB 9).All analysed drugs increased withdrawals due to adverse affects and all but amiodarone, dronedarone and propafenone increased pro-arrhythmia. Only 11 trials reported data on stroke. None of them found any significant difference with the exception of a single trial than found less strokes in the group treated with dronedarone compared to placebo. This finding was not confirmed in others studies on dronedarone.We could not analyse heart failure and use of anticoagulation because few original studies reported on these measures. AUTHORS' CONCLUSIONS Several class IA, IC and III drugs, as well as class II drugs (beta-blockers), are moderately effective in maintaining sinus rhythm after conversion of atrial fibrillation. However, they increase adverse events, including pro-arrhythmia, and some of them (disopyramide, quinidine and sotalol) may increase mortality. Possible benefits on clinically relevant outcomes (stroke, embolism, heart failure) remain to be established.
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Affiliation(s)
- Carmelo Lafuente-Lafuente
- Service de Gériatrie à Orientation Cardiologique et Neurologique, Groupe Hospitalier Pitié-Salpêtrière-Charles Foix, AP-HP, Université Pierre et Marie Curie, 7 Avenue de la République, Ivry-sur-Seine, Ile-de-France, France, 94205
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12
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Fish oil for the reduction of atrial fibrillation recurrence, inflammation, and oxidative stress. J Am Coll Cardiol 2015; 64:1441-8. [PMID: 25277614 DOI: 10.1016/j.jacc.2014.07.956] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Revised: 06/15/2014] [Accepted: 07/01/2014] [Indexed: 11/22/2022]
Abstract
BACKGROUND Recent trials of fish oil for the prevention of atrial fibrillation (AF) recurrence have provided mixed results. Notable uncertainties in the existing evidence base include the roles of high-dose fish oil, inflammation, and oxidative stress in patients with paroxysmal or persistent AF not receiving conventional antiarrhythmic (AA) therapy. OBJECTIVES The aim of this study was to evaluate the influence of high-dose fish oil on AF recurrence, inflammation, and oxidative stress parameters. METHODS We performed a double-blind, randomized, placebo-controlled, parallel-arm study in 337 patients with symptomatic paroxysmal or persistent AF within 6 months of enrollment. Patients were randomized to fish oil (4 g/day) or placebo and followed, on average, for 271 ± 129 days. RESULTS The primary endpoint was time to first symptomatic or asymptomatic AF recurrence lasting >30 s. Secondary endpoints were high-sensitivity C-reactive protein (hs-CRP) and myeloperoxidase (MPO). The primary endpoint occurred in 64.1% of patients in the fish oil arm and 63.2% of patients in the placebo arm (hazard ratio: 1.10; 95% confidence interval: 0.84 to 1.45; p = 0.48). hs-CRP and MPO were within normal limits at baseline and decreased to a similar degree at 6 months (Δhs-CRP, 11% vs. -11%; ΔMPO, -5% vs. -9% for fish oil vs. placebo, respectively; p value for interaction = NS). CONCLUSIONS High-dose fish oil does not reduce AF recurrence in patients with a history of AF not receiving conventional AA therapy. Furthermore, fish oil does not reduce inflammation or oxidative stress markers in this population, which may explain its lack of efficacy. (Multi-center Study to Evaluate the Effect of N-3 Fatty Acids [OMEGA-3] on Arrhythmia Recurrence in Atrial Fibrillation [AFFORD]; NCT01235130).
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13
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Barra S, Fynn S. Untreated atrial fibrillation in the United Kingdom: Understanding the barriers and treatment options. J Saudi Heart Assoc 2015; 27:31-43. [PMID: 25544820 PMCID: PMC4274310 DOI: 10.1016/j.jsha.2014.08.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2014] [Accepted: 08/05/2014] [Indexed: 12/16/2022] Open
Abstract
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and a major preventable cause of stroke and hospitalization. Its prevalence is on the rise worldwide and experts believe it will continue to rise for the foreseeable future, due to the ageing population and increased survival from conditions associated with AF. Despite the fact that oral anticoagulation is effective in preventing strokes due to AF, there is extensive evidence suggesting this therapy remains underused. Barriers to the prescription of anticoagulation include patients' age per se, comorbidities, inadequate risk stratification, perceived risk of falls and bleeding, and the difficulty in achieving a stable international normalized ratio (INR) on warfarin. Also, asymptomatic patients with AF may not be identified and therefore not be candidates for anticoagulation. Physicians need continued better education on the identification of patients at risk of stroke and management of oral anticoagulation. This article reviews the barriers to anticoagulation in patients with AF in the United Kingdom and considers how those barriers may be overcome.
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Affiliation(s)
- Sérgio Barra
- Cardiology Department, Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Simon Fynn
- Cardiology Department, Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
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14
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[Long-term results of catheter ablation of atrial fibrillation: cure or just palliation?]. Herzschrittmacherther Elektrophysiol 2014; 25:246-51. [PMID: 25081596 DOI: 10.1007/s00399-014-0328-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2014] [Accepted: 06/12/2014] [Indexed: 10/25/2022]
Abstract
Knowing the pitfalls when evaluating the long-term results after catheter ablation of atrial fibrillation enables a critical analysis of the outcome presented in numerous studies on this topic. Nevertheless, catheter ablation is a long-term successful and safe therapeutic procedure for symptomatic atrial fibrillation, especially for patients with paroxysmal atrial fibrillation. In patients with persistent symptomatic atrial fibrillation, the decision for ablation has to be made with caution due to a higher recurrence rate and higher likelihood for multiple procedures.
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Abstract
Antiarrhythmic drugs are widely used, but are of modest efficacy and have important side effects. However, even with the advance of catheter ablation for atrial fibrillation and ventricular tachycardia, antiarrhythmic drugs remain an important tool for treating arrhythmias. Antiarrhythmic drug development has remained slow despite much effort given our limited understanding of what role various ionic currents play in arrhythmogenesis and how they are modified by arrhythmias. This review will focus on promising new antiarrhythmic drugs undergoing clinical investigation or currently approved for clinical use, including amiodarone analogues, agents with novel ionic targets, and new drug combinations.
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Affiliation(s)
- Kapil Kumar
- Harvard Vanguard Medical Associates, 133 Brookline Avenue, Boston, MA 02215, USA.
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16
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Grond M, Jauss M, Hamann G, Stark E, Veltkamp R, Nabavi D, Horn M, Weimar C, Köhrmann M, Wachter R, Rosin L, Kirchhof P. Improved Detection of Silent Atrial Fibrillation Using 72-Hour Holter ECG in Patients With Ischemic Stroke. Stroke 2013; 44:3357-64. [DOI: 10.1161/strokeaha.113.001884] [Citation(s) in RCA: 161] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background and Purpose—
Adequate diagnosis of atrial fibrillation (AF), including paroxysmal AF, is an important part of stroke workup. Prolonged ECG monitoring may improve the detection of paroxysmal, previously undiagnosed AF (unknown AF). Therefore, we evaluated systematic 72-hour Holter ECG monitoring to detect unknown AF for the workup of patients with stroke.
Methods—
Unselected survivors of a stroke or transient ischemic attack (TIA) without known AF were enrolled in a prospective, multicenter cohort study of 72-hour Holter ECG monitoring in 9 German secondary and tertiary stroke centers between May 2010 and January 2011. In addition to standardized workup of stroke pathogenesis according to the German Stroke Unit protocol, all patients underwent 72-hour Holter ECG monitoring directly after admission. All ECGs were centrally analyzed by 2 independent observers. We determined the proportion of unknown AF and compared the detection rates of 72- and 24-hour monitoring.
Results—
A total of 1135 patients were enrolled (mean age, 67 years [SD, 13.1 years], 45% women, 29% TIA). Unknown AF was detected in 49 out of 1135 patients (4.3%, [95% confidence interval, 3.4–5.2%]) by 72-hour ECG monitoring. Unknown AF was diagnosed in 29 patients (2.6%) within the first 24 hours of ECG monitoring, and in 20 more patients only by 72 hours of ECG monitoring. The number needed to screen by 72-hour ECG was 55 patients (95% confidence interval [35–123]) for each additional AF diagnosis. Patients with unknown AF were significantly older and had more often a history of previous stroke. Patients with unknown AF were equally distributed within categories of pathogenesis according to Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification.
Conclusions—
In unselected survivors of stroke or TIA, 72-hour ECG monitoring is feasible and improves the detection rate of silent paroxysmal AF.
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Affiliation(s)
- Martin Grond
- From the Department of Neurology, Kreisklinikum Siegen, Siegen, Germany (M.G.); Department of Neurology, Hainich Klinikum, Mühlhausen, Germany (M.J.); Department of Neurology, HSK Klinik, Wiesbaden, Germany (G.H.); Department of Neurology, Klinikum Offenbach, Offenbach, Germany (E.S.); Department of Neurology, University of Heidelberg, Germany (R.V.); Department of Neurology, Vivantes Klinikum Neukölln, Berlin, Germany (D.N.); Department of Neurology, Klinikum Bad Hersfeld, Bad Hersfeld, Germany (M
| | - Marek Jauss
- From the Department of Neurology, Kreisklinikum Siegen, Siegen, Germany (M.G.); Department of Neurology, Hainich Klinikum, Mühlhausen, Germany (M.J.); Department of Neurology, HSK Klinik, Wiesbaden, Germany (G.H.); Department of Neurology, Klinikum Offenbach, Offenbach, Germany (E.S.); Department of Neurology, University of Heidelberg, Germany (R.V.); Department of Neurology, Vivantes Klinikum Neukölln, Berlin, Germany (D.N.); Department of Neurology, Klinikum Bad Hersfeld, Bad Hersfeld, Germany (M
| | - Gerhard Hamann
- From the Department of Neurology, Kreisklinikum Siegen, Siegen, Germany (M.G.); Department of Neurology, Hainich Klinikum, Mühlhausen, Germany (M.J.); Department of Neurology, HSK Klinik, Wiesbaden, Germany (G.H.); Department of Neurology, Klinikum Offenbach, Offenbach, Germany (E.S.); Department of Neurology, University of Heidelberg, Germany (R.V.); Department of Neurology, Vivantes Klinikum Neukölln, Berlin, Germany (D.N.); Department of Neurology, Klinikum Bad Hersfeld, Bad Hersfeld, Germany (M
| | - Erwin Stark
- From the Department of Neurology, Kreisklinikum Siegen, Siegen, Germany (M.G.); Department of Neurology, Hainich Klinikum, Mühlhausen, Germany (M.J.); Department of Neurology, HSK Klinik, Wiesbaden, Germany (G.H.); Department of Neurology, Klinikum Offenbach, Offenbach, Germany (E.S.); Department of Neurology, University of Heidelberg, Germany (R.V.); Department of Neurology, Vivantes Klinikum Neukölln, Berlin, Germany (D.N.); Department of Neurology, Klinikum Bad Hersfeld, Bad Hersfeld, Germany (M
| | - Roland Veltkamp
- From the Department of Neurology, Kreisklinikum Siegen, Siegen, Germany (M.G.); Department of Neurology, Hainich Klinikum, Mühlhausen, Germany (M.J.); Department of Neurology, HSK Klinik, Wiesbaden, Germany (G.H.); Department of Neurology, Klinikum Offenbach, Offenbach, Germany (E.S.); Department of Neurology, University of Heidelberg, Germany (R.V.); Department of Neurology, Vivantes Klinikum Neukölln, Berlin, Germany (D.N.); Department of Neurology, Klinikum Bad Hersfeld, Bad Hersfeld, Germany (M
| | - Darius Nabavi
- From the Department of Neurology, Kreisklinikum Siegen, Siegen, Germany (M.G.); Department of Neurology, Hainich Klinikum, Mühlhausen, Germany (M.J.); Department of Neurology, HSK Klinik, Wiesbaden, Germany (G.H.); Department of Neurology, Klinikum Offenbach, Offenbach, Germany (E.S.); Department of Neurology, University of Heidelberg, Germany (R.V.); Department of Neurology, Vivantes Klinikum Neukölln, Berlin, Germany (D.N.); Department of Neurology, Klinikum Bad Hersfeld, Bad Hersfeld, Germany (M
| | - Markus Horn
- From the Department of Neurology, Kreisklinikum Siegen, Siegen, Germany (M.G.); Department of Neurology, Hainich Klinikum, Mühlhausen, Germany (M.J.); Department of Neurology, HSK Klinik, Wiesbaden, Germany (G.H.); Department of Neurology, Klinikum Offenbach, Offenbach, Germany (E.S.); Department of Neurology, University of Heidelberg, Germany (R.V.); Department of Neurology, Vivantes Klinikum Neukölln, Berlin, Germany (D.N.); Department of Neurology, Klinikum Bad Hersfeld, Bad Hersfeld, Germany (M
| | - Christian Weimar
- From the Department of Neurology, Kreisklinikum Siegen, Siegen, Germany (M.G.); Department of Neurology, Hainich Klinikum, Mühlhausen, Germany (M.J.); Department of Neurology, HSK Klinik, Wiesbaden, Germany (G.H.); Department of Neurology, Klinikum Offenbach, Offenbach, Germany (E.S.); Department of Neurology, University of Heidelberg, Germany (R.V.); Department of Neurology, Vivantes Klinikum Neukölln, Berlin, Germany (D.N.); Department of Neurology, Klinikum Bad Hersfeld, Bad Hersfeld, Germany (M
| | - Martin Köhrmann
- From the Department of Neurology, Kreisklinikum Siegen, Siegen, Germany (M.G.); Department of Neurology, Hainich Klinikum, Mühlhausen, Germany (M.J.); Department of Neurology, HSK Klinik, Wiesbaden, Germany (G.H.); Department of Neurology, Klinikum Offenbach, Offenbach, Germany (E.S.); Department of Neurology, University of Heidelberg, Germany (R.V.); Department of Neurology, Vivantes Klinikum Neukölln, Berlin, Germany (D.N.); Department of Neurology, Klinikum Bad Hersfeld, Bad Hersfeld, Germany (M
| | - Rolf Wachter
- From the Department of Neurology, Kreisklinikum Siegen, Siegen, Germany (M.G.); Department of Neurology, Hainich Klinikum, Mühlhausen, Germany (M.J.); Department of Neurology, HSK Klinik, Wiesbaden, Germany (G.H.); Department of Neurology, Klinikum Offenbach, Offenbach, Germany (E.S.); Department of Neurology, University of Heidelberg, Germany (R.V.); Department of Neurology, Vivantes Klinikum Neukölln, Berlin, Germany (D.N.); Department of Neurology, Klinikum Bad Hersfeld, Bad Hersfeld, Germany (M
| | - Ludger Rosin
- From the Department of Neurology, Kreisklinikum Siegen, Siegen, Germany (M.G.); Department of Neurology, Hainich Klinikum, Mühlhausen, Germany (M.J.); Department of Neurology, HSK Klinik, Wiesbaden, Germany (G.H.); Department of Neurology, Klinikum Offenbach, Offenbach, Germany (E.S.); Department of Neurology, University of Heidelberg, Germany (R.V.); Department of Neurology, Vivantes Klinikum Neukölln, Berlin, Germany (D.N.); Department of Neurology, Klinikum Bad Hersfeld, Bad Hersfeld, Germany (M
| | - Paulus Kirchhof
- From the Department of Neurology, Kreisklinikum Siegen, Siegen, Germany (M.G.); Department of Neurology, Hainich Klinikum, Mühlhausen, Germany (M.J.); Department of Neurology, HSK Klinik, Wiesbaden, Germany (G.H.); Department of Neurology, Klinikum Offenbach, Offenbach, Germany (E.S.); Department of Neurology, University of Heidelberg, Germany (R.V.); Department of Neurology, Vivantes Klinikum Neukölln, Berlin, Germany (D.N.); Department of Neurology, Klinikum Bad Hersfeld, Bad Hersfeld, Germany (M
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Forleo GB, Di Biase L, Della Rocca DG, Fassini G, Santini L, Natale A, Tondo C. Exploring the Potential Role of Catheter Ablation in Patients with Asymptomatic Atrial Fibrillation: Should We Move away from Symptom Relief? J Atr Fibrillation 2013; 6:961. [PMID: 28496903 DOI: 10.4022/jafib.961] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Revised: 10/26/2013] [Accepted: 10/26/2013] [Indexed: 01/19/2023]
Abstract
Although silent atrial fibrillation (AF) accounts for a significant proportion of patients with AF, asymptomatic patients have been excluded from AF ablation trials. This population presents unique challenges to disease management. Recent evidence suggests that patients with asymptomatic AF may have a different risk profile and even worse long-term outcomes compared to patients with symptomatic AF. For the same reasons they might be more prone to side-effects of antiarrhythmic drugs, including pro-arrhythmias. The poor correlation between symptoms and AF demonstrated in several studies should caution physicians against making clinical decisions depending on symptoms. Although current guidelines recommend AF ablation only in patients with symptoms, more attention should be paid to the AF burden and a rhythm control strategy has the potential to improve morbidity and mortality in AF patients. However, limited data exist regarding the use of catheter ablation for asymptomatic AF patients. As ablation techniques have improved, AF ablation has become more widespread and complication rate decreased. As a result, referrals of asymptomatic patients for catheter ablation of AF are on the rise. In this review we discuss the many unresolved questions concerning the role of the ablative approach in asymptomatic patients with AF.
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Affiliation(s)
| | - Luigi Di Biase
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, TX, USA.,Department of Cardiology, University of Foggia, Foggia, Italy
| | | | - Gaetano Fassini
- Cardiac Arrhythmia Research Center, Centro Cardiologico Monzino IRCCS. Milan. Italy
| | - Luca Santini
- Policlinico Universitario Tor Vergata, Rome, Italy
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, TX, USA
| | - Claudio Tondo
- Cardiac Arrhythmia Research Center, Centro Cardiologico Monzino IRCCS. Milan. Italy
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18
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Fibrilación auricular en la práctica clínica: todavía faltan respuestas. Med Clin (Barc) 2013; 141:295-6. [DOI: 10.1016/j.medcli.2013.04.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2013] [Accepted: 04/18/2013] [Indexed: 10/26/2022]
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A comparison of clinical characteristics and long-term prognosis in asymptomatic and symptomatic patients with first-diagnosed atrial fibrillation: the Belgrade Atrial Fibrillation Study. Int J Cardiol 2013; 168:4744-9. [PMID: 23958417 DOI: 10.1016/j.ijcard.2013.07.234] [Citation(s) in RCA: 71] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2013] [Revised: 07/11/2013] [Accepted: 07/25/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND To investigate baseline characteristics and long-term prognosis of carefully characterized asymptomatic and symptomatic patients with atrial fibrillation (AF) in a 'real-world' cohort of first-diagnosed non-valvular AF over a 10-year follow-up period. METHODS AND RESULTS We conducted an observational, non-interventional, and single-centre registry-based study of consecutive first-diagnosed AF patients. Of 1100 patients (mean age 52.7±12.2 years and mean follow-up 9.9±6.1 years), 146 (13.3%) had asymptomatic AF. Persistent or permanent AF, slower ventricular rate during AF (<100/min), CHA2DS2-VASc score of 0, history of diabetes mellitus and male gender were independent baseline risk factors for asymptomatic AF presentation (all p<0.01) with a good predictive ability of the multivariable model (c-statistic 0.86, p<0.001). Kaplan-Meier 10-year estimates of survival free of progression of AF (log-rank test=33.4, p<0.001) and ischemic stroke (log-rank test=6.2, p=0.013) were significantly worse for patients with asymptomatic AF compared to those with symptomatic arrhythmia. In the multivariable Cox regression analysis, intermittent asymptomatic AF was significantly associated with progression to permanent AF (Hazard Ratio 1.6; 95% CI, 1.1-2.2; p=0.009). CONCLUSIONS In a 'real-world' setting, patients with asymptomatic presentation of their first-diagnosed AF could have different risk profile and long-term outcomes compared to those with symptomatic AF. Whether more intensive monitoring and comprehensive AF management including AF ablation at early stage following the incident episode of AF and increased quality of oral anticoagulation could alter the long-term prognosis of these patients requires further investigation.
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20
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Meesmann M. [Diagnosis of atrial fibrillation. From the standard ECG to analysis of electrograms]. Herzschrittmacherther Elektrophysiol 2013; 24:97-102. [PMID: 23793288 DOI: 10.1007/s00399-013-0269-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
The early diagnosis of asymptomatic atrial fibrillation is important because of the associated risk for arterial embolism. Routine ECG recording, however, is not effective in asymptomatic patients. The goal of this article is to show the general practitioner and internist how the search for atrial fibrillation can be made more efficacious. For example, recording an ECG in patients older than 65 years with irregularities in their pulse or repeated ECG recording in patients older than 75 years with hypertension shows improved results in this regard. It is interesting that elements of the CHA2DS2-VASc score, which was developed to predict risk for arterial embolism, are also effective for defining populations to screen for atrial fibrillation. In the subgroup of patients with a pacemaker or implantable converter-defibrillator (ICD), histograms or intracardiac electrograms can be used to identify previously undiagnosed atrial fibrillation. The general practitioner should take these results which are usually obtained by a cardiologist into consideration in the follow-up treatment of his or her patients.
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Affiliation(s)
- Malte Meesmann
- Medizinische Klinik - Schwerpunkt Kardiologie und Internistische Intensivmedizin, Stiftung Juliusspital Würzburg, Juliuspromenade 19, 97070, Würzburg, Deutschland.
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Kircher S, Hindricks G, Sommer P. Long-term success and follow-up after atrial fibrillation ablation. Curr Cardiol Rev 2013; 8:354-61. [PMID: 22920479 PMCID: PMC3492818 DOI: 10.2174/157340312803760758] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2012] [Revised: 04/12/2012] [Accepted: 04/12/2012] [Indexed: 11/22/2022] Open
Abstract
Atrial fibrillation (AF) is the most prevalent sustained arrhythmia in clinical practice. It is associated with significant morbidity and mortality and has been identified as an independent risk factor for ischemic stroke and thromboembolic events. Catheter ablation has become an established rhythm control therapy in patients with highly symptomatic drug-refractory AF. The definition of ablation success remains controversial since current symptom-based or intermittent electrocardiogram monitoring strategies fail to sufficiently disclose rhythm outcome. This failure is mainly related to the high incidence of asymptomatic AF recurrences, the unpredictable nature of arrhythmia relapses, and the poor correlation of symptoms and AF episodes. There is a clear correlation between the intensity of the monitoring strategy and the sensitivity for it to detect arrhythmia recurrences. Furthermore, several clinical studies assessing the long-term efficacy of catheter ablation procedures have reported late AF recurrences in patients who were initially considered responders to catheter ablation. In certain subsets of patients, precise long-term monitoring may help to guide therapy, e.g. patients in whom withdrawal of antithrombotic therapy may be considered if they are free of arrhythmia recurrences. Recently, sub-cutaneous implantable cardiac monitors (ICM) have been introduced for prolonged and continuous rhythm monitoring. The performance of a leadless ICM equipped with a dedicated AF detection algorithm has recently been assessed in a clinical trial demonstrating a high sensitivity and overall accuracy for identifying patients with AF. The clinical impact of ICM-based follow-up strategies, however, has to be evaluated in prospective clinical trials.
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Affiliation(s)
- S Kircher
- University of Leipzig, Heart Center, Department of Electrophysiology, Struempellstr. 39, 04289 Leipzig, Germany
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22
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Jiang K, Huang C, Ye SM, Chen H. High accuracy in automatic detection of atrial fibrillation for Holter monitoring. J Zhejiang Univ Sci B 2013; 13:751-6. [PMID: 22949366 DOI: 10.1631/jzus.b1200107] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Atrial fibrillation (AF) has been considered as a growing epidemiological problem in the world, with a substantial impact on morbidity and mortality. Ambulatory electrocardiography (e.g., Holter) monitoring is commonly used for AF diagnosis and therapy and the automated detection of AF is of great significance due to the vast amount of information provided. This study presents a combined method to achieve high accuracy in AF detection. Firstly, we detected the suspected transitions between AF and sinus rhythm using the delta RR interval distribution difference curve, which were then classified by a combination analysis of P wave and RR interval. The MIT-BIH AF database was used for algorithm validation and a high sensitivity and a high specificity (98.2% and 97.5%, respectively) were achieved. Further, we developed a dataset of 24-h paroxysmal AF Holter recordings (n=45) to evaluate the performance in clinical practice, which yielded satisfactory accuracy (sensitivity=96.3%, specificity=96.8%).
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Affiliation(s)
- Kai Jiang
- Key Laboratory of Biomedical Engineering of Education Ministry, Zhejiang University, Hangzhou 310058, China
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Tampieri A, Rusconi AM, Lenzi T. Cardioversion in atrial fibrillation. Focus on recent-onset atrial fibrillation. Intern Emerg Med 2012; 7 Suppl 3:S241-50. [PMID: 23073864 DOI: 10.1007/s11739-012-0863-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Atrial fibrillation is the most common sustained arrhythmia encountered in clinical practice. Its prevalence is rising due to an increasing elderly population and the improvement in management of life-threatening diseases such as myocardial infarction and heart failure. Over the past few years effective non-pharmacological treatments, new antiarrhythmics drugs, and anticoagulants have been introduced. Regardless of rate-control or rhythm control strategy, adequate stroke prevention still remains a cornerstone in the treatment of this arrhythmia. This review aims to illustrate the main practical issues in the management of atrial fibrillation, focusing on patients with recent-onset and hemodynamically stable atrial fibrillation.
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Affiliation(s)
- Andrea Tampieri
- Emergency Department, Ospedale Civile Santa Maria della Scaletta, via Montericco 4, 40026, Imola (Bo), Italy.
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Rienstra M, Lubitz SA, Mahida S, Magnani JW, Fontes JD, Sinner MF, Van Gelder IC, Ellinor PT, Benjamin EJ. Symptoms and functional status of patients with atrial fibrillation: state of the art and future research opportunities. Circulation 2012; 125:2933-43. [PMID: 22689930 DOI: 10.1161/circulationaha.111.069450] [Citation(s) in RCA: 140] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Michiel Rienstra
- Cardiovascular Research Center, Massachusetts General Hospital, Charlestown, MA, USA
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Goli NM, Thompson T, Sears SF, Mounsey JP, Chung E, Schwartz J, Wood K, Walker J, Guise K, Gehi AK. Educational attainment is associated with atrial fibrillation symptom severity. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2012; 35:1090-6. [PMID: 22817646 DOI: 10.1111/j.1540-8159.2012.03482.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Atrial fibrillation (AF), the most common arrhythmia encountered in clinical practice, is often managed with a rhythm control strategy. Despite the emphasis on symptom relief as the motivation for a rhythm controlling strategy in AF, it remains unclear what factors affect the patient's experienced severity of AF symptoms. We hypothesize that demographic variables may affect AF symptom severity as many AF symptoms (palpitations, dyspnea, fatigue) are nonspecific and may require particular patient insight. METHODS We assessed demographic variables, cardiac and noncardiac comorbidities, AF burden, and AF-specific self-reported symptom severity in a cohort of 300 outpatients with AF presenting to outpatient electrophysiology clinics. RESULTS In unadjusted analyses, decreased educational attainment, unemployed working status, and non-Caucasian race were associated with worsened AF symptom severity. After adjusting for potential confounders, the association of decreased educational attainment with worsened AF symptom severity persisted. CONCLUSIONS Possible links between these demographic features and AF symptom severity are socioeconomic status and health literacy. Further study into the relationship between educational attainment and AF symptom severity is warranted.
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Affiliation(s)
- Neeta M Goli
- Eastern Virginia Medical School, Norfolk, Virginia, USA.
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Franken RA, Rosa RF, Santos SCM. Atrial fibrillation in the elderly. J Geriatr Cardiol 2012; 9:91-100. [PMID: 22916053 PMCID: PMC3418896 DOI: 10.3724/sp.j.1263.2011.12293] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2011] [Revised: 04/20/2012] [Accepted: 04/27/2012] [Indexed: 11/25/2022] Open
Abstract
This review discusses atrial fibrillation according to the guidelines of Brazilian Society of Cardiac Arrhythmias and the Brazilian Cardiogeriatrics Guidelines. We stress the thromboembolic burden of atrial fibrillation and discuss how to prevent it as well as the best way to conduct cases of atrial fibrillatios in the elderly, reverting the arrhythmia to sinus rhythm, or the option of heart rate control. The new methods to treat atrial fibrillation, such as radiofrequency ablation, new oral direct thrombin inhibitors and Xa factor inhibitors, as well as new antiarrhythmic drugs, are depicted.
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Affiliation(s)
- Roberto A. Franken
- Department of Internal Medicine, Santa Casa São Paulo Medical School, R.Dr.Franco da Rocha 163/52, São Paulo 05015-040, Brazil
| | - Ronaldo F. Rosa
- Department of Internal Medicine, Santa Casa São Paulo Medical School, R.Dr.Franco da Rocha 163/52, São Paulo 05015-040, Brazil
| | - Silvio CM Santos
- Brazilian Society of Cardiology, Rua Padre bartolomeu Tadei 18, Santos 11035-150, Brazil
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Lafuente-Lafuente C, Longas-Tejero MA, Bergmann JF, Belmin J. Antiarrhythmics for maintaining sinus rhythm after cardioversion of atrial fibrillation. Cochrane Database Syst Rev 2012:CD005049. [PMID: 22592700 DOI: 10.1002/14651858.cd005049.pub3] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) is the most frequent sustained arrhythmia. AF recurs frequently after restoration of normal sinus rhythm. Antiarrhythmic drugs have been widely used to prevent recurrence, but the effect of these drugs on mortality and other clinical outcomes is unclear. OBJECTIVES To determine, in patients who recovered sinus rhythm after AF, the effect of long-term treatment with antiarrhythmic drugs on death, stroke and embolism, adverse effects, pro-arrhythmia, and recurrence of AF. SEARCH METHODS We updated the searches of CENTRAL on The Cochrane Libary (Issue 1 of 4, 2010), MEDLINE (1950 to February 2010) and EMBASE (1966 to February 2010). The reference lists of retrieved articles, recent reviews and meta-analyses were checked. SELECTION CRITERIA Two independent reviewers selected randomised controlled trials comparing any antiarrhythmic with a control (no treatment, placebo or drugs for rate control) or with another antiarrhythmic, in adults who had AF and in whom sinus rhythm was restored. Post-operative AF was excluded. DATA COLLECTION AND ANALYSIS Two reviewers independently assessed quality and extracted data. Studies were pooled, if appropriate, using Peto odds ratio (OR). All results were calculated at one year of follow-up. MAIN RESULTS In this update, 11 new studies met inclusion criteria, making a total of 56 included studies, comprising 20,771 patients. Compared with controls, class IA drugs quinidine and disopyramide (OR 2.39, 95% confidence interval (95%CI) 1.03 to 5.59, number needed to harm (NNH) 109, 95%CI 34 to 4985) and sotalol (OR 2.47, 95%CI 1.2 to 5.05, NNH 166, 95%CI 61 to 1159) were associated with increased all-cause mortality. Other antiarrhythmics did not seem to modify mortality.Several class IA (disopyramide, quinidine), IC (flecainide, propafenone) and III (amiodarone, dofetilide, dronedarone, sotalol) drugs significantly reduced recurrence of AF (OR 0.19 to 0.70, number needed to treat (NNT) 3 to 16). Beta-blockers (metoprolol) also reduced significantly AF recurrence (OR 0.62, 95% CI 0.44 to 0.88, NNT 9).All analysed drugs increased withdrawals due to adverse affects and all but amiodarone, dronedarone and propafenone increased pro-arrhythmia. We could not analyse other outcomes because few original studies reported them. AUTHORS' CONCLUSIONS Several class IA, IC and III drugs, as well as class II (beta-blockers), are moderately effective in maintaining sinus rhythm after conversion of atrial fibrillation. However, they increase adverse events, including pro-arrhythmia, and some of them (disopyramide, quinidine and sotalol) may increase mortality. Possible benefits on clinically relevant outcomes (stroke, embolisms, heart failure) remain to be established.
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Affiliation(s)
- Carmelo Lafuente-Lafuente
- Service deGériatrie à orientation Cardiologique etNeurologique, Groupe hospitalier Pitié-Salpêtrière-Charles Foix, AP-HP,UniversitéPierre et Marie Curie (Paris 6), Ivry-sur-Seine, France.
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Manolis AJ, Kallistratos MS, Poulimenos LE. Recent Clinical Trials in Atrial Fibrillation in Hypertensive Patients. Curr Hypertens Rep 2012; 14:350-9. [DOI: 10.1007/s11906-012-0268-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Hypertension and atrial fibrillation: diagnostic approach, prevention and treatment. Position paper of the Working Group 'Hypertension Arrhythmias and Thrombosis' of the European Society of Hypertension. J Hypertens 2012; 30:239-52. [PMID: 22186358 DOI: 10.1097/hjh.0b013e32834f03bf] [Citation(s) in RCA: 152] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Hypertension is the most common cardiovascular disorder and atrial fibrillation is the most common clinically significant arrhythmia. Both these conditions frequently coexist and their prevalence increases rapidly with aging. There are different risk factors and clinical conditions predisposing to the development of atrial fibrillation, but due its high prevalence, hypertension is still the main risk factor for the development of atrial fibrillation. Several pathophysiologic mechanisms (such as structural changes, neurohormonal activation, fibrosis, atherosclerosis, etc.) have been advocated to explain the onset of atrial fibrillation. The presence of atrial fibrillation per se increases the risk of stroke but its coexistence with high blood pressure leads to an abrupt increase of cardiovascular complications. Different risk models are available for the risk stratification and the prevention of thromboembolism in patients with atrial fibrillation. In all of them hypertension is present and is an important risk factor. Antihypertensive treatment may contribute to reduce this risk, and it seems some classes are superior to others in the prevention of new-onset atrial fibrillation and prevention of stroke. Antithrombotic treatment with warfarin is effective in the prevention of thromboembolic events, although quite recently, new classes of anticoagulants that do not require international normalized ratio monitoring have been introduced with promising results.
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GOLDEN KEITH, MOUNSEY JOHNPAUL, CHUNG EUGENE, ROOMIANI PAHRESAH, MORSE MICHAELANDEW, PATEL ANKIT, GEHI ANIL. Atrial Fibrillation Ablation Using a Closed Irrigation Radiofrequency Ablation Catheter. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2012; 35:506-16. [DOI: 10.1111/j.1540-8159.2011.03309.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Prasad V, Kaplan RM, Passman RS. New Frontiers for Stroke Prevention in Atrial Fibrillation. Cerebrovasc Dis 2012; 33:199-208. [DOI: 10.1159/000334979] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2011] [Accepted: 11/03/2011] [Indexed: 11/19/2022] Open
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N-Terminal-proBrain natriuretic peptide measurement at presentation to identify patients with recent onset of atrial fibrillation. Int J Cardiol 2012; 154:208-9. [DOI: 10.1016/j.ijcard.2011.10.060] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2011] [Accepted: 10/18/2011] [Indexed: 11/21/2022]
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Meune C, Vermillet A, Wahbi K, Guerin S, Aelion H, Weber S, Chenevier-Gobeaux C. Mid-regional pro atrial natriuretic peptide allows the accurate identification of patients with atrial fibrillation of short time of onset: A pilot study. Clin Biochem 2011; 44:1315-9. [DOI: 10.1016/j.clinbiochem.2011.08.906] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2011] [Revised: 07/29/2011] [Accepted: 08/04/2011] [Indexed: 10/17/2022]
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Savelieva I, Kirchhof P, Danchin N, de Graeff PA, Camm AJ. Regulatory pathways for development of antiarrhythmic drugs for management of atrial fibrillation/flutter. Europace 2011; 13:1063-76. [DOI: 10.1093/europace/eur181] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Brunetti ND, De Gennaro L, Pellegrino PL, Dellegrottaglie G, Antonelli G, Di Biase M. Atrial fibrillation with symptoms other than palpitations: incremental diagnostic sensitivity with at-home tele-cardiology assessment for emergency medical service. Eur J Prev Cardiol 2011; 19:306-13. [PMID: 21502279 DOI: 10.1177/1741826711406060] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Clinical presentation of atrial fibrillation (AF) is usually represented by palpitations; nevertheless, atypical presentation of AF with symptoms other than palpitations may be not uncommon in elderly patients. This study therefore aimed to evaluate incremental diagnostic value of tele-medicine at-home assessment in patients who called emergency medical service (EMS). METHODS A total of 27,841 consecutive EMS patients referred for suspected heart disease underwent ECG assessment with a mobile ECG-recorder device. ECGs were transmitted with mobile-phone support to a tele-cardiology 'hub' active 24/7 where a cardiologist read the ECGs. Rate of prevalence of AF, age of patients, and symptoms were analysed. RESULTS AF was diagnosed in 11.67% of patients who underwent ECG examination. Typical symptoms were complained by 6.56% of whole patients, only 14.05% of patients with AF: rate of subjects with AF and typical symptoms significantly decreased with age (<65 years 29.58%, 65-75 years 17.06%, >75 years 10.35%, p < 0.001). Number needed to diagnose an AF with atypical presentation (number needed to treat) decreased from 45 (<65 years) to 9 (65-75 years) and 5 (>75 years) (p < 0.001). Tele-cardiology support increased the rate of at-home diagnosis of AF from two-fold (in 40-year-olds) up to four-fold (60-year-olds) and seven-fold (70-year-olds). CONCLUSIONS AF with symptoms other than palpitations is a common finding in elderly EMS patients. Tele-cardiology support improves the sensitivity of diagnosis of AF in elderly EMS patients and is useful in at-home identification of subjects with AF and atypical presentation.
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Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA, Halperin JL, Kay GN, Le Huezey JY, Lowe JE, Olsson SB, Prystowsky EN, Tamargo JL, Wann LS. 2011 ACCF/AHA/HRS Focused Updates Incorporated Into the ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation. Circulation 2011; 123:e269-367. [PMID: 21382897 DOI: 10.1161/cir.0b013e318214876d] [Citation(s) in RCA: 592] [Impact Index Per Article: 45.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA, Halperin JL, Kay GN, Le Huezey JY, Lowe JE, Olsson SB, Prystowsky EN, Tamargo JL, Wann LS. 2011 ACCF/AHA/HRS Focused Updates Incorporated Into the ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation. J Am Coll Cardiol 2011; 57:e101-98. [PMID: 21392637 DOI: 10.1016/j.jacc.2010.09.013] [Citation(s) in RCA: 543] [Impact Index Per Article: 41.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Abstract
Three different types of implantable cardiac devices are now commonly used in clinical medicine: pacemakers (including cardiac resynchronization systems), cardiac defibrillators, and loop recorders. Although pacing specialists and electrophysiologists have traditionally been responsible for device follow-up, the newest generation of implanted devices stores a wealth of information that can be useful to the clinical cardiologist. Important information, in addition to device function, such as incidence and type of arrhythmias, general clinical condition of the patient, and hemodynamic status can now be stored on large databases that are available via web access to all physicians caring for an individual patient. The advent of the remote monitoring capability of implanted devices has initiated a rapidly accelerating paradigm shift in device follow-up that can potentially improve patient care at lower cost.
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Affiliation(s)
- Fred Kusumoto
- Electrophysiology and Pacing Service, Division of Cardiology, Department of Medicine, Mayo Clinic, Jacksonville, Florida, USA.
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Simon H, Simon Demel K, Ritscher G, Turschner O, Brachmann J. [New developments in the antiarrhythmic therapy of atrial fibrillation]. Herzschrittmacherther Elektrophysiol 2010; 21:212-216. [PMID: 21107985 DOI: 10.1007/s00399-010-0093-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Atrial fibrillation, which is associated with a worsening of congestive heart failure symptoms, an increased rate of stoke, and increased mortality, is still difficult to treat. New therapies must not only increase effectiveness, but also have to have an improved safety profile, in order to avoid sodium channel block in the ventricle of older patients with atrial fibrillation, and also prevent electrical and morphological remodeling. Dronedarone is less effective compared to amiodarone, but has a better side effect profile which leads to fewer discontinuations of treatment. The atrial ion channels are specifically blocked by a number of prospective antiarrhythmic substances. The most advanced is the testing of vernakalant (RSD1235), which primarily suppresses the I(Kur) current. Ranolazine is a new antianginal substance which influences the atrial ion channels and leads to a significant reduction of atrial and more specifically ventricular tachyarrhythmias. A number of other drugs are in development. They will lead to a better understanding of which form of atrial fibrillation can be best treated with which antiarrhythmic agent.
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Affiliation(s)
- H Simon
- Kardiopulmonales Zentrum, Klinikum Coburg, Ketschendorferstr. 33, 96450, Coburg, Deutschland.
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Gil Núñez A. Avances en la prevención de la isquemia cerebral por fibrilación auricular. Neurologia 2010. [DOI: 10.1016/j.nrl.2010.03.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Marinigh R, Lip GYH, Lane DA. Stroke prevention in atrial fibrillation patients. Expert Opin Pharmacother 2010; 11:2331-50. [DOI: 10.1517/14656566.2010.498819] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Prystowsky EN, Camm J, Lip GYH, Allessie M, Bergmann JF, Breithardt G, Brugada J, Crijns H, Ellinor PT, Mark D, Naccarelli G, Packer D, Tamargo J. The impact of new and emerging clinical data on treatment strategies for atrial fibrillation. J Cardiovasc Electrophysiol 2010; 21:946-58. [PMID: 20384658 DOI: 10.1111/j.1540-8167.2010.01770.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
INTRODUCTION The Atrial Fibrillation (AF) Exchange Group, an international multidisciplinary group concerned with the management of AF, was convened to review recent advances in the field and the potential impact on treatment strategies. METHODS Issues discussed included epidemiology and the impact of the rising incidence of AF on health care systems, developments in pharmacological and surgical interventions in the management of arrhythmias and thromboprophylaxis, the potential to affect treatment strategies, and barriers to implementing them. RESULTS The incidence of AF and the associated burden on health care systems are increasing with aging populations, prevalence of comorbidities and more effective treatment of cardiovascular diseases. Advances in available medical treatments, in particular dronedarone and dabigatran, with other products in development, offer the possibility of changes in treatment paradigms and a greater emphasis on reducing hospitalizations and improvement in long-term outcomes instead of a symptom/safety-driven approach in which the priority is symptom suppression without provoking drug toxicity. Developments in catheter ablation techniques may mean that, in experienced centers, ablation may be offered as first-line treatment in selected patient populations. Barriers to optimal treatment include underdiagnosis, lack of recognition as a serious condition and as a risk factor for stroke, limited access to care, inadequate implementation of guidelines, and poor adherence to treatment. CONCLUSIONS The focus of the management of AF may be changing as a consequence of new treatments based on the outcome improvements they offer. However, the benefits will not be fully realized if guidelines and guidance are not observed in routine clinical practice.
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Watson T, Arya A, Sulke N, Lip GY. Relationship of Indices of Inflammation and Thrombogenesis to Arrhythmia Burden in Paroxysmal Atrial Fibrillation. Chest 2010; 137:869-76. [DOI: 10.1378/chest.09-1426] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
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RUITER JACOBH, MULDER ELLES, SCHUCHERT ANDREAS, BURRI HARAN, STÜHLINGER MARKUSC, HARTIKAINEN JUHA, SERMASI SERGIO, VLAŠÍNOVÁ JITKA, MAIRESSE GEORGESH, BUB EBERHARD, LEWALTER THORSTEN. The Feasibility of Fully Automated Pacemaker Advise in Treating Atrial Tachyarrhythmias. Pacing Clin Electrophysiol 2010; 33:605-14. [DOI: 10.1111/j.1540-8159.2010.02689.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Advances in the Prevention of Cerebral Ischaemia Due to Atrial Fibrillation. NEUROLOGÍA (ENGLISH EDITION) 2010. [DOI: 10.1016/s2173-5808(10)70076-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Kleemann T, Becker T, Strauss M, Schneider S, Seidl K. Prevalence of Left Atrial Thrombus and Dense Spontaneous Echo Contrast in Patients With Short-Term Atrial Fibrillation < 48 Hours Undergoing Cardioversion: Value of Transesophageal Echocardiography to Guide Cardioversion. J Am Soc Echocardiogr 2009; 22:1403-8. [DOI: 10.1016/j.echo.2009.09.015] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2009] [Indexed: 11/24/2022]
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Staubach S, Steinberg DH, Zimmermann W, Wawra N, Wilson N, Wunderlich N, Sievert H. New onset atrial fibrillation after patent foramen ovale closure. Catheter Cardiovasc Interv 2009; 74:889-95. [DOI: 10.1002/ccd.22172] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Amara W. [Management of atrial fibrillation in patients with cardiac stimulators or defibrillators: the possibilities of telemonitoring]. Ann Cardiol Angeiol (Paris) 2009; 58:226-229. [PMID: 18951118 DOI: 10.1016/j.ancard.2008.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2007] [Accepted: 07/13/2008] [Indexed: 05/27/2023]
Abstract
Some cardiac stimulators and defibrillators can be followed by telemonitoring. Telemonitoring permits diagnosis of atrial fibrillation episodes, which are frequently asymptomatic. Combination of holter memories with telemonitoring gives numerous informations about arrhythmias occurring. This can help to optimize rhythm control, rate control or anticoagulation. Examples issued from practice are presented in this article.
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Affiliation(s)
- W Amara
- Unité de rythmologie, CHI Le Raincy-Montfermeil, 10, rue du général-Leclerc, 93370 Montfermeil, France.
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