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Mostaza JM, Pintó X, Armario P, Masana L, Real JT, Valdivielso P, Arrobas-Velilla T, Baeza-Trinidad R, Calmarza P, Cebollada J, Civera-Andrés M, Cuende Melero JI, Díaz-Díaz JL, Espíldora-Hernández J, Fernández Pardo J, Guijarro C, Jericó C, Laclaustra M, Lahoz C, López-Miranda J, Martínez-Hervás S, Muñiz-Grijalvo O, Páramo JA, Pascual V, Pedro-Botet J, Pérez-Martínez P, Puzo J. SEA 2024 Standards for Global Control of Vascular Risk. CLINICA E INVESTIGACION EN ARTERIOSCLEROSIS : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE ARTERIOSCLEROSIS 2024; 36:133-194. [PMID: 38490888 DOI: 10.1016/j.arteri.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 02/03/2024] [Indexed: 03/17/2024]
Abstract
One of the objectives of the Spanish Society of Arteriosclerosis is to contribute to the knowledge, prevention and treatment of vascular diseases, which are the leading cause of death in Spain and entail a high degree of disability and health expenditure. Atherosclerosis is a multifactorial disease and its prevention requires a global approach that takes into account the associated risk factors. This document summarises the current evidence and includes recommendations for patients with established vascular disease or at high vascular risk: it reviews the symptoms and signs to evaluate, the laboratory and imaging procedures to request routinely or in special situations, and includes the estimation of vascular risk, diagnostic criteria for entities that are vascular risk factors, and general and specific recommendations for their treatment. Finally, it presents aspects that are not usually referenced in the literature, such as the organisation of a vascular risk consultation.
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Affiliation(s)
- José María Mostaza
- Servicio de Medicina Interna, Unidad de Lípidos y Arteriosclerosis, Hospital La Paz-Carlos III, Madrid, España.
| | - Xavier Pintó
- Unidad de Riesgo Vascular, Servicio de Medicina Interna, Hospital Universitario Bellvitge, Centro de Investigación Biomédica en Red, Fisiopatología de la Obesidad y Nutrición (CIBERobn), Fundación para la Investigación y Prevención de las Enfermedades Cardiovasculares (FIPEC), Universidad de Barcelona, Instituto de Investigación Biomédica de Bellvitge (IDIBELL), Barcelona, España
| | - Pedro Armario
- Servicio de Medicina Interna, Área de Atención Integrada de Riesgo Vascular, Complex Hospitalari Universitari Moisès Broggi, Consorci Sanitari Integral (CSI), Sant Joan Despí, Universidad de Barcelona, Barcelona, España
| | - Luis Masana
- Unidad de Medicina Vascular y Metabolismo (UVASMET), Institut d'Investigació Sanitària Pere Virgili (IISPV), Hospital Universitari Sant Joan de Reus, Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Universitat Rovira i Virgili, Tarragona, España
| | - José T Real
- Servicio de Endocrinología y Nutrición, Hospital Clínico, Universidad de València, Valencia, España; Departamento de Medicina, Universidad de Valencia, Valencia, España; CIBER de Diabetes y Enfermedades Metabólicas (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Madrid, España
| | - Pedro Valdivielso
- Unidad de Lípidos, Servicio de Medicina Interna, Hospital Universitario Virgen de la Victoria, Málaga, España; Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina (IBIMA-Bionand), Universidad de Málaga, Málaga, España
| | - Teresa Arrobas-Velilla
- Laboratorio de Nutrición y RCV, UGC de Bioquímica clínica, Hospital Virgen Macarena, Sevilla, España
| | | | - Pilar Calmarza
- Servicio de Bioquímica Clínica, Hospital Universitario Miguel Servet, Zaragoza, España; Centro de Investigación en Red en Enfermedades Cardiovasculares (CIBERCV), Instituto de Investigación Sanitaria (ISS) de Aragón, Universidad de Zaragoza, Zaragoza, España
| | - Jesús Cebollada
- Servicio de Medicina Interna, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España
| | - Miguel Civera-Andrés
- Servicio de Endocrinología y Nutrición, Hospital Clínico, Universidad de València, Valencia, España; Departamento de Medicina, Universidad de Valencia, Valencia, España
| | - José I Cuende Melero
- Consulta de Riesgo Cardiovascular, Servicio de Medicina Interna, Complejo Asistencial Universitario de Palencia, Palencia, España
| | - José L Díaz-Díaz
- Sección de Medicina Interna, Unidad de Lípidos y Riesgo Cardiovascular, Hospital Abente y Lago Complejo Hospitalario Universitario A Coruña, La Coruña, España
| | - Javier Espíldora-Hernández
- Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina (IBIMA-Bionand), Universidad de Málaga, Málaga, España; Unidad de Lípidos y Unidad Asistencial de Hipertensión Arterial- Riesgo Vascular (HTA-RV), UGC Medicina Interna, Hospital Universitario Virgen de la Victoria, Málaga, España
| | - Jacinto Fernández Pardo
- Servicio de Medicina Interna, Hospital General Universitario Reina Sofía de Murcia, Universidad de Murcia, Murcia, España
| | - Carlos Guijarro
- Unidad de Medicina Interna, Hospital Universitario Fundación Alcorcón, Universidad Rey Juan Carlos, Alcorón, España
| | - Carles Jericó
- Servicio de Medicina Interna, Área de Atención Integrada de Riesgo Vascular, Complex Hospitalari Universitari Moisès Broggi, Consorci Sanitari Integral (CSI), Sant Joan Despí, Universidad de Barcelona, Barcelona, España
| | - Martín Laclaustra
- Centro de Investigación en Red en Enfermedades Cardiovasculares (CIBERCV), Instituto de Investigación Sanitaria (ISS) de Aragón, Universidad de Zaragoza, Zaragoza, España
| | - Carlos Lahoz
- Servicio de Medicina Interna, Unidad de Lípidos y Arteriosclerosis, Hospital La Paz-Carlos III, Madrid, España
| | - José López-Miranda
- Unidad de Lípidos y Arteriosclerosis, UGC de Medicina Interna, Hospital Universitario Reina Sofía, Córdoba, España; Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Universidad de Córdoba, Córdoba, España; CIBER Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III (ISCIII), Madrid, España
| | - Sergio Martínez-Hervás
- Servicio de Endocrinología y Nutrición, Hospital Clínico, Universidad de València, Valencia, España; Departamento de Medicina, Universidad de Valencia, Valencia, España; CIBER de Diabetes y Enfermedades Metabólicas (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Madrid, España
| | - Ovidio Muñiz-Grijalvo
- Servicio de Medicina Interna, UCERV, UCAMI, Hospital Virgen del Rocío de Sevilla, Sevilla, España
| | - José A Páramo
- Servicio de Hematología, Clínica Universidad de Navarra, Navarra, España; Laboratorio Aterotrombosis, CIMA, Universidad de Navarra, Pamplona, España
| | - Vicente Pascual
- Centro de Salud Palleter, Universidad CEU-Cardenal Herrera, Castellón, España
| | - Juan Pedro-Botet
- Unidad de Lípidos y Riesgo Vascular, Servicio de Endocrinología y Nutrición, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, España
| | - Pablo Pérez-Martínez
- Unidad de Lípidos y Arteriosclerosis, UGC de Medicina Interna, Hospital Universitario Reina Sofía, Córdoba, España; Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Universidad de Córdoba, Córdoba, España; CIBER Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III (ISCIII), Madrid, España
| | - José Puzo
- Servicio de Bioquímica Clínica, Unidad de Lípidos, Hospital General Universitario San Jorge de Huesca, Huesca, España; Departamento de Medicina, Universidad de Zaragoza, Zaragoza, España
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Wahbi K, Bassez G, Duchateau J, Salort-Campana E, Vicart S, Desaphy JF, Labombarda F, Sellal JM, Deharo JC. Expert opinion on mexiletine treatment in adult patients with myotonic dystrophy. Arch Cardiovasc Dis 2024:S1875-2136(24)00059-7. [PMID: 38677940 DOI: 10.1016/j.acvd.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 03/13/2024] [Accepted: 03/25/2024] [Indexed: 04/29/2024]
Abstract
In France, mexiletine - a class I antiarrhythmic drug - can be prescribed for the symptomatic treatment of myotonia of the skeletal muscles in adult patients with myotonic dystrophy under a compassionate use programme. Mexiletine is used according to its summary of product characteristics, which describes its use for myotonia treatment in adult patients with non-dystrophic myotonia, a different neuromuscular condition without cardiac involvement. A cardiac assessment is required prior to initiation and throughout treatment due to potential proarrhythmic effects. The presence of conduction system disease, the most common cardiac manifestation of myotonic dystrophy, mandates repeated cardiac evaluations in patients with this condition, and becomes even more important when they are given mexiletine. A group of experts, including three neurologists and five cardiologists from French neuromuscular reference centres, were involved in a task force to develop a treatment algorithm to guide mexiletine use in myotonic dystrophy. The recommendations are based on data from a literature review of the safety of mexiletine-treated patients with myotonic dystrophy, the compassionate use protocol for mexiletine and the personal clinical experience of the experts. The main conclusion of the expert group is that, although existing safety data in mexiletine-treated patients with myotonic dystrophy are reassuring, cardiac assessments should be reinforced in such patients compared with mexiletine-treated patients with non-dystrophic myotonia. This expert opinion to guide mexiletine treatment in patients with myotonic dystrophy should help to reduce the risk of severe adverse events and facilitate interactions between specialists involved in the routine care of patients with myotonic dystrophy.
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Affiliation(s)
- Karim Wahbi
- Centre de Référence des Maladies Neuromusculaires Nord/Est/Île-de-France, Cardiology Department, Cochin Hospital, AP-HP, Paris Cité University, 75014 Paris, France; Paris Cardiovascular Research Centre (PARCC), Inserm Unit 970, Georges-Pompidou European Hospital, 75015 Paris, France.
| | - Guillaume Bassez
- Constitutive Reference Centre for Neuromuscular Diseases, Neuro-Myology Department, Pitié-Salpêtrière University Hospital, AP-HP, 75013 Paris, France
| | - Josselin Duchateau
- Department of Cardiology, Electrophysiology and Cardiac Pacing, Haut l'Evêque Cardiology Hospital, CHU de Bordeaux, 33604 Pessac, France
| | - Emmanuelle Salort-Campana
- Reference Centre for Neuromuscular Diseases PACA/Réunion/Rhône Alpes, La Timone Hospital, CHU de Marseille, AP-HM, 13385 Marseille, France; FILNEMUS, Neuromuscular Rare Diseases Healthcare Professional Network, La Timone Hospital, CHU de Marseille, AP-HM, 13385 Marseille, France
| | - Savine Vicart
- Muscle Channelopathies Reference Centre, Neuro-Myology Department, Pitié-Salpêtrière University Hospital, AP-HP, Inserm UMR 974, Institute of Myology, Sorbonne University, 75013 Paris, France
| | - Jean-François Desaphy
- Department of Precision and Regenerative Medicine and Ionian Area, School of Medicine, University of Bari Aldo Moro, 70124 Bari, Italy
| | - Fabien Labombarda
- Cardiology Department, CHU de Caen, UR 4650, UNICAEN, 14000 Caen, France
| | | | - Jean-Claude Deharo
- Cardiology Department, La Timone Hospital, CHU de Marseille, AP-HM, 13385 Marseille, France; C2VN, Aix-Marseille Université, 13005 Marseille, France
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Pharmacologic Rate versus Rhythm Control for Atrial Fibrillation in Heart Failure Patients. Medicina (B Aires) 2022; 58:medicina58060743. [PMID: 35744006 PMCID: PMC9228123 DOI: 10.3390/medicina58060743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 05/25/2022] [Accepted: 05/26/2022] [Indexed: 11/24/2022] Open
Abstract
Atrial fibrillation (AF) and Heart failure (HF) constitute two frequently coexisting cardiovascular diseases, with a great volume of the scientific research referring to strategies and guidelines associated with the best management of patients suffering from either of the two or both of these entities. The common pathophysiological paths, the adverse outcomes, the hospitalization rates, and the mortality rates that occur from various reports and trials indicate that a targeted therapy to the common background of these cardiovascular conditions may reverse the progression of their interrelating development. Among other optimal treatments concerning the prevalence of both AF and HF, the introduction of rhythm and rate control strategies in the guidelines has underlined the importance of sinus rhythm and heart rate control in the prevention of deleterious complications. The use of these strategies in the clinical practice has led to a debate about the superiority of rhythm versus rate control. The current guidelines as well as the published randomized trials and studies have not proved that rhythm control is more beneficial than the rate control treatments in the terms of survival, all-cause mortality, hospitalization rates, and quality of life. Therefore, the current therapeutic strategy is based on the therapy guidelines and the clinical judgment and experience. The aim of this review was to elucidate the endpoints of pharmacologic randomized clinical trials and the clinical data of each antiarrhythmic or rate-limiting medication, so as to promote their effective, individualized, evidence-based clinical use.
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Lacoste JL, Szymanski TW, Avalon JC, Kabulski G, Kohli U, Marrouche N, Singla A, Balla S, Jahangir A. Atrial Fibrillation Management: A Comprehensive Review with a Focus on Pharmacotherapy, Rate, and Rhythm Control Strategies. Am J Cardiovasc Drugs 2022; 22:475-496. [PMID: 35353353 DOI: 10.1007/s40256-022-00529-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/24/2022] [Indexed: 11/25/2022]
Abstract
Atrial fibrillation (AF) is an increasingly common arrhythmia encountered in clinical practice that leads to a substantial increase in utilization of healthcare services and a decrease in the quality of life of patients. The prevalence of AF will continue to increase as the population ages and develops cardiac comorbidities; thus, prompt and effective treatment is important to help mitigate systemic resource utilization. Treatment of AF involves two tenets: prevention of stroke and systemic embolism and symptom control with either a rate or a rhythm control strategy. Historically, due to the safe nature of medications like beta-blockers and non-dihydropyridine calcium channel blockers, used in rate control, it has been the initial strategy used for symptom control in AF. Newer data suggest that a rhythm control strategy with antiarrhythmic medications with or without catheter ablation may lead to a reduction in major adverse cardiovascular events, particularly in patients newly diagnosed with AF. Modulation of factors that promote AF or its complications is another important aspect of the overall holistic management of AF. This review provides a comprehensive focus on the management of patients with AF and an in-depth review of pharmacotherapy of AF in the rate and rhythm control strategies.
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Affiliation(s)
- Jordan L Lacoste
- Department of Pharmacy, WVU Medicine, 1 Medical Center Drive, Morgantown, WV, 26505, USA.
| | - Thomas W Szymanski
- Department of Pharmacy, WVU Medicine, 1 Medical Center Drive, Morgantown, WV, 26505, USA
| | - Juan Carlo Avalon
- Department of Internal Medicine, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Galen Kabulski
- Department of Pharmacy, WVU Medicine, 1 Medical Center Drive, Morgantown, WV, 26505, USA
| | - Utkarsh Kohli
- Department of Pediatrics, WVU School of Medicine, Morgantown, WV, USA
| | - Nassir Marrouche
- Department of Medicine, Section of Cardiology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Atul Singla
- Department of Medicine, Section of Cardiology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Sudarshan Balla
- Department of Cardiovascular and Thoracic Surgery, WVU School of Medicine, Morgantown, WV, USA
| | - Arshad Jahangir
- Center for Advanced Atrial Fibrillation Therapies at Aurora St. Luke's Medical Center, Milwaukee, WI, 53215, USA
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Gelfman DM. Appropriately Targeting Treatment of Atrial Fibrillation to Maximize Benefits in Older Adults. Am J Med 2022; 135:3-4. [PMID: 34343518 DOI: 10.1016/j.amjmed.2021.06.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 06/28/2021] [Indexed: 11/27/2022]
Affiliation(s)
- Daniel M Gelfman
- Division of Clinical Affairs, Marian University College of Osteopathic Medicine, Indianapolis, Ind.
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Gelfman DM. Reflections on quinine and its importance in dermatology today. Clin Dermatol 2021; 39:900-903. [PMID: 34785019 DOI: 10.1016/j.clindermatol.2021.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Quinine and its D-isomer quinidine have been used medically in Europe since the 1600s. They were originally found within the bark of the cinchona tree in the jungle of the Andes. They were recognized to have multiple beneficial medical properties, ranging from a combined antipyretic and analgesic effect to the first effective treatment for malaria and later atrial fibrillation. With the development of other medications and the recognition of the potential life-threatening toxic reactions to these drugs, their medical use declined. Quinine is available without a prescription in many countries and is present in tonic water. Quinine has an extensive following of users who believe it is salutary and harmless, considering it a food supplement. In the past, dermatologists were frequently the first to recognize disease caused by these drugs owing to early findings of dermatitis or petechiae. Even though the medical use of these drugs has markedly decreased, drug eruptions may still be due to quinine, and patients may even be unaware they are taking this medication.
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Affiliation(s)
- Daniel M Gelfman
- Division of Clinical Affairs, Marian University College of Osteopathic Medicine, Indianapolis, Indiana, USA.
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Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, Boriani G, Castella M, Dan GA, Dilaveris PE, Fauchier L, Filippatos G, Kalman JM, La Meir M, Lane DA, Lebeau JP, Lettino M, Lip GYH, Pinto FJ, Thomas GN, Valgimigli M, Van Gelder IC, Van Putte BP, Watkins CL. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J 2021; 42:373-498. [PMID: 32860505 DOI: 10.1093/eurheartj/ehaa612] [Citation(s) in RCA: 4881] [Impact Index Per Article: 1627.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Grubb A, Mentz RJ. Pharmacological management of atrial fibrillation in patients with heart failure with reduced ejection fraction: review of current knowledge and future directions. Expert Rev Cardiovasc Ther 2020; 18:85-101. [PMID: 32066285 DOI: 10.1080/14779072.2020.1732210] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Introduction: Both heart failure with reduced ejection fraction (HFrEF) and atrial fibrillation (AF) independently cause significant morbidity and mortality. The two conditions commonly coexist and AF in the setting of HFrEF is associated with worse mortality, hospitalizations, and quality of life compared to HFrEF without AF. Despite the large burden of these conditions, there is no clear optimal management strategy for when they occur together.Areas covered: This review focuses on the pharmacological management of AF in HFrEF. Studies were identified through PubMed search of relevant keywords. The authors review key clinical trials that have influenced management strategies and guidelines. The authors focus on the classes of drugs used to treat AF for both rate and rhythm control strategies including beta-blockers, digoxin, amiodarone, and dofetilide. Additionally, the authors discuss select non-antiarrhythmic medications that affect AF in HFrEF. The authors highlight the strengths and weakness of the data supporting the use of these medications and suggest future directions.Expert opinion: The pharmacological treatment of AF in HFrEF will need further refinement alongside the emerging role of catheter ablation. Novel HF medications and antiarrhythmics offer new tools to prevent the development of AF, as well as for rate and rhythm control strategies.
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Affiliation(s)
- Alex Grubb
- Department of Medicine, Duke University Hospital, Durham, NC, USA
| | - Robert J Mentz
- Division of Cardiology, Department of Medicine, Duke University Hospital, Durham NC, USA.,Duke Clinical Research Institute, Durham NC, USA
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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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10
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Abstract
Despite proven effectiveness in treating tachyarrhythmias, sotalol is proarrhythmic and can cause torsades de pointes. Given the emergence of studies that show no benefit from rhythm control strategies in managing atrial fibrillation, as well as the introduction of nonpharmacological approaches to treating arrhythmias, we felt it necessary to ascertain if there was any role for sotalol given its side effects. Review of the literature regarding sotalol use in the prevention and treatment of supraventricular and ventricular tachyarrhythmias seems to show that more effective and safer agents and nonpharmacological alternatives are currently available. However, sotalol still seems to be useful in preventing supraventricular tachyarrhythmias postcardiac surgery and in reverting hemodynamically stable sustained ventricular tachycardias in the setting of coronary artery disease. Its role in the prevention of tachyarrhythmias in the setting of arrhythmogenic right ventricular cardiomyopathy requires further investigation.
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11
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Quinidine Rebooted. JACC Clin Electrophysiol 2019; 5:383-386. [DOI: 10.1016/j.jacep.2019.01.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 01/10/2019] [Accepted: 01/17/2019] [Indexed: 11/17/2022]
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12
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Management of Atrial Fibrillation in Patients with Heart Failure: Time to Implement Ablation Control. Curr Cardiol Rep 2019; 21:10. [PMID: 30790104 DOI: 10.1007/s11886-019-1093-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
PURPOSE OF THE REVIEW Atrial fibrillation (AF) in patients with heart failure and reduced systolic ejection fraction (HFrEF) is common and associated with increased morbidity and mortality, and managing AF in this population has been particularly challenging with sparse data regarding the optimal treatment strategy. RECENT FINDINGS Recent data suggests that rhythm control with catheter ablation can be of particular benefit to patients with coexisting AF and HFrEF. Recent randomized control trials actually suggest that catheter ablation could potentially improve mortality in this particular patient population. This is in stark contrast to the current practice recommendations that reserve catheter ablation for symptomatic AF in the general population. In this paper, we will review the most current randomized controlled studies using catheter ablation in HFrEF patients with the hope to increase awareness of the potential mortality benefits the need for prioritization of catheter ablation in HFrEF patients in the next AF management guidelines.
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13
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Brieger D, Amerena J, Attia J, Bajorek B, Chan KH, Connell C, Freedman B, Ferguson C, Hall T, Haqqani H, Hendriks J, Hespe C, Hung J, Kalman JM, Sanders P, Worthington J, Yan TD, Zwar N. National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand: Australian Clinical Guidelines for the Diagnosis and Management of Atrial Fibrillation 2018. Heart Lung Circ 2019; 27:1209-1266. [PMID: 30077228 DOI: 10.1016/j.hlc.2018.06.1043] [Citation(s) in RCA: 199] [Impact Index Per Article: 39.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
| | - David Brieger
- Department of Cardiology, Concord Hospital, Sydney, Australia; University of Sydney, Sydney, Australia.
| | - John Amerena
- Geelong Cardiology Research Unit, University Hospital Geelong, Geelong, Australia
| | - John Attia
- University of Newcastle, Hunter Medical Research Institute, University of Newcastle, Newcastle, Australia
| | - Beata Bajorek
- Graduate School of Health, University of Technology Sydney & Department of Pharmacy, Royal North Shore Hospital, Australia
| | - Kim H Chan
- Royal Prince Alfred Hospital, Sydney, Australia; Sydney Medical School, The University of Sydney, Sydney, Australia
| | - Cia Connell
- The National Heart Foundation of Australia, Melbourne, Australia
| | - Ben Freedman
- Sydney Medical School, The University of Sydney, Sydney, Australia; Heart Research Institute, Charles Perkins Centre, University of Sydney, Sydney, Australia
| | - Caleb Ferguson
- Western Sydney University, Western Sydney Local Health District, Blacktown Clinical and Research School, Blacktown Hospital, Sydney, Australia
| | | | - Haris Haqqani
- University of Queensland, Department of Cardiology, Prince Charles Hospital, Brisbane, Australia
| | - Jeroen Hendriks
- Department of Cardiology, Royal Adelaide Hospital, Adelaide, Australia; Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Charlotte Hespe
- General Practice and Primary Care Research, School of Medicine, The University of Notre Dame Australia, Sydney, Australia
| | - Joseph Hung
- Medical School, Sir Charles Gairdner Hospital Unit, University of Western Australia, Perth, Australia
| | - Jonathan M Kalman
- University of Melbourne, Director of Heart Rhythm Services, Royal Melbourne Hospital, Melbourne, Australia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders (CHRD), South Australian Health and Medical Research Institute (SAHMRI), University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - John Worthington
- RPA Comprehensive Stroke Service, Royal Prince Alfred Hospital, Sydney, Australia
| | | | - Nicholas Zwar
- Graduate Medicine, University of Wollongong, Wollongong, Australia
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14
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Pharmacological Therapy for Ventricular Arrhythmias: A State-of-the Art Review. Heart Lung Circ 2019; 28:49-56. [DOI: 10.1016/j.hlc.2018.10.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 09/28/2018] [Accepted: 10/01/2018] [Indexed: 12/20/2022]
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15
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Affiliation(s)
- Norman C Wang
- University of Pittsburgh Medical Center, Pittsburgh, PA
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16
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Mascarenhas DA, Sharma M. Revisiting the Role of Antiarrhythmic Drugs in Prevention of Atrial Fibrillation Recurrence: A Single Center Retrospective Review. Cardiol Res 2018; 9:165-170. [PMID: 29904452 PMCID: PMC5997443 DOI: 10.14740/cr724w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 04/25/2018] [Indexed: 11/29/2022] Open
Abstract
Background We conducted a retrospective analysis to revisit the efficacy of four different commonly used antiarrhythmic drugs (AADs) in a single community hospital setting in the U.S. We used cardiac implantable electronic devices (CIEDs) to continuously monitor the patients for maintenance of sinus rhythm. The CIEDs in our study included insertable cardiac monitor (ICM), permanent pacemaker (PPM) and cardiac resynchronization therapy-defibrillator (CRT-D). The aim was to compare efficacy of commonly used AADs for maintenance of sinus rhythm in atrial fibrillation (AF) patients. Methods We conducted our retrospective study in a real world practice setting. We analyzed electronic medical records of 145 consecutive patients with paroxysmal and persistent AF who were treated with AADs for maintenance of sinus rhythm between the period of April 2014 and February 2018. Results Total 34 out of 145 patients (23.45%) had AF recurrence. The mean duration of first AF recurrence in total patient cohort was 18.01 ± 12 months. There was no major difference in efficacy in terms of prevention of first episode of AF recurrence among commonly used class III and class IC AADs. Conclusions Higher doses clearly seem to be more effective in preventing the recurrence of AF in class III AADs; sotalol and amiodarone. Use of CIEDs helps to continuously monitor patients for recurrence of AF and detects proarrhythmic effects of AADs.
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Affiliation(s)
- Daniel An Mascarenhas
- Department of Cardiology, Drexel University College of Medicine, Easton Hospital, Easton, PA, USA
| | - Munish Sharma
- Department of Internal Medicine, Easton Hospital, Easton, PA, USA
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17
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Bhatia S, Sugrue A, Asirvatham S. Atrial Fibrillation: Beyond Rate Control. Mayo Clin Proc 2018; 93:373-380. [PMID: 29502567 DOI: 10.1016/j.mayocp.2017.10.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 10/19/2017] [Accepted: 10/24/2017] [Indexed: 12/22/2022]
Abstract
Atrial fibrillation is the most common cardiac dysrhythmia encountered in the primary care setting. Although a rate control strategy is pursued by physicians for the initial treatment of atrial fibrillation, the efficacy of a rhythm control approach is often undervalued despite offering effective treatment options. There are many pharmacological therapies available to patients, with drug choice often dictated by safety concerns (toxicities and proarrhythmic adverse effects) as well as patient characteristics and comorbidities. This article presents a simplified approach to understanding the rhythm control strategy, including the advantages and disadvantages of various antiarrhythmic drugs and common drug-drug interactions encountered in the primary care setting.
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Affiliation(s)
- Subir Bhatia
- Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Alan Sugrue
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
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18
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Cardiac sodium channel antagonism - Translation of preclinical in vitro assays to clinical QRS prolongation. J Pharmacol Toxicol Methods 2017; 89:9-18. [PMID: 29042254 DOI: 10.1016/j.vascn.2017.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 08/31/2017] [Accepted: 10/09/2017] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Cardiac sodium channel antagonists have historically been used to treat cardiac arrhythmias by preventing the reentry of the electrical impulse that could occur following myocardial damage. However, clinical studies have highlighted a significant increase in mortality associated with such treatment. Cardiac sodium channel antagonist activity is now seen as an off-target pharmacology that should be mitigated during the drug development process. The aim of this study was to examine the correlation between in vitro/ex vivo assays that are routinely used to measure Nav1.5 activity and determine the translatability of the individual assays to QRS prolongation in the clinic. METHODS A set of clinical compounds with known Nav1.5 activity was profiled in several in vitro/ex vivo assays (binding, membrane potential, patch clamp and the Langendorff isolated heart). Clinical data comprising compound exposure levels and changes in QRS interval were obtained from the literature. Sensitivity/specificity analysis was performed with respect to the clinical outcome. RESULTS The in vitro assays showed utility in predicting QRS prolongation in the clinic. Optimal thresholds were defined for each assay (binding: IC20; membrane potential: IC10; patch clamp: IC20) and sensitivity (69-88%) and specificity (53-84%) values were shown to be similar between assay formats. DISCUSSION The data provide clear statistical insight into the translatability of Nav1.5 antagonism data generated in vitro to potential clinical outcomes. These results improve our ability to understand the liability posed by such activity in novel development compounds at an early stage.
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19
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Abstract
Cardiac arrhythmias are a leading cause of morbidity and mortality. Currently available therapeutic options lack sufficient efficacy and safety. Gene therapy has been proposed for treatment of cardiac arrhythmias. This review will discuss the current state of development for arrhythmia gene therapy. So far, all published studies are short-term, proof-of-concept animal studies. Potential replacement of cardiac pacemakers has been shown for combination gene therapy using the HCN2 gene and either the gene for adenylate cyclase, the skeletal muscle isoform of the sodium channel, or a dominant negative mutant of the potassium channel responsible for resting membrane potential. Atrial fibrillation has been prevented by gene transfer of either a dominant negative mutant of a repolarizing potassium channel, a gap junction, or an siRNA directed against caspase 3. Inherited arrhythmia syndromes have been corrected by replacement of the causative genes. Post-infarct ventricular tachycardia has been reduced by gene therapy with the skeletal muscle sodium channel and connexins and eliminated with the dominant negative mutant of the potassium channel responsible for resting membrane potential. These ideas show considerable promise. Long-term efficacy and safety studies are required to see if they can become viable therapies.
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Affiliation(s)
- J Kevin Donahue
- University of Massachusetts Medical School, Division of Cardiology, 55 Lake Ave. North, Worcester, MA 01655, United States.
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20
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Itäinen S, Lehto M, Vasankari T, Mustonen P, Kotamäki M, Numminen A, Lahtela H, Bah A, Hartikainen J, Hekkala AM, Airaksinen JKE. Non-vitamin K antagonist oral anticoagulants in atrial fibrillation patients undergoing elective cardioversion. Europace 2017; 20:565-568. [DOI: 10.1093/europace/eux116] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 04/10/2017] [Indexed: 11/13/2022] Open
Affiliation(s)
- Saga Itäinen
- Heart and Lung Center, Helsinki University Hospital and University of Helsinki
| | - Mika Lehto
- Heart and Lung Center, Helsinki University Hospital and University of Helsinki
| | - Tuija Vasankari
- Heart Center, Turku University Hospital and University of Turku
| | | | - Mervi Kotamäki
- Heart and Lung Center, Helsinki University Hospital and University of Helsinki
| | | | | | - Aissa Bah
- Heart Center, Kuopio University Hospital, University of Eastern Finland
| | - Juha Hartikainen
- Heart Center, Kuopio University Hospital, University of Eastern Finland
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21
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Osadchii OE. Role of abnormal repolarization in the mechanism of cardiac arrhythmia. Acta Physiol (Oxf) 2017; 220 Suppl 712:1-71. [PMID: 28707396 DOI: 10.1111/apha.12902] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
In cardiac patients, life-threatening tachyarrhythmia is often precipitated by abnormal changes in ventricular repolarization and refractoriness. Repolarization abnormalities typically evolve as a consequence of impaired function of outward K+ currents in cardiac myocytes, which may be caused by genetic defects or result from various acquired pathophysiological conditions, including electrical remodelling in cardiac disease, ion channel modulation by clinically used pharmacological agents, and systemic electrolyte disorders seen in heart failure, such as hypokalaemia. Cardiac electrical instability attributed to abnormal repolarization relies on the complex interplay between a provocative arrhythmic trigger and vulnerable arrhythmic substrate, with a central role played by the excessive prolongation of ventricular action potential duration, impaired intracellular Ca2+ handling, and slowed impulse conduction. This review outlines the electrical activity of ventricular myocytes in normal conditions and cardiac disease, describes classical electrophysiological mechanisms of cardiac arrhythmia, and provides an update on repolarization-related surrogates currently used to assess arrhythmic propensity, including spatial dispersion of repolarization, activation-repolarization coupling, electrical restitution, TRIaD (triangulation, reverse use dependence, instability, and dispersion), and the electromechanical window. This is followed by a discussion of the mechanisms that account for the dependence of arrhythmic vulnerability on the location of the ventricular pacing site. Finally, the review clarifies the electrophysiological basis for cardiac arrhythmia produced by hypokalaemia, and gives insight into the clinical importance and pathophysiology of drug-induced arrhythmia, with particular focus on class Ia (quinidine, procainamide) and Ic (flecainide) Na+ channel blockers, and class III antiarrhythmic agents that block the delayed rectifier K+ channel (dofetilide).
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Affiliation(s)
- O. E. Osadchii
- Department of Health Science and Technology; University of Aalborg; Aalborg Denmark
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22
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Abstract
This cohort study uses UK primary care database data to explore the association between long-term quinine exposure and all-cause mortality.
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Affiliation(s)
- Laurence Fardet
- EA 7379 EpiDermE, Université Paris Est Créteil, Créteil, France
| | - Irwin Nazareth
- Department of Primary Care and Population Health, University College London, London, United Kingdom
| | - Irene Petersen
- Department of Primary Care and Population Health, University College London, London, United Kingdom
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23
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Effects of Na+ channel blockers on the restitution of refractory period, conduction time, and excitation wavelength in perfused guinea-pig heart. PLoS One 2017; 12:e0172683. [PMID: 28231318 PMCID: PMC5322976 DOI: 10.1371/journal.pone.0172683] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Accepted: 02/08/2017] [Indexed: 12/29/2022] Open
Abstract
Na+ channel blockers flecainide and quinidine can increase propensity to ventricular tachyarrhythmia, whereas lidocaine and mexiletine are recognized as safe antiarrhythmics. Clinically, ventricular fibrillation is often precipitated by transient tachycardia that reduces action potential duration, suggesting that a critical shortening of the excitation wavelength (EW) may contribute to the arrhythmic substrate. This study examined whether different INa blockers can produce contrasting effects on the rate adaptation of the EW, which would explain the difference in their safety profile. In perfused guinea-pig hearts, effective refractory periods (ERP), conduction times, and EW values were determined over a wide range of cardiac pacing intervals. All INa blockers tested were found to flatten the slope of ERP restitution, indicating antiarrhythmic tendency. However, with flecainide and quinidine, the beneficial changes in ERP were reversed owing to the use-dependent conduction slowing, thereby leading to significantly steepened restitution of the EW. In contrast, lidocaine and mexiletine had no effect on ventricular conduction, and therefore reduced the slope of the EW restitution, as expected from their effect on ERP. These findings suggest that the slope of the EW restitution is an important electrophysiological determinant which can discriminate INa blockers with proarrhythmic and antiarrhythmic profile.
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24
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Chiang CE, Wu TJ, Ueng KC, Chao TF, Chang KC, Wang CC, Lin YJ, Yin WH, Kuo JY, Lin WS, Tsai CT, Liu YB, Lee KT, Lin LJ, Lin LY, Wang KL, Chen YJ, Chen MC, Cheng CC, Wen MS, Chen WJ, Chen JH, Lai WT, Chiou CW, Lin JL, Yeh SJ, Chen SA. 2016 Guidelines of the Taiwan Heart Rhythm Society and the Taiwan Society of Cardiology for the management of atrial fibrillation. J Formos Med Assoc 2016; 115:893-952. [PMID: 27890386 DOI: 10.1016/j.jfma.2016.10.005] [Citation(s) in RCA: 92] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Revised: 08/24/2016] [Accepted: 10/10/2016] [Indexed: 12/21/2022] Open
Abstract
Atrial fibrillation (AF) is the most common sustained arrhythmia. Both the incidence and prevalence of AF are increasing, and the burden of AF is becoming huge. Many innovative advances have emerged in the past decade for the diagnosis and management of AF, including a new scoring system for the prediction of stroke and bleeding events, the introduction of non-vitamin K antagonist oral anticoagulants and their special benefits in Asians, new rhythm- and rate-control concepts, optimal endpoints of rate control, upstream therapy, life-style modification to prevent AF recurrence, and new ablation techniques. The Taiwan Heart Rhythm Society and the Taiwan Society of Cardiology aimed to update the information and have appointed a jointed writing committee for new AF guidelines. The writing committee members comprehensively reviewed and summarized the literature, and completed the 2016 Guidelines of the Taiwan Heart Rhythm Society and the Taiwan Society of Cardiology for the Management of Atrial Fibrillation. This guideline presents the details of the updated recommendations, along with their background and rationale, focusing on data unique for Asians. The guidelines are not mandatory, and members of the writing committee fully realize that treatment of AF should be individualized. The physician's decision remains most important in AF management.
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Affiliation(s)
- Chern-En Chiang
- General Clinical Research Center, Division of Cardiology, Taipei Veterans General Hospital and National Yang-Ming University, Taipei, Taiwan.
| | - Tsu-Juey Wu
- Cardiovascular Center, Department of Internal Medicine, Taichung Veterans General Hospital and National Yang-Ming University, Taipei, Taiwan
| | - Kwo-Chang Ueng
- Department of Internal Medicine, School of Medicine, Chung-Shan Medical University (Hospital), Taichung, Taiwan
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Kuan-Cheng Chang
- Division of Cardiology, Department of Medicine, China Medical University Hospital, Taichung, Taiwan; Graduate Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan
| | - Chun-Chieh Wang
- Department of Internal Medicine, Section of Cardiology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yenn-Jiang Lin
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Wei-Hsian Yin
- Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan; Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Jen-Yuan Kuo
- Division of Cardiology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan; Department of Medicine, Mackay Medical College, Taipei, Taiwan
| | - Wei-Shiang Lin
- Division of Cardiology, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan
| | - Chia-Ti Tsai
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan
| | - Yen-Bin Liu
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan; Division of Cardiology, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Kun-Tai Lee
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Department of Internal Medicine, Faculty of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Li-Jen Lin
- Department of Internal Medicine, National Cheng Kung University College of Medicine and Hospital, Tainan, Taiwan
| | - Lian-Yu Lin
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan
| | - Kang-Ling Wang
- General Clinical Research Center, Division of Cardiology, Taipei Veterans General Hospital and National Yang-Ming University, Taipei, Taiwan
| | - Yi-Jen Chen
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Division of Cardiovascular Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Mien-Cheng Chen
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | | | - Ming-Shien Wen
- Department of Internal Medicine, Section of Cardiology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Wen-Jone Chen
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan; Division of Cardiology, Poh-Ai Hospital, Yilan, Taiwan
| | - Jyh-Hong Chen
- Department of Internal Medicine, National Cheng Kung University College of Medicine and Hospital, Tainan, Taiwan; College of Medicine, China Medical University, Taichung, Taiwan
| | - Wen-Ter Lai
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Department of Internal Medicine, Faculty of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chuen-Wang Chiou
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Jiunn-Lee Lin
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan
| | - San-Jou Yeh
- Department of Internal Medicine, Section of Cardiology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan.
| | - Shih-Ann Chen
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan.
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Czick ME, Shapter CL, Silverman DI. Atrial Fibrillation: The Science behind Its Defiance. Aging Dis 2016; 7:635-656. [PMID: 27699086 PMCID: PMC5036958 DOI: 10.14336/ad.2016.0211] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 02/11/2016] [Indexed: 12/19/2022] Open
Abstract
Atrial fibrillation (AF) is the most prevalent arrhythmia in the world, due both to its tenacious treatment resistance, and to the tremendous number of risk factors that set the stage for the atria to fibrillate. Cardiopulmonary, behavioral, and psychological risk factors generate electrical and structural alterations of the atria that promote reentry and wavebreak. These culminate in fibrillation once atrial ectopic beats set the arrhythmia process in motion. There is growing evidence that chronic stress can physically alter the emotion centers of the limbic system, changing their input to the hypothalamic-limbic-autonomic network that regulates autonomic outflow. This leads to imbalance of the parasympathetic and sympathetic nervous systems, most often in favor of sympathetic overactivation. Autonomic imbalance acts as a driving force behind the atrial ectopy and reentry that promote AF. Careful study of AF pathophysiology can illuminate the means that enable AF to elude both pharmacological control and surgical cure, by revealing ways in which antiarrhythmic drugs and surgical and ablation procedures may paradoxically promote fibrillation. Understanding AF pathophysiology can also help clarify the mechanisms by which emerging modalities aiming to correct autonomic imbalance, such as renal sympathetic denervation, may offer potential to better control this arrhythmia. Finally, growing evidence supports lifestyle modification approaches as adjuncts to improve AF control.
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Affiliation(s)
| | | | - David I. Silverman
- Echocardiography Laboratory, Hartford Hospital, Hartford, CT 06106, USA.
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26
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Aguilar M, Nattel S. The Past, Present, and Potential Future of Sodium Channel Block as an Atrial Fibrillation Suppressing Strategy. J Cardiovasc Pharmacol 2016; 66:432-40. [PMID: 25923324 DOI: 10.1097/fjc.0000000000000271] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Despite major advances in arrhythmia therapy, atrial fibrillation (AF) remains a challenge. A significant limitation in AF management is the lack of safe and effective drugs to restore and/or maintain sinus rhythm. The rational design of a new generation of AF-selective Na(+) channel blockers (NCBs) is emerging as a promising AF-suppressing strategy. Recent theoretical and experimental advances have generated insights into the mechanisms underlying AF maintenance and termination by antiarrhythmic drugs. Our understanding of antiarrhythmic drug-induced proarrhythmia has also grown in sophistication. These discoveries have created new possibilities in therapeutic targeting and renewed interest in improved NCB antiarrhythmic drugs. Recently described differences in atrial versus ventricular electrophysiology can be exploited in the prospective design of atrial-selective NCBs. Furthermore, state-dependent block has been shown to be an important modulator of NCB rate selectivity. Together, differential atrial-ventricular electrophysiological actions and state-dependent block form the backbone for the rational design of an AF-selective NCB. Synergistic combinations incorporating both NCB and block of K(+) currents may allow for further enhancement of AF selectivity. Future work on translating these basic research advances into the development of an optimized AF-selective NCB has the potential to provide safer and more effective pharmacotherapeutic options for AF, thereby fulfilling a major unmet clinical need.
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Affiliation(s)
- Martin Aguilar
- *Research Center, Montreal Heart Institute, Montreal, Québec, Canada; †Department of Physiology, Université de Montréal, Montreal, Québec, Canada; ‡Department of Medicine, McGill University, Montreal, Québec, Canada; §Department of Medicine, Université de Montréal, Montreal, Québec, Canada; and ¶Department of Pharmacology and Therapeutics, McGill University, Montreal, Québec, Canada
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Waks JW, Zimetbaum P. Antiarrhythmic Drug Therapy for Rhythm Control in Atrial Fibrillation. J Cardiovasc Pharmacol Ther 2016; 22:3-19. [DOI: 10.1177/1074248416651722] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and affects over 33 million people worldwide. AF is associated with stroke and systemic thromboembolism, unpleasant symptoms and reduced quality of life, heart failure, and increased mortality, and treatment of AF and its complications are associated with significant cost. Antiarrhythmic drugs (AADs) can suppress AF, allowing long-term maintenance of sinus rhythm, and have the potential to relieve symptoms and reverse or prevent adverse effects associated with AF. However, large randomized controlled studies evaluating use of AADs have not demonstrated a clear benefit to maintaining sinus rhythm, and AADs often have significant limitations, including a modest rate of overall success at maintaining sinus rhythm, frequent side effects, and potentially life-threatening toxicities. Although some of the currently available AADs have been available for almost 100 years, better tolerated and more efficacious AADs have recently been developed both for long-term maintenance of sinus rhythm and for chemical cardioversion of AF to sinus rhythm. Advances in automated AF detection with cardiac implantable electronic devices have suggested that AADs might be useful for suppressing AF to allow safe discontinuation of anticoagulation in select patients who are in sinus rhythm for prolonged periods of time. AADs may also have synergistic effects with catheter ablation of AF. This review summarizes the pharmacology and clinical use of currently available AADs for treatment of AF and discusses novel AADs and future directions for rhythm control in AF.
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Affiliation(s)
- Jonathan W. Waks
- Harvard-Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Peter Zimetbaum
- Harvard-Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Kang Y, Daly BJ, Kim JS. Uncertainty and Its Antecedents in Patients With A trial Fibrillation. West J Nurs Res 2016; 26:770-83. [PMID: 15466613 DOI: 10.1177/0193945904265815] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The aim of this descriptive, correlational, and cross-sectional survey was to explore uncertainty in patients with atrial fibrillation and to examine the relationships between uncertainty and its antecedents, including education, social support, and perceived seriousness of illness in patients newly diagnosed with atrial fibrillation. The theoretical framework of the study was Mishel’s middle-range nursing theory of uncertainty in illness. A convenience sample of 81 participants recruited from two academic medical centers over 10 months was interviewed. Uncertainty was moderately high in patients with atrial fibrillation compared to other clinical populations. Among antecedents of uncertainty, higher education was significantly associated with less uncertainty (= -.21 to -.25). Except for tangible support, persons with greater social supports perceived less uncertainty (= -.25 to -.27), and individuals with greater perceived seriousness of illness reported greater uncertainty (= .30 to .33).
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Affiliation(s)
- Younhee Kang
- College of Nursing Science, Ewha Womans University, Seoul, Korea.
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Abstract
Several types of supraventricular tachyarrhythmias occur commonly during intensive care. The specific type can usually be diagnosed using standard electrocardiographic techniques. Several new drugs have significantly improved the ability to successfully manage these arrhythmias.
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Affiliation(s)
- D M Salerno
- University of Minnesota Medical School-Minneapolis
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Influence of Gender on the Tolerability, Safety, and Efficacy of Quinidine Used for Treatment of Supraventricular and Ventricular Arrhythmias. Am J Cardiol 2015; 116:1845-51. [PMID: 26514302 DOI: 10.1016/j.amjcard.2015.09.042] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Revised: 09/06/2015] [Accepted: 09/06/2015] [Indexed: 11/23/2022]
Abstract
Quinidine, a class IA antiarrhythmic drug (AAD), has been used for the treatment of arrhythmias since the early 1900s. Use has decreased recently because of the availability of newer AADs and concerns about side effects and safety. Quinidine can cause QT prolongation, and women have longer QT intervals and are more susceptible to torsades de pointes (TdP) than are men. We sought to evaluate the influence of gender on quinidine tolerability, safety, and efficacy. We performed retrospective analyses of patients at our institution prescribed quinidine as an AAD between 2000 and 2012. Time to quinidine discontinuation and arrhythmia recurrence were evaluated using Cox proportional hazards models. In 179 patients, 23.5% were women and median age was 65.8 years. Quinidine indication was supraventricular arrhythmias in 68.7% and ventricular arrhythmias in 27.9% of patients. At 3 years after quinidine initiation, Kaplan-Meier probability of quinidine discontinuation was 65.7% for men and 82.4% for women (p = 0.015). Women were more likely than men to discontinue quinidine for QT prolongation (14.3 vs 4.4%, p = 0.036) and TdP (4.8 vs 0%, p = 0.054). After multivariate adjustment, female gender remained independently associated with quinidine discontinuation (adjusted hazard ratio 1.97, p = 0.014). Gender had no influence on arrhythmia recurrence: 1 year after quinidine initiation, Kaplan-Meier probability of freedom from recurrent arrhythmia was 62.4% in men and 57.9% in women (p = 0.33). Quinidine is highly effective in both genders. However, women are more likely than men to experience QT prolongation and TdP on quinidine and are more likely to discontinue quinidine independent of these side effects.
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Claro JC, Candia R, Rada G, Baraona F, Larrondo F, Letelier LM. Amiodarone versus other pharmacological interventions for prevention of sudden cardiac death. Cochrane Database Syst Rev 2015; 2015:CD008093. [PMID: 26646017 PMCID: PMC8407095 DOI: 10.1002/14651858.cd008093.pub2] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Sudden cardiac death (SCD) is one of the main causes of cardiac death. There are two main strategies to prevent it: managing cardiovascular risk factors and reducing the risk of ventricular arrhythmias. Implantable cardiac defibrillators (ICDs) constitute the standard therapy for both primary and secondary prevention; however, they are not widely available in settings with limited resources. The antiarrhythmic amiodarone has been proposed as an alternative to ICD. OBJECTIVES To evaluate the effectiveness of amiodarone for primary or secondary prevention in SCD compared with placebo or no intervention or any other antiarrhythmic drugs in participants at high risk (primary prevention) or who have recovered from a cardiac arrest or a syncope due to Ventricular Tachycardia/Ventricular Fibrillation, or VT/VF (secondary prevention). SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (OVID), EMBASE (OVID), CINAHL (EBSCO) and LILACS on 26 March 2015. We reviewed reference lists of included studies and selected reviews on the topic, contacted authors of included studies, screened relevant meetings and searched in registers for ongoing trials. We applied no language restrictions. SELECTION CRITERIA Randomised and quasi-randomised trials assessing the efficacy of amiodarone versus placebo, no intervention, or other antiarrhythmics in adults. For primary prevention we considered participants at high risk for SCD. For secondary prevention we considered participants recovered from cardiac arrest or syncope due to ventricular arrhythmias. DATA COLLECTION AND ANALYSIS Two authors independently assessed the trials for inclusion and extracted relevant data. We contacted trial authors for missing data. We performed meta-analyses using a random-effects model. We calculated risk ratios (RR) for dichotomous outcomes with 95% confidence intervals (CIs). Three studies included more than one comparison. MAIN RESULTS We included 24 studies (9,997 participants). Seventeen studies evaluated amiodarone for primary prevention and six for secondary prevention. Only three studies used an ICD concomitantly with amiodarone for the comparison (all of them for secondary prevention).For primary prevention, amiodarone compared to placebo or no intervention (17 studies, 8383 participants) reduced SCD (RR 0.76; 95% CI 0.66 to 0.88), cardiac mortality (RR 0.86; 95% CI 0.77 to 0.96) and all-cause mortality (RR 0.88; 95% CI 0.78 to 1.00). The quality of the evidence was low.Compared to other antiarrhythmics (three studies, 540 participants), amiodarone reduced SCD (RR 0.44; 95% CI 0.19 to 1.00), cardiac mortality (RR 0.41; 95% CI 0.20 to 0.86) and all-cause mortality (RR 0.37; 95% CI 0.18 to 0.76). The quality of the evidence was moderate.For secondary prevention, amiodarone compared to placebo or no intervention (two studies, 440 participants) appeared to increase the risk of SCD (RR 4.32; 95% CI 0.87 to 21.49) and all-cause mortality (RR 3.05; 1.33 to 7.01). However, the quality of the evidence was very low. Compared to other antiarrhythmics (four studies, 839 participants) amiodarone appeared to increase the risk of SCD (RR 1.40; 95% CI 0.56 to 3.52; very low quality of evidence), but there was no effect in all-cause mortality (RR 1.03; 95% CI 0.75 to 1.42; low quality evidence).Amiodarone was associated with an increase in pulmonary and thyroid adverse events. AUTHORS' CONCLUSIONS There is low to moderate quality evidence that amiodarone reduces SCD, cardiac and all-cause mortality when compared to placebo or no intervention for primary prevention, and its effects are superior to other antiarrhythmics.It is uncertain if amiodarone reduces or increases SCD and mortality for secondary prevention because the quality of the evidence was very low.
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Affiliation(s)
- Juan Carlos Claro
- Department of Internal Medicine and Evidence-Based Healthcare Program, Faculty of Medicine, Pontificia Universidad Católica de Chile, Lira 63, 1st floor, Santiago, Region Metropolitana, Chile
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Viskin S, Havakuk O, Schwaber MJ. Pro-Arrhythmic Effects of Noncardiac Medications. J Am Coll Cardiol 2015; 66:2185-2188. [DOI: 10.1016/j.jacc.2015.09.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Accepted: 09/08/2015] [Indexed: 12/01/2022]
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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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Haberman ZC, Jahn RT, Bose R, Tun H, Shinbane JS, Doshi RN, Chang PM, Saxon LA. Wireless Smartphone ECG Enables Large-Scale Screening in Diverse Populations. J Cardiovasc Electrophysiol 2015; 26:520-6. [PMID: 25651872 DOI: 10.1111/jce.12634] [Citation(s) in RCA: 149] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Revised: 01/29/2015] [Accepted: 02/01/2015] [Indexed: 01/01/2023]
Abstract
BACKGROUND The ubiquitous presence of internet-connected phones and tablets presents a new opportunity for cost-effective and efficient electrocardiogram (ECG) screening and on-demand diagnosis. Wireless, single-lead real-time ECG monitoring supported by iOS and android devices can be obtained quickly and on-demand. ECGs can be immediately downloaded and reviewed using any internet browser. OBJECTIVE We compared the standard 12-lead ECG to the smartphone ECG in healthy young adults, elite athletes, and cardiology clinic patients. Accuracy for determining baseline ECG intervals and rate and rhythm was assessed. METHODS In 381 participants, 30-second lead I ECG waveforms were obtained using an iPhone case or iPad. Standard 12-lead ECGs were acquired immediately after the smartphone tracing was obtained. De-identified ECGs were interpreted by automated algorithms and adjudicated by two board-certified electrophysiologists. RESULTS Both smartphone and standard ECGs detected atrial rate and rhythm, AV block, and QRS delay with equal accuracy. Sensitivities ranged from 72% (QRS delay) to 94% (atrial fibrillation). Specificities were all above 94% for both modalities. CONCLUSION Smartphone ECG accurately detects baseline intervals, atrial rate, and rhythm and enables screening in diverse populations. Efficient ECG analysis using automated discrimination and an enhanced smartphone application with notification capabilities are features that can be easily incorporated into the acquisition process.
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Affiliation(s)
| | - Ryan T Jahn
- Keck School of Medicine of USC, Los Angeles, California, USA
| | - Rupan Bose
- Keck School of Medicine of USC, Los Angeles, California, USA
| | - Han Tun
- Keck School of Medicine of USC, Los Angeles, California, USA
| | | | - Rahul N Doshi
- Keck School of Medicine of USC, Los Angeles, California, USA
| | - Philip M Chang
- Keck School of Medicine of USC, Los Angeles, California, USA
| | - Leslie A Saxon
- Keck School of Medicine of USC, Los Angeles, California, USA
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Hakalahti A, Biancari F, Nielsen JC, Raatikainen MJP. Radiofrequency ablation vs. antiarrhythmic drug therapy as first line treatment of symptomatic atrial fibrillation: systematic review and meta-analysis. Europace 2015; 17:370-8. [PMID: 25643988 DOI: 10.1093/europace/euu376] [Citation(s) in RCA: 136] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
AIMS New evidence about first-line radiofrequency catheter ablation (RFA) in symptomatic atrial fibrillation (AF) has emerged. In a single study the comparative treatment effect is potentially diminished by the high rate of cross-over to the alternative therapy. Therefore, we conducted a systematic review and meta-analysis of the available data to further evaluate the efficacy and safety of RFA vs. antiarrhythmic drugs (AADs). METHODS AND RESULTS Five databases were searched for randomized controlled trials comparing RFA and AAD therapy as first-line treatment of AF in August 2014. Three studies with 491 patients with recurrent symptomatic AF were included. The patients were relatively young and the majority of them had paroxysmal AF (98.7%) and no major comorbidity. Radiofrequency catheter ablation was associated with significantly higher freedom from AF recurrence compared with AAD therapy [risk ratio (RR) 0.63, 95% confidence interval (CI) 0.44-0.92, P = 0.02]. The difference in the rate of symptomatic AF recurrences was not statistically significant (RR 0.57, 95% CI 0.30-1.08, P = 0.09). There was one procedure-related death and seven tamponades with RFA, whereas symptomatic bradycardia was more frequent with AAD therapy. CONCLUSION Radiofrequency catheter ablation seems to be more effective than medical therapy as first-line treatment of paroxysmal AF in relatively young and otherwise healthy patients, but may also cause more severe adverse effects. These findings support the use of RFA as first-line therapy in selected patients, who understand the benefits and risks of the procedure.
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Affiliation(s)
- Antti Hakalahti
- Division of Cardiology, Oulu University Hospital, P.O. Box 5000, Oulu 90014, Finland
| | - Fausto Biancari
- Department of Surgery, Oulu University Hospital, Oulu, Finland
| | | | - M J Pekka Raatikainen
- Heart Center Co., Tampere University Hospital, Tampere, Finland Central Finland Central Hospital, Jyväskylä, Finland
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Sankaranarayanan R, Kirkwood G, Visweswariah R, Fox DJ. How does Chronic Atrial Fibrillation Influence Mortality in the Modern Treatment Era? Curr Cardiol Rev 2015; 11:190-8. [PMID: 25182145 PMCID: PMC4558350 DOI: 10.2174/1573403x10666140902143020] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Revised: 08/22/2014] [Accepted: 08/27/2014] [Indexed: 12/12/2022] Open
Abstract
Atrial fibrillation (AF) continues to impose a significant burden upon healthcare resources. A sustained increase in the ageing population and better survival from conditions such as ischaemic heart disease have ensured that both the incidence and prevalence of AF continue to increase significantly. AF can lead to complications such as embolism and heart failure and these acting in concert with its associated co-morbidities portend increased mortality risk. Whilst some studies suggest that the mortality risk from AF is due to the "bad company it keeps" i.e. the associated co-morbidities rather than AF itself; undoubtedly some of the mortality is also due to the side-effects of various therapeutic strategies (anti-arrhythmic drugs, bleeding side-effects due to anti-coagulants or invasive procedures). Despite several treatment advances including newer anti-arrhythmic drugs and developments in catheter ablation, anti-coagulation remains the only effective means to reduce the mortality due to AF. Warfarin has been used as the oral anticoagulant in the treatment of AF for many years but suffers from disadvantages such as unpredictable INR levels, bleeding risks and need for haematological monitoring. This has therefore spurred a renewed interest in research and clinical studies directed towards developing safer and more efficacious anti-coagulants. We shall review in this article the epidemiological features of AF-related mortality from several studies as well as the cardiovascular and non-cardiac mortality mechanisms. We shall also elucidate why a rhythm control strategy has appeared to be counter-productive and attempt to predict the likely future impact of novel anti-coagulants upon mortality reduction in AF.
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Affiliation(s)
- Rajiv Sankaranarayanan
- Cardiology Specialist Registrar in Electrophysiology and British Heart Foundation Clinical Research Fellow, University Hospital South Manchester and University of Manchester, Manchester, UK.
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Flaker G, Lopes RD, Hylek E, Wojdyla DM, Thomas L, Al-Khatib SM, Sullivan RM, Hohnloser SH, Garcia D, Hanna M, Amerena J, Harjola VP, Dorian P, Avezum A, Keltai M, Wallentin L, Granger CB. Amiodarone, anticoagulation, and clinical events in patients with atrial fibrillation: insights from the ARISTOTLE trial. J Am Coll Cardiol 2014; 64:1541-50. [PMID: 25301455 DOI: 10.1016/j.jacc.2014.07.967] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Revised: 06/17/2014] [Accepted: 07/08/2014] [Indexed: 11/16/2022]
Abstract
BACKGROUND Amiodarone is an effective medication in preventing atrial fibrillation (AF), but it interferes with the metabolism of warfarin. OBJECTIVES This study sought to examine the association of major thrombotic clinical events and bleeding with the use of amiodarone in the ARISTOTLE (Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation) trial. METHODS Baseline characteristics of patients who received amiodarone at randomization were compared with those who did not receive amiodarone. The interaction between randomized treatment and amiodarone was tested using a Cox model, with main effects for randomized treatment and amiodarone and their interaction. Matching on the basis of a propensity score was used to compare patients who received and who did not receive amiodarone at the time of randomization. RESULTS In ARISTOTLE, 2,051 (11.4%) patients received amiodarone at randomization. Patients on warfarin and amiodarone had time in the therapeutic range that was lower than patients not on amiodarone (56.5% vs. 63.0%; p < 0.0001). More amiodarone-treated patients had a stroke or a systemic embolism (1.58%/year vs. 1.19%/year; adjusted hazard ratio [HR]: 1.47, 95% confidence interval [CI]: 1.03 to 2.10; p = 0.0322). Overall mortality and major bleeding rates were elevated, but were not significantly different in amiodarone-treated patients and patients not on amiodarone. When comparing apixaban with warfarin, patients who received amiodarone had a stroke or a systemic embolism rate of 1.24%/year versus 1.85%/year (HR: 0.68, 95% CI: 0.40 to 1.15), death of 4.15%/year versus 5.65%/year (HR: 0.74, 95% CI: 0.55 to 0.98), and major bleeding of 1.86%/year versus 3.06%/year (HR: 0.61, 95% CI: 0.39 to 0.96). In patients who did not receive amiodarone, the stroke or systemic embolism rate was 1.29%/year versus 1.57%/year (HR: 0.82, 95% CI: 0.68 to 1.00), death was 3.43%/year versus 3.68%/year (HR: 0.93, 95% CI: 0.83 to 1.05), and major bleeding was 2.18%/year versus 3.03%/year (HR: 0.72, 95% CI: 0.62 to 0.84). The interaction p values for amiodarone use by apixaban treatment effects were not significant. CONCLUSIONS Amiodarone use was associated with significantly increased stroke and systemic embolism risk and a lower time in the therapeutic range when used with warfarin. Apixaban consistently reduced the rate of stroke and systemic embolism, death, and major bleeding compared with warfarin in amiodarone-treated patients and patients who were not on amiodarone.
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Affiliation(s)
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Elaine Hylek
- Boston University Medical Center, Boston, Massachusetts
| | - Daniel M Wojdyla
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Laine Thomas
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Sana M Al-Khatib
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | | | | | - David Garcia
- Division of Hematology, University of Washington, Seattle, Washington
| | | | - John Amerena
- Geelong Cardiology Research Center, Deakin University, Victoria, Australia
| | - Veli-Pekka Harjola
- Department of Medicine, Helsinki University Central Hospital, Helsinki, Finland
| | - Paul Dorian
- St. Michael's Hospital, Toronto, Ontario, Canada
| | - Alvaro Avezum
- Danta Pazzanese Institute of Cardiology, São Paulo, Brazil
| | - Matyas Keltai
- Hungarian Institute of Cardiology, Semmelweis University, Budapest, Hungary
| | - Lars Wallentin
- Cardiology and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Christopher B Granger
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
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Ramdjan TTTK, van der Does LJME, Knops P, Res JCJ, de Groot NMS. Right versus left atrial pacing in patients with sick sinus syndrome and paroxysmal atrial fibrillation (Riverleft study): study protocol for randomized controlled trial. Trials 2014; 15:445. [PMID: 25403703 PMCID: PMC4247220 DOI: 10.1186/1745-6215-15-445] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Accepted: 10/27/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The incidence of sick sinus syndrome will increase due to population ageing. Consequently, this will result in an increase in the number of pacemaker implantations. The atrial lead is usually implanted in the right atrial appendage, but this position may be ineffective for prevention of atrial fibrillation. It has been suggested that pacing distally in the coronary sinus might be more successful in preventing atrial fibrillation episodes. The aim of this trial is to study the efficacy of distal coronary sinus versus right atrial appendage pacing in preventing atrial fibrillation episodes in patients with sick sinus syndrome. METHODS/DESIGN This study is designed as a multicenter, randomized controlled trial. Patients with sick sinus syndrome and at least one atrial fibrillation episode of 30 seconds or more in the six months before recruitment will be eligible for participation in this study.All participants will be randomized between pacing distally in the coronary sinus and right atrial appendage. Randomization is stratified for all participating centers. Conventional dual-chamber pacemakers with advanced home monitoring functionality will be implanted. The ventricular lead will be implanted in the right ventricular apex. The first three months of the 36-month follow-up period are considered as run-in time. During the pre-randomization visit and follow-up, an interview, electrocardiogram and pacemaker assessment will be performed, prescribed antiarrhythmic medication will be reviewed and patients will be asked to complete an SF-36 questionnaire. An echocardiographic examination will be conducted in the pre-randomization phase and at the end of each follow-up year. Home monitoring will be used to send daily reports in case of atrial fibrillation episodes. DISCUSSION This randomized controlled trial is the first in which home monitoring will be used to compare atrial fibrillation recurrences between pacing in the distal coronary sinus or right atrial appendage. Home monitoring gives the opportunity to accurately detect atrial fibrillation episodes and to study characteristics of atrial fibrillation episodes. Should distal coronary sinus pacing significantly diminish atrial fibrillation recurrences, this study will redefine the preferential location of an atrial lead for preventive pacing. TRIAL REGISTRATION Current Controlled Trials ISRCTN65911661, registered on 8 July 2013.
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Affiliation(s)
| | | | | | | | - Natasja M S de Groot
- Unit translational electrophysiology, Department of Cardiology, Erasmus Medical Center, 's-Gravendijkwal 230, 3015 CE Rotterdam, Netherlands.
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Pattee GL, Wymer JP, Lomen-Hoerth C, Appel SH, Formella AE, Pope LE. An open-label multicenter study to assess the safety of dextromethorphan/quinidine in patients with pseudobulbar affect associated with a range of underlying neurological conditions. Curr Med Res Opin 2014; 30:2255-65. [PMID: 25062507 PMCID: PMC4743597 DOI: 10.1185/03007995.2014.940040] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Pseudobulbar affect (PBA) is associated with neurological disorders or injury affecting the brain, and characterized by frequent, uncontrollable episodes of crying and/or laughing that are exaggerated or unrelated to the patient's emotional state. Clinical trials establishing dextromethorphan and quinidine (DM/Q) as PBA treatment were conducted in patients with amyotrophic lateral sclerosis (ALS) or multiple sclerosis (MS). This trial evaluated DM/Q safety in patients with PBA secondary to any neurological condition affecting the brain. OBJECTIVE To evaluate the safety and tolerability of DM/Q during long-term administration to patients with PBA associated with multiple neurological conditions. METHODS Fifty-two-week open-label study of DM/Q 30/30 mg twice daily. Safety measures included adverse events (AEs), laboratory tests, electrocardiograms (ECGs), vital signs, and physical examinations. CLINICAL TRIAL REGISTRATION #NCT00056524. RESULTS A total of 553 PBA patients with >30 different neurological conditions enrolled; 296 (53.5%) completed. The most frequently reported treatment-related AEs (TRAEs) were nausea (11.8%), dizziness (10.5%), headache (9.9%), somnolence (7.2%), fatigue (7.1%), diarrhea (6.5%), and dry mouth (5.1%). TRAEs were mostly mild/moderate, generally transient, and consistent with previous controlled trials. Serious AEs (SAEs) were reported in 126 patients (22.8%), including 47 deaths, mostly due to ALS progression and respiratory failure. No SAEs were deemed related to DM/Q treatment by investigators. ECG results suggested no clinically meaningful effect of DM/Q on myocardial repolarization. Differences in AEs across neurological disease groups appeared consistent with the known morbidity of the primary neurological conditions. Study interpretation is limited by the small size of some disease groups, the lack of a specific efficacy measure and the use of a DM/Q dose higher than the eventually approved dose. CONCLUSIONS DM/Q was generally well tolerated over this 52 week trial in patients with PBA associated with a wide range of neurological conditions.
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Affiliation(s)
- Gary L. Pattee
- Neurology Associates
Lincoln, NEUSA
- Address for correspondence:
Gary L. Pattee MD, Neurology Associates,
PC, 2631 South 70th Street, Lincoln, NE 68506, USA. Tel.: +1 402 483 7226; Fax: +1 402 483 5440;
| | - James P. Wymer
- The Neurosciences Institute, Albany Medical Center
Albany, NYUSA
| | | | - Stanley H. Appel
- Department of Neurology, Methodist Neurological Institute, The Methodist Hospital Research Institute, The Methodist Hospital
Houston, TXUSA
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Nachimuthu S, Assar MD, Schussler JM. Drug-induced QT interval prolongation: mechanisms and clinical management. Ther Adv Drug Saf 2014; 3:241-53. [PMID: 25083239 DOI: 10.1177/2042098612454283] [Citation(s) in RCA: 188] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The prolonged QT interval is both widely seen and associated with the potentially deadly rhythm, Torsades de Pointes (TdP). While it can occur spontaneously in the congenital form, there is a wide array of drugs that have been implicated in the prolongation of the QT interval. Some of these drugs have either been restricted or withdrawn from the market due to the increased incidence of fatal polymorphic ventricular tachycardia. The list of drugs that cause QT prolongation continues to grow, and an updated list of specific drugs that prolong the QT interval can be found at www.qtdrugs.org. This review focuses on the mechanism of drug-induced QT prolongation, risk factors for TdP, culprit drugs, prevention and monitoring of prolonged drug-induced QT prolongation and treatment strategies.
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Affiliation(s)
- Senthil Nachimuthu
- Baylor University Medical Center, Jack and Jane Hamilton, Heart and Vascular Hospital Dallas, TX, USA
| | - Manish D Assar
- Baylor University Medical Center, Jack and Jane Hamilton, Heart and Vascular Hospital Dallas, TX, USA
| | - Jeffrey M Schussler
- Baylor University Medical Center, Jack and Jane Hamilton, Heart and Vascular Hospital, 621 North Hall Street, Suite 500, Dallas, TX 75226, USA
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Effects of Na+ Channel Blockers on Extrasystolic Stimulation-evoked Changes in Ventricular Conduction and Repolarization. J Cardiovasc Pharmacol 2014; 63:240-51. [DOI: 10.1097/fjc.0000000000000041] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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W Daniell M D H. Cytochrome P450-2D6 Genotype Definition May Improve Therapy for Paroxysmal Atrial Fibrillation A Case of Syncope Following "Pill-in-the-Pocket" Quinidine plus Propafenone. J Atr Fibrillation 2014; 6:978. [PMID: 27957038 DOI: 10.4022/jafib.978] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2013] [Revised: 01/07/2014] [Accepted: 01/13/2014] [Indexed: 12/31/2022]
Abstract
Classes 1A, 1C and III anti-arrhythmics may be ineffective or induce adverse events including potentially fatal arrhythmias when administered in recommended doses. Serum levels of these medications vary widely during conventional dosing due in large part to variations in cytochrome P450-2D6 isoenzyme activity which metabolizes most antiarrhythmics in addition to over 25% of other commonly prescribed medications. 2D6 activity is also profoundly inhibited by some antiarrhythmics and other commonly used medications and varies widely between the individuals of all populations, a pattern which has resulted in separation of subjects into 4 phenotypes and genotypes consisting of poor metabolizers (PM), intermediate metabolizers (IM), efficient metabolizers (EM), and ultra-rapid metabolizers (UM). Patients with a phenotype PM classification almost universally are also genotype PM due to the possession of two inactive 2D6 alleles, with this PM pattern often inducing supratherapeutic and toxic antiarrhythmic blood levels during conventional antiarrhythmic therapy. UM individuals have supranormal levels of 2D6 activity often created by the presence of 3 or more active alleles which often induce subtherapeutic and ineffective drug levels during antiarrhythmic administration in conventional doses. We searched for evidence relating Cytochrome P450-2D6 phenotypes or genotypes to antiarrhythmic metabolism in order to judge whether this analysis might contribute to improved safety and effectiveness of antiarrhythmic medications commonly utilized in the treatment of atrial fibrillation. The available evidence strongly supported these possibilities. We also describe a patient in whom knowledge of his IM/PM CYP2D6 genotype might have prevented the only episode of syncope and myocardial stunning which developed during his 28 years of "Pill-in-a-Pocket" therapy.
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Affiliation(s)
- Harry W Daniell M D
- Department of Family Practice University of California Medical School at Davis Davis, California, USA
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Abstract
Atrial fibrillation is the most common arrhythmia affecting patients today. Disease prevalence is increasing at an alarming rate worldwide, and is associated with often catastrophic and costly consequences, including heart failure, syncope, dementia, and stroke. Therapies including anticoagulants, anti-arrhythmic medications, devices, and non-pharmacologic procedures in the last 30 years have improved patients' functionality with the disease. Nonetheless, it remains imperative that further research into AF epidemiology, genetics, detection, and treatments continues to push forward rapidly as the worldwide population ages dramatically over the next 20 years.
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Affiliation(s)
- Thomas M. Munger
- Heart Rhythm Services, Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN 55905, USA;
| | - Li-Qun Wu
- Department of Cardiology, Rui Jin Hospital, Shanghai Jiao Tong University of Medicine, Shanghai 200025, China;
| | - Win K. Shen
- Division of Cardiovascular Diseases, Mayo Clinic, Phoenix, AZ 85054, USA.
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DE Sisti A, Leclercq JF, Halimi F, Fiorello P, Bertrand C, Attuel P. Evaluation of time course and predicting factors of progression of paroxysmal or persistent atrial fibrillation to permanent atrial fibrillation. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2013; 37:345-55. [PMID: 24236932 DOI: 10.1111/pace.12264] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2013] [Revised: 07/07/2013] [Accepted: 08/04/2013] [Indexed: 01/24/2023]
Abstract
BACKGROUND To evaluate time course and predictors of progression of paroxysmal or persistent atrial fibrillation (AF) to permanent AF. METHODS AND RESULTS We included 460 patients referred for paroxysmal (n = 337) or persistent (n = 123) AF between 1994 and 2012. Mean follow-up was 13.2 ± 6.5 years. AF progression rate was 3.7% per year, 19.7% at 5 years, and 38.1% at 10 years. Lone AF was diagnosed in 217 patients (47%). Predictors of permanent AF were: age, persistent AF, left atrial (LA) size, left ventricular-fractional shortening (LV-FS), lack of antiarrhythmic (AA) drugs, VVI pacing (P < 0.001 for all), and valvular disease (P < 0.02). Independent predictors were age (P < 0.001), persistent AF (P < 0.001), LA diameter (P < 0.005), lack of AA drugs (P < 0.005), and VVI pacing (P < 0.01). When adjusted at means of covariates, persistent AF and age >75 years remained highly significant (P < 0.01). LA dimension >50 mm was highly significant at univariate model (P < 0.001) but to a lesser extent when adjusted (P < 0.05). In patients with paroxysmal AF-with age <75 years-on AA drugs, progression rate to permanent AF was 6.5% at 5 years and 23.7% at 10 years. Among four predictors (age, LA size, LV-FS, and VVI pacing), only age (P < 0.01) and LA size (P < 0.005) remained independently significant, but LA size was not significant when adjusted. CONCLUSIONS Progression to permanent AF is a slow process. Aging, LA size, VVI pacing, lack of AA therapy, and a persistent form of AF independently increased the progression to permanent AF.
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Affiliation(s)
- Antonio DE Sisti
- Rhythmology Department, Parly II Private Hospital, Le Chesnay, France; Rhythmology Unit, Clinique Paul Picquet, Sens, France
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Noheria A, Asirvatham SJ. Periprocedural dabigatran anticoagulation for atrial fibrillation ablation: do we have enough information to make a rational decision. J Interv Card Electrophysiol 2013; 37:209-11. [PMID: 23892446 DOI: 10.1007/s10840-013-9821-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Accepted: 06/27/2013] [Indexed: 11/30/2022]
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Viskin S, Wilde AA, Guevara-Valdivia ME, Daoulah A, Krahn AD, Zipes DP, Halkin A, Shivkumar K, Boyle NG, Adler A, Belhassen B, Schapachnik E, Asrar F, Rosso R. Quinidine, A Life-Saving Medication for Brugada Syndrome, Is Inaccessible in Many Countries. J Am Coll Cardiol 2013; 61:2383-7. [DOI: 10.1016/j.jacc.2013.02.077] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Revised: 01/18/2013] [Accepted: 02/06/2013] [Indexed: 12/01/2022]
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