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Wilton SB, Kaul P, Islam S, Atzema CL, Cruz J, MacFarlane K, McKelvie R, Poon S, Lambert L, Rush K, Deyell M, Wyse DG, Cox JL, Skanes A, Sandhu RK. Surveillance for Outcomes Selected as Atrial Fibrillation Quality Indicators in Canada: 10-Year Trends in Stroke, Major Bleeding, and Heart Failure. CJC Open 2021; 3:609-618. [PMID: 34036258 PMCID: PMC8134946 DOI: 10.1016/j.cjco.2021.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 01/04/2021] [Indexed: 11/29/2022] Open
Abstract
Background Whether advances in identification and management of atrial fibrillation and atrial flutter (collectively, AF) have led to improved outcomes is unclear. We sought to study trends in clinical outcomes selected as quality indicators for nonvalvular AF in Canada. Methods We identified hospitalized patients with a first diagnosis of nonvalvular AF between April 2006 and March 2015, in all of Canada except Quebec. We assessed trends in 1-year incidence of stroke/systemic embolism (SSE), major bleeding, and initial heart failure (HF) hospitalization. Results The cohort included 466,476 patients. The median age was 77 years (interquartile range, 68-84 years), 46% were female, and 68% had a Congestive Heart Failure, Hypertension, Age (≥75 years), Diabetes, Stroke/Transient Ischemic Attack, Vascular Disease, Age (65-74 years), Sex (Female) (CHA2DS2-VASc) score > 3. Within 1 year of discharge, 3.5% were hospitalized for stroke or SSE, 1.6% for major bleeding, and 8.6% for new HF. Over the study period, the crude rate of SSE declined from 3.6% to 3.3% (P = 0.002), whereas the rates of hospitalization for new HF and for major bleeding did not significantly change. After adjustment for CHA2DS2-VASc score, the yearly rates of incident SSE (risk ratio, 0.99; 95% confidence interval [CI], 0.98-0.99; P = 0.002) and HF (risk ratio, 0.99; 95% CI, 0.99-1.00; P = 0.001) declined ≤ 1% absolute, whereas major bleeding remained unchanged (risk ratio, 1.00; 95% CI, 0.99-1.00; P = 0.28). Conclusions Among hospitalized patients with nonvalvular AF in Canada, the rate of SSE and new HF decreased modestly over a 10-year period, with no significant change in major bleeding. Efforts to study process-based quality indicators, with increased focus on HF prevention, are needed.
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Affiliation(s)
- Stephen B Wilton
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Padma Kaul
- Department of Medicine, Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - Sunjidatul Islam
- Department of Medicine, Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - Clare L Atzema
- Department of Emergency Services, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Jennifer Cruz
- Cardiac Arrhythmia Service, St Michael's Hospital, Toronto, Ontario, Canada
| | | | - Robert McKelvie
- Division of Cardiology, Western University, London, Ontario, Canada
| | - Stephanie Poon
- Division of Cardiology, Sunnybrook Hospital, Toronto, Ontario, Canada
| | - Laurie Lambert
- Institut national d'excellence en santé et en services sociaux, Montreal, Quebec, Canada
| | - Kathy Rush
- Faculty of Health and Social Development, School of Nursing, University of British Columbia, Kelowna, British Columbia, Canada.,Departments of Medicine and of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Marc Deyell
- Department of Medicine, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - D George Wyse
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Jafna L Cox
- Departments of Medicine and of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Allan Skanes
- Department of Medicine, London Heart Institute, University of Western Ontario, London, Ontario, Canada
| | - Roopinder K Sandhu
- Department of Medicine, Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
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Andrade JG, Aguilar M, Atzema C, Bell A, Cairns JA, Cheung CC, Cox JL, Dorian P, Gladstone DJ, Healey JS, Khairy P, Leblanc K, McMurtry MS, Mitchell LB, Nair GM, Nattel S, Parkash R, Pilote L, Sandhu RK, Sarrazin JF, Sharma M, Skanes AC, Talajic M, Tsang TSM, Verma A, Verma S, Whitlock R, Wyse DG, Macle L. The 2020 Canadian Cardiovascular Society/Canadian Heart Rhythm Society Comprehensive Guidelines for the Management of Atrial Fibrillation. Can J Cardiol 2020; 36:1847-1948. [PMID: 33191198 DOI: 10.1016/j.cjca.2020.09.001] [Citation(s) in RCA: 272] [Impact Index Per Article: 68.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 09/05/2020] [Accepted: 09/05/2020] [Indexed: 12/20/2022] Open
Abstract
The Canadian Cardiovascular Society (CCS) atrial fibrillation (AF) guidelines program was developed to aid clinicians in the management of these complex patients, as well as to provide direction to policy makers and health care systems regarding related issues. The most recent comprehensive CCS AF guidelines update was published in 2010. Since then, periodic updates were published dealing with rapidly changing areas. However, since 2010 a large number of developments had accumulated in a wide range of areas, motivating the committee to complete a thorough guideline review. The 2020 iteration of the CCS AF guidelines represents a comprehensive renewal that integrates, updates, and replaces the past decade of guidelines, recommendations, and practical tips. It is intended to be used by practicing clinicians across all disciplines who care for patients with AF. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system was used to evaluate recommendation strength and the quality of evidence. Areas of focus include: AF classification and definitions, epidemiology, pathophysiology, clinical evaluation, screening and opportunistic AF detection, detection and management of modifiable risk factors, integrated approach to AF management, stroke prevention, arrhythmia management, sex differences, and AF in special populations. Extensive use is made of tables and figures to synthesize important material and present key concepts. This document should be an important aid for knowledge translation and a tool to help improve clinical management of this important and challenging arrhythmia.
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Affiliation(s)
- Jason G Andrade
- University of British Columbia, Vancouver, British Columbia, Canada; Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada.
| | - Martin Aguilar
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | - Alan Bell
- University of Toronto, Toronto, Ontario, Canada
| | - John A Cairns
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Jafna L Cox
- Dalhousie University, Halifax, Nova Scotia, Canada
| | - Paul Dorian
- University of Toronto, Toronto, Ontario, Canada
| | | | | | - Paul Khairy
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | | | | | - Girish M Nair
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Stanley Nattel
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | | | | | - Jean-François Sarrazin
- Institut universitaire de cardiologie et de pneumologie de Québec, Université Laval, Québec, Québec, Canada
| | - Mukul Sharma
- McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada
| | | | - Mario Talajic
- Montreal Heart Institute, University of Montreal, Montréal, Quebec, Canada
| | - Teresa S M Tsang
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Atul Verma
- Southlake Regional Health Centre, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | - Laurent Macle
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
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Sandhu RK, Wilton SB, Islam S, Atzema CL, Deyell M, Wyse DG, Cox JL, Skanes A, Kaul P. Temporal Trends in Population Rates of Incident Atrial Fibrillation and Atrial Flutter Hospitalizations, Stroke Risk, and Mortality Show Decline in Hospitalizations. Can J Cardiol 2020; 37:310-318. [PMID: 32360794 DOI: 10.1016/j.cjca.2020.04.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 04/20/2020] [Accepted: 04/21/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Hospitalization for nonvalvular atrial fibrillation (NVAF) is common and results in substantial cost burden. Current national data trends for the incidence, stroke risk profiles, and mortality of hospitalization for NVAF and atrial flutter (AFL) are sparse. METHODS The Canadian Institute of Health Information Discharge Abstract Database was used to identify patients ≥ 20 years with incident NVAF/AFL (NVAF, ICD-9 code 427.3 or ICD-10 I48) in any diagnosis field from 2006 to 2015 in Canada, except Québec. National and provincial trends in rate over time (rate ratio, 95% confidence interval [CI]) were calculated for age-sex standardized hospitalizations. Trends in stroke risk profiles and in-hospital mortality rates adjusted for stroke risk factors were also calculated. RESULTS A total of 578,947 patients were hospitalized with incident NVAF/AFL. The median age was 77 years (interquartile range: 68-84), 82% were ≥ 65 years, 54% were men, 54% had a CHADS2 ≥ 2, and 69% had a CHA2DS2-Vasc ≥ 3. The overall age- and sex-standardized rate of NVAF/AFL hospitalization was 315 per 100,000 population and declined by 2% per year (P < 0.001). There was an annual rate decline in NVAF/AFL hospitalizations in every province. The majority of hospitalized patients are at high risk of stroke, and this risk remained unchanged. The average adjusted in-hospital mortality was 8.80 per 100 patients 95% CI, 8.80-8.81 with a 2% annual decline in rate (P < 0.001). CONCLUSION Between 2006 and 2015, we found national and provincial hospitalization rates for incident NVAF/AFL are declining. The majority of patients are at high risk for stroke. In-hospital mortality has declined but remains substantial.
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Affiliation(s)
- Roopinder K Sandhu
- Department of Medicine, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada; Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada.
| | - Stephen B Wilton
- Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
| | - Sunjiduatul Islam
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Clare L Atzema
- Department of Emergency Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Mark Deyell
- Department of Medicine, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - D George Wyse
- Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
| | - Jafna L Cox
- Departments of Medicine and of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Allan Skanes
- Department of Medicine, London Heart Institute, University of Western Ontario, London, Ontario, Canada
| | - Padma Kaul
- Department of Medicine, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada; Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
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Andrade JG, Verma A, Mitchell LB, Parkash R, Leblanc K, Atzema C, Healey JS, Bell A, Cairns J, Connolly S, Cox J, Dorian P, Gladstone D, McMurtry MS, Nair GM, Pilote L, Sarrazin JF, Sharma M, Skanes A, Talajic M, Tsang T, Verma S, Wyse DG, Nattel S, Macle L. 2018 Focused Update of the Canadian Cardiovascular Society Guidelines for the Management of Atrial Fibrillation. Can J Cardiol 2019; 34:1371-1392. [PMID: 30404743 DOI: 10.1016/j.cjca.2018.08.026] [Citation(s) in RCA: 168] [Impact Index Per Article: 33.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 08/14/2018] [Accepted: 08/15/2018] [Indexed: 11/19/2022] Open
Abstract
The Canadian Cardiovascular Society (CCS) Atrial Fibrillation Guidelines Committee provides periodic reviews of new data to produce focused updates that address clinically important advances in atrial fibrillation (AF) management. This 2018 Focused Update addresses: (1) anticoagulation in the context of cardioversion of AF; (2) the management of antithrombotic therapy for patients with AF in the context of coronary artery disease; (3) investigation and management of subclinical AF; (4) the use of antidotes for the reversal of non-vitamin K antagonist oral anticoagulants; (5) acute pharmacological cardioversion of AF; (6) catheter ablation for AF, including patients with concomitant AF and heart failure; and (7) an integrated approach to the patient with AF and modifiable cardiovascular risk factors. The recommendations were developed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) standards. Individual studies and literature were reviewed for quality and bias; the literature review process and evidence tables are included as Supplementary Material and are available on the CCS Web site. Details of the updated recommendations are presented, along with their background and rationale. This document is linked to an updated summary of all CCS AF guidelines recommendations, from 2010 to the present 2018 Focused Update, which is provided in the Supplementary Material.
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Affiliation(s)
- Jason G Andrade
- University of British Columbia, Vancouver, British Columbia, Canada; Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Atul Verma
- Southlake Regional Health Centre, Newmarket, Ontario, Canada
| | - L Brent Mitchell
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
| | - Ratika Parkash
- QEII Health Sciences Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Kori Leblanc
- University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Clare Atzema
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | - Jeff S Healey
- McMaster University, Hamilton, Ontario, Canada; Hamilton General Hospital, Hamilton, Ontario, Canada
| | - Alan Bell
- University of Toronto, Toronto, Ontario, Canada
| | - John Cairns
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Stuart Connolly
- McMaster University, Hamilton, Ontario, Canada; Hamilton General Hospital, Hamilton, Ontario, Canada
| | - Jafna Cox
- QEII Health Sciences Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Paul Dorian
- St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - David Gladstone
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | - M Sean McMurtry
- University of Alberta, Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Girish M Nair
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Louise Pilote
- McGill University Health Centre, Montréal, Quebec, Canada
| | | | - Mike Sharma
- McMaster University, Hamilton, Ontario, Canada; Hamilton General Hospital, Hamilton, Ontario, Canada
| | - Allan Skanes
- London Heart Institute, Western University, London, Ontario, Canada
| | - Mario Talajic
- Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Teresa Tsang
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Subodh Verma
- St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - D George Wyse
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
| | - Stanley Nattel
- Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Laurent Macle
- Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada.
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Jolly SS, Gao P, Cairns JA, Yusuf S, Bhatt DL, Wyse DG, Wells GA, Džavík V. Risks of Overinterpreting Interim Data: Lessons From the TOTAL Trial (Thrombectomy With PCI Versus PCI Alone in Patients With STEMI). Circulation 2019; 137:206-209. [PMID: 29311352 DOI: 10.1161/circulationaha.117.030656] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Sanjit S Jolly
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Canada (S.S.J., P.G., S.Y.)
| | - Peggy Gao
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Canada (S.S.J., P.G., S.Y.)
| | - John A Cairns
- University of British Columbia, Vancouver, Canada (J.A.C.)
| | - Salim Yusuf
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Canada (S.S.J., P.G., S.Y.)
| | - Deepak L Bhatt
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA (D.L.B.)
| | - D George Wyse
- Libin Cardiovascular Institute, Cumming School of Medicine, Calgary, Canada (D.G.W.)
| | | | - Vladimír Džavík
- Peter Munk Cardiac Centre, University Health Network, Toronto, Canada (V.D.)
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Wyse DG. Targeted Therapeutic Drug Monitoring for Direct Oral Anticoagulants: What Is Its Potential Place and Can It Limit Black Swan Events? Can J Cardiol 2018; 34:1393-1395. [DOI: 10.1016/j.cjca.2018.08.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 08/01/2018] [Indexed: 10/28/2022] Open
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Verma A, Ha AC, Kirchhof P, Hindricks G, Healey JS, Hill MD, Sharma M, Wyse DG, Champagne J, Essebag V, Wells G, Gupta D, Heidbuchel H, Sanders P, Birnie DH. The Optimal Anti-Coagulation for Enhanced-Risk Patients Post-Catheter Ablation for Atrial Fibrillation (OCEAN) trial. Am Heart J 2018; 197:124-132. [PMID: 29447772 DOI: 10.1016/j.ahj.2017.12.007] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 12/05/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND The optimal long-term antithrombotic regimen for patients after successful catheter-based atrial fibrillation (AF) ablation is not well defined. Presently, practice variation exists, and the benefits of oral anticoagulation over antiplatelet therapy across the entire spectrum of stroke risk profile remain undefined in the postablation population. To date, there are no randomized trials to inform clinicians on this therapeutic question. OBJECTIVE The objective was to assess whether rivaroxaban is superior to acetylsalicylic acid (ASA) in reducing the risk of clinically overt stroke, systemic embolism, or covert stroke among patients without apparent recurrent atrial arrhythmias for at least 1 year after their most recent AF ablation procedure. METHODS/DESIGN A prospective, multicenter, open-label, randomized trial with blinded assessment of outcomes is under way (NCT02168829). Atrial fibrillation patients with at least 1 stroke risk factor (as defined by the CHA2DS2-VASc score) and without known atrial arrhythmia recurrences for at least 12 months after ablation are randomized to rivaroxaban 15 mg or ASA 75-160 mg daily. The primary outcome is a composite of clinically overt stroke, systemic embolism, and covert stroke based on brain magnetic resonance imaging. Key secondary outcomes include major bleeding outcomes, intracranial hemorrhage, transient ischemic attack, neuropsychological testing, quality of life, and an economic analysis. Subjects will be followed for 3 years. The estimated overall sample size is 1,572 subjects (786 per arm). DISCUSSION The OCEAN trial is a multicenter randomized controlled trial evaluating 2 antithrombotic treatment strategies for patients with risk factors for stroke after apparently successful AF ablation. We hypothesize that rivaroxaban will reduce the occurrence of clinically overt stroke, systemic embolism, and covert stroke when compared with ASA alone.
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Wilton SB, Exner DV, Wyse DG, Yetisir E, Wells G, Tang AS, Healey JS. Frequency and Outcomes of Postrandomization Atrial Tachyarrhythmias in the Resynchronization/Defibrillation in Ambulatory Heart Failure Trial. Circ Arrhythm Electrophysiol 2016; 9:CIRCEP.115.003807. [DOI: 10.1161/circep.115.003807] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 03/22/2016] [Indexed: 11/16/2022]
Affiliation(s)
- Stephen B. Wilton
- From the Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada (S.B.W., D.V.E., D.G.W.); University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada (E.Y., G.W.); Department of Medicine, Western University, London, United Kingdom (A.S.L.T.); and Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada (J.S.H.)
| | - Derek V. Exner
- From the Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada (S.B.W., D.V.E., D.G.W.); University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada (E.Y., G.W.); Department of Medicine, Western University, London, United Kingdom (A.S.L.T.); and Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada (J.S.H.)
| | - D. George Wyse
- From the Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada (S.B.W., D.V.E., D.G.W.); University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada (E.Y., G.W.); Department of Medicine, Western University, London, United Kingdom (A.S.L.T.); and Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada (J.S.H.)
| | - Elizabeth Yetisir
- From the Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada (S.B.W., D.V.E., D.G.W.); University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada (E.Y., G.W.); Department of Medicine, Western University, London, United Kingdom (A.S.L.T.); and Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada (J.S.H.)
| | - George Wells
- From the Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada (S.B.W., D.V.E., D.G.W.); University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada (E.Y., G.W.); Department of Medicine, Western University, London, United Kingdom (A.S.L.T.); and Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada (J.S.H.)
| | - Anthony S.L. Tang
- From the Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada (S.B.W., D.V.E., D.G.W.); University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada (E.Y., G.W.); Department of Medicine, Western University, London, United Kingdom (A.S.L.T.); and Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada (J.S.H.)
| | - Jeffrey S. Healey
- From the Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada (S.B.W., D.V.E., D.G.W.); University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada (E.Y., G.W.); Department of Medicine, Western University, London, United Kingdom (A.S.L.T.); and Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada (J.S.H.)
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Wyse DG. Rate Control Versus Rhythm Control in the ORBIT-AF Registry. JACC Clin Electrophysiol 2016; 2:230-232. [DOI: 10.1016/j.jacep.2015.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 11/26/2015] [Indexed: 10/22/2022]
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Wong JA, Quinn FR, Gillis AM, Burland L, Chen G, Wyse DG, Wilton SB. Temporal Patterns and Predictors of Rate vs Rhythm Control in Patients Attending a Multidisciplinary Atrial Fibrillation Clinic. Can J Cardiol 2016; 32:1247.e7-1247.e13. [PMID: 26992570 DOI: 10.1016/j.cjca.2016.01.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Revised: 12/19/2015] [Accepted: 01/05/2016] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND Contemporary trends in the selection of and persistence with rate vs rhythm control for atrial fibrillation (AF) are not well studied, particularly in the context of multidisciplinary AF clinics. METHODS The initial arrhythmia management strategy in 1031 consecutive patients attending a multidisciplinary AF clinic from 2005-2012 was analyzed. RESULTS The 397 (38.5%) patients initially treated with rhythm control were younger (57.4 ± 14 years vs 65.6 ± 13 years; P < 0.0001) and more likely to be men (64.5% vs 56.9%; P = 0.019). They also had fewer comorbidities, lower CHADS2 (Congestive Heart Failure, Hypertension, Age, Diabetes, Stroke/Transient Ischemic Attack) scores, and greater symptom burden. The proportion treated with rhythm control declined from 46.9% in 2005-2006 to 28.4% in 2012 (P for trend < 0.0001). Compared with those initially selecting rate control, patients treated with rhythm control required more frequent clinic encounters (7 [interquartile range {IQR}, 3-12] vs 3 [IQR, 2-7]; P < 0.001) and longer follow-up (266 days [IQR, 84-548 days] vs 99 days [IQR, 0-313 days]; P < 0.001). Younger age, absence of diabetes and sleep apnea, earlier treatment year, higher symptom burden, and rural residence were independently associated with rhythm control. Persistence with the initial treatment strategy was reduced in the rhythm-control group (P = 0.003). CONCLUSIONS Use of rhythm control as the initial arrhythmia management strategy for AF in a specialty AF clinic is declining. Rhythm control requires more intensive follow-up and was more likely to lead to a change in arrhythmia management strategy.
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Affiliation(s)
- Jorge A Wong
- Cardiac Arrhythmia Service, Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, Cuming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
| | - F Russell Quinn
- Cardiac Arrhythmia Service, Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, Cuming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Anne M Gillis
- Cardiac Arrhythmia Service, Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, Cuming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Laurie Burland
- Cardiac Arrhythmia Service, Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, Cuming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Guanmin Chen
- Cardiac Arrhythmia Service, Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, Cuming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - D George Wyse
- Cardiac Arrhythmia Service, Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, Cuming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Stephen B Wilton
- Cardiac Arrhythmia Service, Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, Cuming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Cox JL, Dai S, Gong Y, McKelvie R, McMurtry MS, Oakes GH, Skanes A, Verma A, Wilton SB, Wyse DG. The Development and Feasibility Assessment of Canadian Quality Indicators for Atrial Fibrillation. Can J Cardiol 2016; 32:1566-1569. [PMID: 27297003 DOI: 10.1016/j.cjca.2016.02.059] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 02/01/2016] [Accepted: 02/05/2016] [Indexed: 10/22/2022] Open
Abstract
In 2010, the Canadian Cardiovascular Society embarked on an initiative to develop pan-Canadian quality indicators (QIs) and standardized data definitions with the ultimate goal of monitoring, comparing, and contrasting national cardiovascular care and its outcomes. One of the first working groups to be established was tasked with identifying and then defining a set of QIs for atrial fibrillation/flutter (AF/AFL). The Canadian Cardiovascular Society "Best Practices for Developing Cardiovascular Quality Indicators" methodology was used to develop an initial catalogue of 25 QIs intended to measure critical issues around access, process, and outcomes relating to AF/AFL management. This list was subsequently pared down to 5 QIs felt to have the greatest relative importance for quality assurance and measurability so as to facilitate early adoption. Three of these QIs were finally selected to assess the feasibility of their measurement using existing administrative datasets. These were the number of patients with a diagnosis of nonvalvular AF/AFL at high risk of stroke (75 years or older, or CHADS2 ≥ 2) receiving an oral anticoagulant, and the rates of stroke and major haemorrhage in patients with nonvalvular AF/AFL according to CHA2DS2-VASc score and anticoagulant use. Despite their clear importance in assessing AF/AFL care, none of these 3 QIs were found to be readily measurable across Canada using existing national datasets. Investment in new medical data infrastructure is required to facilitate regular monitoring of QIs to improve cardiovascular care.
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Affiliation(s)
- Jafna L Cox
- Departments of Medicine and of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada.
| | - Sulan Dai
- Centre for Chronic Disease Prevention and Control, Public Health Agency of Canada, Ottawa, Ontario, Canada
| | - Yanyan Gong
- Health System Performance, Canadian Institute for Health Information, Ottawa, Ontario, Canada
| | - Robert McKelvie
- Department of Medicine, Population Health Research Institute, McMaster University, London, Ontario, Canada
| | - M Sean McMurtry
- Department of Medicine, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Garth H Oakes
- Cardiac Care Network of Ontario, Toronto, Ontario, Canada
| | - Allan Skanes
- Department of Medicine, London Heart Institute, University of Western Ontario, London, Ontario, Canada
| | - Atul Verma
- Southlake Regional Health Centre, University of Toronto, Newmarket, Ontario, Canada
| | - Stephen B Wilton
- Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
| | - D George Wyse
- Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
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Andrade JG, Roy D, Wyse DG, Tardif JC, Talajic M, Leduc H, Tourigny JC, Shohoudi A, Dubuc M, Rivard L, Guerra PG, Thibault B, Dyrda K, Macle L, Khairy P. Heart rate and adverse outcomes in patients with atrial fibrillation: A combined AFFIRM and AF-CHF substudy. Heart Rhythm 2016; 13:54-61. [DOI: 10.1016/j.hrthm.2015.08.028] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Indexed: 10/23/2022]
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13
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Tremblay-Gravel M, Khairy P, Roy D, Leduc H, Wyse DG, Cadrin-Tourigny J, Macle L, Dubuc M, Andrade J, Rivard L, Guerra PG, Thibault B, Ahmed A, Talajic M, Guertin MC, White M. Systolic blood pressure and mortality in patients with atrial fibrillation and heart failure: insights from the AFFIRM and AF-CHF studies. Eur J Heart Fail 2014; 16:1168-74. [PMID: 25296634 DOI: 10.1002/ejhf.168] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Revised: 08/07/2014] [Accepted: 08/15/2014] [Indexed: 11/11/2022] Open
Abstract
AIMS To investigate the association between baseline systolic blood pressure levels and mortality in patients with AF with or without LV dysfunction. Hypertension leads to cardiovascular disease but, in specific groups, low blood pressure has been associated with a paradoxical increase in mortality. In patients with AF and heart failure, the relationship between blood pressure and death remains largely unknown. METHODS AND RESULTS We conducted a post-hoc combined analysis on pooled data from AFFIRM and AF-CHF trials and assessed the relationship between baseline systolic blood pressure (SBP) and mortality and hospitalizations. Patients were classified according to LVEF (>40%, ≤40%) and baseline SBP (<120 mmHg, 120-140 mmHg, >140 mmHg). A total of 5436 patients with non-permanent AF were followed for 41 ± 16 months. In patients with LVEF >40%, baseline SBP was not related to mortality using multivariate Cox regression analyses to adjust for baseline differences (P = 0.563). In contrast, in patients with LVEF ≤40% (n = 1980), SBP <120 mmHg and SBP >140 mmHg were both associated with a significant increase in total mortality compared with SBP 120-140 mmHg [hazard ratio (HR) 1.75, 95% confidence interval (CI) 1.41-2.17; and HR 1.40, 95% CI 1.04-1.90, respectively]. Hospitalizations were unrelated to SBP regardless of LVEF. CONCLUSIONS Mortality is modulated by baseline SBP levels in patients with AF and depressed EF but not in patients with normal EF. Targeted therapy of AF patients based on SBP merits further prospective investigation.
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14
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Wyse DG. Death and Digoxin: Stop Me If You've Heard This One Before. Can J Cardiol 2014; 30:1145-7. [DOI: 10.1016/j.cjca.2014.05.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2014] [Revised: 05/02/2014] [Accepted: 05/02/2014] [Indexed: 01/20/2023] Open
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15
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Wyse DG, Van Gelder IC, Ellinor PT, Go AS, Kalman JM, Narayan SM, Nattel S, Schotten U, Rienstra M. Lone atrial fibrillation: does it exist? J Am Coll Cardiol 2014; 63:1715-23. [PMID: 24530673 PMCID: PMC4008692 DOI: 10.1016/j.jacc.2014.01.023] [Citation(s) in RCA: 148] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2013] [Revised: 12/29/2013] [Accepted: 01/02/2014] [Indexed: 01/01/2023]
Abstract
The historical origin of the term "lone atrial fibrillation" (AF) predates by 60 years our current understanding of the pathophysiology of AF, the multitude of known etiologies for AF, and our ability to image and diagnose heart disease. The term was meant to indicate AF in patients for whom subsequent investigations could not demonstrate heart disease, but for many practitioners has become synonymous with "idiopathic AF." As the list of heart diseases has expanded and diagnostic techniques have improved, the prevalence of lone AF has fallen. The legacy of the intervening years is that definitions of lone AF in the literature are inconsistent so that studies of lone AF are not comparable. Guidelines provide a vague definition of lone AF but do not provide direction about how much or what kind of imaging and other testing are necessary to exclude heart disease. There has been an explosion in the understanding of the pathophysiology of AF in the last 20 years in particular. Nevertheless, there are no apparently unique mechanisms for AF in patients categorized as having lone AF. In addition, the term "lone AF" is not invariably useful in making treatment decisions, and other tools for doing so have been more thoroughly and carefully validated. It is, therefore, recommended that use of the term "lone AF" be avoided.
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Affiliation(s)
- D George Wyse
- Libin Cardiovascular Institute of Alberta/University of Calgary, Calgary, Alberta, Canada.
| | - Isabelle C Van Gelder
- Department of Cardiology, Thoraxcenter, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Patrick T Ellinor
- Cardiac Arrhythmia Service and Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Alan S Go
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Jonathan M Kalman
- Department of Cardiology, Royal Melbourne Hospital, and Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Sanjiv M Narayan
- University of California and Veterans' Affairs Medical Centers, San Diego, California
| | - Stanley Nattel
- Department of Medicine and Research Center, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Ulrich Schotten
- Department of Physiology, University Maastricht, Maastricht, the Netherlands
| | - Michiel Rienstra
- Department of Cardiology, Thoraxcenter, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
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Wyse DG. In overweight or obese patients with atrial fibrillation, a weight reduction program reduced symptoms. Ann Intern Med 2014; 160:JC6. [PMID: 24638184 DOI: 10.7326/0003-4819-160-6-201403180-02006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Wyse DG. A Critical Perspective on the Role of Catheter Ablation in Management of Atrial Fibrillation. Can J Cardiol 2013; 29:1150-7. [DOI: 10.1016/j.cjca.2013.03.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Revised: 02/26/2013] [Accepted: 03/01/2013] [Indexed: 11/29/2022] Open
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18
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White M, Tremblay-Gravel M, Khairy P, Roy D, Leduc H, Wyse DG, Ahmed A, Cadrin-Tourigny J, Macle L, Dubuc M, Andrade J, Rivard L, Guerra PG, Thibault B, Talajic M. BLOOD PRESSURE LEVELS MODULATE MORTALITY IN PATIENTS WITH ATRIAL FIBRILLATION AND HEART FAILURE WITH DEPRESSED BUT NOT IN PATIENTS WITH PRESERVED EJECTION FRACTION. J Am Coll Cardiol 2013. [DOI: 10.1016/s0735-1097(13)60734-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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19
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Ziegler PD, Glotzer TV, Daoud EG, Singer DE, Ezekowitz MD, Hoyt RH, Koehler JL, Coles J, Wyse DG. Detection of previously undiagnosed atrial fibrillation in patients with stroke risk factors and usefulness of continuous monitoring in primary stroke prevention. Am J Cardiol 2012; 110:1309-14. [PMID: 22819433 DOI: 10.1016/j.amjcard.2012.06.034] [Citation(s) in RCA: 122] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2012] [Revised: 06/13/2012] [Accepted: 06/13/2012] [Indexed: 11/16/2022]
Abstract
The detection of undiagnosed atrial tachycardia/atrial fibrillation (AT/AF) among patients with stroke risk factors could be useful for primary stroke prevention. We analyzed newly detected AT/AF (NDAF) using continuous monitoring in patients with stroke risk factors but without previous stroke or evidence of AT/AF. NDAF (AT/AF >5 minutes on any day) was determined in patients with implantable cardiac rhythm devices and ≥1 stroke risk factors (congestive heart failure, hypertension, age ≥75 years, or diabetes). All devices were capable of continuously monitoring the daily cumulative time in AT/AF. Of 1,368 eligible patients, NDAF was identified in 416 (30%) during a follow-up of 1.1 ± 0.7 years and was unrelated to the CHADS(2) score (congestive heart failure, hypertension [blood pressure consistently >140/90 mm Hg or hypertension treated with medication], age ≥75 years, diabetes mellitus, previous stroke or transient ischemic attack). The presence of AT/AF >6 hours on ≥1 day increased significantly with increased CHADS(2) scores and was present in 158 (54%) of 294 patients with NDAF and a CHADS(2) score of ≥2. NDAF was sporadic, and 78% of patients with a CHADS(2) score of ≥2 with NDAF experienced AT/AF on <10% of the follow-up days. The median interval to NDAF detection in these higher risk patients was 72 days (interquartile range 13 to 177). In conclusion, continuous monitoring identified NDAF in 30% of patients with stroke risk factors. In patients with NDAF, AT/AF occurred sporadically, highlighting the difficulty in detecting paroxysmal AT/AF using traditional monitoring methods. However, AT/AF also persisted for >6 hours on ≥1 days in most patients with NDAF and multiple stroke risk factors. Whether patients with CHADS(2) risk factors but without a history of AF might benefit from implantable monitors for the selection and administration of anticoagulation for primary stroke prevention merits additional investigation.
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20
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Wyse DG. ACP Journal Club. Short-term was less effective than long-term flecainide for preventing recurrent AF after cardioversion. Ann Intern Med 2012; 157:JC3-9. [PMID: 22986401 DOI: 10.7326/0003-4819-157-6-201209180-02009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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22
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Wyse DG. It's Health Care Delivery, Stupid: Implementing the New Canadian Cardiovascular Society Atrial Fibrillation Treatment Guidelines. Can J Cardiol 2011; 27:14-8. [DOI: 10.1016/j.cjca.2010.11.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2010] [Revised: 11/14/2010] [Accepted: 11/15/2010] [Indexed: 01/08/2023] Open
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Pratt CM, Roy D, Torp-Pedersen C, Wyse DG, Toft E, Juul-Moller S, Retyk E, Drenning DH. Usefulness of vernakalant hydrochloride injection for rapid conversion of atrial fibrillation. Am J Cardiol 2010; 106:1277-83. [PMID: 21029824 DOI: 10.1016/j.amjcard.2010.06.054] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2010] [Revised: 06/15/2010] [Accepted: 06/15/2010] [Indexed: 10/18/2022]
Abstract
The objective of the present study was to assess the safety and effectiveness of vernakalant hydrochloride injection (RSD1235), a novel antiarrhythmic drug, for the conversion of atrial fibrillation (AF) or atrial flutter to sinus rhythm (SR). Patients with either AF or atrial flutter were randomized in a 1:1 ratio to receive vernakalant (n = 138) or placebo (n = 138) and were stratified by an arrhythmia duration of >3 hours to ≤7 days (short duration) and 8 to ≤45 days (long duration). The first infusion of placebo or vernakalant (3 mg/kg) was given for 10 minutes followed by a second infusion of placebo or vernakalant (2 mg/kg) 15 minutes later if the arrhythmia had not terminated. A total of 265 patients were randomized and received treatment. The primary end point was conversion of AF to SR for ≥1 minute within 90 minutes of the start of the drug infusion in the short-duration AF group. Of the 86 patients receiving vernakalant in the short-duration AF group, 44 (51.2%) demonstrated conversion to SR compared to 3 (3.6%) of the 84 in the placebo group (p <0.0001). The median interval to conversion of short-duration AF to SR in the responders given vernakalant was 8 minutes. Of the entire AF population (short- and long-duration AF), 47 (39.8%) of the 118 vernakalant patients experienced conversion of AF to SR compared to 4 (3.3%) of the 121 placebo patients (p <0.0001). Transient dysgeusia and sneezing were the most common adverse events in the vernakalant patients. One vernakalant patient who had severe aortic stenosis experienced hypotension and ventricular fibrillation and died. In conclusion, vernakalant demonstrated a rapid and high rate of conversion for short-duration AF and was well tolerated.
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24
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Ziegler PD, Glotzer TV, Daoud EG, Wyse DG, Singer DE, Ezekowitz MD. Response to Letter by Willey. Stroke 2010. [DOI: 10.1161/strokeaha.110.584821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | | | - D. George Wyse
- Libin Cardiovascular Institute of Alberta, Alberta, Canada
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25
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Talajic M, Khairy P, Levesque S, Connolly SJ, Dorian P, Dubuc M, Guerra PG, Hohnloser SH, Lee KL, Macle L, Nattel S, Pedersen OD, Stevenson LW, Thibault B, Waldo AL, Wyse DG, Roy D. Maintenance of Sinus Rhythm and Survival in Patients With Heart Failure and Atrial Fibrillation. J Am Coll Cardiol 2010; 55:1796-802. [DOI: 10.1016/j.jacc.2010.01.023] [Citation(s) in RCA: 111] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2009] [Revised: 12/17/2009] [Accepted: 01/25/2010] [Indexed: 11/16/2022]
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26
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Ziegler PD, Glotzer TV, Daoud EG, Wyse DG, Singer DE, Ezekowitz MD, Koehler JL, Hilker CE. Incidence of newly detected atrial arrhythmias via implantable devices in patients with a history of thromboembolic events. Stroke 2009; 41:256-60. [PMID: 20044517 DOI: 10.1161/strokeaha.109.571455] [Citation(s) in RCA: 145] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND AND PURPOSE Evidence of atrial tachycardia/atrial fibrillation (AT/AF) is often sought in patients with ischemic stroke or transient ischemic attack. We studied patients with previous thromboembolic events (TE) who were implanted with devices capable of continuous arrhythmia monitoring to comprehensively quantify the incidence and duration of newly detected AT/AF. METHODS This study represents a subgroup analysis of the TRENDS trial, which included patients with clinical indications for pacemakers or defibrillators and >or=1 stroke risk factors (heart failure, hypertension, age 65 or older, diabetes, or previous TE). A history of AF was not required. All implanted devices were capable of continuously monitoring the cumulative time spent in AT/AF each day. This analysis focuses primarily on the incidence and duration of newly detected AT/AF (defined as >or=5 minutes of AT/AF on any day) in patients with previous TE, no documented history of AF, and no warfarin or antiarrhythmic drug use. RESULTS A total of 319 patients had a history of TE and >or=1 day of device data. Patients with a documented history of AF (n=80), warfarin use (n=56), or antiarrhythmic drug use (n=20) were excluded from analysis. Of the remaining 163 patients, newly detected AT/AF was identified via the device in 45 patients (28%) over a mean follow-up of 1.1+/-0.7 years. AT/AF recurred infrequently, with only 12 patients experiencing AT/AF on >10% of follow-up days. CONCLUSIONS Newly detected episodes of AT/AF were found via continuous monitoring in 28% of patients with previous TE. Most episodes would not have been detected by standard intermittent monitoring techniques.
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27
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Affiliation(s)
- D. George Wyse
- From the Libin Cardiovascular Institute of Alberta/University of Calgary, Calgary, Alberta, Canada
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28
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Glotzer TV, Daoud EG, Wyse DG, Singer DE, Ezekowitz MD, Hilker C, Miller C, Qi D, Ziegler PD. The relationship between daily atrial tachyarrhythmia burden from implantable device diagnostics and stroke risk: the TRENDS study. Circ Arrhythm Electrophysiol 2009; 2:474-80. [PMID: 19843914 DOI: 10.1161/circep.109.849638] [Citation(s) in RCA: 640] [Impact Index Per Article: 42.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND It is unknown if brief episodes of device-detected atrial fibrillation (AF) increase thromboembolic event (TE) risk. METHODS AND RESULTS TRENDS was a prospective, observational study enrolling patients with > or = 1 stroke risk factor (heart failure, hypertension, age > or = 65 years, diabetes, or prior TE) receiving pacemakers or defibrillators that monitor atrial tachycardia (AT)/AF burden (defined as the longest total AT/AF duration on any given day during the prior 30-day period). This time-varying exposure was updated daily during follow-up and related to TE risk. Annualized TE rates were determined according to AT/AF burden subsets: zero, low (<5.5 hours [median duration of subsets with nonzero burden]), and high (> or = 5.5 hours). A multivariate Cox model provided hazard ratios including terms for stroke risk factors and time-varying AT/AF burden and antithrombotic therapy. Patients (n=2486) had at least 30 days of device data for analysis. During a mean follow-up of 1.4 years, annualized TE risk (including transient ischemic attacks) was 1.1% for zero, 1.1% for low, and 2.4% for high burden subsets of 30-day windows. Compared with zero burden, adjusted hazard ratios (95% CIs) in the low and high burden subsets were 0.98 (0.34 to 2.82, P=0.97) and 2.20 (0.96 to 5.05, P=0.06), respectively. CONCLUSIONS The TE rate was low compared with patients with traditional AF with similar risk profiles. The data suggest that TE risk is a quantitative function of AT/AF burden. AT/AF burden > or = 5.5 hours on any of 30 prior days appeared to double TE risk. Additional studies are needed to more precisely investigate the relationship between stroke risk and AT/AF burden.
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Affiliation(s)
- Taya V Glotzer
- Hackensack University Medical Center, Hackensack, NJ, USA.
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29
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Wyse DG. Change is coming: Lead, follow, or get out of the way. J Interv Card Electrophysiol 2009; 25:163-5. [PMID: 19609659 DOI: 10.1007/s10840-009-9406-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2009] [Accepted: 04/06/2009] [Indexed: 11/26/2022]
Affiliation(s)
- D George Wyse
- Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta/University of Calgary, Room G009, Health Sciences Center, 3330 Hospital Dr. NW, Calgary, AB, Canada, T2N 1N4.
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Dorian P, Guerra PG, Kerr CR, O’Donnell SS, Crystal E, Gillis AM, Mitchell LB, Roy D, Skanes AC, Rose MS, Wyse DG. Validation of a New Simple Scale to Measure Symptoms in Atrial Fibrillation. Circ Arrhythm Electrophysiol 2009; 2:218-24. [PMID: 19808471 DOI: 10.1161/circep.108.812347] [Citation(s) in RCA: 118] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Atrial fibrillation (AF) is commonly associated with impaired quality of life. There is no simple validated scale to quantify the functional illness burden of AF. The Canadian Cardiovascular Society Severity in Atrial Fibrillation (CCS-SAF) scale is a bedside scale that ranges from class 0 to 4, from no effect on functional quality of life to a severe effect on life quality. This study was performed to validate the scale.
Methods and Results—
In 484 patients with documented AF (62.2�12.5 years of age, 67% men; 62% paroxysmal and 38% persistent/permanent), the SAF class was assessed and 2 validated quality-of-life questionnaires were administered: the SF-36 generic scale and the disease-specific AFSS (University of Toronto Atrial Fibrillation Severity Scale). There is a significant linear graded correlation between the SAF class and measures of symptom severity, physical and emotional components of quality of life, general well-being, and health care consumption related to AF. Patients with SAF class 0 had age- and sex-standardized SF-36 scores of 0.15�0.16 and −0.04�0.31 (SD units), that is, units away from the mean population score for the mental and physical summary scores, respectively. For each unit increase in SAF class, there is a 0.36 and 0.40 SD unit decrease in the SF-36 score for the physical and mental components. As the SAF class increases from 0 to 4, the symptom severity score (range, 0 to 35) increases from 4.2�5.0 to 18.4�7.8 (
P
<0.0001).
Conclusions—
The CCS-SAF scale is a simple semiquantitative scale that closely approximates patient-reported subjective measures of quality of life in AF and may be practical for clinical use.
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Affiliation(s)
- Paul Dorian
- From the Division of Cardiology (P.D., S.S.O.), St Michael’s Hospital and the University of Toronto, Toronto, Ontario; the Division of Cardiology (P.G.G., D.R.), Montreal Heart Institute and the Université de Montréal, Montreal, Quebec; the Division of Cardiology (C.R.K.), St Paul’s Hospital and the University of British Columbia, Vancouver, British Columbia; the Division of Cardiology (E.C.), Sunnybrook and Women’s College Health Sciences Centre and the University of Toronto, Toronto, Ontario
| | - Peter G. Guerra
- From the Division of Cardiology (P.D., S.S.O.), St Michael’s Hospital and the University of Toronto, Toronto, Ontario; the Division of Cardiology (P.G.G., D.R.), Montreal Heart Institute and the Université de Montréal, Montreal, Quebec; the Division of Cardiology (C.R.K.), St Paul’s Hospital and the University of British Columbia, Vancouver, British Columbia; the Division of Cardiology (E.C.), Sunnybrook and Women’s College Health Sciences Centre and the University of Toronto, Toronto, Ontario
| | - Charles R. Kerr
- From the Division of Cardiology (P.D., S.S.O.), St Michael’s Hospital and the University of Toronto, Toronto, Ontario; the Division of Cardiology (P.G.G., D.R.), Montreal Heart Institute and the Université de Montréal, Montreal, Quebec; the Division of Cardiology (C.R.K.), St Paul’s Hospital and the University of British Columbia, Vancouver, British Columbia; the Division of Cardiology (E.C.), Sunnybrook and Women’s College Health Sciences Centre and the University of Toronto, Toronto, Ontario
| | - Suzan S. O’Donnell
- From the Division of Cardiology (P.D., S.S.O.), St Michael’s Hospital and the University of Toronto, Toronto, Ontario; the Division of Cardiology (P.G.G., D.R.), Montreal Heart Institute and the Université de Montréal, Montreal, Quebec; the Division of Cardiology (C.R.K.), St Paul’s Hospital and the University of British Columbia, Vancouver, British Columbia; the Division of Cardiology (E.C.), Sunnybrook and Women’s College Health Sciences Centre and the University of Toronto, Toronto, Ontario
| | - Eugene Crystal
- From the Division of Cardiology (P.D., S.S.O.), St Michael’s Hospital and the University of Toronto, Toronto, Ontario; the Division of Cardiology (P.G.G., D.R.), Montreal Heart Institute and the Université de Montréal, Montreal, Quebec; the Division of Cardiology (C.R.K.), St Paul’s Hospital and the University of British Columbia, Vancouver, British Columbia; the Division of Cardiology (E.C.), Sunnybrook and Women’s College Health Sciences Centre and the University of Toronto, Toronto, Ontario
| | - Anne M. Gillis
- From the Division of Cardiology (P.D., S.S.O.), St Michael’s Hospital and the University of Toronto, Toronto, Ontario; the Division of Cardiology (P.G.G., D.R.), Montreal Heart Institute and the Université de Montréal, Montreal, Quebec; the Division of Cardiology (C.R.K.), St Paul’s Hospital and the University of British Columbia, Vancouver, British Columbia; the Division of Cardiology (E.C.), Sunnybrook and Women’s College Health Sciences Centre and the University of Toronto, Toronto, Ontario
| | - L. Brent Mitchell
- From the Division of Cardiology (P.D., S.S.O.), St Michael’s Hospital and the University of Toronto, Toronto, Ontario; the Division of Cardiology (P.G.G., D.R.), Montreal Heart Institute and the Université de Montréal, Montreal, Quebec; the Division of Cardiology (C.R.K.), St Paul’s Hospital and the University of British Columbia, Vancouver, British Columbia; the Division of Cardiology (E.C.), Sunnybrook and Women’s College Health Sciences Centre and the University of Toronto, Toronto, Ontario
| | - Denis Roy
- From the Division of Cardiology (P.D., S.S.O.), St Michael’s Hospital and the University of Toronto, Toronto, Ontario; the Division of Cardiology (P.G.G., D.R.), Montreal Heart Institute and the Université de Montréal, Montreal, Quebec; the Division of Cardiology (C.R.K.), St Paul’s Hospital and the University of British Columbia, Vancouver, British Columbia; the Division of Cardiology (E.C.), Sunnybrook and Women’s College Health Sciences Centre and the University of Toronto, Toronto, Ontario
| | - Allan C. Skanes
- From the Division of Cardiology (P.D., S.S.O.), St Michael’s Hospital and the University of Toronto, Toronto, Ontario; the Division of Cardiology (P.G.G., D.R.), Montreal Heart Institute and the Université de Montréal, Montreal, Quebec; the Division of Cardiology (C.R.K.), St Paul’s Hospital and the University of British Columbia, Vancouver, British Columbia; the Division of Cardiology (E.C.), Sunnybrook and Women’s College Health Sciences Centre and the University of Toronto, Toronto, Ontario
| | - M. Sarah Rose
- From the Division of Cardiology (P.D., S.S.O.), St Michael’s Hospital and the University of Toronto, Toronto, Ontario; the Division of Cardiology (P.G.G., D.R.), Montreal Heart Institute and the Université de Montréal, Montreal, Quebec; the Division of Cardiology (C.R.K.), St Paul’s Hospital and the University of British Columbia, Vancouver, British Columbia; the Division of Cardiology (E.C.), Sunnybrook and Women’s College Health Sciences Centre and the University of Toronto, Toronto, Ontario
| | - D. George Wyse
- From the Division of Cardiology (P.D., S.S.O.), St Michael’s Hospital and the University of Toronto, Toronto, Ontario; the Division of Cardiology (P.G.G., D.R.), Montreal Heart Institute and the Université de Montréal, Montreal, Quebec; the Division of Cardiology (C.R.K.), St Paul’s Hospital and the University of British Columbia, Vancouver, British Columbia; the Division of Cardiology (E.C.), Sunnybrook and Women’s College Health Sciences Centre and the University of Toronto, Toronto, Ontario
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Benjamin EJ, Chen PS, Bild DE, Mascette AM, Albert CM, Alonso A, Calkins H, Connolly SJ, Curtis AB, Darbar D, Ellinor PT, Go AS, Goldschlager NF, Heckbert SR, Jalife J, Kerr CR, Levy D, Lloyd-Jones DM, Massie BM, Nattel S, Olgin JE, Packer DL, Po SS, Tsang TSM, Van Wagoner DR, Waldo AL, Wyse DG. Prevention of atrial fibrillation: report from a national heart, lung, and blood institute workshop. Circulation 2009; 119:606-18. [PMID: 19188521 DOI: 10.1161/circulationaha.108.825380] [Citation(s) in RCA: 381] [Impact Index Per Article: 25.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
The National Heart, Lung, and Blood Institute convened an expert panel April 28 to 29, 2008, to identify gaps and recommend research strategies to prevent atrial fibrillation (AF). The panel reviewed the existing basic scientific, epidemiological, and clinical literature about AF and identified opportunities to advance AF prevention research. After discussion, the panel proposed the following recommendations: (1) enhance understanding of the epidemiology of AF in the population by systematically and longitudinally investigating symptomatic and asymptomatic AF in cohort studies; (2) improve detection of AF by evaluating the ability of existing and emerging methods and technologies to detect AF; (3) improve noninvasive modalities for identifying key components of cardiovascular remodeling that promote AF, including genetic, fibrotic, autonomic, structural, and electrical remodeling markers; (4) develop additional animal models reflective of the pathophysiology of human AF; (5) conduct secondary analyses of already-completed clinical trials to enhance knowledge of potentially effective methods to prevent AF and routinely include AF as an outcome in ongoing and future cardiovascular studies; and (6) conduct clinical studies focused on secondary prevention of AF recurrence, which would inform future primary prevention investigations.
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Affiliation(s)
- Emelia J Benjamin
- Framingham Heart Study, 73 Mount Wayte Ave, Suite 2, Framingham, MA 01702-5827, USA.
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Hallstrom AP, Wyse DG, McAnulty J. Clinical criteria for predicting benefit of ICD/PM in post myocardial infarction patients: an AVID and CAST analysis. J Interv Card Electrophysiol 2008; 23:159-66. [PMID: 18810620 DOI: 10.1007/s10840-008-9304-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2008] [Accepted: 07/11/2008] [Indexed: 11/24/2022]
Abstract
BACKGROUND Three clinical factors from the Antiarrhythmics Versus Implantable Defibrillators (AVID) trial-heart failure, left ventricular dysfunction and certain historical features defined a subgroup in which an implantable cardioverter defibrillator (ICD/PM) has a mortality advantage over amiodarone. METHODS These three factors were jointly evaluated in the AVID cohort with ischemic heart disease (IHD) and the results applied in placebo-treated post-infarction patients in the cardiac arrhythmia suppression trial (CAST). RESULTS Similar predictive power was noted in AVID patients with IHD. In CAST the factors defined three groups; one group (5.8%), corresponding to AVID patients that had high risk and benefited from an ICD/PM and another group (17.2%) corresponding to patients in AVID where the risk was moderate and ICD/PM and amiodarone had equal efficacy, demonstrated a two-fold higher risk of sudden arrhythmic than non-arrhythmic death and hence would be expected to benefit from antiarrhythmia therapy. The third group, corresponding to AVID patients with low risk of arrhythmia, demonstrated similar and low risks of sudden arrhythmic and non-arrhythmic death. Thus this group (77%) is unlikely to benefit from indiscriminate antiarrhythmia therapy. Onset of risk of death in CAST patients was offset from randomization by 3 to 6 months. CONCLUSIONS Readily available clinical criteria identify a small group likely to benefit from an ICD/PM after recent myocardial infarction (MI) and the remainder unlikely to benefit from nonselective ICD/PM therapy. Additional risk stratification should focus on the latter patients and be timed to allow ICD/PM implantation between 2 and 6 months after MI.
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Affiliation(s)
- Alfred P Hallstrom
- Department of Biostatistics, University of Washington, Seattle, WA 98105, USA.
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Roy D, Talajic M, Nattel S, Wyse DG, Dorian P, Lee KL, Bourassa MG, Arnold JMO, Buxton AE, Camm AJ, Connolly SJ, Dubuc M, Ducharme A, Guerra PG, Hohnloser SH, Lambert J, Le Heuzey JY, O'Hara G, Pedersen OD, Rouleau JL, Singh BN, Stevenson LW, Stevenson WG, Thibault B, Waldo AL. Rhythm control versus rate control for atrial fibrillation and heart failure. N Engl J Med 2008; 358:2667-77. [PMID: 18565859 DOI: 10.1056/nejmoa0708789] [Citation(s) in RCA: 1085] [Impact Index Per Article: 67.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND It is common practice to restore and maintain sinus rhythm in patients with atrial fibrillation and heart failure. This approach is based in part on data indicating that atrial fibrillation is a predictor of death in patients with heart failure and suggesting that the suppression of atrial fibrillation may favorably affect the outcome. However, the benefits and risks of this approach have not been adequately studied. METHODS We conducted a multicenter, randomized trial comparing the maintenance of sinus rhythm (rhythm control) with control of the ventricular rate (rate control) in patients with a left ventricular ejection fraction of 35% or less, symptoms of congestive heart failure, and a history of atrial fibrillation. The primary outcome was the time to death from cardiovascular causes. RESULTS A total of 1376 patients were enrolled (682 in the rhythm-control group and 694 in the rate-control group) and were followed for a mean of 37 months. Of these patients, 182 (27%) in the rhythm-control group died from cardiovascular causes, as compared with 175 (25%) in the rate-control group (hazard ratio in the rhythm-control group, 1.06; 95% confidence interval, 0.86 to 1.30; P=0.59 by the log-rank test). Secondary outcomes were similar in the two groups, including death from any cause (32% in the rhythm-control group and 33% in the rate-control group), stroke (3% and 4%, respectively), worsening heart failure (28% and 31%), and the composite of death from cardiovascular causes, stroke, or worsening heart failure (43% and 46%). There were also no significant differences favoring either strategy in any predefined subgroup. CONCLUSIONS In patients with atrial fibrillation and congestive heart failure, a routine strategy of rhythm control does not reduce the rate of death from cardiovascular causes, as compared with a rate-control strategy. (ClinicalTrials.gov number, NCT00597077.)
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Affiliation(s)
- Denis Roy
- Montreal Heart Institute and the Université de Montréal, Montreal, QC H1T 1C8, Canada.
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Roy D, Pratt CM, Torp-Pedersen C, Wyse DG, Toft E, Juul-Moller S, Nielsen T, Rasmussen SL, Stiell IG, Coutu B, Ip JH, Pritchett EL, Camm AJ. Vernakalant Hydrochloride for Rapid Conversion of Atrial Fibrillation. Circulation 2008; 117:1518-25. [PMID: 18332267 DOI: 10.1161/circulationaha.107.723866] [Citation(s) in RCA: 234] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
The present study assessed the efficacy and safety of vernakalant hydrochloride (RSD1235), a novel compound, for the conversion of atrial fibrillation (AF).
Methods and Results—
Patients were randomized in a 2:1 ratio to receive vernakalant or placebo and were stratified by AF duration of 3 hours to 7 days (short duration) and 8 to 45 days (long duration). A first infusion of placebo or vernakalant (3 mg/kg) was given for 10 minutes, followed by a second infusion of placebo or vernakalant (2 mg/kg) 15 minutes later if AF was not terminated. The primary end point was conversion of AF to sinus rhythm for at least 1 minute within 90 minutes of the start of drug infusion in the short-duration AF group. A total of 336 patients were randomized and received treatment (short duration, n=220; long duration, n=116). Of the 145 vernakalant patients, 75 (51.7%) in the short-duration AF group converted to sinus rhythm (median time, 11 minutes) compared with 3 of the 75 placebo patients (4.0%;
P
<0.001). Overall, in the short- and long-duration AF groups, 83 of the 221 vernakalant patients (37.6%) experienced termination of AF compared with 3 of the 115 placebo patients (2.6%;
P
<0.001). Transient dysgeusia and sneezing were the most common side effects in vernakalant-treated patients. Four vernakalant-related serious adverse events (hypotension [2 events], complete atrioventricular block, and cardiogenic shock) occurred in 3 patients.
Conclusion—
Vernakalant demonstrated rapid conversion of short-duration AF and was well tolerated.
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Affiliation(s)
- Denis Roy
- From the Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada (D.R.); Department of Cardiology, Methodist DeBakey Heart Center, Methodist Hospital Research Institute, Houston, Tex (C.M.P.); Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark (C.T.-P.); Libin Cardiovascular Institute of Alberta, Calgary, Alberta, Canada (D.G.W.); Department for Health Science and Technology, Aalborg University, and Department of Cardiology, Aalborg Hospital, Aalborg, Denmark (E.T.)
| | - Craig M. Pratt
- From the Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada (D.R.); Department of Cardiology, Methodist DeBakey Heart Center, Methodist Hospital Research Institute, Houston, Tex (C.M.P.); Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark (C.T.-P.); Libin Cardiovascular Institute of Alberta, Calgary, Alberta, Canada (D.G.W.); Department for Health Science and Technology, Aalborg University, and Department of Cardiology, Aalborg Hospital, Aalborg, Denmark (E.T.)
| | - Christian Torp-Pedersen
- From the Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada (D.R.); Department of Cardiology, Methodist DeBakey Heart Center, Methodist Hospital Research Institute, Houston, Tex (C.M.P.); Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark (C.T.-P.); Libin Cardiovascular Institute of Alberta, Calgary, Alberta, Canada (D.G.W.); Department for Health Science and Technology, Aalborg University, and Department of Cardiology, Aalborg Hospital, Aalborg, Denmark (E.T.)
| | - D. George Wyse
- From the Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada (D.R.); Department of Cardiology, Methodist DeBakey Heart Center, Methodist Hospital Research Institute, Houston, Tex (C.M.P.); Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark (C.T.-P.); Libin Cardiovascular Institute of Alberta, Calgary, Alberta, Canada (D.G.W.); Department for Health Science and Technology, Aalborg University, and Department of Cardiology, Aalborg Hospital, Aalborg, Denmark (E.T.)
| | - Egon Toft
- From the Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada (D.R.); Department of Cardiology, Methodist DeBakey Heart Center, Methodist Hospital Research Institute, Houston, Tex (C.M.P.); Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark (C.T.-P.); Libin Cardiovascular Institute of Alberta, Calgary, Alberta, Canada (D.G.W.); Department for Health Science and Technology, Aalborg University, and Department of Cardiology, Aalborg Hospital, Aalborg, Denmark (E.T.)
| | - Steen Juul-Moller
- From the Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada (D.R.); Department of Cardiology, Methodist DeBakey Heart Center, Methodist Hospital Research Institute, Houston, Tex (C.M.P.); Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark (C.T.-P.); Libin Cardiovascular Institute of Alberta, Calgary, Alberta, Canada (D.G.W.); Department for Health Science and Technology, Aalborg University, and Department of Cardiology, Aalborg Hospital, Aalborg, Denmark (E.T.)
| | - Tonny Nielsen
- From the Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada (D.R.); Department of Cardiology, Methodist DeBakey Heart Center, Methodist Hospital Research Institute, Houston, Tex (C.M.P.); Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark (C.T.-P.); Libin Cardiovascular Institute of Alberta, Calgary, Alberta, Canada (D.G.W.); Department for Health Science and Technology, Aalborg University, and Department of Cardiology, Aalborg Hospital, Aalborg, Denmark (E.T.)
| | - S. Lind Rasmussen
- From the Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada (D.R.); Department of Cardiology, Methodist DeBakey Heart Center, Methodist Hospital Research Institute, Houston, Tex (C.M.P.); Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark (C.T.-P.); Libin Cardiovascular Institute of Alberta, Calgary, Alberta, Canada (D.G.W.); Department for Health Science and Technology, Aalborg University, and Department of Cardiology, Aalborg Hospital, Aalborg, Denmark (E.T.)
| | - Ian G. Stiell
- From the Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada (D.R.); Department of Cardiology, Methodist DeBakey Heart Center, Methodist Hospital Research Institute, Houston, Tex (C.M.P.); Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark (C.T.-P.); Libin Cardiovascular Institute of Alberta, Calgary, Alberta, Canada (D.G.W.); Department for Health Science and Technology, Aalborg University, and Department of Cardiology, Aalborg Hospital, Aalborg, Denmark (E.T.)
| | - Benoit Coutu
- From the Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada (D.R.); Department of Cardiology, Methodist DeBakey Heart Center, Methodist Hospital Research Institute, Houston, Tex (C.M.P.); Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark (C.T.-P.); Libin Cardiovascular Institute of Alberta, Calgary, Alberta, Canada (D.G.W.); Department for Health Science and Technology, Aalborg University, and Department of Cardiology, Aalborg Hospital, Aalborg, Denmark (E.T.)
| | - John H. Ip
- From the Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada (D.R.); Department of Cardiology, Methodist DeBakey Heart Center, Methodist Hospital Research Institute, Houston, Tex (C.M.P.); Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark (C.T.-P.); Libin Cardiovascular Institute of Alberta, Calgary, Alberta, Canada (D.G.W.); Department for Health Science and Technology, Aalborg University, and Department of Cardiology, Aalborg Hospital, Aalborg, Denmark (E.T.)
| | - Edward L.C. Pritchett
- From the Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada (D.R.); Department of Cardiology, Methodist DeBakey Heart Center, Methodist Hospital Research Institute, Houston, Tex (C.M.P.); Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark (C.T.-P.); Libin Cardiovascular Institute of Alberta, Calgary, Alberta, Canada (D.G.W.); Department for Health Science and Technology, Aalborg University, and Department of Cardiology, Aalborg Hospital, Aalborg, Denmark (E.T.)
| | - A. John Camm
- From the Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada (D.R.); Department of Cardiology, Methodist DeBakey Heart Center, Methodist Hospital Research Institute, Houston, Tex (C.M.P.); Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark (C.T.-P.); Libin Cardiovascular Institute of Alberta, Calgary, Alberta, Canada (D.G.W.); Department for Health Science and Technology, Aalborg University, and Department of Cardiology, Aalborg Hospital, Aalborg, Denmark (E.T.)
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Estes NAM, Halperin JL, Calkins H, Ezekowitz MD, Gitman P, Go AS, McNamara RL, Messer JV, Ritchie JL, Romeo SJW, Waldo AL, Wyse DG. ACC/AHA/Physician Consortium 2008 clinical performance measures for adults with nonvalvular atrial fibrillation or atrial flutter: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures and the Physician Consortium for Performance Improvement (Writing Committee to Develop Clinical Performance Measures for Atrial Fibrillation): developed in collaboration with the Heart Rhythm Society. Circulation 2008; 117:1101-20. [PMID: 18283199 DOI: 10.1161/circulationaha.107.187192] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Estes NM, Halperin JL, Calkins H, Ezekowitz MD, Gitman P, Go AS, McNamara RL, Messer JV, Ritchie JL, Romeo SJ, Waldo AL, Wyse DG. ACC/AHA/Physician Consortium 2008 Clinical Performance Measures for Adults With Nonvalvular Atrial Fibrillation or Atrial Flutter. J Am Coll Cardiol 2008; 51:865-84. [DOI: 10.1016/j.jacc.2008.01.006] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Bousser MG, Bouthier J, Büller HR, Cohen AT, Crijns H, Davidson BL, Halperin J, Hankey G, Levy S, Pengo V, Prandoni P, Prins MH, Tomkowski W, Torp-Pedersen C, Wyse DG. Comparison of idraparinux with vitamin K antagonists for prevention of thromboembolism in patients with atrial fibrillation: a randomised, open-label, non-inferiority trial. Lancet 2008; 371:315-21. [PMID: 18294998 DOI: 10.1016/s0140-6736(08)60168-3] [Citation(s) in RCA: 210] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Vitamin K antagonists, the current standard treatment for prophylaxis against stroke and systemic embolism in patients with atrial fibrillation, require regular monitoring and dose adjustment; an unmonitored, fixed-dose anticoagulant regimen would be preferable. The aim of this randomised, open-label non-inferiority trial was to compare the efficacy and safety of idraparinux with vitamin K antagonists. METHODS Patients with atrial fibrillation at risk for thromboembolism were randomly assigned to receive either subcutaneous idraparinux (2.5 mg weekly) or adjusted-dose vitamin K antagonists (target of an international normalised ratio of 2-3). Assessment of outcome was done blinded to treatment. The primary efficacy outcome was the cumulative incidence of all stroke and systemic embolism. The principal safety outcome was clinically relevant bleeding. Analyses were done by intention to treat; the non-inferiority hazard ratio was set at 1.5. This trial is registered with ClinicalTrials.gov, number NCT00070655. FINDINGS The trial was stopped after randomisation of 4576 patients (2283 to receive idraparinux, 2293 to receive vitamin K antagonists) and a mean follow-up period of 10.7 (SD 5.4) months because of excess clinically relevant bleeding with idraparinux (346 cases vs 226 cases; 19.7 vs 11.3 per 100 patient-years; p<0.0001). There were 21 instances of intracranial bleeding with idraparinux and nine with vitamin K antagonists (1.1 vs 0.4 per 100 patient-years; p=0.014); elderly patients and those with renal impairment were at greater risk of such complications. There were 18 cases of thromboembolism with idraparinux and 27 cases with vitamin K antagonists (0.9 vs 1.3 per 100 patient-years; hazard ratio 0.71, 95% CI 0.39-1.30; p=0.007), satisfying the non-inferiority criterion. There were 62 deaths with idraparinux and 61 with vitamin K anatagonists (3.2 vs 2.9 per 100 patient-years; p=0.49). INTERPRETATION In patients with atrial fibrillation at risk for thromboembolism, long-term treatment with idraparinux was no worse than vitamin K antagonists in terms of efficacy, but caused significantly more bleeding.
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Cairns JA, Wittes J, Wyse DG, Pogue J, Gent M, Hirsh J, Marler J, Pritchett ELC. Monitoring the ACTIVE-W trial: some issues in monitoring a noninferiority trial. Am Heart J 2008; 155:33-41. [PMID: 18082486 DOI: 10.1016/j.ahj.2007.09.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2007] [Accepted: 09/04/2007] [Indexed: 11/15/2022]
Abstract
Noninferiority comparisons of new to current therapies and the use of composite outcomes represent significant advances in the design of clinical trials. They increasingly characterize trials of new cardiovascular agents, posing new challenges to Data Safety Monitoring Boards (DSMB) and principal investigators. The ACTIVE-W study was a noninferiority comparison of the combination of clopidogrel and acetylsalicylic acid versus oral anticoagulant among patients with atrial fibrillation. When unexpectedly high rates of stroke and then of the composite outcome of stroke, non-central nervous system systemic embolism, myocardial infarction, and vascular death emerged, the DSMB modified its monitoring plan and conducted its first formal interim analysis much earlier than had been planned in the DSMB charter. The study was terminated when only 27% of the anticipated outcomes had occurred. This paper discusses issues of appropriate stopping guidelines for noninferiority trials and the early emergence of significant harm in relation to one component (stroke) of a composite outcome. Conditional power was not determined concurrently with the HRs during the monitoring of ACTIVE-W; however, the members of the DSMB now believe that such calculations should be considered as useful adjuncts to the calculation of HRs and could lead to earlier termination of noninferiority trials whose interim results suggest futility, without the need for convincing proof of harm.
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Affiliation(s)
- John A Cairns
- University of British Columbia, Vancouver, British Columbia, Canada.
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Abstract
Atrial fibrillation (AF) is the most common sustained arrhythmia encountered in clinical practice. There are many pharmacological and nonpharmacological options available for AF patients. There is, however, a great deal of dissatisfaction with the available treatments of this arrhythmia. Furthermore, AF management remains associated with many challenges that make the treatment of AF a vexing problem. The present overview discusses these challenges and explores the opportunities associated with them.
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Affiliation(s)
- Ahmad Hersi
- Libin Cardiovascular Institute of Alberta, University of Calgary, and Calgary Health Region, Alberta
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Abstract
Atrial fibrillation (AF) is the most common sustained tachyarrhythmia encountered in clinical practice. The management of AF remains associated with many challenges that make its treatment a vexing problem. However, in recent years extraordinary progress has been made in the understanding and management of AF. In general, antiarrhythmic drugs for rhythm control have been disappointing. We have a better understanding of pharmacologic cardioversion and this has led to newer strategies, such as intermittent therapy. Several studies have been completed comparing pharmacologic rhythm control with pharmacologic heart rate control. There is also an emerging body of evidence concerning the value of adjunctive drug use for rhythm control using drugs that would not usually be considered to be antiarrhythmic. Finally, antithrombotic therapy is an increasingly important part of the medical management of AF. This article summarizes the results of many of the recent publications and their clinical implications concerning management of this common rhythm disorder.
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Affiliation(s)
- Ahmad Hersi
- The Libin Cardiovascular Institute of Alberta, University of Calgary, Room G009, 3330 Hospital Drive NW,Calgary AB, T2N 4N1, Canada
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Wyse DG. Economics of Managing Atrial Fibrillation: Broadening the Focus to Include Efficiency. J Cardiovasc Electrophysiol 2007; 18:634-5. [PMID: 17472712 DOI: 10.1111/j.1540-8167.2007.00836.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
Anticoagulation therapy in patients with atrial fibrillation is important. This review consists of three parts: chronic anticoagulation, anticoagulation for cardioversion, and a brief comment on anticoagulation around the time of left atrial radiofrequency ablation. The risk stratification scheme of the American College of Cardiology/American Heart Association/European Society of Cardiology (ACC/AHA/ESC) guidelines for chronic anticoagulation is briefly reviewed. Although there are several other similar schemes, they are not identical. The key point is the balance between benefit and risk. Some emerging controversies are outlined. Two specific questions explored are: is well-controlled hypertension a risk factor, and does paroxysmal atrial fibrillation confer the same risk as continuous atrial fibrillation? Differences in the risk of bleeding while taking a vitamin K antagonist noted in recent compared with older data are discussed. Risk of bleeding in the elderly and combined antithrombotic therapy with a vitamin K antagonist and an antiplatelet agent in high-risk patients are briefly discussed. Recent failures of studies attempting to find a suitable alternative to vitamin K antagonists are outlined. The treatment guidelines for anticoagulation for cardioversion are briefly reviewed. The risk of thromboembolism according to international normalized ratio and use of low-molecular-weight heparin as an alternative to warfarin are discussed. Anticoagulation before and after left atrial radiofrequency ablation is empirical, and long-term anticoagulation seems advisable for high risk patients at the present time. The two most pressing needs for further investigation are (1) clarification, simplification, and consolidated of risk stratification schemes and treatment recommendations and (2) discovery of alternatives to warfarin.
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Affiliation(s)
- D George Wyse
- Libin Cardiovascular Institute of Alberta, University of Calgary, and Calgary Health Region, Calgary, Alberta, Canada.
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Van Gelder IC, Wyse DG, Chandler ML, Cooper HA, Olshansky B, Hagens VE, Crijns HJGM. Does intensity of rate-control influence outcome in atrial fibrillation? An analysis of pooled data from the RACE and AFFIRM studies. ACTA ACUST UNITED AC 2006; 8:935-42. [PMID: 16973686 DOI: 10.1093/europace/eul106] [Citation(s) in RCA: 116] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
AIMS The AFFIRM and RACE studies showed that rate control is an acceptable treatment strategy for atrial fibrillation (AF). We examined whether strict rate control offers benefit over more lenient rate control. METHODS AND RESULTS We compared the outcome of patients enrolled in the rate-control arms of AFFIRM and RACE, using data from patients who met a composite of overlapping inclusion and exclusion criteria. We evaluated 1091 patients, 874 from AFFIRM and 217 from RACE. In AFFIRM, the rate-control strategy aimed for a resting heart rate < or =80 bpm and heart rate during daily activity of < or =110 bpm. In RACE, a more lenient approach was taken: resting heart rate <100 bpm. Primary endpoint was a composite of mortality, cardiovascular hospitalization, and myocardial infarction. Mean heart rate across all follow-up visits for patients in AF was lower in AFFIRM (76.1 vs. 83.4 bpm). Event-free survival for the occurrence of the primary endpoint did not differ (64% in AFFIRM vs. 66% in RACE). Patients with mean heart rates during AF within the AFFIRM (< or =80) or RACE (<100) criteria had a better outcome than patients with heart rates > or =100 (hazard ratios 0.69 and 0.58, respectively, for < or =80 and <100 compared with > or =100 bpm). CONCLUSION Stringency of the approach to rate control, based on the comparison of the AFFIRM and RACE studies, was not associated with an important difference in clinical events.
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Affiliation(s)
- Isabelle C Van Gelder
- Department of Cardiology, Thoraxcenter, University Medical Center Groningen, University of Groningen, PO Box 30.001, 9700 RB Groningen, The Netherlands.
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Dorian P, Cvitkovic SS, Kerr CR, Crystal E, Gillis AM, Guerra PG, Mitchell LB, Roy D, Skanes AC, Wyse DG. A novel, simple scale for assessing the symptom severity of atrial fibrillation at the bedside: the CCS-SAF scale. Can J Cardiol 2006; 22:383-6. [PMID: 16639472 PMCID: PMC2560532 DOI: 10.1016/s0828-282x(06)70922-9] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The severity of symptoms caused by atrial fibrillation (AF) is extremely variable. Quantifying the effect of AF on patient well-being is important but there is no simple, commonly accepted measure of the effect of AF on quality of life (QoL). Current QoL measures are cumbersome and impractical for clinical use. OBJECTIVE To create a simple, concise and readily usable AF severity score to facilitate treatment decisions and physician communication. METHODS The Canadian Cardiovascular Society (CCS) Severity of Atrial Fibrillation (SAF) Scale is analogous to the CCS Angina Functional Class. The CCS-SAF score is determined using three steps: documentation of possible AF-related symptoms (palpitations, dyspnea, dizziness/syncope, chest pain, weakness/fatigue); determination of symptom-rhythm correlation; and assessment of the effect of these symptoms on patient daily function and QoL. CCS-SAF scores range from 0 (asymptomatic) to 4 (severe impact of symptoms on QoL and activities of daily living). Patients are also categorized by type of AF (paroxysmal versus persistent/permanent). The CCS-SAF Scale will be validated using accepted measures of patient-perceived severity of symptoms and impairment of QoL and will require 'field testing' to ensure its applicability and reproducibility in the clinical setting. CONCLUSIONS This type of symptom severity scale, like the New York Heart Association Functional Class for heart failure symptoms and the CCS Functional Class for angina symptoms, trades precision and comprehensiveness for simplicity and ease of use at the bedside. A common language to quantify AF severity may help to improve patient care.
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Affiliation(s)
- Paul Dorian
- Division of Cardiology, St. Michael's Hospital, University of Toronto, Ontario, Canada.
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Wyse DG. Pharmacologic approaches to rhythm versus rate control in atrial fibrillation—where are we now? Int J Cardiol 2006; 110:301-12. [PMID: 16516313 DOI: 10.1016/j.ijcard.2005.12.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2005] [Revised: 12/02/2005] [Accepted: 12/14/2005] [Indexed: 11/30/2022]
Abstract
Until recently, contemporary drug treatment of atrial fibrillation (AF) focused primarily on restoration and maintenance of sinus rhythm, predicated on the belief that if AF is abolished then problems associated with AF would be abolished too. Recently completed clinical trials using drug therapy and comparing maintenance of sinus rhythm with control of ventricular rate have challenged this assumption, showing that simple control of ventricular rate with anticoagulation is an acceptable primary therapy, notably in older patients with persistent AF, minimally symptomatic or asymptomatic, and at increased risk for thromboembolic events. However, rate control and anticoagulation is not a panacea; existing trial results should not be interpreted to mean all patients should be treated with the rate control approach. Despite the limited efficacy and poor safety of current antiarrhythmic drugs, strategies for maintenance of sinus rhythm remain justified in many patients, such as those with first-episode AF, highly symptomatic patients, younger patients, and those with a history of congestive heart failure (CHF). Commonly used current and some investigational agents designated for "rhythm control" have enough pharmacologic overlap with rate control agents to be considered to have a dual mode of action, simultaneously addressing both rhythm and rate control. Furthermore, there is much interest in non-pharmacologic therapies, such as radiofrequency ablation, for rhythm control. The lack of appropriately designed and controlled trials at this time makes it difficult to determine the place of radiofrequency ablation and its impact on the rhythm versus rate question.
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Affiliation(s)
- D George Wyse
- Libin Cardiovascular Institute of Alberta, Department of Cardiac Sciences, University of Calgary/Calgary Health Region, Calgary, Alberta, Canada.
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Wyse DG. Classification of atrial fibrillation: reply. Eur Heart J 2006. [DOI: 10.1093/eurheartj/ehi723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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George Wyse D. Pulmonary vein isolation was better than antiarrhythmic drugs for symptomatic atrial fibrillation. Evid Based Med 2006; 11:16. [PMID: 17213058 DOI: 10.1136/ebm.11.1.16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Affiliation(s)
- D George Wyse
- Libin Cardiovascular Institute of Alberta, Calgary, Alberta, Canada
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Glotzer TV, Daoud EG, Wyse DG, Singer DE, Holbrook R, Pruett K, Smith K, Hilker CE. Rationale and design of a prospective study of the clinical significance of atrial arrhythmias detected by implanted device diagnostics: The TRENDS study. J Interv Card Electrophysiol 2006; 15:9-14. [PMID: 16680544 DOI: 10.1007/s10840-006-7622-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2005] [Accepted: 02/05/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND Sustained atrial fibrillation (AF) is a common risk factor for stroke. While intermittent AF also appears to pose a substantial stroke risk, the quantitative relationship between the percentage of time spent in AF and stroke risk is poorly specified and "intermittent" AF is not the same as paroxysmal AF. Improved assessment of the impact of AF burden on stroke risk will allow more targeted and safer use of antithrombotic therapy. METHODS AND RESULTS The primary objective of this study is to determine if AT/AF (all device detected atrial tachyarrhythmias, including atrial flutter, atrial fibrillation, and atrial tachycardia) burden over a 30 day period is an independent predictor of the occurrence of ischemic stroke, transient ischemic attack (TIA) and/or systemic embolism in subjects not receiving anticoagulation therapy. TRENDS is a prospective, post-market, non-randomized, multicenter study designed to enroll 3100 subjects who have an independent Class I/II indication for cardiac rhythm device implantation and who have demographic features suggestive of an increased risk for thromboembolic complications related to AT/AF. All implanted devices will have the ability to collect long-term AT/AF burden trending data and will be equivalently programmed to ensure consistent data collection. All subjects will be followed with device interrogations every 3 months and clinic visits every 6 months for 1 year. Subjects with a documented history of AT/AF prior to enrollment and those who develop AT/AF during the 12-month follow-up will be followed until the last subject enrolled in the study has completed their 24-month follow-up. CONCLUSIONS The results of the TRENDS study should help clarify the implications of data retrieved from an implantable device with regard to the risk for thromboembolic complications from atrial arrhythmias, even in the absence of symptoms.
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MESH Headings
- Anti-Arrhythmia Agents/therapeutic use
- Atrial Fibrillation/complications
- Atrial Fibrillation/epidemiology
- Atrial Fibrillation/physiopathology
- Atrial Fibrillation/therapy
- Atrial Flutter/complications
- Atrial Flutter/epidemiology
- Atrial Flutter/physiopathology
- Atrial Flutter/therapy
- Cardiac Pacing, Artificial
- Defibrillators, Implantable
- Follow-Up Studies
- Heart Rate
- Humans
- Intracranial Embolism/epidemiology
- Intracranial Embolism/etiology
- Ischemic Attack, Transient/epidemiology
- Ischemic Attack, Transient/etiology
- Pacemaker, Artificial
- Predictive Value of Tests
- Product Surveillance, Postmarketing
- Prospective Studies
- Quality of Life
- Research Design
- Risk Factors
- Stroke/epidemiology
- Stroke/etiology
- Tachycardia, Ectopic Atrial/complications
- Tachycardia, Ectopic Atrial/epidemiology
- Tachycardia, Ectopic Atrial/physiopathology
- Tachycardia, Ectopic Atrial/therapy
- Treatment Outcome
- United States/epidemiology
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Affiliation(s)
- Taya V Glotzer
- Hackensack University Medical Center, Hackensack, NJ, USA.
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