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Tonegawa-Kuji R, Yamagata K, Kanaoka K, Wakamiya A, Inoue YY, Miyamoto K, Miyamoto Y, Kiyohara E, Kusano K. Maximum burn prevention practice vs conventional care after direct current cardioversion treatment: The BURN-PREVENTION trial. Heart Rhythm 2024:S1547-5271(24)02330-0. [PMID: 38599471 DOI: 10.1016/j.hrthm.2024.03.1818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Received: 03/08/2024] [Revised: 03/21/2024] [Accepted: 03/24/2024] [Indexed: 04/12/2024]
Affiliation(s)
- Reina Tonegawa-Kuji
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, Suita, Japan; Genomic Medicine Institute, Cleveland Clinic, Lerner Research Institute, Cleveland, Ohio
| | - Kenichiro Yamagata
- Department of Cardiovascular Medicine, The University of Tokyo, Tokyo, Japan; Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan.
| | - Koshiro Kanaoka
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Akinori Wakamiya
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yuko Y Inoue
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Koji Miyamoto
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yoshihiro Miyamoto
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Eiji Kiyohara
- Department of Dermatology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Kengo Kusano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan.
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Malkoc A, Phan A, Falatoonzadeh P, Mac O, Sherman W, Wong DT. Gender Differences With Ibutilide Effectiveness and Safety in Cardioversion of Atrial Fibrillation. J Surg Res 2024; 296:10-17. [PMID: 38181644 DOI: 10.1016/j.jss.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 11/13/2023] [Accepted: 12/07/2023] [Indexed: 01/07/2024]
Abstract
INTRODUCTION Few studies have examined the use of ibutilide in noncardiac surgical populations. Our study considered the effectiveness and safety of ibutilide in cardioversion of atrial fibrillation (AF) in medical and surgical intensive care patients. METHODS A retrospective chart review was performed for patients with a confirmed diagnosis of AF who were hemodynamically stable and received ibutilide after the initial diagnosis. Patients were administered 1 mg of ibutilide fumarate intravenous for 10 min with a second dose administered if AF persisted after 30 min. Patients were pretreated with intravenous magnesium sulfate if their blood magnesium level was <2 mg/dL. RESULTS Fifty seven total female patients and 99 male patients received ibutilide. Females had an 88% conversion rate to normal sinus rhythm (NSR) compared to 68% in males (P = 0.008). A 70% successful return to NSR was observed in patients from all groups pretreated with magnesium sulfate (P = 0.045). One year after discharge, 74% of the patients stayed in the NSR. CONCLUSIONS Within our population, pretreatment with magnesium sulfate followed by ibutilide was associated with increased conversion to NSR. Additionally, we noted that females had a higher conversion rate to NSR compared to males, regardless of whether they were pretreated with magnesium sulfate.
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Affiliation(s)
- Aldin Malkoc
- Department of Surgery, Arrowhead Regional Medical Center, Colton, California
| | - Alexander Phan
- Department of Surgery, Arrowhead Regional Medical Center, Colton, California
| | - Payam Falatoonzadeh
- Department of Surgery, Arrowhead Regional Medical Center, Colton, California
| | - Olivia Mac
- Department of Surgery, Arrowhead Regional Medical Center, Colton, California
| | - William Sherman
- Department of Surgery, Arrowhead Regional Medical Center, Colton, California
| | - David T Wong
- Department of Surgery, Arrowhead Regional Medical Center, Colton, California.
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Raniga D, Goda M, Hattingh L, Thorning S, Rowe M, Howes L. Left atrial volume index: A predictor of atrial fibrillation recurrence following direct current cardioversion - A systematic review and meta-analysis. Int J Cardiol Heart Vasc 2024; 51:101364. [PMID: 38426114 PMCID: PMC10902144 DOI: 10.1016/j.ijcha.2024.101364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Revised: 02/09/2024] [Accepted: 02/11/2024] [Indexed: 03/02/2024]
Abstract
This systematic review and meta-analysis was conducted to determine the clinical relevance of echocardiographically measured left atrial (LA) size to predict the recurrence of atrial fibrillation (AF) after direct current cardioversion (DCCV). A search was performed on Medline (Ovid), Embase (Elsevier), Cochrane Central Register of Controlled Trials (CENTRAL) in Cochrane Library, Wiley and Web of Science (Clarivate) to identify relevant studies. Amongst the initial 4066 citations identified, 31 fulfilled the criteria for inclusion in the data analysis incorporating 2725 patients with a mean follow-up period of 6.5 months. The weighted mean left atrial volume index (LAVI) was 40.56 ml/m2 (95 %CI:37.24-43.88) in the sinus rhythm (SR) maintenance group versus 48.69 ml/m2 (95 % CI: 44.42-52.97) in the AF recurrence group with P value of < 0.001, left atrial diameter (LAD) was 42.06 mm (95 %CI: 41.08-43.05) in the SR maintenance group versus 45.13 mm (95 %CI: 44.09-46.16) in the AF recurrence group, P value < 0.001. Effect size analysis of LAVI showed that each unit increase in LAVI resulted in an increase in the risk of AF recurrence by 6 % (95 % CI: 3 %-10 %). Age and AF duration were also statistically significant between the two groups however comorbidities, use of beta blockers or amiodarone were not significantly different. This meta-analysis shows that AF duration, LAVI, LAD and age predict the risk of recurrence of atrial fibrillation post electrical cardioversion with LAVI being the most clinically relevant echocardiographic feature.
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Affiliation(s)
- Dipesh Raniga
- Department of Cardiology, Division of Specialist Medical Services, Gold Coast Hospital and Health Services, Southport, QLD 4215, Australia
| | - Mina Goda
- Department of Cardiology, Division of Specialist Medical Services, Gold Coast Hospital and Health Services, Southport, QLD 4215, Australia
| | - Laetitia Hattingh
- Allied Health Research, Gold Coast Hospital and Health Services, Southport, QLD 4215, Australia
- School of Pharmacy, The University of Queensland, QLD 4102, Australia
- School of Pharmacy and Medical Sciences, Griffith University, QLD 4222, Australia
| | - Sarah Thorning
- Office of Research, Gold Coast Hospital and Health Services, Southport, QLD 4215, Australia
| | - Matthew Rowe
- Department of Cardiology, Division of Specialist Medical Services, Gold Coast Hospital and Health Services, Southport, QLD 4215, Australia
| | - Laurie Howes
- Department of Cardiology, Division of Specialist Medical Services, Gold Coast Hospital and Health Services, Southport, QLD 4215, Australia
- School of Medicine, Griffith University, QLD 4222, Australia
- School of Medicine, Bond University, QLD 4226, Australia
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Norton J, Foy A, Ba DM, Liu G, Leslie D, Zhang Y, Naccarelli GV. Obese patients with new onset atrial fibrillation/flutter have higher risk of hospitalization, cardioversions, and ablations. Am Heart J Plus 2024; 40:100375. [PMID: 38586434 PMCID: PMC10994861 DOI: 10.1016/j.ahjo.2024.100375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Revised: 02/19/2024] [Accepted: 02/20/2024] [Indexed: 04/09/2024]
Abstract
Obesity significantly increases the risk of developing atrial fibrillation (AF) and atrial flutter (AFL) and evidence from randomized trials indicates that weight loss may reduce the burden of AF/AFL in obese patients; however, the relationship between obesity and healthcare resource utilization in AF/AFL patients is lacking. We sought to assess this relationship in patients with newly diagnosed AF/AFL in a nationally representative cohort of the United States by using the MarketScan® claims database. International Classification of Diseases, Tenth Revision [ICD 10] diagnosis codes were used to select individuals with a new diagnosis of AF/AFL in 2017 and 2018, adjudicate baseline variables and to classify them according to obesity status. Patients were followed for two years at which point all data was censored. The primary outcome of the study was hospitalizations due to AF/AFL. Cox proportional hazards regression models were used to assess the adjusted hazard ratio for obese versus non-obese patients. There were 55,271 patients with new onset AF/AFL, which included 43,314 (78.4 %) who were non-obese and 11,957 (21.6 %) who were obese. There were significantly more males than females among non-obese (65.3 % vs. 34.7 %) and obese individuals (62.3 % vs. 37.7 %). The average age (SD) was similar in the non-obese (54.5 (9.7)) and obese cohorts (54.7 (8.4)), respectively. The incidence of Emergency Department visits (4.0 % vs. 6.5 %), hospitalizations (5.5 % vs. 10.7 %), cardioversions (6.6 % vs. 12.7 %), and ablation procedures (5.3 % vs. 8.6 %) were significantly increased among obese patients.
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Affiliation(s)
- Jonathan Norton
- Penn State University College of Medicine, Penn State Heart and Vascular Institute, The Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Andrew Foy
- Penn State University College of Medicine, Penn State Heart and Vascular Institute, The Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Djibril M. Ba
- Penn State University College of Medicine, Department of Public Health Sciences, The Milton S. Hershey Medical Center, Hershey, PA, USA
- Penn State University College of Medicine, Center for Applied Studies in Health Economics (CASHE), The Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Guodong Liu
- Penn State University College of Medicine, Department of Public Health Sciences, The Milton S. Hershey Medical Center, Hershey, PA, USA
- Penn State University College of Medicine, Center for Applied Studies in Health Economics (CASHE), The Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Doug Leslie
- Penn State University College of Medicine, Department of Public Health Sciences, The Milton S. Hershey Medical Center, Hershey, PA, USA
- Penn State University College of Medicine, Center for Applied Studies in Health Economics (CASHE), The Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Yue Zhang
- Penn State University College of Medicine, Penn State Heart and Vascular Institute, The Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Gerald V. Naccarelli
- Penn State University College of Medicine, Penn State Heart and Vascular Institute, The Milton S. Hershey Medical Center, Hershey, PA, USA
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Mattice AMS, Adler S, Eagles D, Yadav K, Hui S, Azward A, Pandey N, Stiell IG. Assessment of physician compliance to the CAEP 2021 Atrial Fibrillation Best Practices Checklist for rate and rhythm control in the emergency department. CAN J EMERG MED 2024:10.1007/s43678-024-00669-5. [PMID: 38519830 DOI: 10.1007/s43678-024-00669-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 02/25/2024] [Indexed: 03/25/2024]
Abstract
OBJECTIVES Acute atrial fibrillation and flutter (AF/AFL) are common arrhythmias treated in the emergency department (ED). The 2021 CAEP Best Practices Checklist provides clear recommendations for management of patients with acute AF/AFL. This study aimed to evaluate physician compliance to Checklist recommendations for risk assessment and ED management of AF/AFL. METHODS This health records review assessed the management of adult patients presenting to two tertiary care EDs for management of acute AF/AFL from January to August, 2022. All ECGs demonstrating AF/AFL with a heart rate greater than 100 were compiled to capture primary and secondary causes. All visits were assessed for rate and rhythm control management, adverse events, return to ED, and safety criteria. Study physicians classified safety criteria from the Checklist into high and moderate concerns. The primary outcome was the proportion of cases with safety concerns and adverse events occurring during management in the ED. Data were analyzed using simple descriptive statistics. RESULTS We included 429 patients with a mean age of 67.7 years and 57.1% male. ED management included rate control (20.4%), electrical (40.1%), and pharmacological (20.1%) cardioversion. Adverse events occurred in 9.5% of cases: 12.5% in rate control, 13.4% in electrical cardioversion, and 6.9% in pharmacologic cardioversion. Overall, 7.9% of cases had management safety concerns. Moderate safety concerns occurred in 4.9% of cases including failure to attain recommended heart rate at time of discharge (3.9%). Severe concerns were identified in 3.0% of cases including failure to cardiovert unstable patients (1.2%). The 30-day return-to-ED rate was 16.5% secondary to AF/AFL. CONCLUSION ED management of AF/AFL was consistent with the CAEP Checklist and was safe overall. Opportunities for optimizing care include attaining recommended targets during rate control, avoidance of calcium channel and beta blockers in patients with systolic dysfunction, and earlier cardioversion for clinically unstable patients.
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Affiliation(s)
- Amanda M S Mattice
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.
| | - Samara Adler
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Debra Eagles
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Krishan Yadav
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Sean Hui
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Althaf Azward
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Nikesh Pandey
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Ian G Stiell
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
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Dehghani MR, Safarzadeh N, Shariati A, Rezaei Y. Predictors of long-term outcomes in patients with persistent atrial fibrillation undergoing electrical cardioversion. J Cardiovasc Thorac Res 2024; 16:21-27. [PMID: 38584655 PMCID: PMC10997977 DOI: 10.34172/jcvtr.32913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 02/10/2024] [Indexed: 04/09/2024] Open
Abstract
Introduction Cardioversion for atrial fibrillation (AF) is routinely implemented in daily practice; however, it can be associated with the development of recurrent AF. In this study we aimed to evaluate the predictors of AF recurrence after electrical cardioversion, and to compare the outcomes of patients with or without AF recurrence during follow-up. Methods Patients with persistent AF were enrolled from March 2015 to September 2018. Patients with recurrent AF within 6 months after the index cardioversion were considered as AF recurrence (AFR) group, and those with normal sinus rhythm were defined as normal sinus rhythm (NSR) group. Thereafter, all patients were followed up for the incidence of adverse events, including death, requiring dialysis, coronary artery intervention/surgeries, cerebrovascular events, heart failure, and recurrent AF beyond 6 months. Results Of 129 patients, 11 patients had failed cardioversion and 7 patients lost to follow-up. So, 34 and 77 patients were categorized as the NSR and the AFR groups. During a median follow-up time of 54 (46-75) months, there was a trend for a higher incidence of major adverse events in the AFR group compared to the NSR group (P=0.063). Lower body mass index (odds ratio [OR] 0.885, 95% confidence interval [CI] 0.794-0.986, P=0.027) and coarse AF before the index cardioversion (OR 3.846, 95% CI 1.189-12.443, P=0.025) were the independent predictors of recurrent AF. Conclusion In patients with persistent AF undergoing cardioversion, the presence of coarse AF and the lower values of body mass index were found to be associated with the AF recurrence.
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Affiliation(s)
- Mohammad Reza Dehghani
- Department of Cardiology, Seyyed-al-Shohada Heart Center, Urmia University of Medical Sciences, Urmia, Iran
| | - Navideh Safarzadeh
- Department of Cardiology, Seyyed-al-Shohada Heart Center, Urmia University of Medical Sciences, Urmia, Iran
| | - Akram Shariati
- Department of Cardiology, Seyyed-al-Shohada Heart Center, Urmia University of Medical Sciences, Urmia, Iran
| | - Yousef Rezaei
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
- Behyan Clinic, Pardis New Town, Tehran, Iran
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Smalley C. Elective cardioversion at a district general hospital: a retrospective evaluation of outcomes. Br J Nurs 2024; 33:115-119. [PMID: 38335104 DOI: 10.12968/bjon.2024.33.3.115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/12/2024]
Abstract
Direct current cardioversion is a procedure for treating abnormal heart rhythms, and cardioversion is often performed electively to restore sinus rhythm in patients with persistent atrial fibrillation or atrial flutter. A retrospective evaluation of elective cardioversion data at a local general hospital was undertaken to evaluate the success and outcomes of cardioversion. This evaluation also considered the outcomes for two subsets of patients with heart failure and obesity, as it has previously been concluded that cardioversion is unsuccessful in these patients. Immediate success rates of cardioversion were high in general and remained high initially in heart failure and obese patients, but there was a drop-off in longer term success in all groups.
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deSouza IS, Shrestha P, Allen R, Koos J, Thode H. Safety and Effectiveness of Antidysrhythmic Drugs for Pharmacologic Cardioversion of Recent-Onset Atrial Fibrillation: a Systematic Review and Bayesian Network Meta-analysis. Cardiovasc Drugs Ther 2024:10.1007/s10557-024-07552-6. [PMID: 38324103 DOI: 10.1007/s10557-024-07552-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 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] [Accepted: 01/15/2024] [Indexed: 02/08/2024]
Abstract
PURPOSE The available evidence to determine which antidysrhythmic drug is superior for pharmacologic cardioversion of recent-onset (onset within 48 h) atrial fibrillation (AF) is uncertain. We aimed to identify the safest and most effective agent for pharmacologic cardioversion of recent-onset AF in the emergency department. METHODS We searched MEDLINE, Embase, and Web of Science from inception to February 21, 2023 (PROSPERO: CRD42018083781). Eligible studies were randomized controlled trials that enrolled adult participants with AF ≤ 48 h, compared a guideline-recommended antidysrhythmic drug with another antidysrhythmic drug or a different formulation of the same drug or placebo and reported specific adverse events. The primary outcome was immediate, serious adverse event - cardiac arrest, sustained ventricular tachydysrhythmia, atrial flutter 1:1 atrioventricular conduction, hypotension, and bradycardia. Additional analyses included the outcomes of conversion to sinus rhythm within 4 h and 24 h. We extracted data according to PRISMA-NMA and appraised trials using Cochrane RoB 2. We performed Bayesian network meta-analysis (NMA) using a Markov Chain Monte Carlo method with random-effect model and vague prior distribution to calculate odds ratios with 95% credible intervals. We assessed confidence using CINeMA. We used surface under the cumulative ranking curve (SUCRA) to rank agent(s). RESULTS The systematic review initially identified 5545 studies. Twenty-five studies met eligibility criteria, and 22 studies (n = 3082) provided data for NMA, which demonstrated that vernakalant (SUCRA = 70.9%) is most likely to be safest. Additional effectiveness NMA demonstrated that flecainide (SUCRA = 89.0%) is most likely to be superior for conversion within 4 h (27 studies; n = 2681), and ranolazine-amiodarone IV (SUCRA 93.7%) is most likely to be superior for conversion within 24 h (24 studies; n = 3213). Confidence in the NMA estimates is variable and limited mostly by within-study bias and imprecision. CONCLUSIONS Among guideline-recommended antidysrhythmic drugs, the combination of digoxin IV and amiodarone IV is definitely among the least safe for cardioversion of recent onset AF; flecainide, vernakalant, ibutilide, propafenone, and amiodarone IV are definitely among the most effective for cardioversion within 4 h; flecainide is definitely among the most effective for cardioversion within 24 h. Further, randomized controlled trials with predetermined and strictly defined, hemodynamic adverse event outcomes are recommended.
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Affiliation(s)
- Ian S deSouza
- Department of Emergency Medicine, SUNY Downstate Health Sciences University and Kings County Hospital Center, 451 Clarkson Avenue, Brooklyn, NY, 11203, USA.
| | - Pragati Shrestha
- Department of Family, Population and Preventive Medicine, Stony Brook University, Stony Brook, NY, USA
| | - Robert Allen
- Department of Emergency Medicine, Los Angeles General Medical Center, Los Angeles, CA, USA
| | - Jessica Koos
- Health Sciences Library, Stony Brook University, Stony Brook, NY, USA
| | - Henry Thode
- Department of Emergency Medicine, Stony Brook University, Stony Brook, NY, USA
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Stiell IG, Eagles D. Modern management of acute atrial fibrillation and atrial flutter. Clin Exp Emerg Med 2024:ceem.23.152. [PMID: 38286500 DOI: 10.15441/ceem.23.152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Accepted: 11/08/2023] [Indexed: 01/31/2024] Open
Abstract
This clinical review is intended to assist emergency physicians manage patients who present to the emergency department (ED) with acute/recent-onset atrial fibrillation (AF) or flutter (AFL). This article is based primarily on the 2021 Canadian Association of Emergency Physicians (CAEP) Acute Atrial Fibrillation/Flutter Best Practices Checklist. We encourage readers to download the open access CAEP Checklist article (https://link.springer.com/article/10.1007/s43678-021-00167-y) and the free smartphone app (CAEP Atrial Fibrillation Guide). We focus on four key elements of ED care: assessment and risk stratification, rate and rhythm control, short-term and long-term stroke prevention, and disposition and follow-up. It is important to determine if AF/AFL with rapid ventricular response is a primary arrhythmia or secondary to medical causes. While it is unusual for patients with primary AF to be unstable, urgent cardioversion is occasionally required. The criteria for when cardioversion is safe have recently changed and it is essential that physicians are well versed in them. When rhythm control is not safe, provide effective and safe IV rate control. When rhythm control is safe, either pharmacological or electrical cardioversion acceptable, per patient and physician preference. Rapid ventricular pre-excitation (Wolff-Parkinson-White Syndrome) usually, but not always, requires urgent electrical cardioversion. ED physicians should prescribe oral anticoagulants at discharge if indicated. No specific direct oral anticoagulant is preferred, and references should be freely consulted for optimal dosing. Hospital admission is rarely required for acute AF/AFL patients, who should be given good discharge instructions.
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Affiliation(s)
- Ian G Stiell
- Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa; Ottawa, Canada
| | - Debra Eagles
- Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa; Ottawa, Canada
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10
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McCusker RJ, Wheelwright J, Smith TJ, Myler CS, Sinz E. Diagnosis and Treatment of New-Onset Perioperative Atrial Fibrillation. Adv Anesth 2023; 41:179-204. [PMID: 38251618 DOI: 10.1016/j.aan.2023.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
This article reviews medical and surgical risk factors for developing atrial fibrillation (AF), the most common sustained dysrhythmia in the United States. Evidence for assessment and management of patients with AF, including AF newly identified in the preoperative clinic, immediately preoperatively, intraoperatively, and unstable AF, is presented. A stepwise approach to guide anesthetic decision-making in the assessment of newly identified preoperative AF is proposed. Anesthetic considerations, including the potential impacts of anesthetic and vasopressor selection, and current evidence related to rate control and rhythm control via pharmacologic or electrical cardioversion as well as anticoagulation strategies are discussed.
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Long B, Brady WJ, Gottlieb M. Emergency medicine updates: Atrial fibrillation with rapid ventricular response. Am J Emerg Med 2023; 74:57-64. [PMID: 37776840 DOI: 10.1016/j.ajem.2023.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 09/03/2023] [Accepted: 09/14/2023] [Indexed: 10/02/2023] Open
Abstract
INTRODUCTION Atrial fibrillation (AF) may lead to stroke, heart failure, and death. When AF occurs in the context of a rapid ventricular rate/response (RVR), this can lead to complications, including hypoperfusion and cardiac ischemia. Emergency physicians play a key role in the diagnosis and management of this dysrhythmia. OBJECTIVE This paper evaluates key evidence-based updates concerning AF with RVR for the emergency clinician. DISCUSSION Differentiating primary and secondary AF with RVR and evaluating hemodynamic stability are vital components of ED assessment and management. Troponin can assist in determining the risk of adverse outcomes, but universal troponin testing is not required in patients at low risk of acute coronary syndrome or coronary artery disease - especially patients with recurrent episodes of paroxysmal AF that are similar to their prior events. Emergent cardioversion is indicated in hemodynamically unstable patients. Rate or rhythm control should be pursued in hemodynamically stable patients. Elective cardioversion is a safe option for select patients and may reduce AF symptoms and risk of AF recurrence. Rate control using beta blockers or calcium channel blockers should be pursued in those with AF with RVR who do not undergo cardioversion. Anticoagulation is an important component of management, and several tools (e.g., CHA2DS2-VASc) are available to assist with this decision. Direct oral anticoagulants are the first-line medication class for anticoagulation. Disposition can be challenging, and several risk assessment tools (e.g., RED-AF, AFFORD, and the AFTER (complex, modified, and pragmatic) scores) are available to assist with disposition decisions. CONCLUSION An understanding of the recent updates in the literature concerning AF with RVR can assist emergency clinicians in the care of these patients.
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Affiliation(s)
- Brit Long
- SAUSHEC, Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
| | - William J Brady
- Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA.
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, USA
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Asad ZUA, Imran S, Parmar M, Bajwa A, Truong D, Agarwal S, Ghani A, Clifton S, Reese J, Khan MS, Munir MB, DeSimone CV, Sivaram C, Jackman WM, Po S, Stavrakis S, Al-Khatib SM. Antero-lateral vs. antero-posterior electrode position for cardioversion of atrial fibrillation: a systematic review and meta-analysis of randomized controlled trials. J Interv Card Electrophysiol 2023; 66:1989-2001. [PMID: 36929367 DOI: 10.1007/s10840-023-01523-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 03/06/2023] [Indexed: 03/18/2023]
Abstract
BACKGROUND Multiple randomized controlled trials (RCTs) have compared the success of antero-lateral vs. antero-posterior electrode position for cardioversion of atrial fibrillation (AF). However, due to small sample size and conflicting results of these RCTs, the optimal electrode positioning for successful cardioversion remains uncertain. METHODS A systematic search of MEDLINE and EMBASE was conducted. Outcomes of interest included overall success of cardioversion with restoration of sinus rhythm, 1st shock success, 2nd shock success, mean shock energy required for successful cardioversion, mean number of shocks required for successful cardioversion, success of cardioversion at high energy (> 150 J) and success of cardioversion at low energy (< 150 J). Mantel-Haenszel risk ratios (RR) with 95% confidence intervals were calculated using random-effects model. RESULTS A total of 14 RCTs comprising 2445 patients were included. There was no statistically significant difference between two cardioversion approaches in the overall success of cardioversion (RR 1.02; 95% CI [0.97-1.06]; p = 0.43), first shock success (RR 1.14; 95% CI [0.99-1.32]), second shock success (RR 1.08; 95% CI [0.94-1.23]), mean shock energy required (mean difference 6.49; 95% CI [-17.33-30.31], success at high energy > 150 J (RR 1.02; 95% CI [0.92-1.14] and success at low energy < 150 J (RR 1.09; 95% CI [0.97-1.22]). CONCLUSIONS This meta-analysis of RCTs shows no significant difference in the success of cardioversion between antero-lateral vs. antero-posterior electrode position for cardioversion of AF. Large well-conducted and adequately powered randomized clinical trials are needed to definitively address this question.
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Affiliation(s)
- Zain Ul Abideen Asad
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.
| | - Sana Imran
- Department of Medicine, Rawalpindi Medical University, Rawalpindi, Pakistan
| | - Miloni Parmar
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Awais Bajwa
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Derek Truong
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Siddharth Agarwal
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Asad Ghani
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Shari Clifton
- Robert M Bird Health Sciences Library, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Jessica Reese
- Department of Biostatistics and Epidemiology, Hudson College of Public Health, Oklahoma City, OK, USA
| | - Muhammad Shahzeb Khan
- Duke Clinical Research Institute and Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Muhammad Bilal Munir
- Section of Electrophysiology, Division of Cardiology, University of California San Diego, La Jolla, CA, USA
| | | | - Chittur Sivaram
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Warren M Jackman
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Sunny Po
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Stavros Stavrakis
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Sana M Al-Khatib
- Duke Clinical Research Institute and Division of Cardiology, Duke University Medical Center, Durham, NC, USA
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13
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Balik M, Maly M, Brozek T, Rulisek J, Porizka M, Sachl R, Otahal M, Brestovansky P, Svobodova E, Flaksa M, Stach Z, Horejsek J, Volny L, Jurisinova I, Novotny A, Trachta P, Kunstyr J, Kopecky P, Tencer T, Pazout J, Belohlavek J, Duska F, Krajcova A, Waldauf P. Propafenone versus amiodarone for supraventricular arrhythmias in septic shock: a randomised controlled trial. Intensive Care Med 2023; 49:1283-1292. [PMID: 37698594 DOI: 10.1007/s00134-023-07208-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 08/21/2023] [Indexed: 09/13/2023]
Abstract
PURPOSE Acute onset supraventricular arrhythmias can contribute to haemodynamic compromise in septic shock. Both amiodarone and propafenone are available interventions, but their clinical effects have not yet been directly compared. METHODS In this two-centre, prospective controlled parallel group double blind trial we recruited 209 septic shock patients with new-onset arrhythmia and a left ventricular ejection fraction above 35%. The patients were randomised in a 1:1 ratio to receive either intravenous propafenone (70 mg bolus followed by 400-840 mg/24 h) or amiodarone (300 mg bolus followed by 600-1800 mg/24 h). The primary outcomes were the proportion of patients who had sinus rhythm 24 h after the start of the infusion, time to restoration of the first sinus rhythm and the proportion of patients with arrhythmia recurrence. RESULTS Out of 209 randomized patients, 200 (96%) received the study drug. After 24 h, 77 (72.8%) and 71 (67.3%) were in sinus rhythm (p = 0.4), restored after a median of 3.7 h (95% CI 2.3-6.8) and 7.3 h (95% CI 5-11), p = 0.02, with propafenone and amiodarone, respectively. The arrhythmia recurred in 54 (52%) patients treated with propafenone and in 80 (76%) with amiodarone, p < 0.001. Patients with a dilated left atrium had better rhythm control with amiodarone (6.4 h (95% CI 3.5; 14.1) until cardioversion vs 18 h (95% CI 2.8; 24.7) in propafenone, p = 0.05). CONCLUSION Propafenone does not provide better rhythm control at 24 h yet offers faster cardioversion with fewer arrhythmia recurrences than with amiodarone, especially in patients with a non-dilated left atrium. No differences between propafenone and amiodarone on the prespecified short- and long-term outcomes were observed.
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Affiliation(s)
- Martin Balik
- Department of Anesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 2, 128 00, Prague 2, Czech Republic.
| | - Michal Maly
- Department of Anesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 2, 128 00, Prague 2, Czech Republic
| | - Tomas Brozek
- Department of Anesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 2, 128 00, Prague 2, Czech Republic
| | - Jan Rulisek
- Department of Anesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 2, 128 00, Prague 2, Czech Republic
| | - Michal Porizka
- Department of Anesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 2, 128 00, Prague 2, Czech Republic
| | - Robert Sachl
- Department of Anesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 2, 128 00, Prague 2, Czech Republic
| | - Michal Otahal
- Department of Anesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 2, 128 00, Prague 2, Czech Republic
| | - Petr Brestovansky
- Department of Anesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 2, 128 00, Prague 2, Czech Republic
| | - Eva Svobodova
- Department of Anesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 2, 128 00, Prague 2, Czech Republic
| | - Marek Flaksa
- Department of Anesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 2, 128 00, Prague 2, Czech Republic
| | - Zdenek Stach
- Department of Anesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 2, 128 00, Prague 2, Czech Republic
| | - Jan Horejsek
- Department of Anesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 2, 128 00, Prague 2, Czech Republic
| | - Lukas Volny
- Department of Anesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 2, 128 00, Prague 2, Czech Republic
| | - Ivana Jurisinova
- Department of Anesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 2, 128 00, Prague 2, Czech Republic
| | - Adam Novotny
- Department of Anesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 2, 128 00, Prague 2, Czech Republic
| | - Pavel Trachta
- Department of Anesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 2, 128 00, Prague 2, Czech Republic
| | - Jan Kunstyr
- Department of Anesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 2, 128 00, Prague 2, Czech Republic
| | - Petr Kopecky
- Department of Anesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 2, 128 00, Prague 2, Czech Republic
| | - Tomas Tencer
- Department of Anesthesiology and Intensive Care, 3rd Faculty of Medicine, Charles University and Kralovske Vinohrady University Hospital in Prague, Prague, Czech Republic
| | - Jaroslav Pazout
- Department of Anesthesiology and Intensive Care, 3rd Faculty of Medicine, Charles University and Kralovske Vinohrady University Hospital in Prague, Prague, Czech Republic
| | - Jan Belohlavek
- 2nd Department of Medicine, Department of Cardiovascular Medicine, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Frantisek Duska
- Department of Anesthesiology and Intensive Care, 3rd Faculty of Medicine, Charles University and Kralovske Vinohrady University Hospital in Prague, Prague, Czech Republic
| | - Adela Krajcova
- Department of Anesthesiology and Intensive Care, 3rd Faculty of Medicine, Charles University and Kralovske Vinohrady University Hospital in Prague, Prague, Czech Republic
| | - Petr Waldauf
- Department of Anesthesiology and Intensive Care, 3rd Faculty of Medicine, Charles University and Kralovske Vinohrady University Hospital in Prague, Prague, Czech Republic
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Lenhoff H, Järnbert-Petersson H, Darpo B, Tornvall P, Frick M. Mortality and ventricular arrhythmias in patients on d,l-sotalol for rhythm control of atrial fibrillation: A nationwide cohort study. Heart Rhythm 2023; 20:1473-1480. [PMID: 37598987 DOI: 10.1016/j.hrthm.2023.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 08/03/2023] [Accepted: 08/11/2023] [Indexed: 08/22/2023]
Abstract
BACKGROUND Use of d,l-sotalol for rhythm control in patients with atrial fibrillation (AF) has raised safety concerns. Previous randomized studies are few and not designed for mortality outcome. OBJECTIVE The purpose of this study was to compare the incidences of mortality and ventricular arrhythmias in AF patients treated with d,l-sotalol for rhythm control vs matched control patients treated with cardioselective beta-blockers. METHODS This population-based cohort study included AF patients from the Swedish National Patient Registry (2006-2017) who underwent rhythm control after a second cardioversion. Incidence rates (IRs) and adjusted hazard ratios (aHRs) for mortality and a composite endpoint of cardiac arrest/death and ventricular arrhythmias were calculated for the overall cohort and a 1:1 propensity score matched cohort of d,l-sotalol vs beta-blocker treatment. RESULTS Among patient treated with d,l-sotalol (n = 4987) and beta-blocker (n = 27,078) (mean follow-up 458 days), all-cause mortality was lower in patients treated with d,l-sotalol: IR 1.21; 95% confidence interval 0.95-1.52 vs 2.42 (2.26-2.60) deaths per 100 patient-years; aHR 0.66 (0.52-0.83). The difference in mortality persisted in the propensity score matched comparison (n = 4953 in each group): aHR 0.63 (0.48-0.86). No differences were observed in the composite outcome: IR in propensity cohorts 2.13 (1.78-2.52) vs 2.07 (1.73-2.53) events per 100 years; aHR 1.01 (0.78-1.29). CONCLUSION There was no excess mortality with d,l-sotalol compared with cardioselective beta-blockers in patients undergoing rhythm control treatment for AF after a second cardioversion. Our results indicate that the risk associated with d,l-sotalol treatment for AF can be mitigated by careful patient selection and strict adherence to follow-up protocols.
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Affiliation(s)
- Hanna Lenhoff
- Department of Clinical Science and Education, Division of Cardiology, Karolinska Institutet, South Hospital, Stockholm, Sweden.
| | - Hans Järnbert-Petersson
- Department of Clinical Science and Education, Karolinska Institutet, South Hospital, Stockholm, Sweden
| | | | - Per Tornvall
- Department of Clinical Science and Education, Division of Cardiology, Karolinska Institutet, South Hospital, Stockholm, Sweden
| | - Mats Frick
- Department of Clinical Science and Education, Division of Cardiology, Karolinska Institutet, South Hospital, Stockholm, Sweden
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15
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Alakhfash AA, Almesned A, Alqwaiee A, Alqurashi HD, Almanea W. Congenital Complete Heart Block Complicated by Atrial Flutter Diagnosis and Management. J Saudi Heart Assoc 2023; 35:226-231. [PMID: 37790854 PMCID: PMC10544175 DOI: 10.37616/2212-5043.1347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 08/16/2023] [Accepted: 08/17/2023] [Indexed: 10/05/2023] Open
Abstract
Seventeen-month-old child was diagnosed in utero to have congenital complete heart block. The mother has Sjogren's syndrome with high Anti Ro antibodies. The baby was delivered at term with a heart rate of 55-60 beats per minute. Echocardiography revealed a structurally normal heart with a small atrial septal defect and moderate patent ductus arteriosus. At the age of 17 months, he developed atrial flutter which was aborted using electrical cardioversion in the Cath lab. No recurrence of the atrial flutter during a one-year follow-up.
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Affiliation(s)
- Ali A. Alakhfash
- Pediatric Cardiology Department, Prince Sultan Cardiac Centre-Qassim, Ministry of Health,
Saudi Arabia
| | - Abdulrahman Almesned
- Pediatric Cardiology Department, Prince Sultan Cardiac Centre-Qassim, Ministry of Health,
Saudi Arabia
| | - Abdullah Alqwaiee
- Pediatric Cardiology Department, Prince Sultan Cardiac Centre-Qassim, Ministry of Health,
Saudi Arabia
| | - Hashem D. Alqurashi
- Pediatric Cardiology Department, King Faisal Specialist Hospital and Research Center, Riyadh,
Saudi Arabia
| | - Waleed Almanea
- Pediatric Cardiology Department, King Faisal Specialist Hospital and Research Center, Riyadh,
Saudi Arabia
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16
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Tourni M, Han SJ, Weber R, Kucinski M, Wan EY, Biviano AB, Konofagou EE. Electromechanical Cycle Length Mapping for atrial arrhythmia detection and cardioversion success assessment. Comput Biol Med 2023; 163:107084. [PMID: 37302374 PMCID: PMC10527498 DOI: 10.1016/j.compbiomed.2023.107084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 04/26/2023] [Accepted: 05/27/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND Direct current cardioversion (DCCV) is an established treatment to acutely convert atrial fibrillation (AF) to normal sinus rhythm. Yet, more than 70% of patients revert to AF shortly thereafter. Electromechanical Cycle Length Mapping (ECLM) is a high framerate, spectral analysis technique shown to non-invasively characterize electromechanical activation in paced canines and re-entrant flutter patients. This study assesses ECLM feasibility to map and quantify atrial arrhythmic electromechanical activation rates and inform on 1-day and 1-month DCCV response. METHODS Forty-five subjects (30 AF; 15 healthy sinus rhythm (SR) controls) underwent transthoracic ECLM in four standard apical 2D echocardiographic views. AF patients were imaged within 1 h pre- and post-DCCV. 3D-rendered atrial ECLM cycle length (CL) maps and spatial CL histograms were generated. CL dispersion and percentage of arrhythmic CLs≤333ms across the entire atrial myocardium were computed transmurally. ECLM results were subsequently used as indicators of DCCV success. RESULTS ECLM successfully confirmed the electrical atrial activation rates in 100% of healthy subjects (R2=0.96). In AF, ECLM maps localized the irregular activation rates pre-DCCV and confirmed successful post-DCCV with immediate reduction or elimination. ECLM metrics successfully distinguished DCCV 1-day and 1-month responders from non-responders, while pre-DCCV ECLM values independently predicted AF recurrence within 1-month post-DCCV. CONCLUSIONS ECLM can characterize electromechanical activation rates in AF, quantify their extent, and identify and predict short- and long-term AF recurrence. ELCM constitutes thus a noninvasive arrhythmia imaging modality that can aid clinicians in simultaneous AF severity quantification, prediction of AF DCCV response, and personalized treatment planning.
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Affiliation(s)
- Melina Tourni
- Depatrment of Biomedical Engineering, Columbia University, 630 W 168th Street, New York, 10032, NY, USA.
| | - Seungyeon Julia Han
- Depatrment of Biomedical Engineering, Columbia University, 630 W 168th Street, New York, 10032, NY, USA
| | - Rachel Weber
- Depatrment of Biomedical Engineering, Columbia University, 630 W 168th Street, New York, 10032, NY, USA
| | - Mary Kucinski
- Depatrment of Biomedical Engineering, Columbia University, 630 W 168th Street, New York, 10032, NY, USA
| | - Elaine Y Wan
- Department of Medicine and Vagelos College of Physicians and Surgeons, Columbia University, 630 W 168th Street, New York, 10032, NY, USA
| | - Angelo B Biviano
- Department of Medicine and Vagelos College of Physicians and Surgeons, Columbia University, 630 W 168th Street, New York, 10032, NY, USA
| | - Elisa E Konofagou
- Depatrment of Biomedical Engineering, Columbia University, 630 W 168th Street, New York, 10032, NY, USA; Department of Radiology, Columbia University, 630 W 168th Street, New York, 10032, NY, USA.
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17
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Burashnikov A, Antzelevitch C. Mild elevation of extracellular potassium greatly potentiates the effect of sodium channel block to cardiovert atrial fibrillation: The Lankenau approach. Heart Rhythm 2023; 20:1257-1264. [PMID: 37169158 DOI: 10.1016/j.hrthm.2023.05.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 05/03/2023] [Accepted: 05/03/2023] [Indexed: 05/13/2023]
Abstract
BACKGROUND Cardioversion of atrial fibrillation (AF) is a common clinical necessity, and there is a need for more effective and safe options for acute cardioversion of AF. OBJECTIVE The purpose of this study was to test the hypothesis that the efficacy and time course of AF cardioversion by sodium channel current (INa) block can be improved by mild elevation of extracellular potassium ([K+]0). METHODS Using a canine acetylcholine (ACh)-mediated AF model (isolated coronary-perfused right atrial preparations with a rim of right ventricle), we evaluated the ability of flecainide to suppress AF in the presence of [K+]0 ranging from 3 to 8 mM. RESULTS At [K+]0 of 4 mM (baseline), persistent AF (>1 hour) was induced in 5 of 5 atria in the presence of 0.5 μM ACh. Flecainide alone (1.5 μM) cardioverted 3 of 6 atria at 4 mM [K+]0, 1 of 6 atria at 3 mM [K+]0, 5 of 5 atria at 5 mM and 6 mM [K+]0, and 4 of 4 atria at 8 mM [K+]0. In the absence of flecainide, an increase in [K+]0 from 4 mM to 5, 6, and 8 mM terminated AF in 0 of 5, 2 of 6, and 4 of 4 atria, respectively. The time to conversion was also abbreviated by elevation of [K+]0. After AF termination with flecainide plus elevated [K+]0, AF was either not inducible or brief (<100 seconds). Combined flecainide and elevated [K+]0 (6 mM) caused an atrial preferential depression of excitability. CONCLUSION Our findings suggest that a combination of INa block accompanied by mild elevation of serum potassium may be a novel approach to more effectively, rapidly, and safely cardiovert AF and prevent its recurrence in the short term.
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Affiliation(s)
- Alexander Burashnikov
- Lankenau Institute for Medical Research, Wynnewood, Pennsylvania; Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania.
| | - Charles Antzelevitch
- Lankenau Institute for Medical Research, Wynnewood, Pennsylvania; Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania; Lankenau Heart Institute, Main Line Health System, Wynnewood, Pennsylvania
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18
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Yan X, Meyre PB, Aeschbacher S, Bossard M, Zimmermann A, Conen D, Kaufmann BA. Right Heart Structure and Function after Electrical Cardioversion for Atrial Fibrillation. Cardiology 2023; 148:402-408. [PMID: 37369183 DOI: 10.1159/000531704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 06/20/2023] [Indexed: 06/29/2023]
Abstract
INTRODUCTION Atrial fibrillation (AF) adversely impacts right ventricular (RV) and right atrial (RA) structure and function. There are limited data on these changes after electrical cardioversion (ECV) and the relative contribution of heart rate to evaluate the immediate (1-2 h) and short-term (4-6 weeks) changes in right cardiac chamber dimensions and RV function after ECV in patients with persistent AF. METHODS Right cardiac chamber dimensions and RV function were measured in 64 patients using transthoracic echocardiography 1-2 h before, immediately after, and 4-6 weeks after ECV. Associations between changes in right-heart measures and rhythm status at follow-up were assessed using linear regression models. RESULTS For patients who remained in sinus rhythm 4-6 weeks after ECV (n = 48), median fractional area change (FAC) at baseline, immediately after ECV, and 4-6 weeks after ECV were 39 (Q1:35, Q3:42) %, 42 (Q1:39, Q3:46) %, 46 (Q1:43, Q3:49) % (p < 0.01); median tricuspid annular plane systolic excursion (TAPSE) values at the same time points were 18 (Q1:17, Q3:20) mm, 20 (Q1:18, Q3:23) mm, and 24 (Q1:22, Q3:26) mm (p < 0.01), respectively. There was no significant difference in RV end systolic area and RA volume index before and after ECV. However, RV end systolic area and RA volume index decreased significantly after 4-6 weeks from a median of 10 (Q1:8, Q3:13) cm2 to 8 (Q1:7, Q3:10) cm2 (p < 0.01), and from a median of 30 (Q1:24, Q3:36) mL/m2 to 24 (Q1:20, Q3:27) mL/m2 (p < 0.01). Changes in TAPSE were significantly associated with sinus rhythm at follow-up (p = 0.027), changes in FAC showed a strong trend to association with sinus rhythm (p = 0.053), and this was not true for RA measures (p = 0.64). CONCLUSIONS Among AF patients who remained in sinus rhythm after ECV, RV function improved immediately after ECV with further improvement at 4-6 weeks following sinus rhythm restoration.
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Affiliation(s)
- Xiaohan Yan
- Division of Cardiology, University Hospital and University of Basel, Basel, Switzerland
| | - Pascal B Meyre
- Division of Cardiology, University Hospital and University of Basel, Basel, Switzerland
- Cardiovascular Research Institute Basel, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Stefanie Aeschbacher
- Division of Cardiology, University Hospital and University of Basel, Basel, Switzerland
- Cardiovascular Research Institute Basel, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Matthias Bossard
- Cardiology Division, Heart Center - Luzerner Kantonsspital, Lucerne, Switzerland
| | - Andreas Zimmermann
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - David Conen
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Beat A Kaufmann
- Division of Cardiology, University Hospital and University of Basel, Basel, Switzerland
- Cardiovascular Research Institute Basel, University Hospital Basel, University of Basel, Basel, Switzerland
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19
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Reiffel JA, Blomström-Lundqvist C, Boriani G, Goette A, Kowey PR, Merino JL, Piccini JP, Saksena S, Camm AJ. Real-world utilization of the pill-in-the-pocket method for terminating episodes of atrial fibrillation: data from the multinational Antiarrhythmic Interventions for Managing Atrial Fibrillation (AIM-AF) survey. Europace 2023; 25:euad162. [PMID: 37354453 PMCID: PMC10290490 DOI: 10.1093/europace/euad162] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 06/02/2023] [Indexed: 06/26/2023] Open
Abstract
AIMS Atrial fibrillation (AF) is the most common sustained arrhythmia encountered in clinical practice. Episodes may stop spontaneously (paroxysmal AF); may terminate only via intervention (persistent AF); or may persist indefinitely (permanent AF) (see European and American guidelines, referenced below, for more precise definitions). Recently, there has been renewed interest in an approach to terminate AF acutely referred to as 'pill-in-the-pocket' (PITP). The PITP is recognized in both the US and European guidelines as an effective option using an oral antiarrhythmic drug for acute conversion of acute/recent-onset AF. However, how PITP is currently used has not been systematically evaluated. METHODS AND RESULTS The recently published Antiarrhythmic Interventions for Managing Atrial Fibrillation (AIM-AF) survey included questions regarding current PITP usage, stratified by US vs. European countries surveyed, by representative countries within Europe, and by cardiologists vs. electrophysiologists. This manuscript presents the data from this planned sub-study. Our survey revealed that clinicians in both the USA and Europe consider PITP in about a quarter of their patients, mostly for recent-onset AF with minimal or no structural heart disease (guideline appropriate). However, significant deviations exist. See the Graphical abstract for a summary of the data. CONCLUSION Our findings highlight the frequent use of PITP and the need for further physician education about appropriate and optimal use of this strategy.
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Affiliation(s)
- James A Reiffel
- Department of Medicine, Division of Cardiology, Columbia University Vagelos College of Physicians & Surgeons, c/o 202 Birkdale Lane, New York, NY 33458, USA
| | - Carina Blomström-Lundqvist
- Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- Department of Medical Science, Uppsala University, akademiska sjukhuset, ingang 35, 2tr 751 85 Uppsala, Sweden
| | - Giuseppe Boriani
- Division of Cardiology, Department of Biomedical, Metabolic, and Neural Sciences, University of Modena and Reggio Emilia, Via Del Pozzo71, 41124 Moderna, Italy
| | - Andreas Goette
- St. Vincenz Hospital, Am Busdorf 2 33098, Paderborn, Germany
| | - Peter R Kowey
- Sidney Kimmel Medical College at Thomas Jefferson University, 1015 Walnut Street, Philadelphia, PA 19107, USA
- Lankenau Heart Institute, 100 East Lancaster, Ave, Wynnewood, PA 19096, USA
| | - Jose L Merino
- Chief, Arrhythmia & Robotic EP Unit, La Paz University Hospital, and Professor of Cardiology, Universidad Autonoma, IDIPAZ, Madrid, Spain
- La Paz University Hospital, Castellana Avenue, 261, 28046 Madrid, Spain
| | - Jonathan P Piccini
- Duke University, Duke Clinical Research Institute, 300 West Morgan Street, Durham, NC 27701, USA
| | - Sanjeev Saksena
- Rutgers Robert Wood Johnson Medical School, Piscataway, NJ, USA
- Medical Director and Trustee, Electrophysiologiy Research Foundation, 161 Washington Valley Road, Warren, NJ 07059, USA
| | - A John Camm
- St George’s University Hospitals, Blackshaw Road, Tooting London SW17 0QT, UK
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20
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Yagel O, Planer D, Elitzur Y, Be'eri R, Elbaz-Greener G. MitraClip detachment after electrical cardioversion: a case report. Eur Heart J Case Rep 2023; 7:ytad226. [PMID: 37207107 PMCID: PMC10188994 DOI: 10.1093/ehjcr/ytad226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 10/19/2022] [Accepted: 04/28/2023] [Indexed: 05/21/2023]
Abstract
Background Transcatheter edge-to-edge repair (TEER) repair is a minimally invasive procedure used for patients with severe mitral regurgitation (MR). Cardioversion is indicated for haemodynamically unstable patients with narrow complex tachycardia and is generally considered safe post-mitral clip. We present a patient who underwent cardioversion post-TEER with a single leaflet detachment (SLD). Case summary An 86-year-old female with severe MR underwent TEER with a MitraClip that reduced MR severity to mild. During the procedure, the patient experienced tachycardia, and cardioversion was performed successfully. However, immediately after the cardioversion, the operators noticed recurrent severe MR with a posterior leaflet clip detachment. Deployment of a new clip adjacent to the detached one was obtained. Discussion Transcatheter edge-to-edge repair is a well-established method for treating severe MR in patients who are not suitable for surgical intervention. However, complications can arise during or after the procedure, such as clip detachment as in this case. Several mechanisms can explain SLD. We presumed that in the current case, immediately after cardioversion, there was an acute (post-pause) increase in left ventricle end-diastolic volume and thus in the left ventricle systolic volume with more vigorous contraction, possibly pulling apart the leaflets and detaching the freshly applied TEER device. This is the first report of SLD related to electrical cardioversion after TEER. Even though electrical cardioversion is considered safe, SLD can occur in this setting.
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Affiliation(s)
- Oren Yagel
- Department of Cardiology, Hadassah University Hospital, Ein-Kerem, POB 12000, Jerusalem 9112001, Israel
| | - David Planer
- Department of Cardiology, Hadassah University Hospital, Ein-Kerem, POB 12000, Jerusalem 9112001, Israel
| | - Yair Elitzur
- Department of Cardiology, Hadassah University Hospital, Ein-Kerem, POB 12000, Jerusalem 9112001, Israel
| | - Ronen Be'eri
- Department of Cardiology, Hadassah University Hospital, Ein-Kerem, POB 12000, Jerusalem 9112001, Israel
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21
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Bertram F, Buchholz J. [Sudden cardiac death after cardioversion]. Herzschrittmacherther Elektrophysiol 2023; 34:165-168. [PMID: 37027044 DOI: 10.1007/s00399-023-00935-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 03/02/2023] [Indexed: 04/08/2023]
Abstract
An 83-year-old woman with heart failure due to atrial tachycardia with reduced left ventricular ejection fraction died after cardioversion. Holter monitoring showed a massive prolongation of the QT interval resulting in torsade de pointe tachycardia with lethal outcome. The only reason of the QT prolongation was impaired left ventricular (LV) function and atrial ectopy.
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Affiliation(s)
- Felix Bertram
- Klinik für Innere Medizin, Evangelisches Krankenhaus Oberhausen (Rheinland), Oberhausen, Deutschland, Virchowstr. 20, 46047 Oberhausen
| | - Jochen Buchholz
- Klinik für Kardiologie, Angiologie und Intensivmedizin, Evangelisches Krankenhaus Oberhausen (Rheinland), Virchowstr. 20, 46047, Oberhausen, Deutschland.
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22
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Toyoshi S, Funaguchi N, Ishigaki H, Yanase K. Primary Squamous Cell Lung Cancer With Frequent Episodes of Sustained Ventricular Tachycardia due to Myocardial Metastasis. J Med Cases 2023; 14:111-117. [PMID: 37188297 PMCID: PMC10181293 DOI: 10.14740/jmc4066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 04/08/2023] [Indexed: 05/17/2023] Open
Abstract
Myocardial metastasis from lung cancer rarely occurs. We encountered a patient with squamous cell lung cancer who was diagnosed with myocardial metastasis before death and sustained ventricular tachycardia during the course of the disease. The patient was a 56-year-old woman. A tumor was noted in the apex area of the left lung and was diagnosed as stage IVA of squamous cell lung cancer after a detailed examination. She underwent concurrent chemoradiotherapy with weekly treatment of carboplatin + paclitaxel. A 12-lead electrocardiogram performed upon admission for additional chemotherapy showed negative T waves in leads III, aVF, and V1-4. Transthoracic echocardiography and computed tomography showed a tumor lesion in the right ventricular wall, which was diagnosed as myocardial metastasis from lung cancer. During the course of the disease, the patient had frequent episodes of sustained ventricular tachycardia, which were refractory to treatment with antiarrhythmic drugs. However, the sinus rhythm was restored with cardioversion. Subsequently, the patient received palliative treatment and eventually died 4 months after the diagnosis of cardiac metastasis and 3 weeks after the diagnosis of ventricular tachycardia. Myocardial metastasis might reflect poor prognosis due to serious arrhythmia or some other complications. Therefore, the early diagnosis and appropriate treatment of cardiac metastasis by chemotherapy, cardiac radiotherapy, or surgery, are necessary prior to the development of symptoms in tolerant cases.
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Affiliation(s)
- Sayaka Toyoshi
- Department of Respiratory Medicine, Asahi University Hospital, Gifu 500-8523, Japan
| | - Norihiko Funaguchi
- Department of Respiratory Medicine, Asahi University Hospital, Gifu 500-8523, Japan
- Corresponding Author: Norihiko Funaguchi, Department of Respiratory Medicine, Asahi University Hospital, Gifu 500-8523, Japan.
| | - Hirotoshi Ishigaki
- Department of Respiratory Medicine, Asahi University Hospital, Gifu 500-8523, Japan
| | - Komei Yanase
- Department of Cardiology and Respiratory Medicine, Gifu University Graduate School of Medicine, Gifu 501-1194, Japan
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23
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Abstract
Cardiac arrhythmias are a leading cause of morbidity and mortality in the developed world, estimated to be responsible for hundreds of thousands of deaths annually. Our understanding of the electrophysiological mechanisms of such arrhythmias has grown since they were formally characterized in the late nineteenth century, and this has led to the development of numerous devices and therapies that have markedly improved outcomes for patients affected by such conditions. Despite these advancements, the application of a single large shock remains the clinical standard for treating deadly tachyarrhythmias. Such defibrillating shocks are undoubtedly effective in terminating such arrhythmias; however, they are applied without forewarning, contributing to the patient's stress and anxiety; they can be intensely painful; and they can have adverse psychological and physiological effects on patients. In recent years, there has been interest in developing defibrillation protocols that can terminate arrhythmias without crossing the human pain threshold for energy delivery, generally estimated to be between 0.1 and 1 J. In this article, we review existing literature on the development of such low-energy defibrillation methods and their underlying mechanisms, in an attempt to broadly describe the current landscape of these technologies.
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Affiliation(s)
- Skylar Buchan
- Electrophysiology Clinical Research and Innovations, Texas Heart Institute, 6770 Bertner Avenue, Houston, TX, 77030, USA
| | - Ronit Kar
- Electrophysiology Clinical Research and Innovations, Texas Heart Institute, 6770 Bertner Avenue, Houston, TX, 77030, USA.,Department of Biomedical Engineering, The University of Texas At Austin, Austin, TX, 78712, USA
| | - Mathews John
- Electrophysiology Clinical Research and Innovations, Texas Heart Institute, 6770 Bertner Avenue, Houston, TX, 77030, USA
| | - Allison Post
- Electrophysiology Clinical Research and Innovations, Texas Heart Institute, 6770 Bertner Avenue, Houston, TX, 77030, USA
| | - Mehdi Razavi
- Electrophysiology Clinical Research and Innovations, Texas Heart Institute, 6770 Bertner Avenue, Houston, TX, 77030, USA. .,Division of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, 77030, USA.
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24
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Peukert S, Gulgeze Efthymiou HB, Mo R, Peng Y, Ma F, Barbe G, Bebernitz G, Fridrich C, Buono C, Williams ET, Daniels T, Li L, Zhang X, Adachi Y, Abe M, Taggart AKP. Discovery of a brain-sparing GIRK1/4 inhibitor for pharmacological cardioversion of atrial fibrillation. Bioorg Med Chem Lett 2023; 85:129237. [PMID: 36924945 DOI: 10.1016/j.bmcl.2023.129237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 03/06/2023] [Accepted: 03/09/2023] [Indexed: 03/17/2023]
Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia, and a significant risk factor for ischemic stroke and heart failure. Marketed anti-arrhythmic drugs can restore sinus rhythm, but with limited efficacy and significant toxicities, including potential to induce ventricular arrhythmia. Atrial-selective ion channel drugs are expected to restore and maintain sinus rhythm without risk of ventricular arrhythmia. One such atrial-selective channel target is GIRK1/4 (G-protein regulated inwardly rectifying potassium channel 1/4). Here we describe 14b, a potent GIRK1/4 inhibitor developed to cardiovert AF to sinus rhythm while minimizing central nervous system exposure - an issue with preceding GIRK1/4 clinical candidates.
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Affiliation(s)
- Stefan Peukert
- Novartis Institutes for Biomedical Research, 181 Massachusetts Avenue, Cambridge, MA 02139, USA.
| | | | - Ruowei Mo
- Novartis Institutes for Biomedical Research, 181 Massachusetts Avenue, Cambridge, MA 02139, USA
| | - Yunshan Peng
- Novartis Institutes for Biomedical Research, 181 Massachusetts Avenue, Cambridge, MA 02139, USA
| | - Fupeng Ma
- Novartis Institutes for Biomedical Research, 181 Massachusetts Avenue, Cambridge, MA 02139, USA
| | - Guillaume Barbe
- Novartis Institutes for Biomedical Research, 181 Massachusetts Avenue, Cambridge, MA 02139, USA
| | | | - Cary Fridrich
- Novartis Institutes for Biomedical Research, 181 Massachusetts Avenue, Cambridge, MA 02139, USA
| | - Chiara Buono
- Novartis Institutes for Biomedical Research, 181 Massachusetts Avenue, Cambridge, MA 02139, USA
| | - Eric T Williams
- Novartis Institutes for Biomedical Research, 181 Massachusetts Avenue, Cambridge, MA 02139, USA
| | - Thomas Daniels
- Novartis Institutes for Biomedical Research, 181 Massachusetts Avenue, Cambridge, MA 02139, USA
| | - Lisha Li
- Novartis Institutes for Biomedical Research, 181 Massachusetts Avenue, Cambridge, MA 02139, USA
| | - Xia Zhang
- Novartis Institutes for Biomedical Research, 181 Massachusetts Avenue, Cambridge, MA 02139, USA
| | - Yuichiro Adachi
- Novartis Institutes for Biomedical Research, 181 Massachusetts Avenue, Cambridge, MA 02139, USA
| | - Mie Abe
- Former Novartis Employee, USA
| | - Andrew K P Taggart
- Novartis Institutes for Biomedical Research, 181 Massachusetts Avenue, Cambridge, MA 02139, USA
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25
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Vinson DR, Rauchwerger AS, Karadi CA, Shan J, Warton EM, Zhang JY, Ballard DW, Mark DG, Hofmann ER, Cotton DM, Durant EJ, Lin JS, Sax DR, Poth LS, Gamboa SH, Ghiya MS, Kene MV, Ganapathy A, Whiteley PM, Bouvet SC, Babakhanian L, Kwok EW, Solomon MD, Go AS, Reed ME. Clinical decision support to Optimize Care of patients with Atrial Fibrillation or flutter in the Emergency department: protocol of a stepped-wedge cluster randomized pragmatic trial (O'CAFÉ trial). Trials 2023; 24:246. [PMID: 37004068 PMCID: PMC10064588 DOI: 10.1186/s13063-023-07230-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 03/08/2023] [Indexed: 04/03/2023] Open
Abstract
BACKGROUND Management of adults with atrial fibrillation (AF) or atrial flutter in the emergency department (ED) includes rate reduction, cardioversion, and stroke prevention. Different approaches to these components of care may lead to variation in frequency of hospitalization and stroke prevention actions, with significant implications for patient experience, cost of care, and risk of complications. Standardization using evidence-based recommendations could reduce variation in management, preventable hospitalizations, and stroke risk. METHODS We describe the rationale for our ED-based AF treatment recommendations. We also describe the development of an electronic clinical decision support system (CDSS) to deliver these recommendations to emergency physicians at the point of care. We implemented the CDSS at three pilot sites to assess feasibility and solicit user feedback. We will evaluate the impact of the CDSS on hospitalization and stroke prevention actions using a stepped-wedge cluster randomized pragmatic clinical trial across 13 community EDs in Northern California. DISCUSSION We hypothesize that the CDSS intervention will reduce hospitalization of adults with isolated AF or atrial flutter presenting to the ED and increase anticoagulation prescription in eligible patients at the time of ED discharge and within 30 days. If our hypotheses are confirmed, the treatment protocol and CDSS could be recommended to other EDs to improve management of adults with AF or atrial flutter. TRIAL REGISTRATION ClinicalTrials.gov NCT05009225 . Registered on 17 August 2021.
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Affiliation(s)
- David R Vinson
- The Permanente Medical Group, Oakland, CA, USA.
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA.
- Department of Emergency Medicine, Kaiser Permanente Roseville Medical Center, Roseville, CA, USA.
| | - Adina S Rauchwerger
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Chandu A Karadi
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente San Jose Medical Center, San Jose, CA, USA
| | - Judy Shan
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
- School of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - E Margaret Warton
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Jennifer Y Zhang
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Dustin W Ballard
- The Permanente Medical Group, Oakland, CA, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente San Rafael Medical Center, San Rafael, CA, USA
| | - Dustin G Mark
- The Permanente Medical Group, Oakland, CA, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente Oakland Medical Center, Oakland, CA, USA
| | - Erik R Hofmann
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente South Sacramento Medical Center, Sacramento, CA, USA
| | - Dale M Cotton
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente South Sacramento Medical Center, Sacramento, CA, USA
| | - Edward J Durant
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente Modesto Medical Center, Modesto, CA, USA
| | - James S Lin
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente Santa Clara Medical Center, Santa Clara, CA, USA
| | - Dana R Sax
- The Permanente Medical Group, Oakland, CA, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente Oakland Medical Center, Oakland, CA, USA
| | - Luke S Poth
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente Walnut Creek Medical Center, Walnut Creek, CA, USA
| | - Stephen H Gamboa
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente San Francisco Medical Center, San Francisco, CA, USA
| | - Meena S Ghiya
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente South San Francisco Medical Center, San Francisco, CA, USA
| | - Mamata V Kene
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente San Leandro Medical Center, San Leandro, CA, USA
| | - Anuradha Ganapathy
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente San Jose Medical Center, San Jose, CA, USA
| | - Patrick M Whiteley
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente San Jose Medical Center, San Jose, CA, USA
| | - Sean C Bouvet
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente Walnut Creek Medical Center, Walnut Creek, CA, USA
| | | | | | - Matthew D Solomon
- The Permanente Medical Group, Oakland, CA, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
- Department of Cardiology, Oakland Medical Center, Oakland, CA, USA
| | - Alan S Go
- The Permanente Medical Group, Oakland, CA, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
- Departments of Epidemiology, Biostatistics, and Medicine, University of California, San Francisco, CA, USA
- Department of Medicine, Stanford University, Palo Alto, CA, USA
| | - Mary E Reed
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
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26
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Troisi F, Guida P, Vitulano N, Quadrini F, Di Monaco A, Grimaldi M. Safety and efficacy of direct oral anticoagulants versus vitamin K antagonists in atrial fibrillation electrical cardioversion: An update systematic review and meta-analysis. Int J Cardiol 2023; 379:40-47. [PMID: 36907451 DOI: 10.1016/j.ijcard.2023.03.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 02/13/2023] [Revised: 03/06/2023] [Accepted: 03/07/2023] [Indexed: 03/12/2023]
Abstract
BACKGROUND A systematic evaluation focused on efficacy and safety for electrical cardioversion of atrial fibrillation (AF) among different Direct Oral Anticoagulants (DOACs) has not been previously performed. In this setting, we conducted a meta-analysis of studies evaluating DOACs vs vitamin K antagonists (VKA) as common comparator. METHODS We searched Cochrane Library, Pubmed, Web Of Science and Scopus databases for all English-only articles concerning studies that have estimated the effect of DOACs and VKA on stroke, transient ischemic attack or systemic embolism (SSE) and major bleeding (MB) events in AF patients undergoing electrical cardioversion. We selected 22 articles comprising 66 cohorts and 24,322 procedures (12,612 with VKA). RESULTS During follow-up (studies' median 42 days), 135 SSE (52 DOACs and 83 VKA) and 165 MB (60 DOACs and 105 VKA) were recorded. The overall pooled effects, DOACs vs VKA, was estimated by an univariate Odds Ratio of 0.92 (0.63-1.33; p = 0.645) for SSE and 0.58 (0.41-0.82; p = 0.002) for MB; at bivariate evaluation, adjusting for study type, were respectively 0.94 (0.55-1.63; p = 0.834) and 0.63 (0.43-0.92, p = 0.016). Each single DOAC showed similar and non statistically different results in outcome occurrence compared to VKA as well as when Apixaban, Dabigatran, Edoxaban and Rivaroxaban were indirectly compared to each other. CONCLUSIONS In patients undergoing electrical cardioversion, compared to VKA, DOACs have similar thromboembolic protection with lower major bleeding incidence. Single molecule does not show difference in event rate compared to each other. Our findings, provide useful information about safety and efficacy profile of DOACs and VKA.
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Affiliation(s)
- Federica Troisi
- Cardiology Department, Regional General Hospital "F. Miulli", Acquaviva delle Fonti, Bari, Italy.
| | - Pietro Guida
- Cardiology Department, Regional General Hospital "F. Miulli", Acquaviva delle Fonti, Bari, Italy
| | - Nicola Vitulano
- Cardiology Department, Regional General Hospital "F. Miulli", Acquaviva delle Fonti, Bari, Italy
| | - Federico Quadrini
- Cardiology Department, Regional General Hospital "F. Miulli", Acquaviva delle Fonti, Bari, Italy
| | - Antonio Di Monaco
- Cardiology Department, Regional General Hospital "F. Miulli", Acquaviva delle Fonti, Bari, Italy; Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Massimo Grimaldi
- Cardiology Department, Regional General Hospital "F. Miulli", Acquaviva delle Fonti, Bari, Italy
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27
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Labbé V, Ederhy S, Legouis D, Joffre J, Razazi K, Sy O, Voicu S, Mekontso-Dessap A, Cohen A, Fartoukh M. Clinical impact of successful cardioversion for new-onset atrial fibrillation in critically ill septic patients: A preliminary study. Arch Cardiovasc Dis 2023; 116:230-233. [PMID: 36805239 DOI: 10.1016/j.acvd.2023.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Received: 11/15/2022] [Revised: 01/20/2023] [Accepted: 01/23/2023] [Indexed: 02/11/2023]
Affiliation(s)
- Vincent Labbé
- Service de médecine intensive réanimation, département médico-universitaire APPROCHES, hôpital Tenon, AP-HP, Sorbonne université, 75020 Paris, France; Groupe de recherche clinique CARMAS, université Paris-Est Créteil, 94010 Créteil, France.
| | - Stephane Ederhy
- Department of Cardiology, UNICO Cardio-Oncology Program, hôpital Saint-Antoine, AP-HP, 75012 Paris, France; Inserm U 856, 75013 Paris, France
| | - David Legouis
- Division of Intensive Care, Department of Acute Medicine, University Hospitals of Geneva, 1205 Geneva, Switzerland; Laboratory of Nephrology, Department of Medicine, University Hospitals of Geneva, 1205 Geneva; and Department of Cell Physiology, Faculty of Medicine, University of Geneva, 1211 Geneva, Switzerland
| | - Jérémie Joffre
- Service de médecine intensive réanimation, hôpital Saint-Antoine, AP-HP, Sorbonne université, 75012 Paris, France
| | - Keyvan Razazi
- Groupe de recherche clinique CARMAS, université Paris-Est Créteil, 94010 Créteil, France; Service de médecine intensive réanimation, département médico-universitaire médecine, hôpitaux universitaires Henri Mondor-Albert Chenevier, AP-HP, 94000 Créteil, France
| | - Oumar Sy
- Service de médecine intensive réanimation, centre hospitalier melun, groupe hospitalier Sud Ile-de-France, 77000 Melun, France
| | - Sebastian Voicu
- Réanimation médicale et toxicologique, hôpital Lariboisière, AP-HP, université de Paris, Inserm UMRS-1144, 75010 Paris, France
| | - Armand Mekontso-Dessap
- Groupe de recherche clinique CARMAS, université Paris-Est Créteil, 94010 Créteil, France; Service de médecine intensive réanimation, département médico-universitaire médecine, hôpitaux universitaires Henri Mondor-Albert Chenevier, AP-HP, 94000 Créteil, France
| | - Ariel Cohen
- Department of Cardiology, UNICO Cardio-Oncology Program, hôpital Saint-Antoine, AP-HP, 75012 Paris, France; Inserm U 856, 75013 Paris, France; UMR-S ICAN 1166, Sorbonne université, 75013 Paris, France
| | - Muriel Fartoukh
- Service de médecine intensive réanimation, département médico-universitaire APPROCHES, hôpital Tenon, AP-HP, Sorbonne université, 75020 Paris, France; Groupe de recherche clinique CARMAS, université Paris-Est Créteil, 94010 Créteil, France
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28
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Goette A, Brandner S. [Atrial fibrillation on the intensive care unit : The special prognostic importance of the first manifestation]. Herzschrittmacherther Elektrophysiol 2022; 33:391-397. [PMID: 36156739 DOI: 10.1007/s00399-022-00899-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 09/01/2022] [Indexed: 06/16/2023]
Abstract
Atrial fibrillation (AF) is the most common arrhythmia in the intensive care unit (ICU) and is associated with increased mortality. The AF is classified into five different forms, initially diagnosed AF, paroxysmal AF, persistent AF, long-standing persistent AF and permanent AF. Studies could confirm that the first manifestation of AF (new onset AF) is of particular importance in intensive care patients. The mortality and costs are much higher than for patients with chronic AF. This important clinical difference of the AF pattern should be taken into consideration in the treatment of intensive care patients. The treatment of comorbidities is essential in the treatment concept on the ICU. In patients with an increased risk of thromboembolic complications, therapeutic anticoagulation is indicated, although the greatly increased risk of bleeding during intensive care treatment should be considered in individual cases. In cases of hemodynamic instability electrical cardioversion should immediately be carried out. Otherwise, pharmacological cardioversion can also be carried out. Apart from a few exceptions, amiodarone is the antiarrhythmic drug of choice for rhythm control due to the contraindications for other drugs.
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Affiliation(s)
- Andreas Goette
- Medizinische Klinik II: Kardiologie und Intensivmedizin, St. Vincenz-Krankenhaus Paderborn, Am Busdorf 2, 33098, Paderborn, Deutschland.
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29
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Gu Y, Lander HL, Abozaid R, Chang FM, Clifford HS, Aktas MK, Lebow BF, Panda K, Wyrobek JA. Anesthetic Management and Considerations for Electrophysiology Procedures. Adv Anesth 2022; 40:131-147. [PMID: 36333043 DOI: 10.1016/j.aan.2022.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
The number of electrophysiology (EP) procedures being performed has dramatically increased in recent years. This escalation necessitates a full understanding by the general anesthesiologist as to the risks, specific considerations, and comorbidities that accompany these now common procedures. Procedures reviewed in this article include atrial fibrillation and flutter ablation, supraventricular tachycardia ablation, ventricular tachycardia ablation, electrical cardioversion, pacemaker insertion, implantable cardioverter-defibrillator (ICD) insertion, and ICD lead extraction. General anesthetic considerations as well as procedure-specific concerns are discussed. Knowledge of these procedures will add to the anesthesiologist's armamentarium in safely caring for patients in the EP laboratory.
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Affiliation(s)
- Yang Gu
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine & Dentistry, 601 Elmwood Avenue, Box 604, Rochester, NY 14642, USA
| | - Heather L Lander
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine & Dentistry, 601 Elmwood Avenue, Box 604, Rochester, NY 14642, USA
| | - Ravie Abozaid
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine & Dentistry, 601 Elmwood Avenue, Box 604, Rochester, NY 14642, USA
| | - Francis M Chang
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine & Dentistry, 601 Elmwood Avenue, Box 604, Rochester, NY 14642, USA
| | - Hugo S Clifford
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine & Dentistry, 601 Elmwood Avenue, Box 604, Rochester, NY 14642, USA
| | - Mehmet K Aktas
- Department of Medicine, Cardiology, University of Rochester School of Medicine & Dentistry, 601 Elmwood Ave, Floor G, Strong Ambulatory Care Facility, Rochester, NY 14642, USA
| | - Brandon F Lebow
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine & Dentistry, 601 Elmwood Avenue, Box 604, Rochester, NY 14642, USA
| | - Kunal Panda
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine & Dentistry, 601 Elmwood Avenue, Box 604, Rochester, NY 14642, USA
| | - Julie A Wyrobek
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine & Dentistry, 601 Elmwood Avenue, Box 604, Rochester, NY 14642, USA.
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Noubiap JJ, Thomas G, Agbaedeng TA, Fitzgerald JL, Gallagher C, Middeldorp ME, Sanders P. Sex differences in clinical profile, management, and outcomes of patients hospitalized for atrial fibrillation in the United States. Eur Heart J Qual Care Clin Outcomes 2022; 8:852-860. [PMID: 34931671 DOI: 10.1093/ehjqcco/qcab096] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 12/09/2021] [Accepted: 12/14/2021] [Indexed: 12/29/2022]
Abstract
AIMS This study aimed to investigate the impact of sex on the clinical profile, utilization of rhythm control therapies, cost of hospitalization, length of stay, and in-hospital mortality in patients admitted for atrial fibrillation (AF) in the United States. METHODS AND RESULTS We used data from the Nationwide Inpatient Sample for the year 2018. Regression analysis was performed to investigate differences between men and women. A P-value ≤ 0.05 was considered significant. We included 82592 patients with a primary diagnosis of of AF 50.8% women. Women were significantly older (mean age 74 vs. 67 years, P < 0.001) and had a higher CHA2DS2-VASc score (median 4 vs. 2, P < 0.001) than men. Women had relatively higher in-hospital mortality (0.9% vs. 0.8%, P = 0.070); however, after adjustment for known risk factors female sex was no longer a predictor of mortality (P = 0.199). In sex-specific regression analyses, increased age, chronic obstructive pulmonary disease, previous stroke, heart failure, and chronic kidney disease were risk factors for in-hospital mortality in both sexes, vascular disease only in women, and race and alcohol abuse only in men. After adjusting for potential confounders, female sex was associated with lower likelihood of receiving catheter ablation [adjusted odds ratio (aOR) 0.69, 95% confidence interval (CI) 0.64-0.74] and electrical cardioversion (aOR 0.69, 95% CI 0.67-0.72), and with longer hospitalization (aOR 1.33, 95% CI 1.28-1.37), whereas sex had no influence on hospitalization costs (P = 0.339). CONCLUSION There were differences in the risk profile, management, and outcomes between men and women hospitalized for AF. Further studies are needed to explore why women are treated differently regarding rhythm control procedures.
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Affiliation(s)
- Jean Jacques Noubiap
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, SA 5000, Australia
| | - Gijo Thomas
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, SA 5000, Australia
| | - Thomas A Agbaedeng
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, SA 5000, Australia
| | - John L Fitzgerald
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, SA 5000, Australia.,Department of Cardiology, Royal Adelaide Hospital, Adelaide, Australia
| | - Celine Gallagher
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, SA 5000, Australia
| | - Melissa E Middeldorp
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, SA 5000, Australia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, SA 5000, Australia.,Department of Cardiology, Royal Adelaide Hospital, Adelaide, Australia
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Eid M, Abu Jazar D, Medhekar A, Khalife W, Javaid A, Ahsan C, Shabarek N, Saad M, Rao M, Ong K, Jneid H, Elbadawi A. Anterior-Posterior versus anterior-lateral electrodes position for electrical cardioversion of atrial fibrillation: A meta-analysis of randomized controlled trials. Int J Cardiol Heart Vasc 2022; 43:101129. [PMID: 36304256 PMCID: PMC9593304 DOI: 10.1016/j.ijcha.2022.101129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 09/15/2022] [Accepted: 10/02/2022] [Indexed: 11/06/2022]
Abstract
Background The optimal electrodes position for elective direct current (DC) cardioversion of patients with atrial fibrillation (AF) remains uncertain. Methods An electronic search of MEDLINE, EMBASE and COCHRANE databases was performed through March 2022 for randomized trials that examined the outcomes of anterior-posterior (AP) versus anterior-lateral (AL) electrodes position during cardioversion of (AF). The main outcome was the success rate of cardioversion. Data were pooled using random effects model. Results The final analysis included 10 RCTs with a total of 1677 patients. There was no difference in the rate of successful cardioversion between the AP versus AL groups (86.6 vs 87.9 %; RR 1.00; 95 % Confidence Interval (CI) 0.95 to 1.06). Subgroup analysis by the shock waveform showed no significant interaction between monophasic and biphasic waveforms (Pintercation = 0.23). meta-regression analyses showed no effect modification of primary outcome according to body mass index (p = 0.15), left atrial diameter (p = 0.64), valvular heart disease (p = 0.34), lone AF (p = 0.58), or the duration of AF (p = 0.70). There was no significant difference between the AP and AL electrode position groups in successful cardioversion at low energy (RR 0.94; 95 % CI 0.74 to 1.19), the number of the delivered shocks (standardized mean difference [SMD] −0.03; 95 % CI −0.32 to 0.26) or the mean energy of the delivered shocks (SMD −0.11 and 95 % CI −0.30 to 0.07). There was lower transthoracic impedance with AP versus AL electrode position (SMD −0.28; 95 %CI −0.47 to −0.10). Conclusion Meta-analysis of randomized data showed no difference between AP and AL electrode positions in the success rate of DC cardioversion of AF. Either AP or AL electrode positions should be acceptable approaches for elective DC cardioversion of patients with AF.
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Affiliation(s)
- Mennaallah Eid
- Department of Internal Medicine, Lincoln Medical Center, New York, NY, United States
| | - Deaa Abu Jazar
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, United States
| | - Ankit Medhekar
- Section of Cardiology, Baylor College of Medicine, Houston, TX, United States
| | - Wissam Khalife
- Division of Cardiology, University of Texas Medical Branch, Galveston, TX, United States
| | - Awad Javaid
- Department of Cardiology-University of Nevada, Las Vegas-Kirk Kirkorian School of Medicine, USA
| | - Chowdhury Ahsan
- Department of Cardiology-University of Nevada, Las Vegas-Kirk Kirkorian School of Medicine, USA
| | - Nehad Shabarek
- Department of Internal Medicine, Lincoln Medical Center, New York, NY, United States
| | - Marwan Saad
- Division of interventional structural Heart Research, Lifespan Cardiovascular Institute Interventional Cardiology and Structural Heart Disease, Rhode Island, NY, United States
| | - Mohan Rao
- Division of Cardiology, Rochester General Hospital, Rochester, NY, United States
| | - Kenneth Ong
- Division of Cardiology, Lincoln Medical Center, New York, NY, United States
| | - Hani Jneid
- Section of Cardiology, Baylor College of Medicine, Houston, TX, United States
| | - Ayman Elbadawi
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX, United States,Corresponding author at: Division of Cardiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-9047, United States.
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Abstract
In the present article, we will focus on the pharmacologic treatment of atrial flutter aimed either at restoring/maintaining sinus rhythm or controlling the ventricular response during tachyarrhythmia. To provide a comprehensive description we will start discussing the electroanatomic substrate underlying the development of atrial flutter and the complex relationship with atrial fibrillation. We will then describe the available drugs for the treatment of atrial flutter on the bases of their electrophysiological effects and data from available clinical studies. We will conclude by discussing the general principles of rhythm and rate control treatment during atrial flutter.
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Guha A, Jain A, Aggarwal A, Dey AK, Dani S, Ganatra S, Marchlinski FE, Addison D, Fradley MG. Length of stay and cost of care associated with admissions for atrial fibrillation among patients with cancer. BMC Cardiovasc Disord 2022; 22:272. [PMID: 35715747 PMCID: PMC9205123 DOI: 10.1186/s12872-022-02697-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 06/01/2022] [Indexed: 12/01/2022] Open
Abstract
Background The aim of this study is to assess the burden of AF-related hospitalizations inclusive of inflation-adjusted cost-of-care and length-of-stay (LOS) among cancer patients and the impact of direct current cardioversion (DCCV) on these outcomes. Methods Using the National Inpatient Sample (NIS), patients hospitalized with either a primary or secondary diagnosis of AF and comorbid cancer were identified and both cost of hospitalization and LOS were evaluated for each group. Subgroup analyses were performed for specific cancer types (breast, lung, colon, prostate and lymphoma), and those receiving DCCV. Results The prevalence of co-morbid AF was 8.2 million (16%) and 35.5 million (10%) among those with vs. those without cancer, respectively (odds ratio = 1.6, 95% confidence interval = 1.5–1.7; P < 0.001). Over time, both primary and prevalent AF admissions among those with comorbid cancer increased from 1.1% and 12.3% in 2003 to 1.5% and 21% in 2015, respectively. The total cost of hospitalization increased 94.4% among those with AF and comorbid cancer compared to 23.9% among those without cancer. Among the subgroup of patients with comorbid cancer and primary admission for AF undergoing DCCV, length of stay (2.7 vs. 2.2 days; P < 0.001, model 1) and cost of care ($7,093 vs. 6,152; P < 0.001) were both significantly higher. Conclusions AF related admissions are increasing for all populations especially amongst those patients with a comorbid diagnosis of cancer, including all cancer subtypes evaluated. Among those patients who underwent DCCV, cancer patients had longer length of stay and increased health care costs. Supplementary Information The online version contains supplementary material available at 10.1186/s12872-022-02697-4.
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Affiliation(s)
- Avirup Guha
- Harrington Heart and Vascular Institute, Case Western Reserve University, Cleveland, OH, USA.,Cardio-Oncology Program, Division of Cardiology, The Ohio State University Medical Center, Columbus, OH, USA
| | - Anubhav Jain
- Department of Internal Medicine, Wayne State University School of Medicine, Ascension Providence Rochester Hospital, Rochester, MI, USA
| | - Ankita Aggarwal
- Department of Internal Medicine, Wayne State University School of Medicine, Ascension Providence Rochester Hospital, Rochester, MI, USA
| | - Amit K Dey
- National Heart, Lung and Blood Institute, Bethesda, MD, USA
| | - Sourbha Dani
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Department of Medicine Landsman Heart and Vascular Center, Lahey Hospital and Medical Center, Burlington, MA, USA
| | - Sarju Ganatra
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Department of Medicine Landsman Heart and Vascular Center, Lahey Hospital and Medical Center, Burlington, MA, USA
| | - Francis E Marchlinski
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Daniel Addison
- Cardio-Oncology Program, Division of Cardiology, The Ohio State University Medical Center, Columbus, OH, USA.,Cancer Control Program, Department of Medicine, Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Michael G Fradley
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. .,Cardio-Oncology Program, Division of Cardiovascular Medicine, Cardio-Oncology Center of Excellence, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA.
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Effat Fakhry E, Tawfik Ibrahim M. Relationship between vitamin D deficiency and success of cardioversion in patients with atrial fibrillation. Herzschrittmacherther Elektrophysiol 2022; 33:209-216. [PMID: 35258692 DOI: 10.1007/s00399-022-00846-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 02/02/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Inflammation plays an important role in the pathogenesis of atrial fibrillation (AF). Vitamin D deficiency has been found to increase vulnerability to AF. The authors aimed to determine the relationship between vitamin D deficiency and cardioversion success in AF patients. METHODS The study included 200 persistent AF patients presenting for cardioversion. Serum vitamin D level was sampled on admission. The success of cardioversion was assessed and patients divided into two groups: successful or failed (group I and II, respectively). Vitamin D level was assessed and patients were divided into three groups: deficient, insufficient, and sufficient vitamin D level. Cardioversion was performed pharmacologically or electrically. Failure of cardioversion was defined as: (1) detection of AF rhythm in 12-lead ECG recording immediately after cardioversion or within 6‑month follow-up, or (2) ECG Holter monitoring of AF lasting > 30 s at 6‑month follow-up. RESULTS There was a highly statistically significant difference in baseline serum vitamin D level between group I and group II (P-value < 0.01). There were no statistically significant differences between the three groups in terms of vitamin D levels regarding age, gender, body mass index, smoking, and left atrial diameter. CONCLUSION This study demonstrated that AF cardioversion failure was associated with vitamin D deficiency in patients without structural heart disease, while sufficient and insufficient vitamin D levels were associated with successful cardioversion. Therefore, vitamin D level assessment before cardioversion may help predict the success of cardioversion, and possible correction of deficient vitamin D levels may increase the chance of successful cardioversion.
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Arshad S, Davis GA, Amir M, Goldberg YH, Gupta VA, Abdel-Latif AK, Smyth S. Trends and Outcomes of Oral Anticoagulation With Direct Current Cardioversion for Atrial Fibrillation/Flutter at an Academic Medical Center. Cardiol Res 2022; 13:88-96. [PMID: 35465085 PMCID: PMC8993439 DOI: 10.14740/cr1352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 02/15/2022] [Indexed: 11/11/2022] Open
Abstract
Background Increasing reports suggest the safe use of direct oral anticoagulants (DOACs) in electrical cardioversion. The aim of this study was to assess the trends and 30-day outcomes associated with anticoagulation for cardioversion. Methods Patients who underwent electrical cardioversion from January 2015 to October 2020 with a 30-day follow-up were included; and outcomes including stroke, transient ischemic attack, intracranial hemorrhage (ICH), and major gastrointestinal bleeding were recorded. Results Of the 515 patients, 351 (68%) were men and 164 (32%) were women, with a mean CHA2DS2VASc score of 2.6 ± 1.6. Outpatient apixaban use increased from 10% in 2015 to 46% in 2020 (P < 0.001) with a decline in the use of warfarin from 24% in 2015 to 10% in 2020 (P = 0.023). Apixaban use peri-procedurally for cardioversion increased from 32% in 2015 to 35% in 2020 (P = 0.317), while warfarin use decreased from 23% in 2015 to 14% in 2020 (P = 0.164). At discharge, apixaban prescriptions increased from 21% in 2015 to 61% in 2020 (P < 0.001), while warfarin prescriptions declined from 30% in 2015 to 13% in 2020 (P = 0.009). No ICH was recorded in the 30 days after cardioversion. Ischemic stroke occurred in four (0.7%) patients with one (0.29%) of the 338 patients on a DOAC, one (0.8%) of the 124 patients on warfarin and two (5.5%) of the 36 patients not receiving anticoagulation post cardioversion. There were seven (1%) major gastrointestinal bleeding events in patients on oral anticoagulation, of which four (3%) were on warfarin and three (0.8%) were on DOACs. Conclusions Our study shows the increasing and safe use of DOACs for the purpose of cardioversion. The rates of 30-day ischemic stroke post cardioversion were low and only occurred in patients admitted in the intensive care unit.
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Affiliation(s)
- Samiullah Arshad
- Department of Internal Medicine, University of Kentucky, Lexington, KY, USA
| | - George A. Davis
- Pharmacy Services and College of Pharmacy, University of Kentucky, Lexington, KY, USA
| | - Muhammad Amir
- Department of Internal Medicine, National University of Medical Sciences, Islamabad, Pakistan
| | | | - Vedant A. Gupta
- Department of Cardiology, University of Kentucky, Lexington, KY, USA
| | - Ahmed K. Abdel-Latif
- Department of Cardiology, University of Michigan, Ann Arbor and the Ann Arbor VA Healthcare System, MI, USA
| | - Susan Smyth
- Department of Cardiology, University of Arkansas Medical Sciences, Little Rock, AZ, USA
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36
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Bode W, Ptaszek LM. Management of Atrial Fibrillation in the Emergency Department. Curr Cardiol Rep 2021; 23:179. [PMID: 34657210 DOI: 10.1007/s11886-021-01611-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/05/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE OF REVIEW Atrial fibrillation (AF) is the most common arrhythmia in adults and is responsible for 600,000 emergency department (ED) visits each year in the USA. Over 60% of these patients are admitted to inpatient units. The prevalence of AF is increasing, resulting in higher numbers of AF-related ED visits and inpatient admissions. These trends underscore the need for improvements in the efficiency of AF management in the ED. RECENT FINDINGS Several treatment protocols have been developed to address challenges associated with AF management in the ED, including: initiation of oral anticoagulant (OAC) therapy, cardioversion, and arranging for outpatient follow-up. Studies of these protocols have demonstrated that they can be utilized safely and effectively. Published treatment protocols for AF in the ED have been shown to reduce unnecessary hospital admissions and improve adherence to guideline-directed OAC therapy. Widespread adoption of AF treatment protocols could improve patient outcomes and reduce the costs associated with inpatient AF treatment.
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Wilson H, Patton D, Moore Z, O'Connor T, Nugent L. Comparison of dronedarone vs. flecainide in the maintenance of sinus rhythm, following electro cardioversion in adults with persistent atrial fibrillation: a systematic review and meta-analysis. Eur Heart J Cardiovasc Pharmacother 2021; 7:363-372. [PMID: 32163173 DOI: 10.1093/ehjcvp/pvaa018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 01/24/2020] [Accepted: 03/05/2020] [Indexed: 11/13/2022]
Abstract
AIMS To compare flecainide and dronedarone for sinus rhythm (SR) maintenance following electrocardioversion of persistent atrial fibrillation (AF), in patients with minimal or no structural heart disease. METHODS AND RESULTS A systematic search of publications using EMBASE, CENTRAL, CINAHL, and MEDLINE (1989-2019), identified a total of 595 articles. No limitations were applied. Nine articles met the inclusion criteria [five randomized controlled trials (RCTs) and four cohort studies], encompassing 1349 persistent AF candidates. Two retrospective studies compared flecainide with dronedarone, indicating a 6% reduced risk of AF recurrence with flecainide; however, results were not statistically significant [risk ratio (RR) 0.94, 95% confidence interval (CI) 0.71-1.24; P = 0.66]. One RCT compared dronedarone to placebo, demonstrating a 28% reduced risk of AF recurrence at 6 months (RR 0.72, 95% CI 0.58-0.90; P = 0.004). Two RCTs compare flecainide to placebo, when a 16% decreased risk of AF recurrence at 6-12 months was indicated; however, these results were not statistically significant (RR 0.84, 95% CI 0.66-1.07; P = 0.16). Within a 6- to 12-month follow-up period, a combined recurrence rate of AF was examined, in which flecainide and dronedarone maintained SR in 50% and 42%, respectively. Four articles satisfied quality appraisal, one of which focused on flecainide data. CONCLUSION Dronedarone and flecainide displayed similar efficacy in maintaining SR in patients following electrocardioversion for persistent AF. The SR maintenance was numerically but not statistically significant in the flecainide group. Side effects uncovered similar pro-arrhythmic activity. However, in light of the deficiency of volume and quality of available evidence, the writer acknowledges the requirement for future research.
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Affiliation(s)
- Hannah Wilson
- School of Nursing and Midwifery, Royal College of Surgeons in Ireland (RCSI), University of Medicine and Health Sciences, 123 St Stephen's Green, Dublin D02 YN77, Ireland.,Mater Private Hospital, Eccles St, Northside, Dublin D07 WKW8, Ireland
| | - Declan Patton
- School of Nursing and Midwifery, Royal College of Surgeons in Ireland (RCSI), University of Medicine and Health Sciences, 123 St Stephen's Green, Dublin D02 YN77, Ireland.,Faculty of Science, Medicine and Health, University of Wollongong, Northfields Ave, Wollongong, NSW 2522, Australia.,Fakeeh College of Health Sciences, Abdul Wahab Naib Al Haram, Al-Hamra'a, Jeddah 23323, Saudi Arabia
| | - Zena Moore
- School of Nursing and Midwifery, Royal College of Surgeons in Ireland (RCSI), University of Medicine and Health Sciences, 123 St Stephen's Green, Dublin D02 YN77, Ireland.,Fakeeh College of Health Sciences, Abdul Wahab Naib Al Haram, Al-Hamra'a, Jeddah 23323, Saudi Arabia.,Faculty of Medicine, Nursing and Health Sciences, Monash University, 27 Rainforest Walk, Wellington Rd, Clayton VIC 3800, Melbourne, Australia.,Department of Public Health, Faculty of Medicine and Health Sciences, Ghent University, De Pintelaan 185, 3K3, Gent 9000, Belgium.,Lida Institute, 1788 Cheting Hwy, Songjiang District, Shanghai, China.,University of Wales, Kind Edward VII Ave, Cardiff CF10 3NS, UK
| | - Tom O'Connor
- School of Nursing and Midwifery, Royal College of Surgeons in Ireland (RCSI), University of Medicine and Health Sciences, 123 St Stephen's Green, Dublin D02 YN77, Ireland.,Fakeeh College of Health Sciences, Abdul Wahab Naib Al Haram, Al-Hamra'a, Jeddah 23323, Saudi Arabia.,Lida Institute, 1788 Cheting Hwy, Songjiang District, Shanghai, China
| | - Linda Nugent
- School of Nursing and Midwifery, Royal College of Surgeons in Ireland (RCSI), University of Medicine and Health Sciences, 123 St Stephen's Green, Dublin D02 YN77, Ireland.,Fakeeh College of Health Sciences, Abdul Wahab Naib Al Haram, Al-Hamra'a, Jeddah 23323, Saudi Arabia
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Wiens EJ, Seifer CM. A case of cautery-version. HeartRhythm Case Rep 2021; 7:573-574. [PMID: 34434712 PMCID: PMC8377258 DOI: 10.1016/j.hrcr.2021.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Affiliation(s)
- Evan J Wiens
- Section of Cardiology, Department of Internal Medicine, University of Manitoba, Winnipeg, Canada
| | - Colette M Seifer
- Section of Cardiology, Department of Internal Medicine, University of Manitoba, Winnipeg, Canada
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Shenthar J, Banavalikar B, Valappil SP, Deshpande S, Nireshwalia A, Padmanabhan D, Reddy SS. Safety and Efficacy of Ibutilide for Acute Pharmacological Cardioversion of Rheumatic Atrial Fibrillation. Cardiology 2021; 146:624-632. [PMID: 34265762 DOI: 10.1159/000516590] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 10/16/2020] [Accepted: 04/16/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Ibutilide is indicated for acute cardioversion of nonvalvular atrial fibrillation (AF). However, its efficacy and safety in the pharmacological cardioversion of rheumatic AF are unknown. METHODS Patients with mild-to-moderate rheumatic mitral valve (MV) disease with symptomatic, paroxysmal, or persistent AF were included in the analysis. Intravenous ibutilide was administered at doses tailored to body weight (0.5-2.0 mg) for over 10 min. The primary end point was efficacy, assessed as the rate of conversion of AF to sinus rhythm. The secondary end point was safety, including arrhythmic events and death within 24 h of drug initiation. RESULTS From June 2016 to October 2018, 165 patients (94 with mitral stenosis, 23 with mitral regurgitation, 11 with mixed MV disease, and 37 with MV replacement) received ibutilide (mean dose 0.90 ± 0.54 mg). Ibutilide successfully converted AF to sinus rhythm in 127/165 (76.9%) patients, with a conversion time of 7.9 ± 4.1 min. The QTc increased from 419.9 ± 15.8 to 487.5 ± 34 ms after ibutilide administration (p < 0.001). The mean change in QTc after ibutilide administration (∆QTc) was 72.01 ± 36.03. There were no deaths, but 3 patients (1.8%) developed torsades de pointes (TdP) requiring defibrillation 55 ± 37 min after infusion. CONCLUSION Ibutilide cardioverted 77% of rheumatic AF to sinus rhythm, indicating its potential as a clinically useful option for pharmacological cardioversion of rheumatic AF. TdP is a potentially serious adverse event that requires careful monitoring.
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Affiliation(s)
- Jayaprakash Shenthar
- Electrophysiology Unit, Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, India
| | - Bharatraj Banavalikar
- Electrophysiology Unit, Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, India
| | - Sanjai Pattu Valappil
- Electrophysiology Unit, Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, India
| | - Saurabh Deshpande
- Electrophysiology Unit, Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, India
| | - Aparna Nireshwalia
- Electrophysiology Unit, Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, India
| | - Deepak Padmanabhan
- Electrophysiology Unit, Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, India
| | - Sathish S Reddy
- Electrophysiology Unit, Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, India
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Stiell IG, Archambault PM, Morris J, Mercier E, Eagles D, Perry JJ, Scheuermeyer F, Clark G, Gosselin S, Vadeboncoeur A, Parkash R, de Wit K, Patey A, Thiruganasambandamoorthy V, Taljaard M; RAFF3 Study Investigators. RAFF-3 Trial: A Stepped-Wedge Cluster Randomized Trial to Improve Care of Acute Atrial Fibrillation and Flutter in the Emergency Department. Can J Cardiol 2021:S0828-282X(21)00351-2. [PMID: 34217808 DOI: 10.1016/j.cjca.2021.06.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 06/21/2021] [Accepted: 06/23/2021] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND We sought to improve care of patients with acute atrial fibrillation (AF) and flutter (AFL) in the emergency department (ED) by implementing the CAEP AAFF Best Practice Checklist. METHODS We conducted a stepped-wedge cluster randomized trial at 11 large community and academic hospital EDs, in five Canadian provinces and enrolled consecutive AF/AFL patients. The study intervention was the introduction of the CAEP Checklist using a knowledge translation-implementation approach that included behavior change techniques and organization/system level strategies. The primary outcome was length of stay in ED and secondary outcomes were discharge home, use of rhythm control, adverse events, and 30-day status. Analysis used mixed effects regression adjusting for covariates. RESULTS Patient visits in the control (N=314) and intervention (N=404) periods were similar with mean age 62.9, 54% male, 71% onset <12 hours, and 86% atrial fibrillation, 14% atrial flutter. We observed a reduction in length of stay of 20.9% (95% CI 5.5 to 33.8%, P=0.01), an increase in use of rhythm control (adjusted odds ratio (OR 4.5, 1.8-11.6; P=0.002), and decrease in use of rate control medications (OR 0.5, 0.2 to 0.9; P=0.02). There was no change in adverse events and no strokes or deaths by 30 days. CONCLUSIONS The RAFF-3 Trial led to optimized care of AF/AFL patients with decreased ED lengths of stay, increased ED rhythm control by drug or electricity, and no increase in adverse events. Early cardioversion allows AF/AFL patients to quickly resume normal activities. CLINICALTRIALS. GOV IDENTIFIER NCT03627143.
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Wong BM, Perry JJ, Cheng W, Zheng B, Guo K, Taljaard M, Skanes AC, Stiell IG. Thromboembolic events following cardioversion of acute atrial fibrillation and flutter: a systematic review and meta-analysis. CAN J EMERG MED 2021; 23:500-511. [PMID: 33715143 DOI: 10.1007/s43678-021-00103-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 02/09/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Recent studies have presented concerning data on the safety of cardioversion for acute atrial fibrillation and flutter. We conducted this meta-analysis to evaluate the effect of oral anticoagulation use on thromboembolic events post-cardioversion of low-risk acute atrial fibrillation and flutter patients of < 48 h in duration. METHODS We searched MEDLINE, Embase, and Cochrane from inception through February 6, 2020 for studies reporting thromboembolic events post-cardioversion of acute atrial fibrillation and flutter. Main outcome was thromboembolic events within 30 days post-cardioversion. Primary analysis compared thromboembolic events based on oral anticoagulation use versus no oral anticoagulation use. Secondary analysis was based on baseline thromboembolic risk. We performed meta-analyses where 2 or more studies were available, by applying the DerSimonian-Laird random-effects model. Risk of bias was assessed with the Quality in Prognostic Studies tool. RESULTS Of 717 titles screened, 20 studies met inclusion criteria. Primary analysis of seven studies with low risk of bias demonstrated insufficient evidence regarding the risk of thromboembolic events associated with oral anticoagulation use (RR = 0.82 where RR < 1 suggests decreased risk with oral anticoagulation use; 95% CI 0.27 to 2.47; I2 = 0%). Secondary analysis of 13 studies revealed increased risk of thromboembolic events with high baseline thromboembolic risk (RR = 2.25 where RR > 1 indicates increased risk with higher CHADS2 or CHA2DS2-VASc scores; 95% CI 1.25 to 4.04; I2 = 0%). CONCLUSION Primary analysis revealed insufficient evidence regarding the effect of oral anticoagulation use on thromboembolic events post-cardioversion of low-risk acute atrial fibrillation and flutter, though the event rate is low in contemporary practice. Our findings can better inform patient-centered decision-making when considering 4-week oral anticoagulation use for acute atrial fibrillation and flutter patients.
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Affiliation(s)
- Brenton M Wong
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Jeffrey J Perry
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Wei Cheng
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Bo Zheng
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Kevin Guo
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Allan C Skanes
- Division of Cardiology, Western University, London, ON, Canada
| | - Ian G Stiell
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.
- Clinical Epidemiology Unit, The Ottawa Hospital, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada.
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Al-Busaidi IS, Clare GC, Joyce LR, Pearson S, Lainchbury J, Than M, Troughton RW. Presentation, Treatment and Long-Term Outcomes of a Multidisciplinary Acute Atrial Fibrillation Pathway: A 12-Month Follow-Up Study. Heart Lung Circ 2021; 31:216-223. [PMID: 34210615 DOI: 10.1016/j.hlc.2021.05.102] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 04/01/2021] [Accepted: 05/16/2021] [Indexed: 11/17/2022]
Abstract
AIM Atrial fibrillation/flutter (AF/AFL) is associated with high rates of emergency department (ED) visits and acute hospitalisation. A recently established multidisciplinary acute AF treatment pathway seeks to avoid hospital admissions by early discharge of haemodynamically stable, low risk patients from the ED with next-working-day return to a ward-based AF clinic for further assessment. We conducted a preliminary analysis of the clinical outcomes of this pathway. METHODS We retrospectively reviewed clinical records of all patients assessed at the AF clinic at Christchurch Hospital over a 12-month period. Data related to presentation, patient characteristics, treatment, and 12-month outcomes were analysed. RESULTS A total of 143 patients (median age 65, interquartile range: 57-74 years, 59% male, 87% European) were assessed. Of these, 87 (60.8%) presented with their first episode of AF/AFL. Spontaneous cardioversion occurred in 41% at ED discharge, and this increased to 73% at AF clinic review. Electrical cardioversion was subsequently performed in 16 patients (11.2%), and 16 (11.2%) ultimately required hospital admission (eight to facilitate electrical cardioversion). At a median of 1 day, 83.9% were discharged from the AF clinic in sinus rhythm. During 12-month follow-up, there were 25 AF-related hospitalisations (20 patients, 14%) and one patient underwent electrical cardioversion; additionally, one patient had had a stroke and eight had bleeding complications giving a combined outcome rate of 6.3%. CONCLUSION Utilising a rate-control strategy with ED discharge and early return to a dedicated AF clinic can safely prevent the majority of hospitalisations, avert unnecessary procedures, and facilitate longitudinal care.
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Affiliation(s)
- Ibrahim S Al-Busaidi
- Department of Medicine, University of Otago, Christchurch, New Zealand; Department of Cardiology, Christchurch Hospital, Christchurch, New Zealand.
| | - Geoffrey C Clare
- Department of Medicine, University of Otago, Christchurch, New Zealand; Department of Cardiology, Christchurch Hospital, Christchurch, New Zealand
| | - Laura R Joyce
- Department of Surgery, University of Otago, Christchurch, New Zealand; Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand
| | - Scott Pearson
- Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand
| | - John Lainchbury
- Department of Medicine, University of Otago, Christchurch, New Zealand; Department of Cardiology, Christchurch Hospital, Christchurch, New Zealand
| | - Martin Than
- Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand
| | - Richard W Troughton
- Department of Medicine, University of Otago, Christchurch, New Zealand; Department of Cardiology, Christchurch Hospital, Christchurch, New Zealand
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Kim H, Kang MG, Park HW, Park JR, Hwang JY, Kim K. Anderson-Fabry disease presenting with atrial fibrillation as earlier sign in a young patient: A case report. World J Clin Cases 2021; 9:4823-4828. [PMID: 34222454 PMCID: PMC8223842 DOI: 10.12998/wjcc.v9.i18.4823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 03/03/2021] [Accepted: 05/15/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Anderson-Fabry disease (AFD) is an X-linked lysosomal storage disorder that results from a deficiency of α-galactosidase A enzyme activity in which glycosphingolipids gradually accumulate in multi-organ systems. Cardiac manifestations are the leading cause of mortality in patients with AFD. Among them, arrhythmias comprise a large portion of the heart disease cases in AFD, most of which are characterized by conduction disorders. However, atrial fibrillation as a presenting sign at the young age group diagnosed with AFD is uncommon.
CASE SUMMARY We report a case of a 26-year-old man who was admitted with chest discomfort. Left ventricular hypertrophy was fulfilled in the criteria by the Sokolow-Lyon index and atrial fibrillation on the 12 Leads-electrocardiography (ECG) that was documented in the emergency room. After spontaneously restored to normal sinus rhythm, relationships between P and R waves, including a shorter PR interval on the ECG, were revealed. The echocardiographic findings showed thickened interventricular septal and left posterior ventricular walls. Based on the clues mentioned earlier, we realized the possibility of AFD. Additionally, we noticed the associated symptoms and signs, including bilateral mild hearing loss, neuropathic pain, anhidrosis, and angiokeratoma on the trunk and hands. He was finally diagnosed with classical AFD, which was confirmed by the gene mutation and abnormal enzyme activity of α-galactosidase A.
CONCLUSION This case is a rare case of AFD as a presentation with atrial fibrillation at a young age. Confirming the relationship between P and Q waves on the ECG through sinus rhythm conversion may help in differential diagnosis of the cause of atrial fibrillation and hypertrophic myocardium.
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Affiliation(s)
- Hangyul Kim
- Department of Internal Medicine, Gyeongsang National University Hospital, Jinju 52727, South Korea
| | - Min Gyu Kang
- Department of Internal Medicine, Gyeongsang National University Hospital, Jinju 52727, South Korea
| | - Hyun Woong Park
- Department of Internal Medicine, Gyeongsang National University Hospital, Jinju 52727, South Korea
| | - Jeong-Rang Park
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju 52727, South Korea
| | - Jin-Yong Hwang
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju 52727, South Korea
| | - Kyehwan Kim
- Department of Internal Medicine, Gyeongsang National University Hospital, Jinju 52727, South Korea
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Farkowski MM, Jubele K, Marín F, Gandjbakhch E, Ptaszynski P, Merino JL, Lenarczyk R, Potpara TS. Diagnosis and management of left atrial appendage thrombus in patients with atrial fibrillation undergoing cardioversion or percutaneous left atrial procedures: results of the European Heart Rhythm Association survey. Europace 2021; 22:162-169. [PMID: 31501852 DOI: 10.1093/europace/euz257] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 08/19/2019] [Indexed: 12/24/2022] Open
Abstract
Practices regarding indications and timing for transoesophageal echocardiography (TOE) before cardioversion (CV) of atrial fibrillation (AF) or left atrial (LA) interventional procedures, and preferred imaging techniques and pharmacotherapy, in cases of thrombus resistant to chronic oral anticoagulation (OAC) treatment, are largely unknown. The European Heart Rhythm Association (EHRA) conducted a survey to capture contemporary clinical practice in those areas of AF care. A 22-item online questionnaire was developed and distributed among the EHRA electrophysiology research network centres. The survey contained questions regarding indications, type and timing of imaging before CV or LA procedures and management of LA appendage (LAA) thrombus with special emphasis on thrombus resistant to OAC. Of 54 responding centres 63% were university hospitals. Most commonly, TOE would be performed in cases of inadequate or unclear pre-procedural anticoagulation, even in AF lasting <48 h (52% and 50%, respectively), and 15% of centres would perform TOE before AF ablation in all patients. If thrombus was diagnosed despite chronic OAC, the prevalent strategy was to change current OAC to another with different mechanism of action; 51% of centres would wait 3-4 weeks after changing the OAC before using another imaging test, and 60% of centres reported two attempts to dissolve the thrombus. Our survey showed a significant utilization of TOE before CV or AF ablation in European centres, extending beyond AF guidelines-suggested indications. When thrombus was diagnosed despite chronic pre-procedural OAC, most centres would use another anticoagulant drug with different mode of action.
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Affiliation(s)
- Michal M Farkowski
- Heart Arrhythmia Ward, II Department of Coronary Artery Disease, Institute of Cardiology, Alpejska 42, Warsaw, Poland
| | - Kristine Jubele
- P. Stradins Clinical University Hospital, Riga Stradins University, Riga, Latvia
| | - Francisco Marín
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, IMIB-Arrixaca, CIBERCV, University of Murcia, Murcia, Spain
| | - Estelle Gandjbakhch
- Sorbonne Universités, APHP, Institute of Cardiology ICAN, Pitié-Salpêtrière University Hospital, Paris, France
| | - Pawel Ptaszynski
- Department of Electrocardiology, Medical University of Lodz, Lodz, Poland
| | - Jose L Merino
- Unidad de Arritmias y Electrofisiología Robotizada, La Paz University Hospital, IDIPAZ, Universidad Autonoma de Madrid, Madrid, Spain
| | - Radoslaw Lenarczyk
- First Department of Cardiology and Angiology, Silesian Centre for Heart Disease, Zabrze, Poland
| | - Tatjana S Potpara
- School of Medicine, Belgrade University; Cardiology Clinic, Clinical Center of Serbia, Belgrade, Serbia
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Gardarsdottir M, Sigurdsson S, Aspelund T, Gardarsdottir VA, Forsberg L, Gudnason V, Arnar DO. Improved brain perfusion after electrical cardioversion of atrial fibrillation. Europace 2021; 22:530-537. [PMID: 31860069 DOI: 10.1093/europace/euz336] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Accepted: 12/04/2019] [Indexed: 01/21/2023] Open
Abstract
AIMS Atrial fibrillation (AF) has been associated with reduced brain volume, cognitive impairment, and reduced cerebral blood flow. The causes of reduced cerebral blood flow in AF are unknown, but no reduction was seen in individuals without the arrhythmia in a previous study. The aim of this study was to test the hypothesis that brain perfusion, measured with magnetic resonance imaging (MRI), improves after cardioversion of AF to sinus rhythm (SR). METHODS AND RESULTS All patients undergoing elective cardioversion at our institution were invited to participate. A total of 44 individuals were included. Magnetic resonance imaging studies were done before and after cardioversion with both brain perfusion and cerebral blood flow measurements. However, 17 did not complete the second MRI as they had a recurrence of AF during the observation period (recurrent AF group), leaving 17 in the SR group and 10 in the AF group to complete both measurements. Brain perfusion increased after cardioversion to SR by 4.9 mL/100 g/min in the whole brain (P < 0.001) and by 5.6 mL/100 g/min in grey matter (P < 0.001). Cerebral blood flow increased by 58.6 mL/min (P < 0.05). Both brain perfusion and cerebral blood flow remained unchanged when cardioversion was unsuccessful. CONCLUSION In this study of individuals undergoing elective cardioversion for AF, restoration, and maintenance of SR for at least 10 weeks after was associated with an improvement of brain perfusion and cerebral blood flow measured by both arterial spin labelling and phase contrast MRI. In those individuals where cardioversion was unsuccessful, there was no change in perfusion or blood flow.
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Affiliation(s)
- Marianna Gardarsdottir
- Department of Radiology, Landspitali-The National University Hospital of Iceland, Reykjavik, Iceland
| | | | - Thor Aspelund
- Icelandic Heart Association, Kopavogur, Iceland.,Faculty of Medicine, School of Health Sciences, University of Iceland, Reykjavik, Iceland
| | - Valdis Anna Gardarsdottir
- Department of Medicine, Landspitali-The National University Hospital of Iceland, 14C, Hringbraut, 101 Reykjavik, Iceland
| | | | - Vilmundur Gudnason
- Icelandic Heart Association, Kopavogur, Iceland.,Faculty of Medicine, School of Health Sciences, University of Iceland, Reykjavik, Iceland
| | - David O Arnar
- Faculty of Medicine, School of Health Sciences, University of Iceland, Reykjavik, Iceland.,Department of Medicine, Landspitali-The National University Hospital of Iceland, 14C, Hringbraut, 101 Reykjavik, Iceland
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deSouza IS, Tadrous M, Sexton T, Benabbas R, Carmelli G, Sinert R. Pharmacologic cardioversion of recent-onset atrial fibrillation: a systematic review and network meta-analysis. Europace 2021; 22:854-869. [PMID: 32176779 DOI: 10.1093/europace/euaa024] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Accepted: 01/21/2020] [Indexed: 12/21/2022] Open
Abstract
AIMS We sought to identify the most effective antidysrhythmic drug for pharmacologic cardioversion of recent-onset atrial fibrillation (AF). METHODS AND RESULTS We searched MEDLINE, Embase, and Web of Science from inception to March 2019, limited to human subjects and English language. We also searched for unpublished data. We limited studies to randomized controlled trials that enrolled adult patients with AF ≤ 48 h and compared antidysrhythmic agents, placebo, or control. We determined these outcomes prior to data extraction: (i) rate of conversion to sinus rhythm within 24 h, (ii) time to cardioversion to sinus rhythm, (iii) rate of significant adverse events, and (iv) rate of thromboembolism within 30 days. We extracted data according to PRISMA-NMA and appraised selected trials using the Cochrane review handbook. The systematic review initially identified 640 studies; 30 met inclusion criteria. Twenty-one trials that randomized 2785 patients provided efficacy data for the conversion rate outcome. Bayesian network meta-analysis using a random-effects model demonstrated that ranolazine + amiodarone intravenous (IV) [odds ratio (OR) 39.8, 95% credible interval (CrI) 8.3-203.1], vernakalant (OR 22.9, 95% CrI 3.7-146.3), flecainide (OR 16.9, 95% CrI 4.1-73.3), amiodarone oral (OR 10.2, 95% CrI 3.1-36.0), ibutilide (OR 7.9, 95% CrI 1.2-52.5), amiodarone IV (OR 5.4, 95% CrI 2.1-14.6), and propafenone (OR 4.1, 95% CrI 1.7-10.5) were associated with significantly increased likelihood of conversion within 24 h when compared to placebo/control. Overall quality was low, and the network exhibited inconsistency. Probabilistic analysis ranked vernakalant and flecainide high and propafenone and amiodarone IV low. CONCLUSION For pharmacologic cardioversion of recent-onset AF within 24 h, there is insufficient evidence to determine which treatment is superior. Vernakalant and flecainide may be relatively more efficacious agents. Propafenone and IV amiodarone may be relatively less efficacious. Further high-quality study is necessary.
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Affiliation(s)
- Ian S deSouza
- Department of Emergency Medicine, SUNY Downstate Health Sciences University, Brooklyn, New York, NY 11203, USA.,Department of Emergency Medicine, Kings County Hospital Center, 451 Clarkson Avenue, Brooklyn, NY 11203, USA
| | - Mina Tadrous
- Women's College Research Institute, Women's College Hospital, 76 Grenville St, Toronto, ON, M5S 1B2, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, ON M5S 3M2, Canada
| | - Theresa Sexton
- Department of Emergency Medicine, SUNY Downstate Health Sciences University, Brooklyn, New York, NY 11203, USA.,Department of Emergency Medicine, Kings County Hospital Center, 451 Clarkson Avenue, Brooklyn, NY 11203, USA
| | - Roshanak Benabbas
- Department of Emergency Medicine, SUNY Downstate Health Sciences University, Brooklyn, New York, NY 11203, USA.,Department of Emergency Medicine, Kings County Hospital Center, 451 Clarkson Avenue, Brooklyn, NY 11203, USA
| | - Guy Carmelli
- Department of Emergency Medicine, SUNY Downstate Health Sciences University, Brooklyn, New York, NY 11203, USA
| | - Richard Sinert
- Department of Emergency Medicine, SUNY Downstate Health Sciences University, Brooklyn, New York, NY 11203, USA.,Department of Emergency Medicine, Kings County Hospital Center, 451 Clarkson Avenue, Brooklyn, NY 11203, USA
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Wałek P, Gorczyca I, Grabowska U, Spałek M, Wożakowska-Kapłon B. The prognostic value of soluble suppression of tumourigenicity 2 and galectin-3 for sinus rhythm maintenance after cardioversion due to persistent atrial fibrillation in patients with normal left ventricular systolic function. Europace 2021; 22:1470-1479. [PMID: 32754725 DOI: 10.1093/europace/euaa135] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 05/04/2020] [Indexed: 11/12/2022] Open
Abstract
AIMS Soluble suppression of tumourigenicity 2 (sST2) and galectin-3 are involved in cardiac fibrosis, inflammation, and remodelling. However, the place of sST2 and galectin-3 in predicting the outcomes of electrical cardioversion of atrial fibrillation (AF) is uncertain. We evaluated whether these biomarkers could predict sinus rhythm (SR) maintenance after cardioversion of persistent AF in patients with normal left ventricular systolic function. METHODS AND RESULTS The study included 80 patients with persistent AF, who underwent cardioversion from February 2016 to August 2018. The blood concentrations of sST-2 and galectin-3 were measured with ELISA and the ASPECT-PLUS assays. Clinical and electrocardiographic follow-up was performed at months 1, 6, and 12. Patients who maintained SR at 12 months had significantly lower concentrations of sST2, measured by ELISA and ASPECT-PLUS assays, than the remaining patients (16.9 ± 9.8 vs. 28 ± 22.9 ng/mL; P < 0.001; 28.7 ± 13.4 vs. 40 ± 25.1 ng/mL; P = 0.003); the concentration of galectin-3 did not differ between these patients. Multivariable logistic regression showed that log-transformed sST2 ELISA was a significant predictor of SR maintenance at 12 months [odds ratio 0.14; 95% confidence interval (CI) 0.03-0.58; P = 0.006]. On receiver-operating characteristic curve analysis, the areas under the curve for the concentration of sST2 was 0.752 (95% CI 0.634-0.870; P < 0.001). The concentrations of sST2 measured with the two assays were strongly correlated (rho = 0.8; CI 95% 0.7-0.87; P = 0.001). CONCLUSION Soluble suppression of tumourigenicity 2, but not galectin-3, can be used to predict SR maintenance after cardioversion of AF in patients with normal left ventricular systolic function. The measurements of sST2 concentrations with the rapid lateral flow and enzyme-linked immunoassays were consistent.
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Affiliation(s)
- Paweł Wałek
- 1st Clinic of Cardiology and Electrotherapy, Voivodship Hospital Kielce, Grunwaldzka 45, 25-736 Kielce, Poland
| | - Iwona Gorczyca
- 1st Clinic of Cardiology and Electrotherapy, Voivodship Hospital Kielce, Grunwaldzka 45, 25-736 Kielce, Poland
| | - Urszula Grabowska
- Medical Laboratory, Voivodship Hospital Kielce, Grunwaldzka 45, 25-736 Kielce, Poland
| | - Michał Spałek
- Department of Anatomy, Collegium Medicum, Jan Kochanowski University, 19 IX Wieków Kielc, 25-317 Kielce, Poland.,Department of Diagnostic Imaging, Holy Cross Center of Oncology, Stefana Artwińskiego 3, 25-734 Kielce, Poland
| | - Beata Wożakowska-Kapłon
- 1st Clinic of Cardiology and Electrotherapy, Voivodship Hospital Kielce, Grunwaldzka 45, 25-736 Kielce, Poland.,Collegium Medicum, Jan Kochanowski University, 19 IX Wieków Kielc Street, 25-317 Kielce, Poland
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Cappato R, Ezekowitz MD, Hohnloser SH, Meng IL, Wosnitza M, Camm AJ. Predictors of sinus rhythm 6 weeks after cardioversion of atrial fibrillation: a pre-planned post hoc analysis of the X-VeRT trial. Europace 2021; 23:1539-1547. [PMID: 34128075 DOI: 10.1093/europace/euab084] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 03/22/2021] [Indexed: 11/13/2022] Open
Abstract
AIMS Using a pre-planned post hoc analysis of patients included in X-VeRT, we evaluated predictors of sinus rhythm at 6 weeks after planned cardioversion. METHODS AND RESULTS Receiver operating characteristic curves and logistic regression models were used to evaluate continuous and categorical variables as predictors of sinus rhythm 6 at weeks from cardioversion (end of study). The primary analysis was performed in successfully cardioverted patients with an evaluable electrocardiogram at end of study. A second analysis evaluated additional patients who spontaneously restored sinus rhythm before planned cardioversion. Of the 1504 patients with atrial fibrillation of >48 h or of unknown duration who were randomly assigned to either rivaroxaban or vitamin K antagonist, 1039 (64.6 ± 10.3 years, 73.4% male) underwent planned cardioversion and were included in this study. Patients receiving early cardioversion (i.e. between 1 and 5 days from hospitalization) had a 67% higher probability to have sinus rhythm at end of study than those who received delayed cardioversion (i.e. between 21 and 56 days from hospitalization) [odds ratio (OR) 1.67, confidence interval (CI) 1.27-2.18; P < 0.0001]. In a multivariate analysis of 17 baseline variables, patients with a CHADS2 score of 0 were 33% less likely to be in sinus rhythm than those with a CHADS2 score ≥2 (OR 0.66, CI 0.47-0.94; P = 0.0225). In the secondary analysis, spontaneous restoration of sinus rhythm was also found to predict sinus rhythm at end of study (OR 8.62, CI 1.54-48.16; P = 0.0142). CONCLUSION In X-VeRT, early cardioversion and high CHADS2 scores predicted sinus rhythm at 6 weeks from cardioversion.
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Affiliation(s)
- Riccardo Cappato
- Arrhythmia & Electrophysiology Center, IRCCS Gruppo MultiMedica, Sesto San Giovanni, Milan, Italy
| | - Michael D Ezekowitz
- The Sidney Kimmel Medical College at Thomas Jefferson University and Lankenau Heart Center and Bryn Mawr Hospital, Philadelphia, PA, USA
| | - Stefan H Hohnloser
- Division of Clinical Electrophysiology, Department of Cardiology, J.W. Goethe University, Frankfurt, Germany
| | | | | | - Arthur John Camm
- Cardiology Clinical Academic Group, St. George's, University of London, London, UK
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Gatta G, Sobota V, Citerni C, Diness JG, Sørensen US, Jespersen T, Bentzen BH, Zeemering S, Kuiper M, Verheule S, Schotten U, van Hunnik A. Effective termination of atrial fibrillation by SK channel inhibition is associated with a sudden organization of fibrillatory conduction. Europace 2021; 23:1847-1859. [PMID: 34080619 PMCID: PMC8576281 DOI: 10.1093/europace/euab125] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 04/22/2021] [Indexed: 11/12/2022] Open
Abstract
AIMS Pharmacological termination of atrial fibrillation (AF) remains a challenge due to limited efficacy and potential ventricular proarrhythmic effects of antiarrhythmic drugs. SK channels are proposed as atrial-specific targets in the treatment of AF. Here, we investigated the effects of the new SK channel inhibitor AP14145. METHODS AND RESULTS Eight goats were implanted with pericardial electrodes for induction of AF (30 days). In an open-chest study, the atrial conduction velocity (CV) and effective refractory period (ERP) were measured during pacing. High-density mapping of both atrial free-walls was performed during AF and conduction properties were assessed. All measurements were performed at baseline and during AP14145 infusion [10 mg/kg/h (n = 1) or 20 mg/kg/h (n = 6)]. At an infusion rate of 20 mg/kg/h, AF terminated in five of six goats. AP14145 profoundly increased ERP and reduced CV during pacing. AP14145 increased spatiotemporal instability of conduction at short pacing cycle lengths. Atrial fibrillation cycle length and pathlength (AF cycle length × CV) underwent a strong dose-dependent prolongation. Conduction velocity during AF remained unchanged and conduction patterns remained complex until the last seconds before AF termination, during which a sudden and profound organization of fibrillatory conduction occurred. CONCLUSION AP14145 provided a successful therapy for termination of persistent AF in goats. During AF, AP14145 caused an ERP and AF cycle length prolongation. AP14145 slowed CV during fast pacing but did not lead to a further decrease during AF. Termination of AF was preceded by an abrupt organization of AF with a decline in the number of fibrillation waves.
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Affiliation(s)
- Giulia Gatta
- Department of Physiology, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands
| | - Vladimir Sobota
- Department of Physiology, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands
| | - Carlotta Citerni
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | | | | | - Thomas Jespersen
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Bo Hjorth Bentzen
- Acesion Pharma, Copenhagen, Denmark.,Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Stef Zeemering
- Department of Physiology, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands
| | - Marion Kuiper
- Department of Physiology, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands
| | - Sander Verheule
- Department of Physiology, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands
| | - Ulrich Schotten
- Department of Physiology, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands
| | - Arne van Hunnik
- Department of Physiology, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands
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Migliore F, Providencia R, Farkowski MM, Dan GA, Daniel S, Potpara TS, Jubele K, Chun JKR, de Asmundis C, Zorzi A, Boveda S. Antithrombotic treatment management in low stroke risk patients undergoing cardioversion of atrial fibrillation <48 h duration: results of an EHRA survey. Europace 2021; 23:1502-1507. [PMID: 33990842 DOI: 10.1093/europace/euab106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 03/31/2021] [Indexed: 11/13/2022] Open
Abstract
Data supporting the safety of cardioversion (CV) of atrial fibrillation (AF) without anticoagulation in patients with AF duration <48 h are scarce. Observational studies suggest that the risk of stroke in these patients is very low when the definite duration of the AF episode is of <48 h and the clinical risk profile as estimated through the CHA2DS2VASc score is low (a score of 0 for men and 1 for women). As the recent 2020 European Society of Cardiology (ESC) guidelines indication for this clinical scenario is based mainly on consensus, we sent out a survey to assess the current clinical practice on anticoagulation prior to and post-CV in patients with AF <24-48 h duration and low stroke risk across centres in Europe. Of the 136 respondents, half were affiliated to university hospitals (68/136; 50%). Non-university hospitals (50/136; 36%) and private hospitals (2/136; 1.4%) accounted over a third of respondents. The main findings of our survey were (i) heterogeneity in the anticoagulation management both before and post-CV in low stroke-risk patients with AF <48 h, (ii) higher utilization of periprocedural low-molecular-weight heparin than of non-vitamin K antagonist oral anticoagulant, (iii) higher utilization of pre-CV transoesophageal echocardiography for electrical CV than for pharmacological CV regardless of the duration of AF, (iv) high adherence to a 4-week post-CV oral anticoagulant (OAC) therapy, mainly for electrical CV, and finally, (v) perceived higher acceptance of lack of post-CV OAC therapy in patients with <24 h than 24-48 h episode duration. The results obtained in this survey highlight the need for more research providing definitive clarification on the safety of CV without anticoagulation in patients with short duration AF.
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Affiliation(s)
- Federico Migliore
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Via N. Giustiniani 2, 35121 Padova, Italy
| | - Rui Providencia
- Barts Heart Centre, St. Bartholomew's Hospital, Barts Health NHS Trust, London, UK.,Institute of Health Informatics Research, University College of London, London, UK
| | - Michal M Farkowski
- II Department of Heart Arrhythmia, National Institute of Cardiology, Warsaw, Poland
| | - Georghe Andrei Dan
- Carol Davila' University of Medicine, Colentina University Hospital, Bucharest, Romania
| | - Scherr Daniel
- Division of Cardiology, Department of Medicine, Medical University of Graz, Graz, Austria
| | - Tatjana S Potpara
- Serbia School of Medicine, University of Belgrade, Belgrade, Serbia.,Department for Intensive Care in Cardiac Arrhythmias, Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia
| | - Kristine Jubele
- P.Stradins Clinical University Hospital, Riga Stradins University, Riga, Latvia
| | - Julian K R Chun
- CCB, Cardiology, Med. Klinik III, Markuskrankenhaus Frankfurt, Germany
| | - Carlo de Asmundis
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Alessandro Zorzi
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Via N. Giustiniani 2, 35121 Padova, Italy
| | - Serge Boveda
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Laarbeeklaan 101, 1090 Brussels, Belgium.,Heart Rhythm Department, Clinique Pasteur, 31076 Toulouse, France
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