Efficacy and safety of antazoline vs propafenone for conversion of paroxysmal atrial fibrillation to sinus rhythm: a randomized, double-blind study (AnProAF)

INTRODUCTION

Antazoline is a frequently used antiarrhythmic drug (AAD); however, to date, no randomized controlled trial has evaluated its efficacy and safety for cardioversion of recent‑onset atrial fibrillation (AF) in comparison with other approved AADs.

OBJECTIVES

This study aimed to compare clinical efficacy and safety of antazoline and propafenone for a rapid conversion of nonvalvular paroxysmal AF to sinus rhythm in patients without heart failure.

PATIENTS AND METHODS

This was a single‑center, randomized, double‑blind study. It included patients with AF (lasting <48 hours) who were in a stable cardiopulmonary condition and eligible for cardioversion. The individuals who fulfilled the inclusion criteria were randomly assigned to receive either antazoline (up to 300 mg) or propafenone (up to 140 mg) intravenously. The primary end point was conversion of AF to sinus rhythm confirmed on electrocardiography.

RESULTS

Overall, 94 participants (46 [48.9%] in the antazoline group and 48 [51.1%] in the propafenone group) were included. The mean (SD) age was 67.5 (14) years, and 40 participants (42.5%) were men. Successful AF conversion was observed in 29 patients (63%) from the antazoline group and 25 individuals (52.1%) from the propafenone group (P = 0.39). The median time to conversion was 10 minutes in the antazoline group and 30 minutes in the propafenone group (P = 0.03). Severe adverse events were observed in 5 patients (10.8%) treated with antazoline and 5 individuals (10.4%) who received propafenone.

CONCLUSIONS

Intravenous antazoline demonstrated efficacy and safety comparable to those of intravenous propafenone for acute conversion of nonvalvular paroxysmal AF to sinus rhythm in patients without heart failure.

Electric Cardioversion in Older Adults. Is Sedation Using Propofol Safe in the Absence of the Direct Anesthetist's Assistance?

Aims: This study aimed to assess the safety of electric cardioversion in the absence of anesthetists assistance. We also evaluated the efficacy and safety of this procedure in older adults (≥80 years) compared to younger populations. Methods: We retrospectively analyzed the data of patients who underwent electric cardioversion at our cardiology department. Patients were divided into 2 groups according to age: ≥ 80 years and <80 years old. Results: The study included 218 participants, 73 were aged 80 years or more (mean age: 84.8 years), and 145 were younger than 80 years (mean age: 66.7 years). Electric cardioversion was effective in 97.3% of older patients and 96.5% of younger patients (P = 1.00). No thromboembolic complications were observed in either of the groups. Asystole >5 s occurred immediately after shock in 4.1% of older and 2.1% of younger patients (P = .405). Propofol was used as a sedative, with a mean dose of 0.83 mg/kg versus 0.93 mg/kg, in older and younger patients, respectively. Intubation, medical intervention, or other advanced resuscitation techniques were not required. During hospitalization, arrhythmia recurred in 9.6% and 12.4% of the older and younger patients, respectively (P = .537). Conclusions: Electrical cardioversion is an effective and safe procedure regardless of patient age. Sedation with propofol administered by cardiologists was safe. Adverse events were not considered serious or reversible.

Electric cardioversion in patients treated with oral anticoagulants: embolic material in the left atrial appendage

Atrial fibrillation (AF) remains the most common arrhythmia. The sinus rhythm restoration procedure without adequate anticoagulant preparation may lead to a thromboembolic event in approximately 5-7% of patients. The initiation of oral anticoagulation significantly reduces this risk by inhibiting formation of embolic material in the heart cavities, especially in the left atrial appendage (LAA). However, there is a group of patients who develop embolic material in the LAA despite oral anticoagulation treatment. The best treatment method to dissolve thrombus in the LAA is not clear, due to the lack of studies with adequate power and endpoints that can determine the best management strategy. We present clinical trials comparing the efficacy and safety of oral anticoagulants in patients undergoing AF cardioversion. We evaluate the frequency of LAA thrombus formation in patients with AF on treatment with oral anticoagulants. Furthermore, we discuss the effectiveness of various treatment strategies on LAA thrombus resolution.

Electric cardioversion in patients treated with oral anticoagulants: embolic material in the left atrial appendage

Atrial fibrillation (AF) remains the most common arrhythmia. The sinus rhythm restoration procedure without adequate anticoagulant preparation may lead to a thromboembolic event in approximately 5-7% of patients. The initiation of oral anticoagulation significantly reduces this risk by inhibiting formation of embolic material in the heart cavities, especially in the left atrial appendage (LAA). However, there is a group of patients who develop embolic material in the LAA despite oral anticoagulation treatment. The best treatment method to dissolve thrombus in the LAA is not clear, due to the lack of studies with adequate power and endpoints that can determine the best management strategy. We present clinical trials comparing the efficacy and safety of oral anticoagulants in patients undergoing AF cardioversion. We evaluate the frequency of LAA thrombus formation in patients with AF on treatment with oral anticoagulants. Furthermore, we discuss the effectiveness of various treatment strategies on LAA thrombus resolution.

Left atrial appendage thrombus in patients with atrial fibrillation who underwent oral anticoagulation

BACKGROUND

Electric cardioversion of atrial fibrillation (AF) is associated with an increased risk of embolism, with embolic material existing in the heart cavities. The initiation of oral anticoagulation therapy reduces the risk of thromboembolic events. The aims of this study were to evaluate the prevalence of left atrial appendage (LAA) thrombi in non-valvular AF, to compare vitamin K antagonists (VKAs) and non-vitamin K oral anticoagulants (NOACs) with respect to thrombus prevalence, and to evaluate the rate of LAA thrombus persistence on repeat transesophageal echocardiography (TEE) after treatment change.

METHODS

We enrolled 160 consecutive AF patients who presented with an AF duration > 48 h and had undergone TEE before cardioversion.

RESULTS

Left atrial appendage thrombus was observed in 12 (7.5%) patients, and spontaneous echo contrast 4 was observed in 19 (11.8%) patients; the incidence was similar between the NOAC and VKA groups (8.9% vs. 3.6% and 12.4% vs. 18.5 %, respectively). Among patients on NOAC, thrombus prevalence was detected in 8.4% of users of rivaroxaban, 8% of users of dabigatran, and 12.5% of users of apixaban.

CONCLUSIONS

The LAA thrombus developed in 7.5% of patients despite anticoagulation therapy, demonstrating similar prevalence rates among patients either on NOAC or VKA. Lower mean LAA flow velocity and a history of vascular disease were independent predictors of embolic material in the LAA. It seems that in the case of embolic materials in LAA under NOAC treatment, switching to VKA provides additional clinical benefit to the patients.

Device Thrombosis After Percutaneous Left Atrial Appendage Occlusion Is Related to Patient and Procedural Characteristics but Not to Duration of Postimplantation Dual Antiplatelet Therapy

BACKGROUND

Device-related thrombus (DRT) after left atrial appendage occlusion is a worrisome finding with little knowledge about when to expect it and how to prevent it. This study sought to investigate correlates of DRT after left atrial appendage occlusion, its time of diagnosis, and particularly, association with postimplantation dual antiplatelet therapy duration.

METHODS AND RESULTS

Consecutive patients (n=102) after left atrial appendage occlusion with AMPLATZER Cardiac Plug/Amulet (n=59) or WATCHMAN (n=43) were included in a prospective registry (October 2011-May 2016). Follow-up was done at 1.5, 3 to 6, and 12 months postimplantation. DRT was classified as early (at 1.5 month), late (at 3-6 month), or very late (at 12-month follow-up). Postimplantation dual antiplatelet therapy was recommended for 30 to 180 days and decided independently by attending physicians. Final analysis included 99 patients, 42 (42.4%) females, with median CHA₂DS₂-VASc of 4.0 (interquartile range [IQR], 3.0-5.0) and median HAS-BLED score of 2.0 (IQR, 1.0-3.0). DRTs were observed in 7 (7.1%) patients: 2 (28.6%) early, 2 (28.6%) late, and 3 (42.9%) very late. When compared with patients without DRT, those with DRT presented more often with a history of prior thromboembolism (5 [71.4%] versus 28 [30.4%]; P=0.04), had lower left ventricular ejection fraction (50.0 [IQR, 35.0-55.0] versus 60.0 [IQR, 55.0-66.0]; P<0.01), and had greater proportion of patients with deep device implantation (6 [85.7%] versus 36 [39.1%]; P=0.04) and with larger devices implanted (30.0 mm [IQR, 27.0-33.0] versus 25.0 mm [IQR, 24.0-28.0]; P<0.01). Postimplantation dual antiplatelet therapy duration was not different between the 2 groups (12.4 weeks [IQR, 6.0-49.7] with DRT versus 13.0 weeks [IQR, 7.3-26.0] without DRT; P=0.77).

CONCLUSIONS

In this real-world series, DRT was observed early, late, and very late after left atrial appendage occlusion. It was related to patient and procedural characteristics but not to postimplantation dual antiplatelet therapy duration.

What is the optimal anatomic location for coronary artery pressure measurement at CT-derived FFR?

BACKGROUND

CT-FFR is an area of growing interest in the field of cardiac imaging. However, the specific anatomic location distal to a lesion of interest where CT-FFR should be computed to yield the most valid results has not been examined. This study investigated the most appropriate anatomic location distal to a coronary artery stenosis for obtaining CT-FFR measurements.

METHODS

73 patients (60 ± 9 years; 58% male) with at least one coronary lesion with 40-90% stenosis on coronary CTA (either a 2 × 128 slice or a 2 × 192 slice dual-source CT scanner) underwent stress cardiac magnetic resonance (CMR) perfusion imaging for inducible ischemia. 133 coronary arteries and corresponding myocardial territories were analyzed. The most appropriate anatomic location for predicting lesion-specific ischemia via CT-FFR (cFFR version 1.4, Siemens) was determined as either the distance from the lesion of interest or as a multiple of the reference vessel diameter distal to the minimum lumen area (MLA).

RESULTS

Inducible myocardial ischemia was found on MRI in 24 (18.1%) vessels/corresponding myocardial territories. The area under the ROC curve was A) 0.866 for CT-FFR measurement locations distal to the MLA expressed as a multiple of the reference diameter, B) 0.854 when expressed as a distance (mm) distal to the MLA, C) 0.803 for CT-FFR values measured in the distal vessel, and D) 0.725 according to stenosis severity on coronary CTA (A vs B p = 0.093; A vs D p = 0.003; A vs C p = 0.019; B vs D p = 0.006; B vs C p = 0.061; C vs D p = 0.082). The most optimal thresholds for agreement of CT-FFR with the reference CMR perfusion were at 41 mm or 10.9 times the proximal reference diameter distal to the MLA.

CONCLUSIONS

Our results suggest that the best agreement of CT-FFR with the reference CMR perfusion study is provided when CT-FFR values are computed at 41 mm or 10.9 times the proximal reference diameter distal to the MLA.

Determination of radionuclides in samples of middle-aged and older human femurs

The paper presents the studies of the presence of gamma isotopes and (90)Sr in 19 middle-to old-aged human femur samples. The samples were taken up during routine orthopedic operations in 2012. The aim of the paper was determination of some radionuclides in human bones and estimation of radiation dose created by (90)Sr and (90)Y (in bones). The (137)Cs, (40)K, (226)Ra, (228)Th, (234)Th and (210)Pb isotopes were determined by gamma spectrometry. The above mentioned radionuclide contents were in the ranges: (137)Cs (0.04-1.45); (40)K (13-86); (226)Ra (1-21.5); (228)Th (1.4-40.2); (234)Th (0.4-5.7); (210)Pb (0.7-8.4) Bq/kg d.w. (90)Sr was assayed based on radiometric measurement of ingrown (90)Y. The (90)Sr content was in the range 0.27-1.85 Bq/kg d.w. Measurements of concentration of (90)Sr and (90)Y in bones were used to estimation of health risk by calculation of radiation dose. Adsorbed doses ranged from 2.7 · 10(-7) to 1.9 · 10(-6) Gy/y for (90)Sr and from 1.2 · 10(-6) to 8.3 · 10(-7) Gy/y for (90)Y.