Marcus, Gregory M.; Olgin, Jeffrey E.; Whooley, Mary; Vittinghoff, Eric; Stone, Katie L.; Mehra, Reena; Hulley, Stephen B.; Schiller, Nelson B.
BACKGROUND Previous studies relying on clinical care data have suggested that atrial fibrillation is less common in African Americans than Caucasians, but the mechanism remains unknown. Clinical care may itself vary by race, potentially affecting the accuracy of atrial fibrillation ascertainment in studies relying on clinical data. We sought to examine racial differences in atrial fibrillation prevalence determined by protocol-driven electrocardiograms (ECGs) obtained in prospective cohort studies and to study racial differences in echocardiographic characteristics. METHODS We pooled primary data from 3 cohort studies with atrial fibrillation adjudicated from study protocol ECGs and documentation of potentially important confounders: the Heart and Soul Study (n = 1014), the Heart and Estrogen-Progestin Replacement Study (n = 2673), and The Osteoporotic Fractures in Men Sleep Study (n = 2911). Left atrial anatomic dimensions were compared among races from sinus rhythm echocardiograms in the Heart and Soul Study. RESULTS Of the 6611 participants, 268 (4%) had atrial fibrillation: Caucasians had the highest prevalence (5%), and African Americans had the lowest (1%; P <.001 for each compared with all other races). After adjustment for potential confounders, Caucasians had a 3.8-fold greater odds of having atrial fibrillation than African Americans (95% confidence interval, 1.6–8.8, P = .002). Although ventricular and atrial volumes and function were similar in Caucasians and African Americans, Caucasians had a 2 mm larger anterior-posterior left atrial diameter after adjusting for potential confounders (95% confidence interval, 1–3 mm, P <.001). CONCLUSION ECG confirmed atrial fibrillation is more common in Caucasians than in African Americans, which might be related to the larger left atrial diameter observed in Caucasians. PMID:20227049
Gómez-Doblas, Juan José; Muñiz, Javier; Martin, Joaquín J Alonso; Rodríguez-Roca, Gustavo; Lobos, José Maria; Awamleh, Paula; Permanyer-Miralda, Gaietá; Chorro, Francisco Javier; Anguita, Manuel; Roig, Eulalia
Atrial fibrillation is associated with substantial morbidity and mortality and both its incidence and prevalence are high. Nevertheless, comprehensive data on this condition in Spain are lacking. The aim of this study was to estimate the prevalence of atrial fibrillation in Spain. A cross-sectional study was conducted in the general Spanish population older than 40 years. Two-stage random sampling was used, in which first-stage units were primary care physicians randomly selected in every Spanish province and second-stage units were 20 randomly selected persons drawn from each participating physician's assigned population. The reported prevalence was standardized for the age and sex distribution of the Spanish population. The electrocardiogram recordings were read centrally. Overall, 8343 individuals were evaluated. The mean age was 59.2 years (95% confidence interval, 58.6-59.8 years), and 52.4% of the participants were female. The overall age-adjusted prevalence of atrial fibrillation was 4.4% (95% confidence interval, 3.8-5.1). Prevalence was similar in both sexes, men 4.4% (3.6-5.2) and women 4.5% (3.6-5.3), rising with increasing age older than 60 years. In patients older than 80 years, the prevalence was 17.7% (14.1-21.3). In 10% of patients an unknown atrial fibrillation was diagnosed. The prevalence of atrial fibrillation in the general Spanish population older than 40 years is high, at 4.4%. The prevalence is similar in both sexes and rises steeply above 60 years of age. It is estimated that there are over 1 million patients with atrial fibrillation in the Spanish population, of whom over 90,000 are undiagnosed. Copyright © 2013 Sociedad Española de Cardiología. Published by Elsevier Espana. All rights reserved.
Moukabary, Talal; Gonzalez, Mario D
Atrial fibrillation is a very common clinical problem with a high prevalence that is expected to rise over time because of increasing risk factors (eg, age, obesity, hypertension). This high prevalence is also associated with high cost, because atrial fibrillation represents about 1% of overall health care spending. The management of atrial fibrillation involves multiple facets: (1) management of underlying disease if present and the management of atrial fibrillation risk factors, (2) prevention of thromboembolism, (3) control of the ventricular rate during atrial fibrillation, and (4) restoration and maintenance of normal sinus rhythm.
Atrial fibrillation is an arrhythmia characterized by no-coordinated atrial contraction that results in an inefficient atrial systole. The clinical classification of atrial fibrillation includes: ocassional, paroxysmal, persistent, and permanent. Multiple mechanisms have been described and accounts for a single ECG manifestation. Treatment should be individualized and has to considered several aspects including age, associated heart disease, and symptoms. Treatment strategies are: rhythm control, rate control, and thromboprophylaxis.
Munger, Thomas M.; Wu, Li-Qun; Shen, Win K.
Atrial fibrillation is the most common arrhythmia affecting patients today. Disease prevalence is increasing at an alarming rate worldwide, and is associated with often catastrophic and costly consequences, including heart failure, syncope, dementia, and stroke. Therapies including anticoagulants, anti-arrhythmic medications, devices, and non-pharmacologic procedures in the last 30 years have improved patients' functionality with the disease. Nonetheless, it remains imperative that further research into AF epidemiology, genetics, detection, and treatments continues to push forward rapidly as the worldwide population ages dramatically over the next 20 years. PMID:24474959
... information about the heart's electrical system and detailed animations, go to the Diseases and Conditions Index How ... can't restore a normal heart rhythm. The animation below shows atrial fibrillation. Click the "start" button ...
Labombarda, Fabien; Hamilton, Robert; Shohoudi, Azadeh; Aboulhosn, Jamil; Broberg, Craig S; Chaix, Marie A; Cohen, Scott; Cook, Stephen; Dore, Annie; Fernandes, Susan M; Fournier, Anne; Kay, Joseph; Macle, Laurent; Mondésert, Blandine; Mongeon, François-Pierre; Opotowsky, Alexander R; Proietti, Anna; Rivard, Lena; Ting, Jennifer; Thibault, Bernard; Zaidi, Ali; Khairy, Paul
Atrial arrhythmias are the most common complication encountered in the growing and aging population with congenital heart disease. This study sought to assess the types and patterns of atrial arrhythmias, associated factors, and age-related trends. A multicenter cohort study enrolled 482 patients with congenital heart disease and atrial arrhythmias, age 32.0 ± 18.0 years, 45.2% female, from 12 North American centers. Qualifying arrhythmias were classified by a blinded adjudicating committee. The most common presenting arrhythmia was intra-atrial re-entrant tachycardia (IART) (61.6%), followed by atrial fibrillation (28.8%), and focal atrial tachycardia (9.5%). The proportion of arrhythmias due to IART increased with congenital heart disease complexity from 47.2% to 62.1% to 67.0% in patients with simple, moderate, and complex defects, respectively (p = 0.0013). Atrial fibrillation increased with age to surpass IART as the most common arrhythmia in those ≥50 years of age (51.2% vs. 44.2%; p < 0.0001). Older age (odds ratio [OR]: 1.024 per year; 95% confidence interval [CI]: 1.010 to 1.039; p = 0.001) and hypertension (OR: 2.00; 95% CI: 1.08 to 3.71; p = 0.029) were independently associated with atrial fibrillation. During a mean follow-up of 11.3 ± 9.4 years, the predominant arrhythmia pattern was paroxysmal in 62.3%, persistent in 28.2%, and permanent in 9.5%. Permanent atrial arrhythmias increased with age from 3.1% to 22.6% in patients <20 years to ≥50 years, respectively (p < 0.0001). IART is the most common presenting atrial arrhythmia in patients with congenital heart disease, with a predominantly paroxysmal pattern. However, atrial fibrillation increases in prevalence and atrial arrhythmias progressively become permanent as the population ages. Copyright © 2017 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.
Dewhurst, Matthew J; Adams, Philip C; Gray, William K; Dewhurst, Felicity; Orega, Golda P; Chaote, Paul; Walker, Richard W
To determine the prevalence of atrial fibrillation (AF) in individuals aged 70 and older in a rural African community. Community-based cross-sectional survey. A demographic surveillance site (DSS) within the rural Hai district of northern Tanzania. Approximately one-quarter (N = 2,232) of the population aged 70 and older of the DSS. Participants were screened for AF using 12-lead electrocardiography; demographic and 1-year mortality data were collected; and functional status, body mass index, and blood pressure were recorded. The sex-specific prevalence of AF in each 5-year age band was determined. Fifteen of 2,232 participants (12 women, 3 men) had AF, giving a crude prevalence rate of 0.67% (95% confidence interval (CI) = 0.33-1.01) and an age-adjusted prevalence of 0.64% (95% CI = 0.31-0.97). Prevalence was 0.96% (95% CI = 0.42-1.49) in women and 0.31% (95% CI = -0.04 to 1.24) in men. Prevalence increased with age, from 0.46% (95% CI = 0.01-0.90) in those aged 70-74-1.30% (95% CI = 0.17-2.42) in those aged 85 and older. One-year mortality was 50% in women and 66.6% in men. This is the first published community-based AF prevalence study from sub-Saharan Africa. The prevalence rate of AF is strikingly lower than in other elderly populations studied, yet the 1-year mortality rate was exceedingly high. © 2012, Copyright the Authors Journal compilation © 2012, The American Geriatrics Society.
Schnabel, Renate B.; Yin, Xiaoyan; PhilimonGona; Larson, Martin G.; Beiser, Alexa S.; McManus, David D.; Newton-Cheh, Christopher; Lubitz, Steven A.; Magnani, Jared W.; Ellinor, Patrick T.; SudhaSeshadri; Wolf, Philip A; Vasan, Ramachandran S.; Benjamin, Emelia J.; Levy, Daniel
Summary Background Comprehensive long-term data on atrial fibrillation trends in men and women are scant. Methods We investigated trends in atrial fibrillation incidence, prevalence, and risk factors, and in stroke and mortality following its onset in Framingham Heart Study participants (n=9511) from 1958 to 2007. To accommodate sex differences in atrial fibrillation risk factors and disease manifestations, sex-stratified analyses were performed. Findings During 50 years of observation (202,417 person-years), there were 1,544 new-onset atrial fibrillation cases (46.8% women). We observed about a fourfold increase in the age-adjusted prevalence and more than a tripling in age-adjusted incidence of atrial fibrillation (prevalence 20.4 versus 96.2 per 1000 person-years in men; 13.7 versus 49.4 in women; incidence rates in first versus last decade 3.7 versus 13.4 per 1000 person-years in men; 2.5 versus 8.6 in women, ptrend<0.0001). For atrial fibrillation diagnosed by ECG during routine Framingham examinations, age-adjusted prevalence increased (12.6versus 25.7 per 1000 person-years in men; 8.1 versus 11.8 in women, ptrend<0.0001). The age-adjusted incidence increased, but did not achieve statistical significance. Although the prevalence of most risk factors changed over time, their associated hazards for atrial fibrillation changed little. Multivariable-adjusted proportional hazards models revealed a 73.5% decline in stroke and a 25.4% decline in mortality following atrial fibrillation onset (ptrend=0.0001, ptrend=0.003, respectively). Interpretation Our data suggest that observed trends of increased incidence of atrial fibrillation in the community were partially due to enhanced surveillance. Stroke occurrence and mortality following atrial fibrillation onset declined over the decades, and prevalence increased approximately fourfold. The hazards for atrial fibrillation risk factors remained fairly constant. Our data indicate a need for measures to enhance early
Otite, Fadar Oliver; Khandelwal, Priyank; Chaturvedi, Seemant; Romano, Jose G; Sacco, Ralph L; Malik, Amer M
To evaluate trends in atrial fibrillation (AF) prevalence in acute ischemic stroke (AIS) and TIA in the United States. We used the Nationwide Inpatient Sample to retrospectively compute weighted prevalence of AF in AIS (n = 4,355,140) and TIA (n = 1,816,459) patients admitted to US hospitals from 2004 to 2013. Multivariate-adjusted models were used to evaluate the association of AF with clinical factors, mortality, length of stay, and cost. From 2004 to 2013, AF prevalence increased by 22% in AIS (20%-24%) and by 38% in TIA (12%-17%). AF prevalence varied by age (AIS: 6% in 50-59 vs 37% in ≥80 years; TIA: 4% in 50-59 vs 24% in ≥80 years), sex (AIS: male 19% vs female 25%; TIA: male 15% vs female 14%), race (AIS: white 26% vs black 12%), and region (AIS: Northeast 25% vs South 20%). Advancing age, female sex, white race, high income, and large hospital size were associated with increased odds of AF in AIS. AF in AIS was a risk factor for in-hospital death (odds ratio 1.93, 95% confidence interval 1.89-1.98) but mortality in AIS with AF decreased from 11.6% to 8.3% (p < 0.001). Compared to no AF, AF was associated with increased cost of $2,310 and length of stay 1.1 days in AIS. AF prevalence in AIS and TIA has continued to increase. Disparity in AF prevalence in AIS and TIA exists by patient and hospital factors. AF is associated with increased mortality in AIS. Innovative AIS preventive strategies are needed in patients with AF, especially in the elderly. © 2016 American Academy of Neurology.
This issue provides a clinical overview of atrial fibrillation, focusing on diagnosis, treatment, and practice improvement. The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), including MKSAP (Medical Knowledge and Self-Assessment Program). Annals of Internal Medicine editors develop In the Clinic in collaboration with the ACP's Medical Education and Publishing divisions and with the assistance of additional science writers and physician writers.
Ketai, Loren H; Teague, Shawn D; Rissing, Stacy M
Background Atrial fibrillation (AF) may be the cause or sequela of left atrial abnormalities and variants. Purpose To determine the prevalence of left atrial (LA) abnormalities in AF patients compared to normal sinus rhythm (NSR) patients. Material and Methods We retrospectively reviewed 281 cardiac CT examinations from 2010 to 2012, excluding patients with prior pulmonary vein ablation, known coronary artery disease, prior coronary stent placement, or coronary artery bypass grafts. The first group consisted of 159 AF patients undergoing cardiac CT prior to pulmonary vein ablation and the second group consisted of 122 NSR patients evaluated with coronary CT angiography. Demographic data were collected. LA abnormalities were analyzed. Left atrial diameter was measured on an axial view. Results A total of 281 patients were included. The male gender has significantly higher prevalence of AF than female gender, P value <0.001. Patients with AF were significantly older (mean age, 57.4 years; standard deviation [SD], 11.8 years) than NSR patients (mean age, 53.4 years; SD, 13.6 years), P value, 0.01. The left atrial diameter was greater in the AF patients (mean diameter, 4.3 cm; SD, 0.82 cm) versus the NSR patients (3.4 cm; SD, 0.58 cm), P value, <0.0001. LA diverticulum was the most prevalent variant, occurring in 28.4% of the entire patient population followed by LA pouch, occurring in 24%. There was no significant between group differences in the prevalence of these or the remainder of the LA variants. Conclusion AF patients differed significantly from NSR patients in LA size, gender, and mean age. There was no statistical significance between the two groups with regard to the LA morphologic abnormalities other than size. PMID:27358747
Lim, Chiao Wen; Kasim, Sazzli; Chua, Nicholas Yul Chye; Najme Khir, Rizmy; Zainal Abidin, Hafisyatul Aiza; Abdul Rahman, Effarezan; Mohd Arshad, Mohd Kamal; Ibrahim Othman, Zubin; Yusoff, Khalid
Background and aim Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia encountered in clinical practice. The REDISCOVER (Responding to Increasing Cardiovascular disease prevalence) study is an observational longitudinal community-based study that tracks changing lifestyles, risk factors and chronic disease in urban and rural areas of Malaysia. In this study, we aim to study the prevalence of AF and its associated risk factors. Methods The study was conducted between 2007 and 2014. Participants were required to complete questionnaires on cardiovascular risk factors and medical history, and undergo physical examinations, blood tests, ECG and echocardiography examinations. Demographic variables including weight, height, blood pressure, serum glucose and serum lipid were recorded. Participants with AF were identified from their baseline ECG and at 3-year follow up. Results A total of 10 805 subjects participated in the study. Mean age was 52.6(±11.6) years and 56% were female; 4.4% of subjects had a diagnosis of ischaemic heart disease, 1.3% had a previous stroke, 16.7% had diabetes mellitus and 45.6% had hypertension. There were 53 subjects diagnosed with AF at baseline, giving a prevalence of 0.49%, and 0.54% at 3 years. AF was more prevalent in males (58.5% in the AF group compared to 43.9% in sinus rhythm (SR) subjects; p=0.03) and the older age group. Ischaemic heart disease was more prevalent in AF subjects (22.6%) compared to SR subjects (4.4%) (p<0.001). In the AF group previous stroke had occurred in 1.9% of subjects compared to 1.3% in the SR population (p=0.51), and 24.5% of subjects in the AF group had diabetes compared to 16.6% in the SR group (p=0.12). There was a significant difference in the prevalence of hypertension between the AF group (59.6%) compared to the SR subjects (45.5%) (p=0.04). Conclusions The prevalence of AF in the Malaysian population was low at 0.54% compared to the global average of 1%. We found that AF was
Stiermaier, Thomas; Santoro, Francesco; Eitel, Charlotte; Graf, Tobias; Möller, Christian; Tarantino, Nicola; Guastafierro, Francesca; Di Biase, Matteo; Thiele, Holger; Brunetti, Natale D; Eitel, Ingo
Takotsubo syndrome (TTS) is associated with a considerable risk of complications during the acute phase and substantial long-term mortality rates. Concomitant atrial fibrillation may have an impact on outcome in these patients. Aim of this study was to assess the prevalence and prognostic relevance of atrial fibrillation in TTS. We performed an international, multicenter study including 387 TTS patients consecutively enrolled at 3 centers. Atrial fibrillation was defined as known history before admission or documented episodes during hospital stay. Long-term mortality was evaluated in median 2.9years after the acute event. Atrial fibrillation was found in 97 TTS patients (25.1%) and was associated with older age (p<0.01), less emotional triggers (p=0.03), higher incidence of cardiogenic shock (p<0.01), lower left ventricular ejection fraction (p<0.01), and a prolonged hospital stay (p<0.01). Determinants of atrial fibrillation at admission (n=34 patients; 9.0%) in multivariate logistic regression analysis were age (p=0.001) and cardiogenic shock (p=0.013). Long-term mortality was significantly higher in TTS patients with as compared to patients without atrial fibrillation (35.2% versus 15.3%; hazard ratio 3.02, 95% confidence interval 1.90-4.78; p<0.001). In multivariate Cox regression analysis atrial fibrillation was identified as an independent determinant of outcome even after adjustment for clinical variables, left ventricular functional parameters (ballooning pattern, ejection fraction), and cardiogenic shock. In TTS patients, atrial fibrillation is frequent and associated with increased long-term mortality rates. Furthermore, our study identifies atrial fibrillation as an independent predictor of outcome and a potential tool for risk stratification in TTS. Copyright © 2017. Published by Elsevier B.V.
Auricular fibrillation - discharge; A-fib - discharge; AF - discharge; Afib - discharge ... been in the hospital because you have atrial fibrillation . This condition occurs when your heart beats faster ...
ANSWERS by heart Cardiovascular Conditions What Is Atrial Fibrillation? Your heart has a natural pacemaker, called the “ ... if the electric signals are normal. In atrial fibrillation (AFib), the heart’s two small upper chambers (atria) ...
... atrial fibrillation include: Alcohol use (especially binge drinking) Coronary artery disease Heart attack or heart bypass surgery Heart failure ... low. An ECG (a test that records the electrical activity of the heart) may show atrial fibrillation ...
Colín Lizalde, L J
Atrial fibrillation (AF) is the most common sustained arrhythmia. AF has now been exhaustively studied: more is known about its mechanism and research is moving towards new forms of treatment. For chronic AF, basically the control of ventricular rate and the brain protection are the main issues. It is well known that with the identification of high risk group for embolism, oral anticoagulation should be administered. Ventricular rate control can be achieved by using betablockers or calcium channel blockers, unless these are contraindicated for the elderly. Oral anticoagulation prevents the stroke. The main mechanism of AF is the re-entry of multiple wavelets, but now it is more frequently found on patients with focal AF. Therapies are employed to bring the patient to a sinusal rhythm as soon as possible with antiarryhthmics or electric cardioversion externally or internally. The internal procedure includes 1 to 15 J and the success rate is of 91% vs 67% in relation to the external one. The introduction of the catheter ablation has opened new frontiers for the treatment of AF, first as the ablate-and-pace technique and now trying to mimic the maze procedure or with the ablation of the focal tachycardia. The stimulation for prevention of AF under research, as well as the implantable dysfibrillation for selected patients. On going studies will show the possible benefit of this type of benefits.
Upshaw, Charles B.
Electrocardiographic differences occur between African-American and white persons. The cardiac rhythms of 2123 African-American and white hospital patients from 20 through 99 years of age were studied in a consecutive manner. The prevalence of atrial fibrillation increases dramatically with advancing age in both African-American and white patients. The prevalence of atrial fibrillation begins to increase at age 60 years and continues to increase through the 10th decade of life, although the rate of rise of the prevalence of atrial fibrillation is less in African-American patients compared with white patients. The cause of the reduced prevalence of atrial fibrillation in African-American patients remains unexplained. Atrial fibrillation occurs in 2.5% of African-American patients compared with 7.8% of white patients attending an urban hospital. There is little difference in the prevalence of atrial fibrillation between men and women. Atrial fibrillation occurs nearly seven times more often than does atrial flutter. PMID:11995632
... from the NHLBI on Twitter. How Is Atrial Fibrillation Treated? Treatment for atrial fibrillation (AF) depends on ... much thyroid hormone). Who Needs Treatment for Atrial Fibrillation? People who have AF but don't have ...
Bulanova, N A; Stazhadze, L L; Alekseeva, L A; Dubrovina, E V; Dorofeeva, E V
Prevalence of atrial fibrillation among patients attending our policlinic (2.44 and 3.78% in 2002 and 2009, respectively) was higher among men than among women and progressively increased with age achieving maximum in the group of patients aged more or equal 85 years. Paroxysmal and persistent forms were more frequent than permanent AF. Thromboembolic complications, heart failure and valvular heart disease were to a greater degree characteristic of permanent AF.
... think you are pregnant If you notice red, dark brown or black urine or stools If you ... Fibrillation • Introduction • What is Atrial Fibrillation? • Why AFib Matters • Understand your Risk for AFib Children • Symptoms of ...
Guo, Yutao; Tian, Yingchun; Wang, Hao; Si, Quanjin; Wang, Yutang; Lip, Gregory Y H
Much of the epidemiology of atrial fibrillation (AF) is based on data from Western populations. Despite the huge population of Asia, data on the clinical epidemiology of AF in Asian countries are limited. The current study aimed to investigate the prevalence and incidence of newly diagnosed (ie, incident) AF, as well as lifetime risk, in China and to determine the clinical risk factors contributing to its development. Using a medical insurance database involving > 10 million individuals for the years 2001 to 2012 in the southwest of China, trends in incident AF were calculated using Kaplan-Meier analysis and Cox regression. The usefulness of the CHADS2 (congestive heart failure, hypertension, age, diabetes, stroke [doubled]) and CHA2DS2-VASc (congestive heart failure, hypertension, age ≥ 75 [doubled], diabetes, stroke [doubled], vascular disease, age 65-74, and sex category [female]) scores was tested in predicting the occurrence of incident AF. A total of 471,446 individuals (aged ≥ 20 years) were studied, with 1,924,975 person-years of experience. We identified 921 patients with incident AF (62% male; mean age, 62 years). The prevalence of incident AF in subjects aged ≥ 20 years was 0.2 per 100 people, with an incidence of AF of 0.05 per 100 person-years overall. Over an 11-year period, the prevalence of AF increased 20-fold, whereas AF-related stroke increased 13-fold. The lifetime risk of AF was approximately one in five among Chinese adults, and it increased with advancing age. The CHA2DS2-VASc score was superior to the CHADS2 score in predicting the risk of incident AF in our Chinese population (DeLong test, Z = 6.621, P < .001). The AF burden, as well as the risk of AF-related stroke, has increased significantly over the past 11 years in the southwest of China. The public health burden of AF and its complications are greatest in the very elderly, with major implications for health-care systems given the global burden of this common arrhythmia.
Executive Summary Objective To review the effectiveness, safety, and costing of ablation methods to manage atrial fibrillation (AF). The ablation methods reviewed were catheter ablation and surgical ablation. Clinical Need Atrial fibrillation is characterized by an irregular, usually rapid, heart rate that limits the ability of the atria to pump blood effectively to the ventricles. Atrial fibrillation can be a primary diagnosis or it may be associated with other diseases, such as high blood pressure, abnormal heart muscle function, chronic lung diseases, and coronary heart disease. The most common symptom of AF is palpitations. Symptoms caused by decreased blood flow include dizziness, fatigue, and shortness of breath. Some patients with AF do not experience any symptoms. According to United States data, the incidence of AF increases with age, with a prevalence of 1 per 200 people aged between 50 and 60 years, and 1 per 10 people aged over 80 years. In 2004, the Institute for Clinical Evaluative Sciences (ICES) estimated that the rate of hospitalization for AF in Canada was 582.7 per 100,000 population. They also reported that of the patients discharged alive, 2.7% were readmitted within 1 year for stroke. One United States prevalence study of AF indicated that the overall prevalence of AF was 0.95%. When the results of this study were extrapolated to the population of Ontario, the prevalence of AF in Ontario is 98,758 for residents aged over 20 years. Currently, the first-line therapy for AF is medical therapy with antiarrhythmic drugs (AADs). There are several AADs available, because there is no one AAD that is effective for all patients. The AADs have critical adverse effects that can aggravate existing arrhythmias. The drug selection process frequently involves trial and error until the patient’s symptoms subside. The Technology Ablation has been frequently described as a “cure” for AF, compared with drug therapy, which controls AF but does not cure it
Koçağra Yağız, İdil Gökçen; Bayata, Serdar; Yeşil, Murat; Kurt İncesu, Tülay; Arıkan, Erdinç; Postacı, Nursen
This cross-sectional, observational study investigated prevalence and clinical features of atrial fibrillation (AF) in diabetic patient groups with or without autonomic neuropathy. One hundred and fourteen consecutive patients with pharmacologically treated type-II diabetes mellitus were enrolled for this study in our institution between January 2010 and December 2010. All patients underwent 12-lead electrocardiography on the day of enrollment for AF detection. All diabetic patients underwent neurologic examination for the presence of diabetic autonomic neuropathy (DAN). Following clinical evaluation, sympathetic skin responses (SSR) and RR interval variability (RRIV) analysis were used for the detection of autonomic neurologic involvement. Patients were divided into two groups according to presence (Group 1) or absence (Group 2) of DAN. Patient groups with or without DAN were compared for AF occurrence. Continuous and categorical data were compared with independent samples t- test and Chi-square statistical tests respectively. Atrial fibrillation prevalence was 24% (n=29) in study population. Diabetic autonomic neuropathy was diagnosed in 47 (39%) patients. Basal characteristics of patients with or without DAN were comparable except glycosylated hemoglobin A (HbA1c) levels. HbA1c levels were found significantly higher in patients with DAN. Atrial fibrillation was diagnosed in 14 patients in Group 1 and in 15 patients in Group 2. Significantly increased AF prevalence (31.9% vs. 20.8%, p=0.014, in groups with and without DAN respectively) was observed in patient group with diabetic autonomic neuropathy. The results of this study demonstrated an increased prevalence of AF in patients with diabetic autonomic neuropathy compared with non-neuropathic, diabetic patients. Further investigation of this relation with prospective studies is needed to demonstrate a causal relationship between diabetic autonomic neuropathy and AF.
Lawrance, Christopher P; Henn, Matthew C; Damiano, Ralph J
Atrial fibrillation is the most common cardiac arrhythmia, and its treatment options include drug therapy or catheter-based or surgical interventions. The surgical treatment of atrial fibrillation has undergone multiple evolutions over the last several decades. The Cox-Maze procedure went on to become the gold standard for the surgical treatment of atrial fibrillation and is currently in its fourth iteration (Cox-Maze IV). This article reviews the indications and preoperative planning for performing a Cox-Maze IV procedure. This article also reviews the literature describing the surgical results for both approaches including comparisons of the Cox-Maze IV to the previous cut-and-sew method.
Lawrance, Christopher P; Henn, Matthew C; Damiano, Ralph J
Atrial fibrillation is the most common cardiac arrhythmia, and its treatment options include drug therapy or catheter-based or surgical interventions. The surgical treatment of atrial fibrillation has undergone multiple evolutions over the last several decades. The Cox-Maze procedure went on to become the gold standard for the surgical treatment of atrial fibrillation and is currently in its fourth iteration (Cox-Maze IV). This article reviews the indications and preoperative planning for performing a Cox-Maze IV procedure. This article also reviews the literature describing the surgical results for both approaches including comparisons of the Cox-Maze IV to the previous cut-and-sew method.
Cea-Calvo, Luis; Redón, Josep; Lozano, José V; Fernández-Pérez, Cristina; Martí-Canales, Juan C; Llisterri, José L; González-Esteban, Jorge; Aznar, José
The aims of this study were to determine the prevalence of atrial fibrillation in individuals aged 60 years or more in Spain using a random sample of the population and to identify associated factors. An analysis of the PREV-ICTUS study, a randomized cross-sectional population-based study of individuals aged 60 years or more, was carried out. Data on demographic variables, cardiovascular risk factors, and cardiovascular disease were obtained from medical records. The diagnosis of atrial fibrillation was based on the patient's medical history and an electrocardiogram performed during the study. In the 7108 individuals studied (mean age 71.9 [7.1] years, 53.6% female), the prevalence of atrial fibrillation was 8.5% (95% confidence interval [CI] 7.9-9.2%). It was higher in males (9.3% vs 7.9% in females; P=.036) and increased from 4.2% in individuals aged 60-64 years to 16.5% in those aged 85 years or more (chi-squared test for linear trend, P< .001). Multivariate analysis showed that existing cardiovascular disease, hypertension, age, and left ventricular hypertrophy had the strongest associations with atrial fibrillation. Although there was a strong relationship between hypertension and atrial fibrillation (odds ratio 2.53, 95% CI, 1.60-4.01), no association was found between poor blood pressure control and atrial fibrillation. A weak association with diabetes mellitus was found only when arterial pressure was included in the model, but not when a diagnosis of hypertension was included. In this cross-sectional population-based study of elderly individuals, the prevalence of atrial fibrillation was 8.5%, and was strongly associated with existing cardiovascular disease, hypertension, age and left ventricular hypertrophy.
... attribute childhood AF to congenital heart abnormalities or post-surgical complications. Learn more about children and arrhythmia. This content was last reviewed July 2016. Atrial Fibrillation • Introduction • What is ...
... Supplements Videos & Tools You Are Here: Home → Multiple Languages → All Health Topics → Atrial Fibrillation URL of this page: https://medlineplus.gov/languages/atrialfibrillation.html Other topics A-Z Expand Section ...
Hayashi, Takekuni; Fukamizu, Seiji; Hojo, Rintaro; Komiyama, Kota; Tanabe, Yasuhiro; Tejima, Tamotsu; Nishizaki, Mitsuhiro; Hiraoka, Masayasu; Ako, Junya; Momomura, Shin-Ichi; Sakurada, Harumizu
Chronic obstructive pulmonary disease (COPD) is one of the important underlying diseases of atrial fibrillation (AF). However, the prevalence and electrophysiological characteristics of typical atrial flutter (AFL) in patients with AF and COPD remain unknown. The purpose of the present study was to investigate those characteristics. We investigated 181 consecutive patients who underwent catheter ablation of AF. Twenty-eight patients were diagnosed with COPD according to the Global Initiatives for Chronic Obstructive Lung Disease (GOLD) criteria. Forty patients with no lung disease served as a control group. We analysed the electrophysiological characteristics in these groups. Typical AFL was more common in the COPD group (19/28, 68%) than in the non-COPD group (13/40, 33%; P = 0.006). The prevalence of AFL increased with the severity of COPD: 4 (50%) of 8 patients with GOLD1, 13 (72%) of 18 patients with GOLD2, and 2 (100%) of 2 patients with GOLD3. Atrial flutter cycle length and conduction time from the coronary sinus (CS) ostium to the low lateral right atrium (RA) during CS ostium pacing before and after the cavotricuspid isthmus ablation were significantly longer in the COPD group than in the non-COPD group (285 vs. 236, 71 vs. 53, 164 vs. 134 ms; P = 0.009, 0.03, 0.002, respectively). In COPD patients with AF, conduction time of RA was prolonged and typical AFL was commonly observed.
Baena-Díez, J M; Grau, M; Forés, R; Fernández-Bergés, D; Elosua, R; Sorribes, M; Félix-Redondo, F J; Segura, A; Rigo, F; Cabrera de León, A; Sanz, H; Marrugat, J; Sala, J
Atrial fibrillation (AF) is the most common type of arrhythmia. The purpose of this study was to determine the prevalence of atrial fibrillation and its relationship with cardiovascular risk factors in Spain. Cross-sectional study based on a grouped analysis of 17,291 randomized individuals recruited in 6 population studies. The prevalence of atrial fibrillation was 1.5% (95% CI:1.3-1.7%). Men had a greater prevalence of the disease than women (1.9 vs. 1.1%, respectively). The prevalence of atrial fibrillation progressively increased with age: 0.05% for patients younger than 45 years, 0.5% for those between 45-59 years of age, 2.3% for those between 60-74 years of age and 6.3% for those older than 75 years. The percentage of individuals who were underwent anticoagulant treatment was 74.3%. The risk factors significantly associated with arrhythmia were an age older than 60 years (odds ratio [OR]: 7.6; 95% CI: 5.1-11.2), the male sex (OR:1.8; 95% CI: 1.4-2.4), arterial hypertension (OR:1.6; 95% CI: 1.2-2.1), obesity (OR:1.5; 95% CI:1.2-2.1) and a history of coronary artery disease (OR:1.9; 95% CI: 1.3-3.0). Atrial fibrillation is a common disease in elderly individuals, while its prevalence is low in individuals younger than 60 years. Most individuals with atrial fibrillation were on anticoagulant treatment. The risk factors for this type of arrhythmia are age, the male sex, hypertension, obesity and a history of coronary artery disease. Copyright © 2014. Published by Elsevier Espana.
Tomlin, Andrew M; Lloyd, Hywel S; Tilyard, Murray W
Background Atrial fibrillation is a major risk factor for stroke and heart disease but there is limited information on its prevalence in New Zealand primary care or the treatment provided to manage thromboembolic risk. Our aim was to estimate the prevalence of atrial fibrillation, assess patient risk for thromboembolism and evaluate the appropriateness of risk reduction using antiplatelet and oral anticoagulation therapy. Design A retrospective cohort study utilising electronic medical records for 739,000 patients registered with 170 general practices in 2014. Methods Patient diagnoses and prescriptions from 2010-2014 were analysed to identify patients with atrial fibrillation in 2014 and co-morbidities included in the CHA2DS2-VASc algorithm. Adjusted prevalence of atrial fibrillation by patient demographic group and the proportion of patients following recommended antithrombotic therapy were calculated. Results 12,712 patients were identified with AF (1.72%, 95% confidence interval 1.69%-1.75%). Prevalence was significantly higher for Maori (odds ratio 1.91, 95% confidence interval 1.80-2.03) than Europeans after adjusting for age, sex, deprivation and clinical risk factors. Stroke risk for Maori and Pacific Island patients was higher than for Europeans across all age groups. Of the 10,406 patients (81.9%) at high risk for thromboembolism, 60.5% were using anticoagulants, 24.1% aspirin monotherapy and 15.4% neither anticoagulants nor aspirin. Oral anticoagulants were used by 31.5% of patients at low risk (CHA2DS2-VASc <2). Conclusions Oral anticoagulants are under-utilised in the management of thromboembolic risk in high risk patients with atrial fibrillation. Better promotion of guideline recommendations for the treatment of patients with atrial fibrillation may be required to improve clinician and patient decision-making.
Olazabal Eizaguirre, N; Chavez, R; González-Torres, M A; Gaviria, M
This paper studies the relationship between atrial fibrillation and panic disorder. There are often doubts on the differential diagnosis in emergency services and general medical settings. Panic disorder prevalence rates have been found to be high in patients suffering from atrial fibrillation. Various studies have observed that patients diagnosed with anxiety disorders frequently have higher cardiovascular disease rates compared to the general population. Usually, patients suffering from panic disorder exhibit somatic complaints suggesting coronary disease, such as chest pain or palpitations. The aim is to make the correct diagnosis and treatment for these different illnesses, and to decrease the costs due to misdiagnosis.
... from the NHLBI on Twitter. How Can Atrial Fibrillation Be Prevented? Following a healthy lifestyle and taking ... for heart disease may help you prevent atrial fibrillation (AF). These steps include: Following a heart healthy ...
Introduction Acute atrial fibrillation is rapid, irregular, and chaotic atrial activity of recent onset. Various definitions of acute atrial fibrillation have been used in the literature, but for the purposes of this review we have included studies where atrial fibrillation may have occurred up to 7 days previously. Risk factors for acute atrial fibrillation include increasing age, cardiovascular disease, alcohol, diabetes, and lung disease. Acute atrial fibrillation increases the risk of stroke and heart failure. The condition resolves spontaneously within 24 to 48 hours in more than 50% of people; however, many people will require interventions to control heart rate or restore sinus rhythm. Methods and outcomes We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of interventions to prevent embolism, for conversion to sinus rhythm, and to control heart rate in people with recent-onset atrial fibrillation (within 7 days) who are haemodynamically stable? We searched: Medline, Embase, The Cochrane Library, and other important databases up to April 2014 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). Results We found 26 studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. Conclusions In this systematic review, we present information relating to the effectiveness and safety of the following interventions: amiodarone, antithrombotic treatment before cardioversion, atenolol, bisoprolol, carvedilol, digoxin, diltiazem, direct current cardioversion, flecainide, metoprolol, nebivolol, propafenone, sotalol, timolol, and verapamil. PMID:25430048
Giorgi, Mariano A; Miguel, Lucas San
Warfarin is the traditional therapeutic option available to manage thromboembolic risk in atrial fibrillation. The hemorrhagic risk with warfarin depends mainly on the international normalized ratio (INR). Data from randomized controlled trials show that patients have a therapeutic INR (2.00–3.00) only 61%–68% of the time while taking warfarin, and this target is sometimes hard to establish. Many compounds have been developed in order to optimize the profile of oral anticoagulants. We focus on one of them, rivaroxaban, comparing it with novel alternatives, ie, dabigatran and apixaban. The indication for rivaroxaban in nonvalvular atrial fibrillation was evaluated in ROCKET-AF (Rivaroxaban-once daily, Oral, direct factor Xa inhibition Compared with vitamin K antagonism for prevention of stroke and Embolism Trial in Atrial Fibrillation). In this trial, rivaroxaban was associated with a 12% reduction in the incidence of the primary endpoint compared with warfarin (hazard ratio 0.88; 95% confidence interval [CI] 0.74–1.03; P < 0.001 for noninferiority and P = 0.12 for superiority). However, patients remained in the therapeutic range for INR only 55% of the time, which is less than that in RE-LY (the Randomized Evaluation of Long-Term Anticoagulation Therapy, 64%) and in the ARISTOTLE trial (Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation, 66%). This shorter time spent in the therapeutic range has been one of the main criticisms of the ROCKET-AF trial, but could actually reflect what happens in real life. In addition, rivaroxaban exhibits good pharmacokinetic and pharmacoeconomic properties. Novel anticoagulants are a viable and commercially available alternative to vitamin K antagonists nowadays for the prevention of thromboembolic complications in atrial fibrillation. Rivaroxaban is an attractive alternative, but the true picture of this novel compound in atrial fibrillation will only become available with more widespread
Ohsawa, Masaki; Tanno, Kozo; Okamura, Tomonori; Yonekura, Yuki; Kato, Karen; Fujishima, Yosuke; Obara, Wataru; Abe, Takaya; Itai, Kazuyoshi; Ogasawara, Kuniaki; Omama, Shinichi; Turin, Tanvir Chowdhury; Miyamatsu, Naomi; Ishibashi, Yasuhiro; Morino, Yoshihiro; Itoh, Tomonori; Onoda, Toshiyuki; Kuribayashi, Toru; Makita, Shinji; Yoshida, Yuki; Nakamura, Motoyuki; Tanaka, Fumitaka; Ohta, Mutsuko; Sakata, Kiyomi; Okayama, Akira
Background While it is assumed that dialysis patients in Japan have a higher prevalence of atrial fibrillation (AF) than the general population, the magnitude of this difference is not known. Methods Standardized prevalence ratios (SPRs) for AF in dialysis patients (n = 1510) were calculated compared to data from the general population (n = 26 454) living in the same area. Results The prevalences of AF were 3.8% and 1.6% in dialysis patients and the general population, respectively. In male subjects, these respective values were 4.9% and 3.3%, and in female subjects they were 1.6% and 0.6%. The SPRs for AF were 2.53 (95% confidence interval [CI], 1.88–3.19) in all dialysis patients, 1.80 (95% CI, 1.30–2.29) in male dialysis patients, and 2.13 (95% CI, 0.66–3.61) in female dialysis patients. Conclusions The prevalence of AF in dialysis patients was twice that in the population-based controls. Since AF strongly contributes to a higher risk of cardiovascular mortality and morbidity in the general population, further longitudinal studies should be conducted regarding the risk of several outcomes attributable to AF among Japanese dialysis patients. PMID:26804038
Thanassoulis, George; Massaro, Joseph M.; O’Donnell, Christopher J.; Hoffmann, Udo; Levy, Daniel; Ellinor, Patrick T.; Wang, Thomas J.; Schnabel, Renate B.; Vasan, Ramachandran S.; Fox, Caroline S.; Benjamin, Emelia J.
Background Obesity represents an important risk factor for atrial fibrillation (AF). We tested the hypothesis that pericardial fat, a unique fat deposit in close anatomic proximity to cardiac structures and autonomic fibers, is associated with prevalent AF. Methods and Results Participants from the Framingham Heart Study underwent multi-detector computed tomography from 2002–2005. We estimated the association between quantitative pericardial, intra-thoracic and visceral adipose tissue volumes (per standard deviation [SD] of volume) with prevalent AF adjusting for established AF risk factors (age, sex, systolic blood pressure, blood pressure treatment, PR interval and clinically significant valvular disease). Of the 3217 eligible participants (mean age 50.6±10.1 years, 48% women), 54 had a confirmed diagnosis of AF. Pericardial fat, but not intra-thoracic or visceral abdominal fat, was associated with prevalent AF in multivariable-adjusted models (Odds Ratio [OR] per SD of pericardial fat volume 1.28, 95% confidence intervals [CI] 1.03–1.58). Further adjustments for body mass index, heart failure, myocardial infarction and intra-thoracic fat volume did not materially change the association between pericardial fat and AF. Conclusions Pericardial fat was associated with prevalent AF even after adjustment for AF risk factors, including body mass index. If this association is replicated, further investigations into the mechanisms linking pericardial fat to AF are merited. PMID:20558845
Hernandez, Marlow B.; Asher, Craig R.; Hernandez, Adrian V.; Novaro, Gian M.
Background. It has been observed that African American race is associated with a lower prevalence of atrial fibrillation (AF) compared to Caucasian race. To better quantify the association between African American race and AF, we performed a meta-analysis of published studies among different patient populations which reported the presence of AF by race. Methods. A literature search was conducted using electronic databases between January 1999 and January 2011. The search was limited to published studies in English conducted in the United States, which clearly defined the presence of AF in African American and Caucasian subjects. A meta-analysis was performed with prevalence of AF as the primary endpoint. Results. In total, 10 studies involving 1,031,351 subjects were included. According to a random effects analysis, African American race was associated with a protective effect with regard to AF as compared to Caucasian race (odds ratio 0.51, 95% CI 0.44 to 0.59, P < 0.001). In subgroup analyses, African American race was significantly associated with a lower prevalence of AF in the general population, those hospitalized or greater than 60 years old, postcoronary artery bypass surgery patients, and subjects with heart failure. Conclusions. In a broad sweep of subjects in the general population and hospitalized patients, the prevalence of AF in African Americans is consistently lower than in Caucasians. PMID:22548197
Weisenburger-Lile, David; Lopez, Delphine; Russel, Stephanie; Kahn, Jean-Emmanuel; Veiga Hellmann, Ana; Scherrer, Antoine; Ramdane, Nassima; Wang, Adrien; Evrard, Serge; Decroix, Jean-Pierre; Mellot, Francois; Bourdain, Frederic; Lapergue, Bertrand
Background Occult atrial fibrillation (AF) may, in part, explain cryptogenic stroke. A 22% prevalence of subdiaphragmatic visceral infarction (SDVI) among patients with ischemic stroke (IS) due to AF has been reported, using abdominal MRI. We sought to assess the reproducibility of this method and to confirm that SDVI is more prevalent in cases of AF-caused IS than in IS of other etiologies. Methods In consecutive patients admitted to our hospital, we compared SDVI prevalence in three groups: patients with IS due to AF (IS+/AF+ group), patients with stroke of another determined cause (IS+/AF- group) and patients with AF without stroke (IS-/AF+ group). Results A total of 111 patients were included. The median time between inclusion and abdominal MRI was six days. SDVI was more frequent in the IS+/AF+ group ( n = 10; 21.3%), than in IS+/AF- ( n = 1; 3.3%) and IS-/AF+ ( n = 0) groups, p = 0.002. The most frequent localization was the kidney. Conclusions The prevalence of SDVI was higher among patients with AF-caused IS. In cases of cryptogenic stroke, a positive abdominal MRI may suggest occult AF as the cause and identify a high risk of AF in this subgroup of patients.
Lawrance, Christopher P.; Henn, Matthew C.; Damiano, Ralph J.
Synopsis Atrial fibrillation is the most common cardiac arrhythmia and its treatment options include drug therapy or, catheter-based or surgical interventions. The surgical treatment of atrial fibrillation has undergone multiple evolutions over the last several decades. The Cox-Maze procedure which was developed by James Cox in 1987 is a procedure where multiple surgical incisions are created along the atria to interrupt the electrical pathways thought to allow atrial fibrillation to persist. This procedure went on to become the gold standard for the surgical treatment of atrial fibrillation and is currently in its 4th iteration called the Cox-Maze IV. The Cox-Maze IV replaced the previous “cut-and-sew” method with a combination of cryoablation and bipolar RF ablation. The adaption of ablation technologies allowed the Cox-Maze IV procedure to be performed through a less invasive right minithoracotomy instead of a traditional sternotomy approach. The aim of this article is to review the indications and preoperative planning for performing a Cox-Maze IV procedure. A description of the operative techniques for both a sternotomy and right mini-thoracotomy approach will be discussed in addition to specific postoperative considerations. Finally, this article will review the literature describing the surgical results for both approaches including comparisons of the Cox-Maze IV to the previous “cut-and-sew” method. PMID:25443237
Duron, Emmanuelle; Hanon, Olivier
Atrial fibrillation (AF), which prevalence increases with age, is a growing public health problem and a well known risk factor for stroke. On the other hand, dementia is one of the most important neurological disorders in the elderly, and with aging of the population in developed countries, the number of demented patients will increase in absence of prevention. In the past decade, several vascular risk factors (hypertension, obesity and metabolic syndrome, hypercholesterolemia) have been found, with various degree of evidence, to be associated with vascular dementia but also, surprisingly, with Alzheimer's disease. This review is devoted to the links between atrial fibrillation, cognitive decline and dementia. Globally, transversal studies showed a significant association between atrial fibrillation, cognitive decline and dementia. However, these studies are particularly sensitive to various biases. In this context, recent longitudinal studies of higher level of evidence have been conducted to assess the link between AF and dementia. One study disclosed a high incidence of dementia among patients suffering from atrial fibrillation during a 4.6 years follow-up. Similarly another study showed that atrial fibrillation was significantly associated with conversion from mild cognitive impairment to dementia during a 3 years follow-up. Nevertheless two other longitudinal studies did not find any significant association between AF and dementia, but this discrepancy should be interpreted taking into account that the comparability of all these studies is moderate because they were using different methodologies (population, cognitive testing, and mean follow-up). Possible explanatory mechanisms for the association between AF and the risk of dementia are proposed, such as thrombo-embolic ischemic damage and cerebral hypo perfusion due to fluctuations in the cardiac output. Thus, there is some evidence that FA could be associated with cognitive decline and dementia but this
Malik, Rahul; Alyeshmerni, Daniel M; Wang, Zuyue; Goldstein, Steven A; Torguson, Rebecca; Lindsay, Joseph; Waksman, Ron; Ben-Dor, Itsik
Systemic embolization threatens patients with atrial fibrillation (AF). The risk is enhanced at the time of cardioversion. Transesophageal echocardiography (TEE) prior to cardioversion to screen for left atrial thrombus (LAT), a marker of high risk for embolization, is recommended for many patients with AF. To determine clinical and echocardiographic factors associated with LAT formation in AF. Data from 600 consecutive patients with AF undergoing TEE prior to cardioversion for the detection of LAT were analyzed. Clinical, laboratory, and echocardiographic parameters were abstracted from the clinical record. TEE identified LAT in 70 (11.6%) and dense (LA) spontaneous echo contrast (SEC) in 156 (26%). Baseline characteristics and echocardiographic parameters of patients with or without LAT are compared. A prior myocardial infarction, 21 (29.4 %) vs. 31 (5.8), (p < 0.001); hypertension, 60 (85.7%) vs. 386 (72.8), (p 0.02); CHADS(2) ≥ 2, 56 (80%) vs. 308 (58.1%), (p < 0.001) prevalence was higher in patients with LAT. Patients with LAT had lower ejection fraction 38.2 ± 15.6 vs. 46.2 ± 14.5, (p < 0.001); higher LA diameter 4.98 ± 0.7 vs. 4.52 ± 0.7, (p <0.001); dense LA SEC 44 (62.8) vs. 112 (21.1), (p < 0.001); and low LA appendage emptying velocity 21.7 ± 12.9 vs. 37.5 ± 19.4, (p < 0.001). Multivariate analysis was done, and it revealed that low LA emptying velocity had the strongest independent association with LAT (HR 0.89 [CI 0.83-0.96], p value <0.001. LAT is not an uncommon finding of AF patients prior to cardioversion. The current practice of TEE examination may be justified since neither clinical nor routine 2D echo examinations reliably identify LAT. Copyright © 2014. Published by Elsevier Inc.
Cardoso, Rhanderson; Garcia, Daniel; Fernandes, Gilson; He, L I; Lichtenberger, Paola; Viles-Gonzalez, Juan; Coffey, James O; Mitrani, Raul D
Chagas' disease (CD) has been associated with atrial fibrillation (AF) and electrocardiographic (ECG) conduction defects. However, prior studies have shown conflicting results. We performed a meta-analysis comparing the prevalence of AF and conduction abnormalities between CD and non-CD patients. PubMed, EMBASE, Cochrane Central, and Latin American databases were searched for studies that directly compared the prevalence of AF and conduction defects in CD and non-CD patients. Odds ratios (OR) were computed using random-effects model due to anticipated heterogeneity. We further performed subanalyses limited to studies that included only patients with cardiomyopathy. A total of 17,238 patients from 30 studies were included, of whom 6,840 (40%) had a positive serology for CD. In the pooled data, AF was significantly more prevalent in the CD group (OR 1.62; 95%CI 1.21-2.15; P = 0.001). However, no significant difference was observed between groups when the analysis included only patients with cardiomyopathy (OR 1.21; 95%CI 0.97-1.50; P = 0.08) or heart failure (OR 1.09; 95%CI 0.81-1.47; P = 0.55). The combination of right bundle branch block (RBBB) and left anterior fascicular block (LAFB) had the highest OR for increased prevalence in patients with Chagas' cardiomyopathy compared to non-CD etiologies (OR 5.31; 95%CI 1.23-22.86; P = 0.03). Our meta-analysis suggests that the prevalence of AF in patients with Chagas' cardiomyopathy is not significantly different from non-CD cardiomyopathies. The pattern of RBBB and LAFB in patients with cardiomyopathy of unknown etiology and epidemiologic risk factors should raise the possibility of CD and prompt specific diagnostic testing. © 2015 Wiley Periodicals, Inc.
Alexa, Ioana Dana; Bucur, Ionela Mirela; Rusu, R I; Ungureanu, G
Atrial fibrillation (AF), a common and serious cardiac rhythm disturbance, is responsible for substantial morbidity and mortality in the population. Currently about 2.3 million people in the US are diagnosed with AF and, based of the US census, this number is expected to rise to 5.6 million by 2050. It doubles in prevalence with each decade of age, reaching almost 9% at age 80-89 years. It has increased in prevalence over the calendar decades, reaching 'epidemic' proportions. The risk of stroke increases from 1.5% in patients with atrial fibrillation from 50-59 years of age to up to 23.5% for such patients aged 80-89 years. Although the diagnosis of atrial fibrillation is usually straightforward, effective treatment is not. We aimed to discuss how rhythm control of atrial fibrillation can best be achieved in elderly patients, the controversy over the rhythm versus rate control, and prevention of thromboembolism.
Sandercock, P.; Bamford, J.; Dennis, M.; Burn, J.; Slattery, J.; Jones, L.; Boonyakarnkul, S.; Warlow, C.
OBJECTIVE--To determine in patients with first ever stroke whether atrial fibrillation influences clinical features, the need to perform computed tomography, and prognosis. DESIGN--Observational cohort study with maximum follow up of 6.5 years. SETTING--Primary care, based on 10 general practices in urban and rural Oxfordshire. SUBJECTS--Consecutive series of 675 patients with first ever stroke registered in the Oxfordshire community stroke project. MAIN OUTCOME MEASURES--Prevalence of atrial fibrillation by type of stroke; effect of atrial fibrillation on case fatality rate and risk of recurrent stroke, vascular death, and death from all causes. RESULTS--Prevalence of atrial fibrillation was 17% (95% confidence interval 14% to 20%) for all stroke types (115/675), 18% (15% to 21%) for cerebral infarction (97/545), 11% (4% to 11%) for primary intercerebral haemorrhage (7/66), and 0% (0 to 11%) for subarachnoid haemorrhage (0/33). For patients with cerebral infarction the 30 day case fatality rate was significantly higher with atrial fibrillation (23%) than with sinus rhythm (8%); the risk of early recurrent stroke (within 30 days) was 1% with atrial fibrillation and 4% with sinus rhythm. In patients who survived at least 30 days the average annual risk of recurrent stroke was 8.2% (5.9% to 10.9%) with sinus rhythm and 11% (6.0% to 17.3%) with atrial fibrillation. CONCLUSIONS--After a first stroke atrial fibrillation was not associated with a definite excess risk of recurrent stroke, either within 30 days or within the first few years. Survivors with and without atrial fibrillation had a clinically important absolute risk of further serious vascular events. PMID:1493391
Chang, Kay-Won; Hsu, Jonathan C; Toomu, Avinash; Fox, Sutton; Maisel, Alan S
While biomarkers have greatly impacted the diagnosis and management of myocardial infarction and heart failure, the use of biomarkers has been slow to permeate management of atrial fibrillation. Guideline recommendations on the use of biomarkers in atrial fibrillation were virtually non-existent until the 2016 European Society of Cardiology guidelines on atrial fibrillation offered a class IIb recommendation to consider using biomarkers such as high sensitivity troponin and natriuretic peptide to further refine stroke and bleeding risk in atrial fibrillation patients. Biomarker levels have been associated with incident atrial fibrillation, post-operative atrial fibrillation, acute atrial fibrillation, diagnosis of myocardial infarction and heart failure in atrial fibrillation, and prognosis in atrial fibrillation. This review will offer an in-depth survey of current evidence on the use of biomarkers in atrial fibrillation and propose clinical algorithms to aid the internist in using biomarkers in atrial fibrillation management. Copyright © 2017. Published by Elsevier Inc.
Bhatia, Subir; Qazi, Mohammad; Erande, Ashwini; Shah, Kunjan; Amin, Alpesh; Patel, Pranav; Malik, Shaista
Previous research has shown that roughly 15% to 30% of those with heart failure (HF) develop atrial fibrillation (AF). Although studies have shown variations in the incidence of AF in patients with HF, there has been no evidence of mortality differences by race. The purpose of this study was to assess AF prevalence and inhospital mortality in patients with HF among different racial groups in the United States. Using the National Inpatient Sample registry, the largest publicly available all-payer inpatient care database representing >95% of the US inpatient population, we analyzed subjects hospitalized with a primary diagnosis of HF from 2001 to 2011 (n = 11,485,673) using the International Classification of Diseases, Ninth Edition (ICD 9) codes 428.0-0.1, 428.20-0.23, 428.30-0.33, 428.40-0.43, and 428.9; patients with AF were identified using the ICD 9 code 427.31. We assessed prevalence and mortality among racial groups. Using logistic regression, we examined odds of mortality adjusted for demographics and co-morbidity using Elixhauser co-morbidity index. We also examined utilization of procedures by race. Of the 11,485,673 patients hospitalized with HF in our study, 3,939,129 (34%) had AF. Patients with HF and AF had greater inhospital mortality compared with those without AF (4.6% vs 3.3% respectively, p <0.0001). Additionally, black, Hispanic, Asian, and white patients with HF and AF had a 24%, 17%, 13%, and 6% higher mortality, respectively, than if they did not have AF. Among patients with HF and AF, minority racial groups had underutilization of catheter ablation and cardioversion compared with white patients. In conclusion, minority patients with HF and AF had a disproportionately higher risk of inpatient death compared with white patients with HF. We also found a significant underutilization of cardioversion and catheter ablation in minority racial groups compared with white patients. PMID:26970814
There is a growing population of veteran endurance athletes, regularly participating in training and competition. Although the graded benefit of exercise on cardiovascular health and mortality is well established, recent studies have raised concern that prolonged and strenuous endurance exercise may predispose to atrial and ventricular arrhythmias. Atrial fibrillation (AF) and atrial flutter are facilitated by atrial remodelling, atrial ectopy, and an imbalance of the autonomic nervous system. Endurance sports practice has an impact on all of these factors and may therefore act as a promoter of these arrhythmias. In an animal model, long-term intensive exercise training induced fibrosis in both atria and increased susceptibility to AF. While the prevalence of AF is low in young competitive athletes, it increases substantially in the aging athlete, which is possibly associated with an accumulation of lifetime training hours and participation in competitions. A recent meta-analysis revealed a 5-fold increased risk of AF in middle-aged endurance athletes with a striking male predominance. Beside physical activity, height and absolute left atrial size are independent risk factors for lone AF and the stature of men per se may explain part of their higher risk of AF. Furthermore, for a comparable amount of training volume and performance, male non-elite athletes exhibit a higher blood pressure at rest and peak exercise, a more concentric type of left ventricular remodelling, and an altered diastolic function, possibly contributing to a more pronounced atrial remodelling. The sports cardiologist should be aware of the distinctive features of AF in athletes. Therapeutic recommendations should be given in close cooperation with an electrophysiologist. Reduction of training volume is often not desired and drug therapy not well tolerated. An early ablation strategy may be appropriate for some athletes with an impaired physical performance, especially when continuation of
Franken, Roberto A.; Rosa, Ronaldo F.; Santos, Silvio CM
This review discusses atrial fibrillation according to the guidelines of Brazilian Society of Cardiac Arrhythmias and the Brazilian Cardiogeriatrics Guidelines. We stress the thromboembolic burden of atrial fibrillation and discuss how to prevent it as well as the best way to conduct cases of atrial fibrillatios in the elderly, reverting the arrhythmia to sinus rhythm, or the option of heart rate control. The new methods to treat atrial fibrillation, such as radiofrequency ablation, new oral direct thrombin inhibitors and Xa factor inhibitors, as well as new antiarrhythmic drugs, are depicted. PMID:22916053
Le Heuzey, J Y
The incidence and prevalence of atrial fibrillation are quickly increasing, mainly due to the ageing of the population. Atrial fibrillation is, to date, a problem of public health. Atrial fibrillation is associated to a five-fold risk of stroke, which may be identified by score risks, such as CHADS(2) score. The classical antithrombotic treatment of atrial fibrillation is based on vitamin K antagonists. Trials made in the 90's have clearly shown that vitamin K antagonists were able to decrease stroke risk by about 60%. New oral anticoagulants are now available on the market to treat patients with atrial fibrillation. These drugs are dabigatran which has demonstrated an interest in the RE-LY trial. Two doses may be prescribed, 110 mg bid and 150 mg bid. Anti Xa have also demonstrated an interest : rivaroxaban in the ROCKET AF trial and apixaban in the AVERROES (versus aspirin) and ARISTOTLE trials. In the future these drugs will have a major place in the armamentarium used to treat patients with atrial fibrillation. In all these trials a decrease in intra cranial haemorrhages has been demonstrated. In the everyday practice it will be necessary to be very cautious in patients with impaired renal function, as all these drugs are eliminated by kidneys.
Horstmann, S; Möhlenbruch, M; Wegele, C; Rizos, T; Laible, M; Rauch, G; Veltkamp, R
Cerebral microbleeds (CMBs) are associated with an increased risk of intracerebral hemorrhage. The impact of oral anticoagulation (OAC) on CMBs is not well characterized. Our aim was to assess the prevalence of CMBs in stroke and transient ischaemic attack (TIA) patients with atrial fibrillation (AF) and to analyze the implications of previous treatment with OAC. In this retrospective analysis on data from a prospectively recruiting stroke registry, patients with ischaemic stroke or TIA with brain magnetic resonance imaging including susceptibility weighted imaging were consecutively enrolled during a 3-year period. For each patient cardiovascular risk factors, AF history and recent diagnosis of AF, present use of OAC and antiplatelets, the National Institute of Health Stroke Scale and the premorbid modified Rankin Scale score were recorded. Two independent raters identified CMBs according to consensus criteria. CMB location was classified as lobar, deep or in the posterior fossa. In all, 785 patients (mean age 63.9 ± 14.2 years) were included. At least one CMB was detected in 186 (23.7%) patients. CMBs were significantly more frequent in patients with AF (30.5% vs. 22.4%). Patients with previous OAC treatment were more likely to have CMBs (36.7% vs. 22.8%, P = 0.03) and abundant CMBs (n > 10) were more frequent in anticoagulated patients even after adjustment for age. However, age was the only independent factor predicting CMBs (P = 0.001). Cerebral microbleeds are common in elderly AF patients with acute ischaemic stroke. Previous OAC is associated with a higher number of CMBs predominantly in the lobar location. Establishing a causal relationship requires prospective longitudinal investigation. © 2014 EAN.
Atienza, Felipe; Jalife, José
The mechanisms of human atrial fibrillation (AF) are poorly understood. Experimental studies have demonstrated that cholinergic AF in the sheep heart is maintained by high-frequency reentrant sources (drivers) that result in a consistent left-to-right frequency gradient. More recently, clinical studies have confirmed the existence of a hierarchical organization in the rate of activation of different regions in the atria of patients with paroxysmal and chronic AF. Although maximal dominant-frequency sites were found to play a crucial role in the maintenance of AF in some patients, whether AF drivers in humans are focal or reentrant and whether changes in driver activity alter spatial frequency gradients are unclear. To test the hypothesis that localized functional reentry maintains AF in humans, we determined the effects of adenosine infusion on local dominant frequency at different sites of both atria. In patients with paroxysmal AF, adenosine infusion increases local dominant frequencies, particularly at the pulmonary vein-left atrial junction region, amplifying a left-to-right frequency gradient. In patients with chronic AF, dominant frequency is significantly higher than in patients with paroxysmal AF in all atrial regions surveyed, with the highest adenosine increase of frequencies outside the pulmonary vein region. Adenosine-induced driver acceleration is strongly suggestive of a reentrant mechanism in both groups of AF patients.
Arguis, M J; Navarro, R; Regueiro, A; Arbelo, E; Sierra, P; Sabaté, S; Galán, J; Ruiz, A; Matute, P; Roux, C; Gomar, C; Rovira, I; Mont, L; Fita, G
Atrial fibrillation is a frequent complication in the perioperative period. When it appears there is an increased risk of perioperative morbidity due to stroke, thromboembolism, cardiac arrest, myocardial infarction, anticoagulation haemorrhage, and hospital readmissions. The current article focuses on the recommendations for the management of perioperative atrial fibrillation based on the latest Clinical Practice Guidelines on atrial fibrillation by the European Society of Cardiology and the Spanish Society of Cardiology. This article pays special attention to the preoperative management, as well as to the acute perioperative episode. For this reason, the latest recommendations for the control of cardiac frequency, antiarrhythmic treatment and anticoagulation are included.
Wolf, Jacek; Dereziński, Tadeusz; Szyndler, Anna; Narkiewicz, Krzysztof
Atrial fibrillation (AF) constitutes the most prevalent arrhythmia, affecting up-to 2% of the general population. Apart from well-established risk factors that increase the odds for the development of AF, e.g. age or arterial hypertension, recent analyses indicate that obstructive sleep apnoea (OSA) may independently, negatively modify the arrhythmia occur-rence profile. Concurrently, erectile dysfunction (ED) is a commonly neglected, potent marker of cardiovascular risk, which considerably worsens men's psychological state. Unrecognised or untreated ED results in substantial deterioration of the patient's therapeutic programme adherence. Because AF, OSA, and ED share multiple risk factors and clinical consequences, in 2013 the concept of their frequent concurrence - OSAFED syndrome - was proposed. The aim of the study was to evaluate the prevalence of OSAFED patients with AF in primary care practice. Retrospective analysis was carried out of data from primary care physician charts (NZOZ Esculap Gniewkowo, central Poland) including 1372 men aged 40-65 years. The primary goal was to determine the diagnosis of paroxysmal and/or perma-nent AF, which was followed by sleep apnoea screening (polygraphy) and erectile function evaluation (IIED-5 questionnaire). Twenty-one (1.5%) patients with documented AF were identified. Based on the sleep-polygraphic studies, 14 (67%) of them had confirmation of OSA with mean apnoea-hypopnea index (AHI) equal to 27.5 ± 17.1. Furthermore, 11 (52%) patients met the OSAFED syndrome criteria. Patients with OSAFED syndrome had a mean score in IIEF-5 of 11.6 ± 3.5. The OSAFED-patients who were not diagnosed with all the of the syndrome components prior to the study-enrolment were characterised by substantially lower fat excess compared to their counterparts with already established OSAFED (body mass index: 30.1 ± 4.9 vs. 37.7 ± 3.9 kg/m², respectively, p = 0.03). Frequently coexisting OSAFED syndrome components in all AF patients from
Jaakkola, Jussi; Mustonen, Pirjo; Kiviniemi, Tuomas; Hartikainen, Juha E. K.; Palomäki, Antti; Hartikainen, Päivi; Nuotio, Ilpo; Ylitalo, Antti; Airaksinen, K. E. Juhani
Atrial fibrillation may remain undiagnosed until an ischemic stroke occurs. In this retrospective cohort study we assessed the prevalence of ischemic stroke or transient ischemic attack as the first manifestation of atrial fibrillation in 3,623 patients treated for their first ever stroke or transient ischemic attack during 2003–2012. Two groups were formed: patients with a history of atrial fibrillation and patients with new atrial fibrillation diagnosed during hospitalization for stroke or transient ischemic attack. A control group of 781 patients with intracranial hemorrhage was compiled similarly to explore causality between new atrial fibrillation and stroke. The median age of the patients was 78.3 [13.0] years and 2,009 (55.5%) were women. New atrial fibrillation was diagnosed in 753 (20.8%) patients with stroke or transient ischemic attack, compared to 15 (1.9%) with intracranial hemorrhage. Younger age and no history of coronary artery disease or other vascular diseases, heart failure, or hypertension were the independent predictors of new atrial fibrillation detected concomitantly with an ischemic event. Thus, ischemic stroke was the first clinical manifestation of atrial fibrillation in 37% of younger (<75 years) patients with no history of cardiovascular diseases. In conclusion, atrial fibrillation is too often diagnosed only after an ischemic stroke has occurred, especially in middle-aged healthy individuals. New atrial fibrillation seems to be predominantly the cause of the ischemic stroke and not triggered by the acute cerebrovascular event. PMID:27936187
Jadidi, Amir S; Sunthorn, Henri; Burri, Haran; Gentil-Baron, Pascale; Shah, Dipen
A 19-year-old girl was referred to our cardiology department for catheter ablation (isolation of the pulmonary veins) of paroxysmal atrial fibrillation (AF). The diagnosis was made upon a 12-lead ECG of the arrhythmia documented in the emergency room. The ECG showed an irregular tachycardia without wide QRS complexes. Careful assessment revealed the irregularity of the rhythm was a sweep artifact due to a mechanic failure of the ECG-machine to advance the article smoothly. During EP study a concealed anteroseptal accessory pathway causing an orthodromic AV reentrant tachycardia was eliminated by radio-frequency ablation. This example emphasizes the need for careful assessment of an ECG tracing, including printed legends and technical data.
Yamase, Yuichiro; Kato, Kimihiko; Horibe, Hideki; Ueyama, Chikara; Fujimaki, Tetsuo; Oguri, Mitsutoshi; Arai, Masazumi; Watanabe, Sachiro; Murohara, Toyoaki; Yamada, Yoshiji
Recent genome-wide association studies (GWASs) identified various genes and loci that confer susceptibility to coronary artery disease or myocardial infarction among Caucasian populations. As myocardial ischemia is an important risk factor for atrial fibrillation, we hypothesized that certain polymorphisms may contribute to the genetic susceptibility to atrial fibrillation through affecting the susceptibility to coronary artery disease. The aim of the present study was to examine the possible association of atrial fibrillation in Japanese individuals with 29 polymorphisms identified as susceptibility loci for coronary artery disease or myocardial infarction in the meta-analyses of GWASs in Caucasian populations. The study subjects comprised 5,470 Japanese individuals (305 subjects with atrial fibrillation and 5,165 controls). Genotypes for 29 polymorphisms were determined by a method that combines the polymerase chain reaction and sequence-specific oligonucleotide probes with suspension array technology. Comparisons of the allele frequencies by the χ(2) test revealed that rs599839 (G→A) of the proline/serine-rich coiled-coil 1 gene (PSRC1, P=0.0084) and rs11556924 (C→T, Arg363His) of the zinc finger, C3HC-type containing 1 gene (ZC3HC1, P=0.0076) were significantly (P<0.01) associated with atrial fibrillation. Multivariable logistic regression analysis with adjustment for age, gender, body mass index, estimated glomerular filtration rate, and the prevalence of smoking, hypertension, diabetes mellitus, and dyslipidemia revealed that rs599839 (P=0.0043; odds ratio, 1.56; dominant model) and rs11556924 (P=0.0043; odds ratio, 1.93; dominant model) were significantly associated with atrial fibrillation, with the minor G and T alleles, respectively, representing risk factors for this condition. PSRC1 and ZC3HC1 may thus be susceptibility loci for atrial fibrillation in Japanese individuals.
Sullivan, M L; Martinez, C M; Gallagher, E J
A young male bodybuilder, consuming large doses of anabolic steroids (AS), presented to the Emergency Department (ED) with symptomatic rapid atrial fibrillation (AF). Echocardiogram revealed significant septal hypokinesis, and posterior and septal wall thickness at the upper limit of normal for highly trained athletes. The atrial fibrillation had not recurred at 10 weeks after discontinuation of AS use. Consumption of these agents in athletes has been associated with hypertension, ischemic heart disease, hypertrophic cardiomyopathy, and sudden death.
Piccini, Jonathan P; Fauchier, Laurent
Many patients with atrial fibrillation have substantial symptoms despite ventricular rate control and require restoration of sinus rhythm to improve their quality of life. Acute restoration (ie, cardioversion) and maintenance of sinus rhythm in patients with atrial fibrillation are referred to as rhythm control. The decision to pursue rhythm control is based on symptoms, the type of atrial fibrillation (paroxysmal, persistent, or long-standing persistent), patient comorbidities, general health status, and anticoagulation status. Many patients have recurrent atrial fibrillation and require further intervention to maintain long term sinus rhythm. Antiarrhythmic drug therapy is generally recommended as a first-line therapy and drug selection is on the basis of the presence or absence of structural heart disease or heart failure, electrocardiographical variables, renal function, and other comorbidities. In patients who continue to have recurrent atrial fibrillation despite medical therapy, catheter ablation has been shown to substantially reduce recurrent atrial fibrillation, decrease symptoms, and improve quality of life, although recurrence is common despite continued advancement in ablation techniques.
Atrial fibrillation in heart failure often occur together. The relationship between atrial fibrillation and heart failure has remained a subject of research. The main manifestation of the violation of hydrodynamics in heart failure is the increased end-diastolic pressure, which is transmitted through the intercommunicated system (left ventricle-left atrium-pulmonary veins-alveolar capillaries) causing increased pulmonary wedge pressure with the danger for pulmonary edema. End-diastolic pressure is the sum of left ventricle diastolic pressure and left atrial systolic pressure. Stopping the mechanical systole of the left atrium can reduce the pressure in the system in heart failure. Atrial fibrillation stops the mechanical systole of the left atrium and decreases the intercommunicating pressure and pulmonary wedge pressure. It is possible that atrial fibrillation is a mechanism for protection from increasing end-diastolic pressure and pulmonary wedge pressure, and prevents the danger of pulmonary edema. This hypothesis may explain the relationship between heart failure and atrial fibrillation and their frequent association. Copyright © 2014 Elsevier Ltd. All rights reserved.
Kanjwal, Yousuf; Imran, Naser; Grubb, Blair
Deglutition induced supraventricular tachycardia is an uncommon condition postulated to be a vagally mediated phenomenon due to mechanical stimulation. Patients usually present with mild symptoms or may have severe debilitating symptoms. Treatment with Class I agents, beta blockers, calcium channel blockers, amiodarone and radiofrquency catheter ablation has shown to be successful in the majority of reported cases. We report the case of a 46-year-old healthy woman presenting with palpitations on swallowing that was documented to be transient atrial tachycardia with aberrant ventricular conduction as well as transient atrial fibrillation. She was successfully treated with propafenone with no induction of swallowing-induced tachycardia after treatment. This is also the first case to show swallowing-induced atrial tachycardia and atrial fibrillation in the same patient.
Sundqvist, Martin; Sandström, Herbert; Sahlin, Carin; Rohani, Morteza; Al-Khalili, Faris; Hörnsten, Rolf; Blomberg, Anders; Wester, Per; Rosenqvist, Mårten; Franklin, Karl A.
Study objectives Obstructive sleep apnea is common among patients with atrial fibrillation, but the prevalence and risk factors for atrial fibrillation among patients who are being investigated on suspicion of sleep apnea are not well known. The aim of the study was to estimate the prevalence of atrial fibrillation among patients investigated for suspected obstructive sleep apnea and to identify risk factors for atrial fibrillation among them. Methods The prevalence of atrial fibrillation was investigated among 201 patients referred for suspected obstructive sleep apnea. Patients without known atrial fibrillation were investigated with a standard 12-lead ECG at hospital and short intermittent handheld ECG recordings at home, during 14 days. Results Atrial fibrillation occurred in 13 of 201 subjects (6.5%), and in 12 of 61 men aged 60 years and older (20%). The prevalence of atrial fibrillation increased with sleep apnea severity (p = 0.038). All patients with atrial fibrillation were men and all had sleep apnea. Age 60 or older, the occurrence of central sleep apnea and diabetes mellitus were independent risk factors for atrial fibrillation after adjustments for body mass index, gender, sleep apnea and cardiovascular disease. Conclusions Atrial fibrillation is common among subjects referred for sleep apnea investigation and the prevalence of atrial fibrillation increases with sleep apnea severity. Independent risk factors for atrial fibrillation among patients investigated for suspected obstructive sleep apnea include the occurrence of coexisting central sleep apnea, age 60 years or older and diabetes mellitus. PMID:28178304
Castrejón-Castrejón, Sergio; Ortega, Marta; Pérez-Silva, Armando; Doiny, David; Estrada, Alejandro; Filgueiras, David; López-Sendón, José L.; Merino, José L.
The efficacy of catheter-based ablation techniques to treat atrial fibrillation is limited not only by recurrences of this arrhythmia but also, and not less importantly, by new-onset organized atrial tachycardias. The incidence of such tachycardias depends on the type and duration of the baseline atrial fibrillation and specially on the ablation technique which was used during the index procedure. It has been repeatedly reported that the more extensive the left atrial surface ablated, the higher the incidence of organized atrial tachycardias. The exact origin of the pathologic substrate of these trachycardias is not fully understood and may result from the interaction between preexistent regions with abnormal electrical properties and the new ones resultant from radiofrequency delivery. From a clinical point of view these atrial tachycardias tend to remit after a variable time but in some cases are responsible for significant symptoms. A precise knowledge of the most frequent types of these arrhythmias, of their mechanisms and components is necessary for a thorough electrophysiologic characterization if a new ablation procedure is required. PMID:21941669
Dalen, James E; Alpert, Joseph S
A new suspected cause of cryptic strokes is "silent atrial fibrillation." Pacemakers and other implanted devices allow continuous recording of cardiac rhythm for months or years. They have discovered that short periods of atrial fibrillation lasting minutes or hours are frequent and usually are asymptomatic. A meta-analysis of 50 studies involving more than 10,000 patients with a recent stroke found that 7.7% had new atrial fibrillation on their admitting electrocardiogram. In 3 weeks during and after hospitalization, another 16.9% were diagnosed. A total of 23.7% of these stroke patients had silent atrial fibrillation; that is, atrial fibrillation diagnosed after hospital admission. Silent atrial fibrillation is also frequent in patients with pacemakers who do not have a recent stroke. In a pooled analysis of 3 studies involving more than 10,000 patients monitored for 24 months, 43% had at least 1 day with atrial fibrillation lasting more than 5 minutes. Ten percent had atrial fibrillation lasting at least 12 hours. Despite the frequency of silent atrial fibrillation in these patients with multiple risk factors for stroke, the annual incidence of stroke was only 0.23%. When silent atrial fibrillation is detected in patients with recent cryptogenic stroke, anticoagulation is indicated. In patients without stroke, silent atrial fibrillation should lead to further monitoring for clinical atrial fibrillation rather than immediate anticoagulation, as some have advocated.
Lanters, Eva A H; Allessie, Maurits A; DE Groot, Natasja M S
The incidence and appearance of focal fibrillation waves on the right and left atrial epicardial surface were visualized during 10 seconds of persistent atrial fibrillation in a 71-year-old woman with valvular heart disease. The frequent, nonrepetitive, widespread, and capricious distribution of focal waves suggests that transmural conduction of fibrillation waves is most likely the mechanism underlying focal fibrillation waves.
Heart is easy to be affected by the abnormal thyroid function because cardiac muscle cells have many thyroid hormone receptors. In addition, thyroid hormone goes higher sensitivity to sympathetic nerve as it increases the number of myocardial beta receptor. Therefore, when the thyroid hormone is excessive value, tachycardia and atrial fibrillation may occur regardless of the cause. The atrial fibrillation in Graves' disease can expect spontaneous reversion to sinus rhythm when the hyperthyroidism is controlled. However, cardioversion is indicated for patients who have not returned to sinus rhythm for at least 3 months after the hyperthyroidism is controlled. In this paper, we report the relationship between hyperthyroidism and heart, and the treatment of atrial fibrillation in Graves' disease.
Li, Liang; Mao, Huzhang; Ishwaran, Hemant; Rajeswaran, Jeevanantham; Ehrlinger, John; Blackstone, Eugene H.
Atrial fibrillation (AF) is an abnormal heart rhythm characterized by rapid and irregular heart beat, with or without perceivable symptoms. In clinical practice, the electrocardiogram (ECG) is often used for diagnosis of AF. Since the AF often arrives as recurrent episodes of varying frequency and duration and only the episodes that occur at the time of ECG can be detected, the AF is often underdiagnosed when a limited number of repeated ECGs are used. In studies evaluating the efficacy of AF ablation surgery, each patient undergo multiple ECGs and the AF status at the time of ECG is recorded. The objective of this paper is to estimate the marginal proportions of patients with or without AF in a population, which are important measures of the efficacy of the treatment. The underdiagnosis problem is addressed by a three-class mixture regression model in which a patient’s probability of having no AF, paroxysmal AF, and permanent AF is modeled by auxiliary baseline covariates in a nested logistic regression. A binomial regression model is specified conditional on a subject being in the paroxysmal AF group. The model parameters are estimated by the EM algorithm. These parameters are themselves nuisance parameters for the purpose of this research, but the estimators of the marginal proportions of interest can be expressed as functions of the data and these nuisance parameters and their variances can be estimated by the sandwich method. We examine the performance of the proposed methodology in simulations and two real data applications. PMID:27983754
Atrial fibrillation is the most frequent arrhythmia. Its "lone" form (when underlying pathology is not discovered) can be detected in a small percentage of endurance sports participants, and in growing numbers among veterans, probably as a result of some cardiac or other irregularities. Enhanced vagal tone and sudden sympathetic impulse, repetitive oxidative stress, inflammatory processes, enlarged atria, electric instabilization can explain the higher occurrence. Treatment of atrial fibrillation enables the affected persons to participate in regular medium-intensity exercise, 3-5 hours a week, which offers a protective role against cardiovascular, metabolic and mental illnesses.
Syed, Faisal F.; DeSimone, Christopher V.; Friedman, Paul A.; Asirvatham, Samuel J.
SYNOPSIS Percutaneous left atrial appendage (LAA) closure is increasingly being used as a treatment strategy to prevent stroke in patients with atrial fibrillation (AF) who have contraindications to anticoagulants. A number of approaches and devices have been developed in the last few years, each with their own unique set of advantages and disadvantages. We review the published studies on surgical and percutaneous approaches to LAA closure; focusing on stroke mechanisms in AF, LAA structure and function relevant to stroke prevention, practical differences in procedural approach, and clinical considerations surrounding management. PMID:25443240
Savoia, Carmine; Sada, Lidia; Volpe, Massimo
Hypertension is one of the major risk factors for atrial fibrillation which in turn is the most prevalent concomitant condition in hypertensive patients. While both these pathological conditions are independent risk factors for stroke, the association of hypertension and atrial fibrillation increases the incidence of disabling strokes. Moreover, documented or silent atrial fibrillation doubles the rate of cardiovascular death. Lowering blood pressure is strongly recommended, particularly for primary stroke prevention. However, a relatively small percentage of hypertensive patients still achieve the recommended blood pressure goals. The management of atrial fibrillation with respect to stroke prevention is changing. New oral anticoagulants represent a major advancement in long-term anticoagulation therapy in non valvular atrial fibrillation. They have several benefits over warfarin, including improved adherence to the anticoagulation therapy. This is an important issue since non-adherence to stroke prevention medications is a risk factor for first and recurrent strokes.
Ramlawi, Basel; Abu Saleh, Walid K
The Cox-maze procedure for the restoration of normal sinus rhythm, initially developed by Dr. James Cox, underwent several iterations over the years. The main concept consists of creating a series of transmural lesions in the right and left atria that disrupt re-entrant circuits responsible for propagating the abnormal atrial fibrillation rhythm. The left atrial appendage is excluded as a component of the Maze procedure. For the first three iterations of the Cox- maze procedure, these lesions were performed using a surgical cut-and-sew approach that ensured transmurality. The Cox-Maze IV is the most currently accepted iteration. It achieves the same lesion set of the Cox- maze III but uses alternative energy sources to create the transmural lesions, potentially in a minimally invasive approach on the beating heart. High-frequency ultrasound, microwave, and laser energy have all been used with varying success in the past. Today, bipolar radiofrequency heat or cryotherapy cooling are the most accepted sources for creating linear lesions with consistent safety and transmurality. The robust and reliable nature of these energy delivery methods has yielded a success rate reaching 90% freedom from atrial fibrillation at 12 months. Such approaches offer a significant long-term advantage over catheter-based ablation, especially in patients having longstanding, persistent atrial fibrillation with characteristics such as dilated left atrial dimensions, poor ejection fraction, and failed catheter ablation. Based on these improved results, there currently is significant interest in developing a hybrid ablation strategy that incorporates the superior transmural robust lesions of surgical ablation, the reliable stroke prevention potential of epicardial left atrial appendage exclusion, and sophisticated mapping and confirmatory catheter-based ablation technology. Such a minimally invasive hybrid strategy for ablation may lead to the development of multidisciplinary "Afib teams" to
Sághy, László; Tutuianu, Cristina; Szilágyi, Judith
One of the most important proarrhythmic complications after left atrial (LA) ablation is regular atrial tachycardia (AT) or flutter. Those tachycardias that occur after atrial fibrillation (AF) ablation can cause even more severe symptoms than those from the original arrhythmia prior to the index ablation procedure since they are often incessant and associated with rapid ventricular response. Depending on the method and extent of LA ablation and on the electrophysiological properties of underlying LA substrate, the reported incidence of late ATs is variable. To establish the exact mechanism of these tachycardias can be difficult and controversial but correlates with the ablation technique and in the vast majority of cases the mechanism is reentry related to gaps in prior ablation lines. When tachycardias occur, conservative therapy usually is not effective, radiofrequency ablation procedure is mostly successful, but can be challenging, and requires a complex approach. PMID:25308808
Malik, Amyn; Ali, Syed Sohail; Rahmatullah, Amin
We present the case of 38-year-old woman who experienced palpitations on swallowing, which were later found to be atrial fibrillation. Her symptoms improved on treatment with disopyramide and verapamil. Within 9 months, she was weaned from both medications without recurrence of symptoms. PMID:16429915
Sternik, Leonid; Schaff, Hartzel V.; Luria, David; Glikson, Michael; Kogan, Alexander; Malachy, Ateret; First, Maya; Raanani, Ehud
The maze procedure is the gold standard for the ablation of atrial fibrillation, and the “box lesion” around the pulmonary veins is the most important part of this procedure. We have created this lesion with a bipolar radiofrequency ablator, abandoning the usual use of this device (to achieve bilateral epicardial isolation of the pulmonary veins). From March 2004 through the end of May 2010, we performed surgical ablation of atrial fibrillation in 240 patients. Of this number, 205 underwent operation by a hybrid maze technique and the remaining 35 (our study cohort) underwent the creation of a box lesion around the pulmonary veins by means of a bipolar radiofrequency device. Ablation lines were created by connecting the left atriotomy to the amputated left atrial appendage, with 2 ablation lines made with a bipolar radiofrequency device above and below the pulmonary veins. Lesions were made along the transverse and oblique sinuses by epicardial and endocardial application of a bipolar device. The left atrial isthmus was ablated by bipolar radiofrequency and cryoprobe. No complications were associated with the box lesion: 90% and 89% of patients were in sinus rhythm at 3 and 6 months of follow-up, respectively. By creating a box lesion around the pulmonary veins, we expect to improve transmurality by means of epicardial and endocardial ablation of 1 rather than 2 layers of atrial wall, as in epicardial pulmonary vein isolation. Isolation of the entire posterior wall of the left atrium is better electrophysiologically and renders dissection around the pulmonary veins unnecessary. PMID:21494518
In selected patients with atrial fibrillation and severe symptoms, non-pharmacological treatment may be an alternative or supplement to drug therapy. Atrioventricular nodal radiofrequency ablation (requires pacemaker implantation), or atrial pacing for sick sinus syndrome, are established treatment modalities. All other non-pharmacological therapies for atrial fibrillation are still experimental. After the Maze operation, atrial depolarization has to follow one specific path determined by surgical scars in the myocardium. This prevents new episodes of atrial fibrillation, but at a cost of perioperative morbidity and mortality. Catheter-based "Maze-like" radiofrequency ablation is technically difficult, and thrombo-embolic complications may occur. Paroxysmal atrial fibrillation sometimes is initiated by spontaneous depolarizations in a pulmonary vein inlet. Radio frequency ablation against such focal activity has been reported with high therapeutic success, but the results await confirmation from several centres. For ventricular rate control, most electrophysiologists presently prefer ablation to induce a complete atrioventricular conduction block (with pacemaker) rather than trying to modify conduction by incomplete block. Atrial or dual chamber pacing may prevent atrial fibrillation induced by bradycardia. It remains to confirm that biatrial or multisite right atrial pacing prevents atrial fibrillation more efficiently than ordinary right atrial pacing. An atrial defibrillator is able to diagnose and convert atrial fibrillation. The equipment is expensive, and therapy without sedation may be unpleasant beyond tolerability.
Czick, Maureen E.; Shapter, Christine L.; Silverman, David I.
Atrial fibrillation (AF) is the most prevalent arrhythmia in the world, due both to its tenacious treatment resistance, and to the tremendous number of risk factors that set the stage for the atria to fibrillate. Cardiopulmonary, behavioral, and psychological risk factors generate electrical and structural alterations of the atria that promote reentry and wavebreak. These culminate in fibrillation once atrial ectopic beats set the arrhythmia process in motion. There is growing evidence that chronic stress can physically alter the emotion centers of the limbic system, changing their input to the hypothalamic-limbic-autonomic network that regulates autonomic outflow. This leads to imbalance of the parasympathetic and sympathetic nervous systems, most often in favor of sympathetic overactivation. Autonomic imbalance acts as a driving force behind the atrial ectopy and reentry that promote AF. Careful study of AF pathophysiology can illuminate the means that enable AF to elude both pharmacological control and surgical cure, by revealing ways in which antiarrhythmic drugs and surgical and ablation procedures may paradoxically promote fibrillation. Understanding AF pathophysiology can also help clarify the mechanisms by which emerging modalities aiming to correct autonomic imbalance, such as renal sympathetic denervation, may offer potential to better control this arrhythmia. Finally, growing evidence supports lifestyle modification approaches as adjuncts to improve AF control. PMID:27699086
Martín-Rioboó, Enrique; García Criado, Emilio; Pérula De Torres, Luis Angel; Cea-Calvo, Luis; Anguita Sánchez, Manuel; López Granados, Amador; Ureña Fernández, Tomás; García Matarín, Lisardo; Molina Díaz, Rafael
The objective of the PREHVIA study was to assess the prevalence of electrocardiographic left ventricular hypertrophy (ECG-LVH) and of atrial fibrillation (AF) among Andalusian hypertensive patients, and the relationship of this complications with cardiovascular disease (CVD). Cross-sectional study with selection of study centres following the distribution of the Andalusian population by provinces and habitat, and randomization of patients included in the sample. Personal history was recorded, and ECG-LVH was assessed using the Cornell (voltage and product) and Sokolow-Lyon criteria, applied by the participant physicians and by an expert cardiologist. The association with ECG-HVH or CVD was studied by logistic regression models. In 570 patients (mean age 65 years, 54.5% women, 50.6% with obesity, 28,2% with diabetes), the prevalence of ECG-LVH was 13.7% (95% confidence interval [CI], 10.8-16.6%). Cornell criterion was fulfilled by 12.6% and Sokolow-Lyon by 1.6%. The prevalence of AF was 5.1% (95% CI, 3.9-7.5%) and 22.1% (95% CI, 18.4-25.4%) had established CVD. In the multivariate analysis, ECG-LVH was associated with female gender (odds ratio=5.10; 95% CI, 2.44-10.64) and with the presence of CVD (odds ratio=2.18; 95% CI, 1.09-4.12). The antecedent of CVD was independently associated with an advanced age, male gender, AF and, less strongly, with low glomerular filtration rate and diabetes mellitus. In Andalusian hypertensives, the prevalence of ECG-LVH was significantly lower than that found in other studies, greater in women and at the expense of the Cornell criterion, the prevalence of AF was 5.1% and it was 22.1% for CVD with independent associations between ECG-LVH and between CVD and AF.
McDivitt, Johnathan D; Barstow, Craig
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia. The prevalence increases with age, especially in the seventh and eighth decades of life. AF also is associated with multiple risk factors and conditions that are managed commonly in family medicine settings, such as hypertension and diabetes. Rhythm control and rate control are primarily equivalent for mortality rate, but patients treated for rhythm control have more hospitalizations; however, rhythm control may be a viable option for select patients. Beta blockers and nondihydropyridine calcium channel blockers can be used to achieve rate control. Pharmacotherapy or electrical cardioversion can be used to achieve rhythm control, and antiarrhythmic drugs are used to maintain sinus rhythm. Catheter ablation is an option for symptomatic patients whose AF is refractory to standard treatment. The CHA2DS2-VASc score should be used to predict the risk of stroke for patients with AF. Patients with nonvalvular AF and a history of stroke or transient ischemic attack or CHA2DS2-VASc scores of 2 or greater should be treated with warfarin or novel oral anticoagulants. Patients with valvular AF should be treated with warfarin.
Dang, David; Arimie, Raluca; Haywood, L. Julian
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and accounts for more physician visits and hospital days than any other cardiac rhythm disturbance. Atrial filbrillation is incresing in frequency as the population ages, and therefore, a knowledge of the clinical spectrum and available treatment regimen is essential. Here, we review the pathophysiology, clinical presentation, and current status of management. Experience is being rapidly accumulated in all of the areas discussed in the management of this important clinical entity. Images Figure 1 Figure 2 PMID:12510703
... What Are the Signs and Symptoms of Atrial Fibrillation? Atrial fibrillation (AF) usually causes the heart's lower ... pain Dizziness or fainting Fatigue (tiredness) Confusion Atrial Fibrillation Complications AF has two major complications— stroke and ...
Lairikyengbam, S; Anderson, M; Davies, A
Atrial fibrillation is the commonest sustained cardiac arrhythmia. It accounts for >35% of all hospital admissions for cardiac arrhythmias in the United States. The presence of atrial fibrillation increases the mortality of a population by up to twofold. The risk of stroke increases from 1.5% in patients with atrial fibrillation from 50–59 years of age to up to 23.5% for such patients aged 80–89 years. Although the diagnosis of atrial fibrillation is usually straightforward, effective treatment is not. This article will discuss how rhythm control of atrial fibrillation can best be achieved, the controversy over the rhythm versus rate control, the maintenance of sinus rhythm with antiarrhythmic drugs after cardioversion, and prevention of thromboembolism. Finally, the recent advances in various non-pharmacological approaches for the treatment of atrial fibrillation will be highlighted. PMID:12612318
Hernández Olmedo, Miguel; Suárez Fernández, Carmen
Atrial fibrillation is currently a very prevalent disease and it represents one of the most common causes of disabling stroke. Antithrombotic therapies have reduced the incidence of this complication although they pose many limitations and difficulties. As a result, a large number of high risk patients do not receive an appropriate treatment. In recent years, four new oral anticoagulants (NOAC) with relevant advantages in comparison to vitaminK antagonists have been released. Four large phaseiii clinical trials have demonstrated that NOAC are at least as safe and efficacious as warfarin in stroke prevention in non-valve atrial fibrillation patients with moderate-high thrombotic risk, being their main advantage the reduction in intracranial hemorrhage. The arrival of these drugs has caused great expectations in the management of these patients but also new doubts. Lacking data in some subgroups of frail patients, the absence of specific antidotes available and specially their high cost represent nowadays the main limitations for their generalization.
Jawad-Ul-Qamar, Muhammad; Kirchhof, Paulus
Atrial fibrillation continues to attract interest in the cardiovascular community and in Heart. Over 60 original research and review papers published in Heart in 2014–2015 cover various aspects of atrial fibrillation, from associated conditions and precipitating factors to new approaches to management. Here, we provide an overview of articles on atrial fibrillation published in Heart in 2014–2015, highlighting new developments, emerging concepts and novel approaches to treatment. PMID:26791994
Park, Young-Ah; Seo, Jiwon
When there is no pulmonary vein reconnection after catheter ablation for atrial fibrillation, patients can experience recurrence of atrial fibrillation without clear evidence of non-pulmonary vein foci. We describe a patient with significant pulmonary vein stenosis and recurrent atrial fibrillation after four ablation procedures. After successful pulmonary vein stenting, the symptoms were resolved, and sinus rhythm was maintained for 2 years without treatment with antiarrhythmic medication. We believe pulmonary vein stenting potentially controlled atrial fibrillation by providing pulmonary vein pressure relief or by compressing the epicardial triggers occurring at the pulmonary vein ostium. PMID:28765746
Pérez-Villacastín, Julián; Pérez Castellano, Nicasio; Moreno Planas, Javier
Atrial fibrillation is the most common sustained arrhythmia. Because of its potentially serious clinical consequences (heart failure, stroke, and cognitive impairment), atrial fibrillation has important socioeconomic and health implications. This article reviews the major studies on the epidemiology of atrial fibrillation in Spain. Recent data suggest that in people older than 40 years, the prevalence of atrial fibrillation may be more than 4%. Given the current Spanish demography, these data would imply that more than 1 million people in Spain have atrial fibrillation.
Gillott, Richard Geoffrey; Willan, Kathryn; Kain, Kirti; Sivananthan, Uduvil Mohanaraj; Tayebjee, Muzahir Hassan
Previous studies indicate that South Asians (SAs) may have a reduced risk of developing atrial fibrillation (AF) despite having a higher prevalence of traditional cardiovascular risk factors. This observational study was designed to explore the relative differences between SAs and Whites in a well-defined, multi-ethnic population with careful consideration of traditional cardiovascular risk factors that are thought to contribute to the development of AF. Anonymized data from 417 575 adults were sourced from primary care records within Bradford Metropolitan District, UK. Atrial fibrillation diagnosis was indicated by the presence on the AF Quality Outcomes Framework register. Self-reported ethnicity was mapped to census ethnic codes. The age-standardized prevalence rates of AF were calculated for comparison between the White and SA populations; our study sample presented relative proportions of 2.39 and 0.4%. Multivariable logistic regression analysis was performed to estimate the odds of developing AF given SA ethnicity. Adjustment for age, sex, and established risk factors found a 71% reduction in odds of AF in SAs when compared with Whites [odds ratio (OR): 0.29, 95% confidence interval (CI): 0.26-0.32]. When stratified by ethnicity, analyses revealed significantly different odds of AF for patients with diabetes; diabetes was not associated with the development of AF in the SA population (0.81, 95% CI: 0.63-1.05). This study, in a multi-ethnic population, presents ethnicity as a predictor of AF in which prevalence is significantly lower in SAs when compared with Whites. This is despite SAs having a higher frequency of established risk factors for the development of AF, such as ischaemic heart disease, heart failure, hypertension, and type 2 diabetes. These findings are consistent with previous literature and add weight to the need for further investigation, although this is the first study to investigate the differential associations of individual risk factors
Suzuki, Hitoshi; Ohira, Tetsuya; Takeishi, Yasuchika; Hosoya, Mitsuaki; Yasumura, Seiji; Satoh, Hiroaki; Kawasaki, Yukihiko; Takahashi, Atsushi; Sakai, Akira; Ohtsuru, Akira; Kobashi, Gen; Ozasa, Kotaro; Yamashita, Shunichi; Kamiya, Kenji; Abe, Masafumi
Previous studies have shown that control of cardiovascular risk factors deteriorates among residents after a natural disaster. This study assessed the hypothesis that the prevalence of atrial fibrillation (AF) increased among residents in the evacuation zone of Fukushima prefecture after the Great East Japan Earthquake. This longitudinal study examined subjects aged 40-90 years using data collected from 26,163 participants (11,628 men and 14,535 women) sourced from general health checkups conducted in twelve communities, including the evacuation zone specified by the government, between 2008 and 2010. The study obtained 12-lead ECG tracings and conducted follow-up examinations from June 2011 to the end of March 2013. A total of 12,410 participants (5704 men and 6706 women, follow-up proportion: 47%) received follow-up examinations after the earthquake, with an average follow-up of 1.4 years. The prevalence of AF increased among participants after the earthquake (before: 1.9% vs. after: 2.4%, P<.001). During the follow-up period, 79 incidences of AF occurred among participants. Excess ethanol intake (≥44 g/day) and obesity showed associations with an increased risk of AF after the earthquake, with multivariable-adjusted hazard ratios (95% confidence interval) of 3.07 (1.55-6.08) and 1.87 (1.19-2.94), respectively. The prevalence of AF increased among residents in the evacuation zone of Fukushima prefecture after the Great East Japan Earthquake, with excess alcohol intake and obesity associated with an increased risk of AF. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.
Nair, Ajith G; Fischer, Avi G
Hypertrophic cardiomyopathy (HCM) is associated with an increased incidence of supraventricular and ventricular arrhythmias. Atrial fibrillation (AF) is the most common arrhythmia in HCM with a prevalence of 20% and an annual incidence of two percent per year. Increased left atrial size and volume along with impaired left atrial function confer an increased likelihood of AF. The onset of AF is often accompanied by a decrease in functional status in conjunction with an increased risk of stroke and overall mortality.
Rogge, C; Hilbert, S; Dagres, N; Hindricks, G
Atrial fibrillation is the most common form of persistent cardiac arrhythmia with a greatly increasing prevalence due to an aging population and increasing cardiovascular risk factors. Apart from impairment of the quality of life atrial fibrillation is associated with a high morbidity, most importantly stroke and heart failure. The therapy is complex and aims at improving symptoms as well as the prevention of thromboembolic complications, heart failure and aggravating comorbidities. Based on individual patient characteristics and symptoms therapy is mainly based on heart rate control by pharmacological means or therapy for maintaining sinus rhythm. This treatment includes antiarrhythmic drugs and catheter ablation. Current research is aimed at the investigation of the electrophysiological mechanisms of recurrent therapy refractive atrial fibrillation and the question whether the maintenance of sinus rhythm can improve the prognosis of atrial fibrillation.
Troupis, John; Crossett, Marcus; Scneider-Kolsky, Michal; Nandurkar, Dee
Accessory left atrial appendages and atrial diverticula have an incidence of 10-27%. Their association with atrial fibrillation needs to be confirmed. This study determined the prevalence, number, size, location and morphology of accessory left atrial appendages/atrial diverticula in patients with atrial fibrillation compared with those in sinus rhythm. A retrospective analysis of 47 consecutive patients with atrial fibrillation who underwent 320 multidetector Coronary CT angiography (CCTA) was performed. A random group of 47 CCTA patients with sinus rhythm formed the control group. The presence, number, size, location and morphology of accessory left atrial appendages and atrial diverticula in each group were analysed. Twenty one patients had a total of 25 accessory left atrial appendages and atrial diverticula in the atrial fibrillation group and 22 patients had a total of 24 accessory left atrial appendages and atrial diverticula in the sinus rhythm group. Twenty-one atrial diverticula were identified in 19 patients in the atrial fibrillation group and 19 atrial diverticula in 17 patients in the sinus rhythm group. The mean length and width of accessory left atrial appendage was 6.9 and 4.7 mm, respectively in the atrial fibrillation group and 12 and 4.6 mm, respectively, in the sinus rhythm group, P = ns (not significant). The mean length and width of atrial diverticulum was 4.7 and 3.6 mm, respectively in the atrial fibrillation group and 6.2 and 5 mm, respectively in the sinus rhythm group (P = ns). Eighty-four % and 96% of the accessory left atrial appendages/atrial diverticula in the atrial fibrillation and sinus rhythm groups were located along the right anterosuperior left atrial wall. Accessory left atrial appendages and atrial diverticula are common structures with similar prevalence in patients with atrial fibrillation and sinus rhythm.
Dilber, Dario; Čerkez-Habek, Jasna; Barić, Hrvoje; Gradišer, Marina
Atrial fibrillation (AF) is the most common arrhythmia and it is an independent risk for serious events. Acupuncture has been growing in popularity in the West, and there are reports of its benefits in treating AF. We report a 57-year-old man who was admitted after having an allergic reaction to amiodarone administered to treat paroxysmal AF with fast ventricular response. Cardioversion with intravenous propafenone was uneventful. Before an attempt of electric cardioversion, he was treated with acupuncture as additional therapy to peroral propafenone. After acupuncture treatment consisting of 10 treatments during 30 days period, both immediate cardioversion to sinus rhythm and no paroxysmal AF during 30 days period were recorded.
Jain, Vageesh; Marshall, Iain J; Crichton, Siobhan L; McKevitt, Christopher; Rudd, Anthony G; Wolfe, Charles D A
Previous studies have found low use of anticoagulation prior to stroke, in people with atrial fibrillation (AF). This study examined data on patients with AF-related stroke from a population-based stroke register, and sought to examine changes in management of AF prior to stroke, and reasons for suboptimal treatment, in those who were known to be at a high risk of stroke. The South London Stroke Register (SLSR) is an ongoing population-based register recording first-in-a-lifetime stroke. Trends in the prevalence of AF, and antithrombotic medication prescribed before the stroke, were investigated from 1995 to 2014. Multivariable logistic regression analyses were conducted to assess the factors associated with appropriate management. Of the 5041 patients on the register, 816 (16.2%) were diagnosed with AF before their stroke. AF related stroke increased substantially among Black Carribean and Black African patients, comprising 5% of the overall cohort in 1995-1998, increasing to 25% by 2011-2014 (p<0.001). Anticoagulant prescription in AF patients at high-risk of stroke (CHADS2 score [> = 2]) increased from 9% (1995-1998) to 30% (2011-2014) (p<0.001). Antiplatelet prescription was more commonly prescribed throughout all time periods (43% to 64% of high-risk patients.) Elderly patients (>65) were significantly less likely to be prescribed an anticoagulant, with ethnicity, gender and deprivation showing no association with anticoagulation. Most AF-related strokes occurred in people who could have been predicted to be at high risk before their stroke, yet were not prescribed optimal preventative treatment. The elderly,despite being at highest stroke risk, were rarely prescribed anticoagulants.
Pistoia, Francesca; Sacco, Simona; Tiseo, Cindy; Degan, Diana; Ornello, Raffaele; Carolei, Antonio
The burden of stroke is increasing due to aging population and unhealthy lifestyle habits. The considerable rise in atrial fibrillation (AF) is due to greater diffusion of risk factors and screening programs. The link between AF and ischemic stroke is strong. The subtype most commonly associated with AF is cardioembolic stroke, which is particularly severe and shows the highest rates of mortality and permanent disability. A trend toward a higher prevalence of cardioembolic stroke in high-income countries is probably due to the greater diffusion of AF and the control of atherosclerotic of risk factors.
Prevalence of Atrial Fibrillation and Antithrombotic Therapy in Hemodialysis Patients: Cross-Sectional Results of the Vienna InVestigation of AtriaL Fibrillation and Thromboembolism in Patients on HemoDIalysis (VIVALDI)
Königsbrügge, Oliver; Posch, Florian; Antlanger, Marlies; Kovarik, Josef; Klauser-Braun, Renate; Kletzmayr, Josef; Schmaldienst, Sabine; Auinger, Martin; Zuntner, Günther; Lorenz, Matthias; Grilz, Ella; Stampfel, Gerald; Steiner, Stefan; Pabinger, Ingrid; Säemann, Marcus; Ay, Cihan
Background Atrial fibrillation (AF) adds significant risk of stroke and thromboembolism in patients on hemodialysis (HD). The aim of this study was to investigate the prevalence of AF in a population-based cohort of HD patients and practice patterns of antithrombotic therapy for stroke prevention in AF. Methods The Vienna InVestigation of AtriaL fibrillation and thromboembolism in patients on hemodialysis (VIVALDI), an ongoing prospective observational cohort study, investigates the prevalence of AF and the risk of thromboembolic events in HD patients in Vienna, Austria. We analyzed cross-sectional data of 626 patients (63.4% men, median age 66 years, approx. 73% of HD patients in Vienna), who provided informed consent. A structured interview with each patient was performed, recent and archived ECGs were viewed and medical histories were verified with electronic records. Results The overall prevalence of AF was 26.5% (166 patients, 71.1% men, median age 72 years) of which 57.8% had paroxysmal AF, 3.0% persistent AF, 32.5% permanent AF, and 6.6% of patients had newly diagnosed AF. The median CHA2DS2-VASc Score was 4 [25th-75th percentile 3–5]. In multivariable analysis, AF was independently associated with age (odds ratio: 1.05 per year increase, 95% confidence interval: 1.03–1.07), male sex (1.7, 1.1–2.6), history of venous thromboembolism (2.0, 1.1–3.6), congestive heart failure (1.7, 1.1–2.5), history of or active cancer (1.5, 1.0–2.4) and time on HD (1.08 per year on HD, 1.03–1.13). Antithrombotic treatment was applied in 84.4% of AF patients (anticoagulant agents in 29.5%, antiplatelet agents in 33.7%, and both in 21.1%). In AF patients, vitamin-K-antagonists were used more often than low-molecular-weight heparins (30.1% and 19.9%). Conclusions The prevalence of AF is high amongst HD patients and is associated with age, sex, and distinct comorbidities. Practice patterns of antithrombotic treatment indicate a lack of consensus for stroke prevention
McCabe, Pamela J; Rhudy, Lori M; DeVon, Holli A
To describe patients' experiences from symptom onset to initial treatment for atrial fibrillation. The estimated number of individuals with atrial fibrillation globally in 2010 was 33·5 million. World-wide, each year, new cases of atrial fibrillation approach 5 million, and prevalence will increase 2·5-fold by 2050. As a result, clinicians worldwide will treat a growing number of patients with atrial fibrillation. Early intervention to promote atrial fibrillation self-management is critical to reduce associated complications of stroke and heart failure. Greater understanding of patients' experiences from symptom onset to initial treatment for atrial fibrillation is needed to guide development of interventions to promote early effective self-management. A descriptive qualitative design was used. Twenty females and 21 males at an academic medical centre were interviewed using open-ended questions to explore their experiences from symptom onset to initial treatment for atrial fibrillation. Data were analysed using qualitative content analysis. Participants' mean age was 64·3 (SD = 10·1) years. Four themes were identified: (1) misinterpreting symptoms; (2) discovering the meaning of atrial fibrillation; (3) facing fears, uncertainty, and moving to acceptance; and (4) receiving validation and reassurance. Participants lacked knowledge of atrial fibrillation and took cues from providers' responses to appraise symptoms and diagnosis. Fear and uncertainty were reduced when providers initiated prompt treatment and took time to explain atrial fibrillation. Patients appreciated receiving clear information about atrial fibrillation, were engaged in learning, and motivated to participate in their care. Providers played a critical role in helping patients to develop an accurate understanding of atrial fibrillation, to cope with the new diagnosis, and motivated them to engage in effective self-management. Insight into participant experiences from symptom onset to initial
Cohoon, Kevin P; McBane, Robert D; Ammash, Naser; Slusser, Joshua P; Grill, Diane E; Wysokinski, Waldemar E
Atrial fibrillation and obesity are two major growing epidemics in the United States and globally. Obese people are at the increased risk of developing atrial fibrillation. The contribution of obesity as an independent risk factor for stroke in the setting of atrial fibrillation remains unclear. We tested the hypothesis that non-valvular atrial fibrillation (NVAF) patients with increased body mass index (BMI) would be at increased risk for the development of left atrial appendage thrombus (LAAT). Consecutive, anticoagulation naïve patients with NVAF referred for a transesophageal echocardiogram (TEE) between January 1, 2007 and October 21, 2009 were approached for study participation. All clinical, laboratory, and TEE measurement data were collected prospectively. Within a group of 400 anticoagulation naïve NVAF patients (mean age 63 ± 15 years, 28 % women; 17 % with LAAT) the prevalence of LAAT was similar across all BMI categories (normal 13 %, overweight 19 %, obese 16 %, morbidly obese 16 %; p = 0.71). Despite a higher CHADS2 score and a higher prevalence of both hypertension and diabetes mellitus, elevated BMI was not an independent predictor of LAAT when analyzed as either a continuous variable, across BMI WHO categories, a dichotomous variable stratified at values above versus below 27 kg/m(2), or BMI stratified on atrial fibrillation duration. Despite a higher prevalence of major risk factors for thromboembolism, the prevalence of LAAT was not increased in overweight, obese, and morbidly obese patients.
Nakamura, Yoshitsugu; Kiaii, Bob; Chu, Michael W. A.
Atrial fibrillation is the most common sustained arrhythmia and is associated with significant risks of thromboembolism, stroke, congestive heart failure, and death. There have been major advances in the management of atrial fibrillation including pharmacologic therapies, antithrombotic therapies, and ablation techniques. Surgery for atrial fibrillation, including both concomitant and stand-alone interventions, is an effective therapy to restore sinus rhythm. Minimally invasive surgical ablation is an emerging field that aims for the superior results of the traditional Cox-Maze procedure through a less invasive operation with lower morbidity, quicker recovery, and improved patient satisfaction. These novel techniques utilize endoscopic or minithoracotomy approaches with various energy sources to achieve electrical isolation of the pulmonary veins in addition to other ablation lines. We review advancements in minimally invasive techniques for atrial fibrillation surgery, including management of the left atrial appendage. PMID:22666609
Almeida, Eduardo Dytz; Guimarães, Raphael Boesche; Stephan, Laura Siga; Medeiros, Alexandre Kreling; Foltz, Katia; Santanna, Roberto Tofani; Pires, Leonardo Martins; Kruse, Marcelo Lapa; Lima, Gustavo Glotz de; Leiria, Tiago Luiz Luz
Atrial fibrillation and atrial flutter account for one third of hospitalizations due to arrhythmias, determining great social and economic impacts. In Brazil, data on hospital care of these patients is scarce. To investigate the arrhythmia subtype of atrial fibrillation and flutter patients in the emergency setting and compare the clinical profile, thromboembolic risk and anticoagulants use. Cross-sectional retrospective study, with data collection from medical records of every patient treated for atrial fibrillation and flutter in the emergency department of Instituto de Cardiologia do Rio Grande do Sul during the first trimester of 2012. We included 407 patients (356 had atrial fibrillation and 51 had flutter). Patients with paroxysmal atrial fibrillation were in average 5 years younger than those with persistent atrial fibrillation. Compared to paroxysmal atrial fibrillation patients, those with persistent atrial fibrillation and flutter had larger atrial diameter (48.6 ± 7.2 vs. 47.2 ± 6.2 vs. 42.3 ± 6.4; p < 0.01) and lower left ventricular ejection fraction (66.8 ± 11 vs. 53.9 ± 17 vs. 57.4 ± 16; p < 0.01). The prevalence of stroke and heart failure was higher in persistent atrial fibrillation and flutter patients. Those with paroxysmal atrial fibrillation and flutter had higher prevalence of CHADS2 score of zero when compared to those with persistent atrial fibrillation (27.8% vs. 18% vs. 4.9%; p < 0.01). The prevalence of anticoagulation in patients with CHA2DS2-Vasc ≤ 2 was 40%. The population in our registry was similar in its comorbidities and demographic profile to those of North American and European registries. Despite the high thromboembolic risk, the use of anticoagulants was low, revealing difficulties for incorporating guideline recommendations. Public health strategies should be adopted in order to improve these rates.
Almeida, Eduardo Dytz; Guimarães, Raphael Boesche; Stephan, Laura Siga; Medeiros, Alexandre Kreling; Foltz, Katia; Santanna, Roberto Tofani; Pires, Leonardo Martins; Kruse, Marcelo Lapa; de Lima, Gustavo Glotz; Leiria, Tiago Luiz Luz
Introduction Atrial fibrillation and atrial flutter account for one third of hospitalizations due to arrhythmias, determining great social and economic impacts. In Brazil, data on hospital care of these patients is scarce. Objective To investigate the arrhythmia subtype of atrial fibrillation and flutter patients in the emergency setting and compare the clinical profile, thromboembolic risk and anticoagulants use. Methods Cross-sectional retrospective study, with data collection from medical records of every patient treated for atrial fibrillation and flutter in the emergency department of Instituto de Cardiologia do Rio Grande do Sul during the first trimester of 2012. Results We included 407 patients (356 had atrial fibrillation and 51 had flutter). Patients with paroxysmal atrial fibrillation were in average 5 years younger than those with persistent atrial fibrillation. Compared to paroxysmal atrial fibrillation patients, those with persistent atrial fibrillation and flutter had larger atrial diameter (48.6 ± 7.2 vs. 47.2 ± 6.2 vs. 42.3 ± 6.4; p < 0.01) and lower left ventricular ejection fraction (66.8 ± 11 vs. 53.9 ± 17 vs. 57.4 ± 16; p < 0.01). The prevalence of stroke and heart failure was higher in persistent atrial fibrillation and flutter patients. Those with paroxysmal atrial fibrillation and flutter had higher prevalence of CHADS2 score of zero when compared to those with persistent atrial fibrillation (27.8% vs. 18% vs. 4.9%; p < 0.01). The prevalence of anticoagulation in patients with CHA2DS2-Vasc ≤ 2 was 40%. Conclusions The population in our registry was similar in its comorbidities and demographic profile to those of North American and European registries. Despite the high thromboembolic risk, the use of anticoagulants was low, revealing difficulties for incorporating guideline recommendations. Public health strategies should be adopted in order to improve these rates. PMID:26016782
Ko, Darae; Rahman, Faisal; Martins, Maria A. P.; Hylek, Elaine M.; Ellinor, Patrick T.; Schnabel, Renate B.; Benjamin, Emelia J.; Christophersen, Ingrid E.
Sex-specific differences in the epidemiology, pathophysiology, presentation, prognosis, and treatment of atrial fibrillation (AF) are increasingly recognized. Women with AF generally experience worse symptoms, poorer quality of life, and have higher risk of stroke and death than men with AF. Effective treatment of the arrhythmia in women is critical to reduce the rate of adverse events. We review the current evidence on sex-specific differences in the utilization and outcomes of treatments for AF, including rate-control and rhythm-control strategies, and stroke-prevention therapy. In addition, we provide a critical evaluation of potential disparities and biases in health-care use that may be associated with differences in the outcomes between women and men.We underscore current knowledge gaps that need to be addressed in future studies to improve the management of AF in women. In particular, we suggest several strategies to produce quality evidence from randomized, clinical trials for women with AF. PMID:27786235
Dilber, Dario; Čerkez-Habek, Jasna; Barić, Hrvoje; Gradišer, Marina
Atrial fibrillation (AF) is the most common arrhythmia and it is an independent risk for serious events. Acupuncture has been growing in popularity in the West, and there are reports of its benefits in treating AF. We report a 57-year-old man who was admitted after having an allergic reaction to amiodarone administered to treat paroxysmal AF with fast ventricular response. Cardioversion with intravenous propafenone was uneventful. Before an attempt of electric cardioversion, he was treated with acupuncture as additional therapy to peroral propafenone. After acupuncture treatment consisting of 10 treatments during 30 days period, both immediate cardioversion to sinus rhythm and no paroxysmal AF during 30 days period were recorded. PMID:26593171
... most common complication after heart surgery . View an animation of atrial fibrillation. Usually, the most serious risk ... patterns of the heart’s electrical system. View an animation of a normal heartbeat. The heart’s normal electrical ...
Lipsett, Mark; Hamilton, Douglas; Lemery, Jay; Polk, James
This slide presentation reviews a possible scenario of an astronaut having Atrial Fibrillation during a Mars Mission. In the case review the presentation asks several questions about the alternatives for treatment, medications and the ramifications of the decisions.
Cerasuolo, Joshua O; Montero-Odasso, Manuel; Ibañez, Agustin; Doocy, Shannon; Lip, Gregory Yh; Sposato, Luciano A
Atrial fibrillation affects 33.5 million people worldwide and its prevalence is expected to double by 2050 because of the aging population. Atrial fibrillation confers a 5-fold higher risk of ischemic stroke compared to sinus rhythm. We present our view of the role of shared medical decision-making to combat global underutilization of oral anticoagulation for stroke prevention in atrial fibrillation patients. Oral anticoagulation underuse is widespread as it is present within atrial fibrillation patients of all risk strata and in countries across all income levels. Reasons for oral anticoagulation underuse include but are probably not limited to poor risk stratification, over-interpretation of contraindications, and discordance between physician prescription preferences and actual administration. By comparing a catastrophic event to the consequences of atrial fibrillation related strokes, it may help physicians and patients understand the negative outcomes associated with oral anticoagulation under-utilization and the magnitude to which oral anticoagulations neutralize atrial fibrillation burden.
Máquez, Manlio F; Gómez Flores, Jorge
Radiofrequency catheter ablation has emerged as a curative therapy for paroxysmal atrial fibrillation based on studies demonstrating the role of triggering foci in the pulmonary veins for the initiation of atrial fibrillation. Catheter ablation is performed by a trans-septal approach using radiofrequency energy at the ostium of each pulmonary vein. Mapping is guided by special catheters. Sequential radiofrequency applications eliminates or dissociates pulmonary vein muscle activity. Although complications exists, this procedure can be curative for these patients.
Antz, Matthias; Hullmann, Bettina; Neufert, Christian; Vocke, Wolfgang
The correct anticoagulation regimen for prevention of thromboembolic events is essential in patients with atrial fibrillation. However, only a minority of patients receives anticoagulation according to the guidelines. The current guidelines are intended to make the indication for anticoagulation more simple and are summarized in the present article. This includes recommendations for chronic anticoagulation, prevention of thromboembolic events after cardioversion and in ablation of atrial fibrillation.
Staffurth, J S; Gibberd, M C; Fui, S N
In 262 patients with thyrotoxicosis and atrial fibrillation there were 26 episodes of arterial embolism (17 cerebral and nine elsewhere) in 21 patients. Twelve incidents occurred with active thyrotoxicosis, three on reversion to sinus rhythm, and 11 after the patients were euthyroid. This important complication is more common than is realised, and most patients should be put on prophylactic anticoagulants when first seen with atrial fibrillation. PMID:902055
Batal, Omar; Schoenhagen, Paul; Shao, Mingyuan; Ayyad, Ala Eddin; Van Wagoner, David R.; Halliburton, Sandra S.; Tchou, Patrick J.; Chung, Mina K.
Background Atrial fibrillation (AF) has been linked to inflammatory factors and obesity. Epicardial fat is a source of several inflammatory mediators related to the development of coronary artery disease. We hypothesized that periatrial fat may have a similar role in the development of AF. Methods and Results Left atrium (LA) epicardial fat pad thickness was measured in consecutive cardiac CT angiograms performed for coronary artery disease or AF. Patients were grouped by AF burden: no (n=73), paroxysmal (n=60), or persistent (n=36) AF. In a short-axis view at the mid LA, periatrial epicardial fat thickness was measured at the esophagus (LA-ESO), main pulmonary artery, and thoracic aorta; retrosternal fat was measured in axial view (right coronary ostium level). LA area was determined in the 4-chamber view. LA-ESO fat was thicker in patients with persistent AF versus paroxysmal AF (P=0.011) or no AF (P=0.003). LA area was larger in patients with persistent AF than paroxysmal AF (P=0.004) or without AF (P<0.001). LA-ESO was a significant predictor of AF burden even after adjusting for age, body mass index, and LA area (odds ratio, 5.30; 95% confidence interval, 1.39 to 20.24; P=0.015). A propensity score–adjusted multivariable logistic regression that included age, body mass index, LA area, and comorbidities was also performed and the relationship remained statistically significant (P=0.008). Conclusions Increased posterior LA fat thickness appears to be associated with AF burden independent of age, body mass index, or LA area. Further studies are necessary to examine cause and effect, and if inflammatory, paracrine mediators explain this association. PMID:20504944
Kumareswaran, Ramanan; Dorian, Paul
Lone atrial fibrillation is a set of heterogeneous disorders grouped together due to our limited understanding of their pathophysiology. Rate control and rhythm control are two strategies used to treat atrial fibrillation but neither has shown improvement in mortality. Therefore, the goal of treatment in patients with lone atrial fibrillation is to improve health related quality of life. Anti-arrhythmic medications are not well studied in lone atrial fibrillation patient population in randomized controlled fashion. However, inferences can be made from trials that mainly included paroxysmal atrial fibrillation patients. Anti-arrhythmic medications are useful in maintenance of sinus rhythm and probably improve quality of life in lone atrial fibrillation.
Nuryani, N.; Solikhah, M.; Nugoho, A. S.; Afdala, A.; Anzihory, E.
Atrial fibrillation is a serious heart problem originated from the upper chamber of the heart. The common indication of atrial fibrillation is irregularity of R peak-to-R-peak time interval, which is shortly called RR interval. The irregularity could be represented using variance or spread of RR interval. This article presents a system to detect atrial fibrillation using variances. Using clinical data of patients with atrial fibrillation attack, it is shown that the variance of electrocardiographic RR interval are higher during atrial fibrillation, compared to the normal one. Utilizing a simple detection technique and variances of RR intervals, we find a good performance of atrial fibrillation detection.
Goyal, Sandeep K; Sharma, Abhishek
Atrial fibrillation (AF) is a common arrhythmia with rising incidence. Obstructive sleep apnea (OSA) is prevalent among patients with AF. This observation has prompted significant research in understanding the relationship between OSA and AF. Multiple studies support a role of OSA in the initiation and progression of AF. This association has been independent of obesity, body mass index and hypertension. Instability of autonomic tone and wide swings in intrathoracic pressure are seen in OSA. These have been mechanistically linked to initiation of AF in OSA patients by lowering atrial effective refractory period, promoting pulmonary vein discharges and atrial dilation. OSA not only promotes initiation of AF but also makes management of AF difficult. Drug therapy and electrical cardioversion for AF are less successful in presence of OSA. There has been higher rate of early and overall recurrence after catheter ablation of AF in patients with OSA. Treatment of OSA with continuous positive airway pressure has been shown to improve control of AF. However, additional studies are needed to establish a stronger relationship between OSA treatment and success of AF therapies. There should be heightened suspicion of OSA in patients with AF. There is a need for guidelines to screen for OSA as a part of AF management. PMID:23802045
Márquez, Manlio F
Radiofrequency catheter ablation has emerged as a curative therapy for atrial flutter based on studies demonstrating the role of the cavotricuspid isthmus. With a high rate of success and minimal complications, catheter ablation is the therapy of choice for patients with the common type of atrial flutter. Left atrial flutter, non-cavotricuspid isthmus dependent, and those associated with heart disease have a worst outcome with catheter ablation. Radiofrequency catheter ablation has also emerged as a curative therapy for paroxysmal atrial fibrillation based on studies demonstrating the role of triggering foci in the pulmonary veins for the initiation of atrial fibrillation. Catheter ablation is performed by a transseptal approach using radiofrequency energy at the ostium of each pulmonary vein. Mapping is guided by special catheters. Sequential radiofrequency applications eliminates or dissociates pulmonary vein muscle activity. Although complications exists, this is the only curative method for these patients.
Berisso, Massimo Zoni; Caruso, Davide
In the last two decades atrial fibrillation (AF) has become one of the most important public health problems and a significant cause of increasing healthcare costs in developed countries. The prevalence of AF is ever increasing, and at present, in Italy, it is twice higher (1.85%) than that reported in the past decade. In addition, the ratio of AF frequency among males and females in each age subgroup is always >1.2. In the real world, the commonest AF treatment strategy is "rate control" accounting for 51-56% of all AF patients. Anticoagulant therapy is still underused, in particular among several selected AF patient subgroups. The present findings suggest the need for improving AF patient management through ad hoc educational programs.
Dhoble, Abhijeet; Patel, Mehul B; Abdelmoneim, Sahar S; Puttarajappa, Chethan; Abela, George S; Bhatt, Deepak L; Thakur, Ranjan K
Porphyrias are a group of inherited disorders affecting enzymes in the heme biosynthesis pathway, leading to overproduction and/or accumulation of porphyrin or its precursors. Porphyrias have been associated with autonomic dysfunction, which in turn can develop atrial fibrillation (AF). The purpose of this study was to characterize the prevalence of AF and atrial flutter (AFl) in patients with porphyrias. A single-center retrospective cohort study was designed using data from chart reviews of patients who were admitted to the hospital from January 2000 to June 2008. Fifty-six distinct cases were found with a discharge diagnosis of porphyria including all its subtypes. From the same database, age- and gender-matched controls were identified using computer-generated random numbers. We selected 1 age- and gender-matched control for each case. Electrocardiograms and echocardiograms were reviewed by 2 independent reviewers. Only patients with available 12-lead electrocardiograms that showed AF/AFl were labeled with that diagnosis. All patients with a diagnosis of porphyria were included in the study irrespective of their age. Seven of 56 patients with porphyria met inclusion criteria, yielding a prevalence of AF/AFl of 12.5%. This association was significant (p = 0.028, relative risk 7.45, 95% confidence interval 1.01 to 66.14) compared with the age- and gender-matched control group (2%). In conclusion, our observations suggest that porphyria may be significantly associated with AF/AFl.
Gladstone, David J; Spring, Melanie; Dorian, Paul; Panzov, Val; Thorpe, Kevin E; Hall, Judith; Vaid, Haris; O'Donnell, Martin; Laupacis, Andreas; Côté, Robert; Sharma, Mukul; Blakely, John A; Shuaib, Ashfaq; Hachinski, Vladimir; Coutts, Shelagh B; Sahlas, Demetrios J; Teal, Phil; Yip, Samuel; Spence, J David; Buck, Brian; Verreault, Steve; Casaubon, Leanne K; Penn, Andrew; Selchen, Daniel; Jin, Albert; Howse, David; Mehdiratta, Manu; Boyle, Karl; Aviv, Richard; Kapral, Moira K; Mamdani, Muhammad
Atrial fibrillation is a leading preventable cause of recurrent stroke for which early detection and treatment are critical. However, paroxysmal atrial fibrillation is often asymptomatic and likely to go undetected and untreated in the routine care of patients with ischemic stroke or transient ischemic attack (TIA). We randomly assigned 572 patients 55 years of age or older, without known atrial fibrillation, who had had a cryptogenic ischemic stroke or TIA within the previous 6 months (cause undetermined after standard tests, including 24-hour electrocardiography [ECG]), to undergo additional noninvasive ambulatory ECG monitoring with either a 30-day event-triggered recorder (intervention group) or a conventional 24-hour monitor (control group). The primary outcome was newly detected atrial fibrillation lasting 30 seconds or longer within 90 days after randomization. Secondary outcomes included episodes of atrial fibrillation lasting 2.5 minutes or longer and anticoagulation status at 90 days. Atrial fibrillation lasting 30 seconds or longer was detected in 45 of 280 patients (16.1%) in the intervention group, as compared with 9 of 277 (3.2%) in the control group (absolute difference, 12.9 percentage points; 95% confidence interval [CI], 8.0 to 17.6; P<0.001; number needed to screen, 8). Atrial fibrillation lasting 2.5 minutes or longer was present in 28 of 284 patients (9.9%) in the intervention group, as compared with 7 of 277 (2.5%) in the control group (absolute difference, 7.4 percentage points; 95% CI, 3.4 to 11.3; P<0.001). By 90 days, oral anticoagulant therapy had been prescribed for more patients in the intervention group than in the control group (52 of 280 patients [18.6%] vs. 31 of 279 [11.1%]; absolute difference, 7.5 percentage points; 95% CI, 1.6 to 13.3; P=0.01). Among patients with a recent cryptogenic stroke or TIA who were 55 years of age or older, paroxysmal atrial fibrillation was common. Noninvasive ambulatory ECG monitoring for a target of
Mantovani, A; Rigolon, R; Civettini, A; Bolzan, B; Morani, G; Bonapace, S; Dugo, C; Zoppini, G; Bonora, E; Targher, G
Several studies have reported an association between hyperuricemia and increased risk of permanent atrial fibrillation (AF) in patients with and without type 2 diabetes mellitus (T2DM). Currently, no published data are available on the relationship between hyperuricemia and risk of paroxysmal AF. We retrospectively evaluated 245 T2DM outpatients without pre-existing AF, cancer, cirrhosis and end-stage renal disease, who underwent a 24-h ECG-Holter monitoring for various clinical indications. Hyperuricemia was defined as a serum uric acid level >7 mg/dl for men and >6 mg/dl for women or allopurinol use. The diagnosis of paroxysmal AF was confirmed in affected individuals on the basis of 24-h ECG-Holter monitoring by experienced cardiologists. Hyperuricemia was observed in 59 (24.1%) patients, whereas paroxysmal AF was found in 11 (4.5%) patients. The prevalence of paroxysmal AF was higher in patients with hyperuricemia than in those without hyperuricemia (10.2 vs. 2.7%, p = 0.026). Logistic regression analysis showed that hyperuricemia was associated with an increased risk of prevalent paroxysmal AF. This association remained significant even after adjustment for age, metabolic syndrome and chronic kidney disease (adjusted-odds ratio 4.01, 95% CI 1.08-14.9; p = 0.039). Similar results were found when we used serum uric acid levels as a continuous measure. This study shows for the first time that hyperuricemia is independently associated with an approximately fourfold increased risk of prevalent paroxysmal AF in patients with T2DM. These findings may partly explain the increased risk of permanent atrial fibrillation and cardiovascular death observed among patients with hyperuricemia.
Bilotta, F; Pizzichetta, F; Fiorani, L; Paoloni, F P; Delfini, R; Rosa, G
The aim of this prospective study was to determine the prevalence of pre-operative atrial fibrillation and the incidence of postoperative atrial fibrillation in patients undergoing elective or emergency intracranial neurosurgical procedures and the relation to survival and neurological outcome at 6-months follow-up compared to patients with sinus rhythm. A total of 2020 patients were enrolled; 1540 patients underwent elective procedures and 480 underwent emergency procedures. Prevalence of pre-operative atrial fibrillation was 3.7% in elective and 7.2% in emergency procedures (p = 0.0012). In patients undergoing elective cerebral procedures with pre-operative atrial fibrillation, compared to patients with sinus rhythm, 6-month neurological outcome and survival rate are similar. In patients undergoing emergency neurosurgical cerebral procedures, the presence of pre-operative atrial fibrillation is related to an increased risk of poor neurological outcome but with similar survival rate.
Hravnak, Marilyn; Hoffman, Leslie A.; Saul, Melissa I.; Zullo, Thomas G.; Whitman, Gayle R.
Background Studies of resource utilization by patients with new-onset atrial fibrillation after coronary artery bypass grafting have addressed only length of stay and bed charges. Objective To compare resource utilization between patients with new-onset atrial fibrillation and patients without atrial fibrillation after isolated coronary artery bypass grafting. Methods Retrospective review of clinical and administrative electronic databases for 720 subjects who underwent isolated coronary artery bypass grafting with cardiopulmonary bypass in 25 months at one medical center. The prevalence of atrial fibrillation was determined, and resource utilization in various hospital cost centers was compared between subjects with and without atrial fibrillation. Results The prevalence of new-onset atrial fibrillation was 33.1%. Compared with subjects without atrial fibrillation, subjects with atrial fibrillation had a longer stay (5.8 ± 2.4 vs 4.4 ± 1.2 days, P< .001), more days receiving mechanical ventilation (P=.002) and oxygen therapy (P< .001), and higher rates of readmission to the intensive care unit (4.6% vs 0.2%, P< .001). Subjects with atrial fibrillation also had more laboratory tests (P< .001) and more days receiving cardiac drugs, heparin, diuretics, and electrolytes. Subjects with atrial fibrillation had higher total postoperative charges ($57261 ± $17 101 vs $50905 ± $10062, P= .001), a mean difference of $6356. The mean differences were greatest for bed charges ($1642), laboratory charges ($1215), pharmacy ($989), and respiratory care ($582). Conclusion The economic impact of atrial fibrillation after coronary artery bypass grafting has been underestimated. PMID:12022486
Currently, interventional treatment modalities for atrial fibrillation chiefly comprise experimental techniques. Among the rate-control procedures, AV-nodal ablation in conjunction with permanent pacemaker implantation and transcatheter radiofrequency modulation of the AV-node are clinically accepted techniques. In contrast, the original corridor operation--which electrically isolates the left and right atrium from the sinus- and AV-node--has been changed over time and ultimately led to the development of the MAZE procedure. Among the procedures for maintenance of sinus rhythm, permanent atrial pacing and bi-atrial pacing may offer an effective--though still experimental--treatment modality in selected patients with vagally mediated or bradycardia-induced atrial fibrillation. Despite the fact that the MAZE procedure is highly effective in restoring sinus rhythm and associated with a reasonably low surgical mortality, the morbidity and complication rate of this procedure are high. Automated transvenous low-energy atrioversion may offer an interesting alternative in the future. However, there remain some significant limitations, such as the pain associated with low-energy shocks, the risk of ventricular fibrillation induction and the cost-benefit issue which needs to be solved before this technique can become clinically applicable. Last but not least, transcatheter radio frequency ablation of atrial fibrillation, a still highly investigational technique, may have the potential to revolutionize interventional therapy of atrial fibrillation in the future. For this to occur, however, the technique still needs significant improvement. In conclusion, although their current impact on clinical practice is rather small, interventional techniques for treatment of atrial fibrillation are rapidly developing and will certainly change our therapeutic strategies in the near future.
Leier, C V; Johnson, T M; Lewis, R P
A patient with coarse atrial fibrillation and a rapid ventricular response developed periods of high grade atrioventricular block interpersed with periods of rapid ventricular conduction after the administration of digitalis and propranolol. Intracardiac atrial recordings showed similar atrial rhythms of high right atrial flutter and left atrial fibrillation. The low right atrial recordings showed flutter during the periods of fast ventricular rates and fibrillation during periods of slower ventricular rates. Images PMID:475927
The author reviews the history of atrial fibrillation, the most common sustained cardiac arrhythmia. The chaotic irregularity of arterial pulse was clearly acknowledged by most of physicians of the ancient China, Egypt and Greece. William Harvey (1578-1657), who first described the circulatory system appropriately, was probably the first to describe fibrillation of the auricles in animals in 1628. The French "clinical pathologist", Jean Baptist de Sénac (1693-1770) was the first who assumed a correlation between "rebellious palpitation" and stenosis of the mitral valve. Robert Adams (1791-1875) also reported in 1827 the association of irregular pulses and mitral stenosis. The discovery of digitalis leaf in 1785 by William Withering (1741-1799) brought relief to patients with atrial fibrillation and congestive heart failure by reducing the ventricular rate. From an analysis of simultaneously recorded arterial and venous pressure curves, the Scottish Sir James Mackenzie (1853-11925) demonstrated that a presystolic wave cannot be seen during "pulsus irregularis perpetuus", a term very first used by Heinrich Ewald Hering (1866-1948). Arthur Cushny (1866-1926) noted the similarity between pulse curves in clinical "delirium cordis" and those in dogs with atrial fibrillation. The first human ECG depicting atrial fibrillation was published by Willem Einthoven (1860-1927) in 1906. The proof of a direct connection between absolute arrhythmia and atrial fibrillation was established by two Viennese physicians, Carl Julius Rothberger and Heinrich Winterberg in 1909. Sir Thomas Lewis (1881-1945), the father of modem electrocardiography, studied electrophysiological characteristics of atrial fibrillation and has shown that its basic perpetuating mechanism is circus movement of electrical impulse (re-entry). After him, the major discoveries relating to the pathophysiology and clinical features of atrial fibrillation in the 20th century stemmed from Karel Frederick Wenckebach
Curtis, Anne B
Atrial fibrillation is one of the most common and complex cardiac arrhythmias. Using currently available evidence, leading medical societies have established recommendations for the optimal management of atrial fibrillation. These guidelines have recently been updated by 4 consensus groups: the European Society of Cardiology, the American College of Chest Physicians, the Canadian Cardiovascular Society, and a task force of 3 societies from the United States: the American College of Cardiology Foundation, the American Heart Association, and the Heart Rhythm Society. The present review focused on the similarities and differences among these recently updated guidelines. Key revisions included updated information on newer treatments for rhythm control, treatment options to reduce atrial fibrillation complications, and updated anticoagulant management for thromboprophylaxis.
Bonilla, Ingrid M.; Sridhar, Arun; Györke, Sandor; Cardounel, Arturo J.; Carnes, Cynthia A.
Oxidative stress has been implicated in the pathogenesis of atrial fibrillation. There are multiple systems in the myocardium which contribute to redox homeostasis, and loss of homeostasis can result in oxidative stress. Potential sources of oxidants include nitric oxide synthases (NOS), which normally produce nitric oxide in the heart. Two NOS isoforms (1 and 3) are normally expressed in the heart. During pathologies such as heart failure, there is induction of NOS 2 in multiple cell types in the myocardium. In certain conditions, the NOS enzymes may become uncoupled, shifting from production of nitric oxide to superoxide anion, a potent free radical and oxidant. Multiple lines of evidence suggest a role for NOS in the pathogenesis of atrial fibrillation. Therapeutic approaches to reduce atrial fibrillation by modulation of NOS activity may be beneficial, although further investigation of this strategy is needed. PMID:22536189
Onuchina, E L; Solov'ev, O V; Mochalova, O V; Kononov, S K; Onuchin, S G
The aim of the study was to elucidate specific features of chronic recurrent atrial fibrillation (AF) in patients with metabolic syndrome (MS) and disturbed carbohydrate metabolism compared with AF patients without MS. It enrolled 145 patients aged 44-83 years: 117 with abdominal obesity (BMI >30 kg/m2, waist circumference >80 and 94 cm in women and men respectively) including 30 without metabolic disturbances; 35 with impaired glucose tolerance (IGT), 52 with type 2 DM, and 28 controls without MS. Parameters measured included frequency and severity of AF, carbohydrate and lipid metabolism, albuminurea, C-reactive peptide level, quality of AH control, results of echocardiography and 24 hour ECG monitoring (sinus rhythm), and insulin resistance index (HOMA IRindex). Groups of AF and MS patients were dominated by women. The frequency and severity of AF relapses in MS patients were higher than in controls (especially in the presence of IGT and DM). IGT and DM2 associated with structural changes in myocardium (left atrial dilatation, prevalence of LV concentric hypertrophy, diastolic dysfunction) coupled to higher systolic AH and marked metabolic disorders (hyperglycemia, IR, elevated microalbuminurea and C-reactive protein level, dyslipidemia). These conditions contribute to the frequency and severity of AF relapses. Development of AF in MS is a multifactor problem necessitating strict control of AH, dyslipidemia, DM2 and IGT, reduction of body weight and abdominal obesity.
You, John J.; Singer, Daniel E.; Howard, Patricia A.; Lane, Deirdre A.; Eckman, Mark H.; Fang, Margaret C.; Hylek, Elaine M.; Schulman, Sam; Go, Alan S.; Hughes, Michael; Spencer, Frederick A.; Manning, Warren J.; Halperin, Jonathan L.
Background: The risk of stroke varies considerably across different groups of patients with atrial fibrillation (AF). Antithrombotic prophylaxis for stroke is associated with an increased risk of bleeding. We provide recommendations for antithrombotic treatment based on net clinical benefit for patients with AF at varying levels of stroke risk and in a number of common clinical scenarios. Methods: We used the methods described in the Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines article of this supplement. Results: For patients with nonrheumatic AF, including those with paroxysmal AF, who are (1) at low risk of stroke (eg, CHADS2 [congestive heart failure, hypertension, age ≥ 75 years, diabetes mellitus, prior stroke or transient ischemic attack] score of 0), we suggest no therapy rather than antithrombotic therapy, and for patients choosing antithrombotic therapy, we suggest aspirin rather than oral anticoagulation or combination therapy with aspirin and clopidogrel; (2) at intermediate risk of stroke (eg, CHADS2 score of 1), we recommend oral anticoagulation rather than no therapy, and we suggest oral anticoagulation rather than aspirin or combination therapy with aspirin and clopidogrel; and (3) at high risk of stroke (eg, CHADS2 score of ≥ 2), we recommend oral anticoagulation rather than no therapy, aspirin, or combination therapy with aspirin and clopidogrel. Where we recommend or suggest in favor of oral anticoagulation, we suggest dabigatran 150 mg bid rather than adjusted-dose vitamin K antagonist therapy. Conclusions: Oral anticoagulation is the optimal choice of antithrombotic therapy for patients with AF at high risk of stroke (CHADS2 score of ≥ 2). At lower levels of stroke risk, antithrombotic treatment decisions will require a more individualized
Atrial fibrillation (AF) affects millions worldwide. Stroke is the most devastating complication of AF and is associated with a huge disease burden. As a preventive measure, anticoagulant therapy is recommended for most AF patients based on presence of stroke risk factors. For the past six decades warfarin remained the gold standard for stroke prevention in AF (SPAF). However, it is associated with numerous limitations such as a high risk of drug-drug, drug-food interactions and need for frequent INR (2-3) monitoring. Novel oral anticoagulant (NOAC) dabigatran etexilate is a selective, specific, reversible direct thrombin inhibitor that has been approved in India for SPAF and primary venous thromboembolism prevention. The efficacy and safety of dabigatran in AF has been established the "Randomized Evaluation of Long-Term Anticoagulant Therapy (RE-LY)", a randomized clinical trial. RE-LY (n = 18,113) demonstrated that the efficacy of dabigatran 110 mg BID was as good as well controlled warfarin and dabigatran 150 mg BID reduced the risk of ischaemic stroke by 25% (P = 0.03). Till date, 150mg dabigatran is the only NOAC offering a superior reduction in most commonly seen ischemic strokes due to AF compared to warfarin. Additionally, both doses of dabigatran significantly reduced the risk of total bleeds, intracranial, and life threatening bleeds versus warfarin (p < 0.05). Dabigatran has advantages over warfarin including predictable pharmacokinetic/pharmacodynamic profile, minimal drug-drug and no drug-food interactions while no monitoring is needed.The 150 mg dose of dabigatran should be considered in younger patients with a low risk of bleeding and good renal function to achieve a superior ischemic stroke reduction, whereas, the 110 mg dose should be considered in elderly patients, those with mild to moderate renal function or those with high risk of bleeding.
Mikulecky, M; Valachova, A
The most popular periodicities in biology and medicine-the circadians and circannuals-stem undoubtedly from the Earth's rotation and its revolution around the sun. The problem is how to explain the existence of circaseptan, i.e. 5-9-day, and other infradian rhythms. They may correspond to the lunar cycles and their 2nd to 6th harmonics. To test such hypothesis, the calendar dates of 127 attacks of atrial fibrillation in one male subject (M.M.) between 1980 and 1994 were transformed into the days numbered 0-29 for the synodic, and 0-26 for tropic lunar cycle. The daily frequencies obtained in this way were smoothed by moving averages of three successive days each. Considerable fluctuations of frequencies of attacks during both cycles were visible by inspection of the corresponding graphs, called lunar plexograms. Thus, a conspicuous nadir is found under the full moon in the synodic cycle, and a marked peak shortly after the extreme southern position of the moon in the tropic cycle. Halberg's cosinor analysis testing the presence of the 1st to 6th harmonic of either lunar cycle rejected the null hypothesis at the alpha = 0.05 level for all harmonics. Accordingly, the occurrence of attacks was cycling with the period lengths of synodic and tropic lunar cycles, and with those of their 1/2-1/6 period lengths, i.e. with a cluster of approximately circa(di)-septan rhythms. This conclusion is supported by similar findings obtained earlier for various medical and biological events.
Thacker, Evan L; Soliman, Elsayed Z; Pulley, LeaVonne; Safford, Monika M; Howard, George; Howard, Virginia J
Atrial fibrillation (AF) is diagnosed more commonly in whites than blacks in the United States. In epidemiologic studies, selection bias could induce a noncausal positive association of white race with prevalent AF if voluntary enrollment was influenced by both race and AF status. We investigated whether nonrandom enrollment biased the association of race with prevalent self-reported AF in the US-based REasons for Geographic And Racial Differences in Stroke Study (REGARDS). REGARDS had a two-stage enrollment process, allowing us to compare 30,183 fully enrolled REGARDS participants with 12,828 people who completed the first-stage telephone survey but did not complete the second-stage in-home visit to finalize their REGARDS enrollment (telephone-only participants). REGARDS enrollment was higher among whites (77.1%) than among blacks (62.3%) but did not differ by self-reported AF status. The prevalence of AF was 8.45% in whites and 5.86% in blacks adjusted for age, sex, income, education, and perceived general health. The adjusted white/black prevalence ratio of self-reported AF was 1.43 (95% CI, 1.32-1.56) among REGARDS participants and 1.38 (1.22-1.55) among telephone-only participants. These findings suggest that selection bias is not a viable explanation for the higher prevalence of self-reported AF among whites in population studies such as REGARDS. Copyright © 2016 Elsevier Inc. All rights reserved.
Geuzebroek, Guillaume S C; van Amersfoorth, Shirley C M; Hoogendijk, Mark G; Kelder, Johannes C; van Hemel, Norbert M; de Bakker, Jacques M T; Coronel, Ruben
Atrial fibrosis is related to atrial fibrillation but may differ in patients with mitral valve disease or lone atrial fibrillation. Therefore, we studied atrial fibrosis in patients with atrial fibrillation+mitral valve disease or with lone atrial fibrillation and compared it with controls. Left and right atrial appendages amputated during Maze III surgery for lone atrial fibrillation (n=85) or atrial fibrillation+mitral valve disease (n=26) were embedded in paraffin, sectioned, and stained with picrosirius red. Atria from 10 deceased patients without a cardiovascular history served as controls. A total of 1048 images (4-μm sections, 10-fold magnification, 4 images per appendage) were obtained and digitized. The percentage of fibrous tissue was calculated by quantitative morphometry. Irrespective of the presence or absence of atrial fibrillation or mitral valve disease, more fibrous tissue was present in right atrial appendages than in left atrial appendages (12.7%±5.7% vs 8.2%±3.9%; P<.0001). The mean amount of fibrous tissue in the atria was significantly larger in patients with atrial fibrillation+mitral valve disease than in patients with lone AF and controls (13.6%±5.8%, 9.7%±3.2%, and 8.8%±2.4%, respectively; P<.01). No significant differences existed between patients with lone atrial fibrillation and patients without a cardiovascular history (controls). Atria of patients with atrial fibrillation and mitral valve disease have more fibrosis than atria of patients with lone atrial fibrillation. However, patients with lone atrial fibrillation have an equal amount of atrial fibrosis compared with controls. These findings support the notion that fibrosis plays a more important role in the pathogenesis of atrial fibrillation secondary to mitral valve disease than in lone atrial fibrillation and potentially explains the relatively poor success of antiarrhythmic surgery in patients with mitral valve disease. Copyright © 2012 The American Association for
Pellman, Jason; Sheikh, Farah
Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia, affecting 1% to 2% of the general population. It is characterized by rapid and disorganized atrial activation leading to impaired atrial function, which can be diagnosed on an EKG by lack of a P-wave and irregular QRS complexes. AF is associated with increased morbidity and mortality and is a risk factor for embolic stroke and worsening heart failure. Current research on AF support and explore the hypothesis that initiation and maintenance of AF require pathophysiological remodeling of the atria, either specifically as in lone AF or secondary to other heart disease as in heart failure-associated AF. Remodeling in AF can be grouped into three categories that include: (i) electrical remodeling, which includes modulation of L-type Ca2+ current, various K+ currents and gap junction function; (ii) structural remodeling, which includes changes in tissues properties, size, and ultrastructure; and (iii) autonomic remodeling, including altered sympathovagal activity and hyperinnervation. Electrical, structural, and autonomic remodeling all contribute to creating an AF-prone substrate which is able to produce AF-associated electrical phenomena including a rapidly firing focus, complex multiple reentrant circuit or rotors. Although various remodeling events occur in AF, current AF therapies focus on ventricular rate and rhythm control strategies using pharmacotherapy and surgical interventions. Recent progress in the field has started to focus on the underlying substrate that drives and maintains AF (termed upstream therapies); however, much work is needed in this area. Here, we review current knowledge of AF mechanisms, therapies, and new areas of investigation. PMID:25880508
Ellinor, Patrick T; Lunetta, Kathryn L; Albert, Christine M; Glazer, Nicole L; Ritchie, Marylyn D; Smith, Albert V; Arking, Dan E; Müller-Nurasyid, Martina; Krijthe, Bouwe P; Lubitz, Steven A; Bis, Joshua C; Chung, Mina K; Dörr, Marcus; Ozaki, Kouichi; Roberts, Jason D; Smith, J Gustav; Pfeufer, Arne; Sinner, Moritz F; Lohman, Kurt; Ding, Jingzhong; Smith, Nicholas L; Smith, Jonathan D; Rienstra, Michiel; Rice, Kenneth M; Van Wagoner, David R; Magnani, Jared W; Wakili, Reza; Clauss, Sebastian; Rotter, Jerome I; Steinbeck, Gerhard; Launer, Lenore J; Davies, Robert W; Borkovich, Matthew; Harris, Tamara B; Lin, Honghuang; Völker, Uwe; Völzke, Henry; Milan, David J; Hofman, Albert; Boerwinkle, Eric; Chen, Lin Y; Soliman, Elsayed Z; Voight, Benjamin F; Li, Guo; Chakravarti, Aravinda; Kubo, Michiaki; Tedrow, Usha B; Rose, Lynda M; Ridker, Paul M; Conen, David; Tsunoda, Tatsuhiko; Furukawa, Tetsushi; Sotoodehnia, Nona; Xu, Siyan; Kamatani, Naoyuki; Levy, Daniel; Nakamura, Yusuke; Parvez, Babar; Mahida, Saagar; Furie, Karen L; Rosand, Jonathan; Muhammad, Raafia; Psaty, Bruce M; Meitinger, Thomas; Perz, Siegfried; Wichmann, H-Erich; Witteman, Jacqueline C M; Kao, W H Linda; Kathiresan, Sekar; Roden, Dan M; Uitterlinden, Andre G; Rivadeneira, Fernando; McKnight, Barbara; Sjögren, Marketa; Newman, Anne B; Liu, Yongmei; Gollob, Michael H; Melander, Olle; Tanaka, Toshihiro; Ch Stricker, Bruno H; Felix, Stephan B; Alonso, Alvaro; Darbar, Dawood; Barnard, John; Chasman, Daniel I; Heckbert, Susan R; Benjamin, Emelia J; Gudnason, Vilmundur; Kääb, Stefan
Atrial fibrillation is a highly prevalent arrhythmia and a major risk factor for stroke, heart failure and death1. We conducted a genome-wide association study (GWAS) in individuals of European ancestry, including 6,707 with and 52,426 without atrial fibrillation. Six new atrial fibrillation susceptibility loci were identified and replicated in an additional sample of individuals of European ancestry, including 5,381 subjects with and 1 0,030 subjects without atrial fibrillation (P < 5 × 10−8). Four of the loci identified in Europeans were further replicated in silico in a GWAS of Japanese individuals, including 843 individuals with and 3,350 individuals without atrial fibrillation. The identified loci implicate candidate genes that encode transcription factors related to cardiopulmonary development, cardiac-expressed ion channels and cell signaling molecules. PMID:22544366
Xu, Joshua; Luc, Jessica G Y; Phan, Kevin
Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia in modern clinical practice, with an estimated prevalence of 1.5-2%. The prevalence of AF is expected to double in the next decades, progressing with age and increasingly becoming a global medical challenge. The first-line treatment for AF is often medical treatment with either rate control or anti-arrhythmic agents for rhythm control, in addition to anti-coagulants such as warfarin for stroke prevention in patient at risk. Catheter ablation has emerged as an alternative for AF treatment, which involves myocardial tissue lesions to disrupt the underlying triggers and substrates for AF. Surgical approaches have also been developed for treatment of AF, particularly for patients requiring concomitant cardiac surgery or those refractory to medical and catheter ablation treatments. Since the introduction of the Cox-Maze III, this procedure has evolved into several modern variations, including the use of alternative energy sources (Cox-Maze IV) such as radiofrequency, cryo-energy and microwave, as well as minimally invasive thoracoscopic epicardial approaches. Another recently introduced technique is the hybrid ablation approach, where in a single setting both epicardial thoracoscopic ablation lesions and endocardial catheter ablation lesions are performed by the cardiothoracic surgeon and cardiologist. There remains controversy surrounding the optimal approach for AF ablation, energy sources, and lesion sets employed. The goal of this article is review the history, classifications, pathophysiology and current treatment options for AF.
Xu, Joshua; Luc, Jessica G. Y.
Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia in modern clinical practice, with an estimated prevalence of 1.5–2%. The prevalence of AF is expected to double in the next decades, progressing with age and increasingly becoming a global medical challenge. The first-line treatment for AF is often medical treatment with either rate control or anti-arrhythmic agents for rhythm control, in addition to anti-coagulants such as warfarin for stroke prevention in patient at risk. Catheter ablation has emerged as an alternative for AF treatment, which involves myocardial tissue lesions to disrupt the underlying triggers and substrates for AF. Surgical approaches have also been developed for treatment of AF, particularly for patients requiring concomitant cardiac surgery or those refractory to medical and catheter ablation treatments. Since the introduction of the Cox-Maze III, this procedure has evolved into several modern variations, including the use of alternative energy sources (Cox-Maze IV) such as radiofrequency, cryo-energy and microwave, as well as minimally invasive thoracoscopic epicardial approaches. Another recently introduced technique is the hybrid ablation approach, where in a single setting both epicardial thoracoscopic ablation lesions and endocardial catheter ablation lesions are performed by the cardiothoracic surgeon and cardiologist. There remains controversy surrounding the optimal approach for AF ablation, energy sources, and lesion sets employed. The goal of this article is review the history, classifications, pathophysiology and current treatment options for AF. PMID:27747025
Caldeira, Daniel; Barra, Márcio; David, Cláudio; Costa, João; Ferreira, Joaquim J; Pinto, Fausto J
Oral anticoagulation (OAC) is an effective treatment in the prevention of thromboembolic events in patients with atrial fibrillation (AF). The aim of this review was to estimate the prevalence of OAC therapy in patients with AF in Portugal. MEDLINE, the Index of Portuguese Medical Journals and SIBUL (the Bibliographic Catalog of the Integrated Library System of the University of Lisbon) were searched for Portuguese observational studies reporting the proportion of anticoagulated patients with AF. The pooled estimated prevalence of anticoagulated patients and respective 95% confidence interval (CI) were determined by means of a meta-analysis. Seven studies were included for analysis, of which four were conducted in a hospital environment and three in the general community. These studies enrolled a total of 891 patients with AF. The pooled estimated prevalence of anticoagulated patients was 40% (95% CI: 32-48%). The prevalence of OAC in Portuguese AF patients is low. There is a need to promote change in OAC prescribing habits for AF patients in Portugal, in accordance with international guidelines. Copyright © 2014 Sociedade Portuguesa de Cardiologia. Published by Elsevier España. All rights reserved.
Käräjämäki, Aki Juhani; Kettunen, Olli; Lepojärvi, Samuli; Koivurova, Olli-Pekka; Kesäniemi, Y. Antero; Huikuri, Heikki; Ukkola, Olavi
Background Chronic liver injury from different etiologies drives liver fibrosis. However, little is known about the associated factors, systemic factors in particular. Recently, non-alcoholic fatty liver disease (NAFLD) and atrial fibrillation have been shown to be associated with each other. Thereby, we aimed to study the association between atrial fibrillation and liver stiffness. Study Extensive clinical measurements including echocardiography of the heart, transient elastography (TE) of the liver and the presence of atrial fibrillation were determined in elderly Finnish study subjects (n = 76, mean age 73 years) from OPERA (Oulu Project Elucidating the Risk of Atherosclerosis) study cohort. Half of the study subjects had non-alcoholic fatty liver disease, whereas others did not have any known hepatic morbidity. The present study was cross-sectional by nature. Results The subjects with atrial fibrillation had higher TE values (with atrial fibrillation TE = 9.3kPa, without atrial fibrillation TE = 6.3kPa, p = 0.018). When the cohort was divided to four subgroups (those without NAFLD or atrial fibrillation, with NAFLD but without atrial fibrillation, with both conditions, and with atrial fibrillation but without NAFLD), the TE value was the highest in the subjects with both conditions (5.3kPa, 7.4kPa, 10.8kPa and 7.8kPa, respectively, p = 0.019). Moreover, the higher the TE value, the more prevalent atrial fibrillation was (the atrial fibrillation prevalence by tertiles of TE 27% / 36% / 77%, p = 0.001). Likewise, the greater the TE value, the greater the left atrial diameter, a collateral of atrial fibrillation (left atrial diameters by tertiles of TE 39mm / 45mm / 48mm, p<0.001) was. All these p-values for continuous variables remained statistically significant even after adjustment for common clinically relevant risk factors. Conclusions There is an association between atrial fibrillation and liver stiffness. This novel association may have multiple
Díez-Manglano, Jesús; Bernabeu-Wittel, Máximo; Barón-Franco, Bosco; Murcia-Zaragoza, José; Fuertes Martín, Aurelio; Alemán, Antonio; Ollero-Baturone, Manuel
To determine the use of oral anticoagulants in polypathological patients with atrial fibrillation and its influence on mortality and loss of functionality. Patients with polypathological patient criteria and atrial fibrillation were included in an observational, prospective and multicenter study. Data on demographic, clinical, functional and sociofamilial characteristics, CHADS2 score, levels of hemoglobin, albumin and creatinine, use of oral anticoagulants and survival and functional status at one year were collected. Five hundred and thirty-two (32.6%) of 1,632 polypathological patients had atrial fibrillation. The stroke risk was high in 505 (94.9%), moderate in 24 (4.5%) and low in 3 (0.6%) patients. Oral anticoagulants were used in 61% of patients with CHADS2 score≥2 and in 37.5% with CHADS2 score=1. Oral anticoagulants were less used in older patients, with more functional and cognitive impairment. Heart failure was associated with more use of oral anticoagulants. There was no difference by the presence of hypertension, diabetes, anemia, renal insufficiency or stroke. In multivariate analysis the use of oral anticoagulants was independently associated with lower age, lower cognitive impairment, absence of hepatic disease and with higher stroke risk. The prescription of oral anticoagulants was independently associated with more survival at one year with no influence on functional status. Oral anticoagulants are underused in polypathological patients with atrial fibrillation despite being associated with more survival. Copyright © 2012 Elsevier España, S.L. All rights reserved.
Del Brutto, Oscar H; Costa, Aldo F; Cano, José A; Peñaherrera, Ernesto; Plaza, Karin J; Ledesma, Ernesto A; Tettamanti, Daniel; Zambrano, Mauricio
Information on the burden of atrial fibrillation (AF) in rural areas of developing countries is limited. Here, we aimed to assess AF prevalence in community-dwelling older adults living in rural Ecuador. Atahualpa residents aged ≥60 years (mean age 70.5 ± 8.1 years) underwent 24-h Holter monitoring. Participants belong to the Amerindian ethnic group. The mean height in the study population was 147.9 ± 8.9 cm. Oily fish was a major source of food (mean intake: 8 ± 4 servings/week). Seven of 298 participants (2.3%) had AF. Persons with AF were older than those without (p = 0.051), but there were no differences in cardiovascular risk factors across groups. None of the seven AF cases had been detected in routine 12-lead ECGs taken at enrollment. Prevalence of AF in older Amerindians living in rural Ecuador is low. Both, racially-determined short stature and frequent dietary oily fish intake might explain the low prevalence of AF in this rural setting.
Piccini, Jonathan P.; Mi, Xiaojuan; DeWald, Tracy A.; Go, Alan S.; Hernandez, Adrian F.; Curtis, Lesley H.
Background There are limited data regarding national patterns of pharmacotherapy for atrial fibrillation (AF) among older patients. Drug exposure data are now captured for Medicare beneficiaries enrolled in prescription drug plans. Objective To describe pharmacotherapy for AF among Medicare beneficiaries. Methods Using a 5% national sample of Medicare claims data, we compared demographic characteristics, comorbidity, and treatment patterns according to Medicare Part D status among patients with prevalent AF in 2006 and 2007. Results In 2006, 27,174 patients (29.3%) with prevalent AF were enrolled in Medicare Part D. In 2007, enrollment increased to 45,711 (49.1%). Most enrollees were taking rate control agents (74.0% in 2007). β-Blocker use was higher in those with concomitant AF and heart failure and increased with higher CHADS2 scores (P < .001). Antiarrhythmic use was 18.7% in 2006 and 19.1% in 2007, with amiodarone accounting for more than 50%. Class Ic drugs were used in 3.2% of patients in 2007. Warfarin use was less than 60% and declined with increasing stroke risk (P < .001). Conclusion Pharmacotherapy for AF varied according to comorbidity and underlying risk. Amiodarone was the most commonly prescribed antiarrhythmic agent. Postmarketing surveillance using Medicare Part D claims data linked to clinical data may help inform comparative safety, effectiveness, and net clinical benefit of drug therapy for AF in older patients in real-world settings. PMID:22537885
Rao, Meena P.; Pokorney, Sean D.; Granger, Christopher B.
Atrial fibrillation is the most common arrhythmia and accounts for one-third of hospitalizations for rhythm disorders in the United States. The prevalence of atrial fibrillation averages 1% and increases with age. With the aging of the population, the number of patients with atrial fibrillation is expected to increase 150% by 2050, with more than 50% of atrial fibrillation patients being over the age of 80. This increasing burden of atrial fibrillation will lead to a higher incidence of stroke, as patients with atrial fibrillation have a five- to sevenfold greater risk of stroke than the general population. Strokes secondary to atrial fibrillation have a worse prognosis than in patients without atrial fibrillation. Vitamin K antagonists (e.g., warfarin), direct thrombin inhibitors (dabigatran), and factor Xa inhibitors (rivaroxaban and apixaban) are all oral anticoagulants that have been FDA approved for the prevention of stroke in atrial fibrillation. This review will summarize the experience of anticoagulants in patients with atrial fibrillation with a focus on the experience at the Duke Clinic Research Institute. PMID:25215263
Kazui, Toshinobu; Henn, Mathew C.; Watanabe, Yoshiyuki; Kovács, Sándor J.; Lawrance, Christopher P.; Greenberg, Jason W.; Moon, Marc; Schuessler, Richard B.; Damiano, Ralph J.
Objective The impact of prolonged episodes of atrial fibrillation on atrial and ventricular function has been incompletely characterized. The purpose of this study was to investigate the influence of atrial fibrillation on left atrial and ventricular function in a rapid paced porcine model of atrial fibrillation. Methods A control group of pigs (group 1, n = 8) underwent left atrial and left ventricular conductance catheter studies and fibrosis analysis. A second group (group 2, n = 8) received a baseline cardiac magnetic resonance imaging to characterize left atrial and left ventricular function. The atria were rapidly paced into atrial fibrillation for 6 weeks followed by cardioversion and cardiac magnetic resonance imaging. Results After 6 weeks of atrial fibrillation, left atrial contractility defined by atrial end-systolic pressure-volume relationship slope was significantly lower in group 2 than in group 1 (1.1 ± 0.5 vs 1.7 ± 1.0; P = .041), whereas compliance from the end-diastolic pressure-volume relationship was unchanged (1.5 ± 0.9 vs 1.6 ± 1.3; P = .733). Compared with baseline, atrial fibrillation resulted in a significantly higher contribution of left atrial reservoir volume to stroke volume (32% vs 17%; P = .005) and lower left atrial booster pump volume contribution to stroke volume (19% vs 28%; P = .029). Atrial fibrillation also significantly increased maximum left atrial volume (206 ± 41 mL vs 90 ± 21 mL; P < .001). Left atrial fibrosis in group 2 was significantly higher than in group 1. Atrial fibrillation decreased left ventricular ejection fraction (29% ± 9% vs 58 ± 8%; P < .001), but left ventricular stroke volume was unchanged. Conclusions In a chronic model of atrial fibrillation, the left atrium demonstrated significant structural remodeling and decreased contractility. These data suggest that early intervention in patients with persistent atrial fibrillation might mitigate against adverse atrial and ventricular structural
Schreiner, Andrew D; Keith, Brad A; Abernathy, Karen E; Zhang, Jingwen; Brzezinski, Walter A
Endurance exercise plays a role in cardiovascular risk reduction, but may also be a risk factor for atrial fibrillation. This study was performed to assess the prevalence of atrial fibrillation in a population of long-term, competitive swimmers compared with patients within an internal medicine clinic with known risk factors for atrial fibrillation such as diabetes mellitus and hypertension. This cross-sectional study utilized survey data comparing the prevalence of atrial fibrillation in swimmers to a general internal medicine population. A multi-national group of swimmers over the age of 60 were surveyed, and a chart review was performed on a random sample of age-matched internal medicine patients. The primary outcome was the diagnosis of atrial fibrillation. Univariate analysis was used for means of proportions of the responses, and a multivariate logistic regression analysis was performed with diagnosis of atrial fibrillation as the dependent variable. Forty-nine swimmers completed surveys and 100 age-matched internal medicine patients underwent chart review. Swimmers reported atrial fibrillation in 13 cases (26.5 %) compared to 7 (7 %) in the comparison group (p = 0.001). A diagnosis of hypertension or diabetes mellitus was present in 23 (46.9 %) and 1 (2 %) of the swimmers, respectively, as compared to 72 (72 %, p = 0.003) and 32 (32 %, p < 0.001) in the comparison group. Age, presence of diabetes mellitus, and swimming history were variables included in the logistic regression, in relation to atrial fibrillation. Swimming was associated with an odds ratio of 8.739 (95 % CI 2.290 to 33.344, p = 0.015). Long-term, competitive swimmers have an increased prevalence of atrial fibrillation compared to internal medicine patients, despite the higher burden of diabetes mellitus and hypertension in the internal medicine group.
Ferreira, Raquel; Primo, João; Adão, Luís; Gonzaga, Anabela; Gonçalves, Helena; Santos, Rui; Fonseca, Paulo; Santos, José; Gama, Vasco
Cardiac surgery for structural heart disease (often involving the left atrium) and radiofrequency catheter ablation of atrial fibrillation have led to an increased incidence of regular atrial tachycardias, often presenting as atypical flutters. This type of flutter is particularly common after pulmonary vein isolation, especially after extensive atrial ablation including linear lesions and/or defragmentation. The authors describe the case of a 51-year-old man, with no relevant medical history, referred for a cardiology consultation in 2009 for paroxysmal atrial fibrillation. After failure of antiarrhythmic therapy, he underwent catheter ablation, with criteria of acute success. Three years later he again suffered palpitations and atypical atrial flutter was documented. The electrophysiology study confirmed the diagnosis of atypical left flutter and reappearance of electrical activity in the right inferior pulmonary vein. This vein was again ablated successfully and there has been no arrhythmia recurrence to date. In an era of frequent catheter ablation it is essential to understand the mechanism of this arrhythmia and to recognize such atypical flutters. Copyright © 2016 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. All rights reserved.
Harris, K; Edwards, D; Mant, J
Atrial fibrillation (AF) is an arrhythmia of increasing prevalence associated with a reducible risk of stroke. We conducted a systematic review to address five questions relating to how we can best detect AF: 1. Are there useful screening tests to determine who should have a 12-lead electrocardiogram (ECG)? Potential screening tests, all with acceptable sensitivity, include pulse palpation, single-lead ECG and newer technologies such as modified sphygmomanometers or a finger probe device. Pulse palpation has a high number of false positives, but is the cheapest method. 2. Is it more effective to offer 12-lead ECGs to the whole population (or specific sub-groups) or only to those who screen positive for AF? The cost-effectiveness of new devices, such as a modified blood pressure monitor, needs to be assessed. It is more cost-effective to opportunistically screen people rather than to offer a 12-lead ECG to everybody. 3. How accurate are different healthcare professionals and interpretative software at diagnosing AF on ECG? Definitive diagnosis of AF should be by 12-lead ECG, interpreted by someone with appropriate expertise. Computer software is not currently sensitive enough to be used alone to diagnose AF on ECG. Primary care practitioners may not accurately detect AF on ECG, but consistently high accuracy can be achieved by healthcare professionals with adequate training. 4. How best can we diagnose paroxysmal atrial fibrillation (PAF)? In patients in whom PAF is suspected, longer periods of monitoring will detect more cases of PAF. 5. What is the impact of the use of different ECG monitoring strategies (e.g. Holter monitoring, serial ECGs, continuous ECG) on AF detection rates post-stroke? In patients post-stroke, a single ECG will miss cases of PAF which can be detected by longer duration monitoring such as Holter monitoring, cardiac event recorders and serial ECGs. Further research into the cost-effectiveness of these methods, the duration of monitoring
Martins, Raphaël P; Mabo, Philippe
Atrial fibrillation (AF) is the most common arrhythmia in clinical practice. Pulmonary veins are a major source of ectopic activities initiating the arrhythmia and the fibrillatory conduction, associating multiple wavelets and high frequency functional reentries called "rotors". AF is responsible for atrial electrophysiological, contractile and structural remodelling, shortening the wavelength, accelerating AF cycle length and sustaining the arrhythmia. A better understanding of the mechanisms responsible for this arrhythmia led to new therapeutic approaches, including ablation, and could eventually lead to the development of new anti-arrhythmic drug agents.
Diouf, Ibrahima; Magliano, Dianna J; Carrington, Melinda J; Stewart, Simon; Shaw, Jonathan E
We sought to describe the prevalence, incidence, risk factors and treatment (according to stroke risk) of atrial fibrillation (AF) in the national, population-based Australian Diabetes, Obesity and Lifestyle (AusDiab) study cohort. ECG data were available from 8273/11,247 participants of AusDiab study in 1999/2000 and from 5422 participants in 2004/2005. Minnesota coding was used to identify prevalent and incident cases of AF. 90 prevalent cases of AF (14.1 per 1000) comprising 56 men (mean age 70.5 ± 1.9 years) and 34 women (aged 78.3 ± 1.2 years) were identified in 1999-2000. AF prevalence was associated with sedentary behaviour versus physically active (PR 2.0, 95% CI 1.2-3.6). 53 incident cases of AF (2.0, 95%, CI 1.5-2.6 per 1000 person-year) were subsequently identified in 2004-2005. Increased risk of incident AF was associated with male sex, obesity, history of angina, myocardial infarction and stroke. Both increased weight gain and increased weight loss appeared to be associated with increased risks of developing AF in women, while no obvious association was observed in men. Despite their high risk for stroke, anti-thrombotic therapy was observed in only 39.3% of participants with CHA2DS2-VASC scores ≥ 2. This study contributes to a better understanding of the AF burden. With the ageing population, coordinated efforts will be needed to anticipate the future health care costs related to AF and its impacts on the health care system. This will include appropriate application of anti-thrombotic therapy according to risk of thrombo-embolic events. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.
Hasegawa, Jumpei; Bieber, Brian; Larkina, Maria; Robinson, Bruce M; Wakai, Sachiko; Akizawa, Tadao; Saito, Akira; Fukuhara, Shunichi; Akiba, Takashi
Atrial fibrillation is one of the most common arrhythmias in hemodialysis patients. We evaluated its clinical outcomes among hemodialysis patients with atrial fibrillation in Japan. Using data derived from the Japanese Dialysis Outcomes and Practice Patterns Study, we analyzed backgrounds and outcomes among hemodialysis patients with and without atrial fibrillation in Japan. Among 7002 hemodialysis patients, the prevalence of atrial fibrillation was 5.7% and the incidence was 0.2 per 100 patient-years. Atrial fibrillation was independently associated with all-cause mortality (hazard ratio, 1.32; 95% confidence interval, 1.02-1.71) and cardiovascular events (hazard ratio, 1.39; 95% confidence interval, 1.15-1.68), but not with stroke events (hazard ratio, 0.77; 95% confidence interval, 0.55-1.06) after adjustment for other variables. We conclude that patients with atrial fibrillation experienced higher mortality and more cardiovascular events than did patients without atrial fibrillation, although the risk of stroke was lower than expected.
Ramos-González-Serna, Amelia; Mateos-García, M Dolores
Ablation of pulmonary veins for treatment of atrial fibrillation involves applying radiofrequency energy wave by a catheter that causes a circumferential lesion to achieve electrical isolation and voltage drop in the interior. It is mainly applied when there is resistance to treatment and recurrence of symptoms affecting the quality of life of patients. The nurse is an important part of the multidisciplinary team who care for patients who undergo this procedure. The provision of comprehensive nursing care should include nursing procedures prior to, during, and after treatment to ensure the careful and systematic quality required. The aims of this article are: to provide specialised knowledge on the procedure of atrial fibrillation ablation, to describe the preparation of the electrophysiology laboratory, analyse nursing care and develop a standardized care plan for patients on whom this procedure is performed using the NANDA (North American Nursing Association) taxonomy and NIC (Nursing Intervention Classification).
Sukhacheva, T V; Eremeeva, M V; Ibragimova, A G; Vaskovskii, V A; Serov, R A; Revishvili, A Sh
The myocardium of the right and left atrial appendages (auricles) in patients with paroxysmal, persistent, and permanent forms of atrial fibrillation was examined by histological methods and electron microscopy. Isolated atrial amyloidosis was detected in the left (50.0-56.3% patients) and in the right (45.0-55.6% patients) atrial appendages. In all cases, immunohistochemistry revealed atrial natriuretic peptide in fibrillary amyloid deposits. Ultrastructurally, amyloid masses formed clusters of myofibrils 8-10 nm in diameter. They were chaotically located in the extracellular space along the sarcolemma as well as in membrane invaginations, dilated tubules of cardiomyocyte T-tubular system, and vascular walls. Amyloidosis was predominantly observed in women; its degree positively correlated with age of patients and duration of atrial fibrillation but negatively correlated with atrial fibrosis. The study revealed positive (in permanent atrial fibrillation) and negative (in paroxysmal atrial fibrillation) correlation of amyloidosis with myofibril content in atrial cardiomyocytes.
Lipset, Mark A.; Lemery, Jay; Polk, J. D.; Hamilton, Douglas R.
Background: A long-duration exploration class mission is fraught with numerous medical contingency plans. Herein, we explore the challenges of symptomatic atrial fibrillation (AF) occurring during an exploration class mission. The actions and resources required to ameliorate the situation, including the availability of appropriate pharmaceuticals, monitoring devices, treatment modalities, and communication protocols will be investigated. Challenges of Atrial Fibrillation during an Exploration Mission: Numerous etiologies are responsible for the initiation of AF. On Earth, we have the time and medical resources to evaluate and determine the causative situation for most cases of AF and initiate therapy accordingly. During a long-duration exploration class mission resources will be severely restricted. How is one to determine if new onset AF is due to recent myocardial infarction, pulmonary embolism, fluid overload, thyrotoxicosis, cardiac structural abnormalities, or CO poisoning? Which pharmaceutical therapy should be initiated and what potential side effects can be expected? Should anti-coagulation therapy be initiated? How would one monitor the therapeutic treatment of AF in microgravity? What training would medical officers require, and which communication strategies should be developed to enable the best, safest therapeutic options for treatment of AF during a long-duration exploration class mission? Summary: These questions will be investigated with expert opinion on disease elucidation, efficient pharmacology, therapeutic monitoring, telecommunication strategies, and mission cost parameters with emphasis on atrial fibrillation being just one illustration of the tremendous challenges that face a long-duration exploration mission. The limited crew training time, medical hardware, and drugs manifested to deal with such an event predicate that aggressive primary and secondary prevention strategies be developed to protect a multibillion-dollar asset like the
Lim, Han S; Zellerhoff, Stephan; Derval, Nicolas; Denis, Arnaud; Yamashita, Seigo; Berte, Benjamin; Mahida, Saagar; Hooks, Darren; Aljefairi, Nora; Shah, Ashok J; Sacher, Frédéric; Hocini, Meleze; Jais, Pierre; Haissaguerre, Michel
Atrial fibrillation (AF) is a dynamic rhythm. Noninvasive mapping overcomes many previous barriers to mapping such a dynamic rhythm, by providing a beat-to-beat, biatrial, panoramic view of the AF process. Catheter ablation of AF drivers guided by noninvasive mapping has yielded promising clinical results and has advanced understanding of the underlying pathophysiologic processes of this common heart rhythm disorder. Copyright © 2015 Elsevier Inc. All rights reserved.
Bulava, Alan; Mokracek, Ales; Hanis, Jiri; Kurfirst, Vojtech; Eisenberger, Martin; Pesl, Ladislav
Background Catheter ablation of persistent atrial fibrillation yields an unsatisfactorily high number of failures. The hybrid approach has recently emerged as a technique that overcomes the limitations of both surgical and catheter procedures alone. Methods and Results We investigated the sequential (staged) hybrid method, which consists of a surgical thoracoscopic radiofrequency ablation procedure followed by radiofrequency catheter ablation 6 to 8 weeks later using the CARTO 3 mapping system. Fifty consecutive patients (mean age 62±7 years, 32 males) with long‐standing persistent atrial fibrillation (41±34 months) and a dilated left atrium (>45 mm) were included and prospectively followed in an unblinded registry. During the electrophysiological part of the study, all 4 pulmonary veins were found to be isolated in 36 (72%) patients and a complete box‐lesion was confirmed in 14 (28%) patients. All gaps were successfully re‐ablated. Twelve months after the completed hybrid ablation, 47 patients (94%) were in normal sinus rhythm (4 patients with paroxysmal atrial fibrillation required propafenone and 1 patient underwent a redo catheter procedure). The majority of arrhythmias recurred during the first 3 months. Beyond 12 months, there were no arrhythmia recurrences detected. The surgical part of the procedure was complicated by 7 (13.7%) major complications, while no serious adverse events were recorded during the radiofrequency catheter part of the procedure. Conclusions The staged hybrid epicardial–endocardial treatment of long‐standing persistent atrial fibrillation seems to be extremely effective in maintenance of normal sinus rhythm compared to radiofrequency catheter or surgical ablation alone. Epicardial ablation alone cannot guarantee durable transmural lesions. Clinical Trial Registration URL: www.ablace.cz Unique identifier: cz‐060520121617 PMID:25809548
Ivers, Noah; Dorian, Paul
Guidelines can be lengthy and complex to apply. We provide a concise summary of important components of outpatient atrial fibrillation management, based on the updated Canadian Cardiovascular Society guidelines. Common questions arising when caring for such patients are addressed, including: what underlying causes should be investigated and treated, how to assess and treat symptoms, how to determine and reduce stroke risk, and when to arrange subspecialty referral. The guidelines emphasize that emergency room visits are rarely necessary and quality of life for most patients with atrial fibrillation can be quite good. The guidelines also clarify that bleeding risk factors should be assessed to identify modifiable issues, rather than as a reason to permanently withhold oral anticoagulant therapy. There is an opportunity to substantially reduce the morbidity and health-system costs related to atrial fibrillation through patient education related to symptom management and adherence to appropriate stroke prevention therapy. Copyright © 2014 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
Saleem, TS Mohamed; Bharani, K; Chetty, C Madhusudhana; Gauthaman, K
Atrial fibrillation is the most common type of tachyarrhythmia caused by multiple re-entrant wave forms within the atria and bombarding the atrioventricular node several times making it beat in a rapid, disorganized fashion termed “fibrillation”. In atrial fibrillation, atria beat more than 300 times per minute. The arrhythmatous condition needs to be controlled, as humans cannot withstand this rapid and chaotic beating of the heart. New investigational drugs like Dronedarone® are being used. Dronedarone is the most recent antiarrhythmic drugs. It was approved by US-FDA on July 2nd 2009 and is available in the USA as Multaq tablets (400 mg). Dronedarone falls under the category of multiple ion channel blocker. It mainly targets the repolarization currents, making them less active and hence prolonging the action potential duration (APD). Dronedarone also exhibits antiadrenergic activity, thus reducing the pace of the pacemaker. Dronedarone has been proven to be a safer and efficacious AAD, evidenced by both animal and human studies. These studies showed that there was prolongation of the APD and absence of QT interval prolongation with long term administration of the drug. Also there was reduced thyroid hormone receptor expression. Dronedarone is significantly safer and effective in maintaining the sinus rhythm and reducing the ventricular proarrhythmias, justifying it for the long term treatment of atrial fibrillation compared to other antiarrhythmic drugs. PMID:27147833
Many studies have reported that there is no significant difference in survival rate between rhythm control and rate control strategies in combination of with anticoagulation in patients with atrial fibrillation. Even in patients with atrial fibrillation and with heart failure there is no significant difference in survival rate between both strategies. There is no need of strict rate control. In patients with permanent atrial fibrillation, lemient rate control(resting heart rate of below 110 beats per minute) is as effective as strict rate control (< 70 beats per minute) and easier to achieve. Digitalis, beta-blockers and Ca channel blockers are used for rate control treatments. Digitalis is the only drug that has both decreasing ventricular response by suppressing atrioventricular conduction and inotropic effects. However, digitalis can not suppress heart rates during exercise. Beta-blockers and Ca channel blockers can suppress heart rates not only at rest but also during exercise. Ca channel blockers can not be used for patients with heart failure due to reduction in contractility of heart muscle. It has been reported that cardiac function and survival rate can be improved by beta-blockers in patients with heart failure if starting low dose and increasing gradually.
Bozorgmanesh, R; Magdesian, K G; Estell, K E; Stern, J A; Swain, E A; Griffiths, L G
There is limited information on the incidence of clinical signs, concurrent illness and treatment options for atrial fibrillation (AF) in New World Camelids (NWC). Describe clinical signs and outcome of AF in NWC. Eight New World Camelids admitted with AF. A retrospective observational study of camelids diagnosed with AF based on characteristic findings on electrocardiogram (ECG). All animals had an irregularly irregular heart rhythm detected on physical examination and 4 cases had obtunded mentation on admission. Three camelids were diagnosed with AF secondary to oleander intoxication, 3 animals had underlying cardiovascular disease, 1 was diagnosed with lone AF and 1 had AF diagnosed on examination for a urethral obstruction. Five of eight animals survived to discharge and nonsurvivors consisted of animals which died or were euthanized as a result of cardiovascular disease (2/8) or extra-cardiac disease unrelated to the AF (1/8). Atrial fibrillation occurs in NWC in association with cardiovascular disease, extra-cardiac disease or as lone AF. Amiodarone and transthoracic cardioversion were attempted in one llama with lone AF, but were unsuccessful. Atrial fibrillation was recorded in 0.1% of admissions. Copyright © 2015 The Authors. Journal of Veterinary Internal Medicine published by Wiley Periodicals, Inc. on behalf of the American College of Veterinary Internal Medicine.
Razminia, Mansour; Demo, Hany; Arrieta-Garcia, Carlos; D'Silva, Oliver J; Wang, Theodore; Kehoe, Richard F
The conventional method of cryoballoon ablation of atrial fibrillation involves the use of fluoroscopy for visual guidance. The use of fluoroscopy is accompanied by significant radiation risks to the patient and the medical staff. Herein, we report our experience in performing successful nonfluoroscopic pulmonary vein isolation using cryoballoon ablation in 5 consecutive patients with paroxysmal atrial fibrillation. Five consecutive patients with paroxysmal atrial fibrillation underwent cryoballoon ablation for pulmonary vein isolation using a nonfluoroscopic approach. Pre-procedural cardiac computed tomography or cardiac magnetic resonance imaging was not performed in any patient. A total of twenty pulmonary veins were identified and successfully isolated (100%) with the guidance of intracardiac echocardiography and 3-dimensional electroanatomic mapping. No fluoroscopy was used for the procedures. There were no major procedural adverse events. In an unselected group of patients undergoing cryoballoon ablation, a nonfluoroscopic approach is feasible and can be performed safely and effectively while eliminating the risks associated with radiation to both the patient and the medical staff.
Korompoki, Eleni; Del Giudice, Angela; Hillmann, Steffi; Malzahn, Uwe; Gladstone, David J; Heuschmann, Peter; Veltkamp, Roland
Background and purpose The detection rate of atrial fibrillation has not been studied specifically in transient ischemic attack (TIA) patients although extrapolation from ischemic stroke may be inadequate. We conducted a systematic review and meta-analysis to determine the rate of newly diagnosed atrial fibrillation using different methods of ECG monitoring in TIA. Methods A comprehensive literature search was performed following a pre-specified protocol the PRISMA statement. Prospective observational studies and randomized controlled trials were considered that included TIA patients who underwent cardiac monitoring for >12 h. Primary outcome was frequency of detection of atrial fibrillation ≥30 s. Analyses of subgroups and of duration and type of monitoring were performed. Results Seventeen studies enrolling 1163 patients were included. The pooled atrial fibrillation detection rate for all methods was 4% (95% CI: 2-7%). Yield of monitoring was higher in selected (higher age, more extensive testing for arrhythmias before enrolment, or presumed cardioembolic/cryptogenic cause) than in unselected cohorts (7% vs 3%). Pooled mean atrial fibrillation detection rates rose with duration of monitoring: 4% (24 h), 5% (24 h to 7 days) and 6% (>7 days), respectively. Yield of non-invasive was significantly lower than that of invasive monitoring (4% vs. 11%). Significant heterogeneity was observed among studies (I(2)=60.61%). Conclusion This first meta-analysis of atrial fibrillation detection in TIA patients finds a lower atrial fibrillation detection rate in TIA than reported for IS and TIA cohorts in previous meta-analyses. Prospective studies are needed to determine actual prevalence of atrial fibrillation and optimal diagnostic procedure for atrial fibrillation detection in TIA.
Verrier, Richard L; Fuller, Henrique; Justo, Fernanda; Nearing, Bruce D; Rajamani, Sridharan; Belardinelli, Luiz
Detection of atrial repolarization waves free of far-field signal contamination by ventricular activation would allow investigation of atrial electrophysiology and factors that influence susceptibility to atrial tachycardia and atrial fibrillation (AF). The purpose of this study was to identify means for high-resolution intracardiac recording of atrial repolarization (Ta) waves using standard clinical electrocatheters and to assess fundamental electrophysiologic properties relevant to AF risk. In alpha-chloralose anesthetized Yorkshire pigs, we studied effects of vagus nerve stimulation (VNS) on PTa and QT intervals and effects of acute atrial ischemia or administration of intrapericardial acetylcholine followed by intravenous epinephrine on susceptibility to AF. Electrocatheters with closely spaced (1-mm) electrode pairs yielded high-resolution tracings of atrial repolarization waves. These recordings permitted detection of differential effects of right or left VNS, which shortened atrial PTa interval by 30% vs. 21% (P <.01) and lengthened QT interval by 1.5% vs. 9%, respectively (P < .05). During atrial ischemia, STa segments were elevated 3.4-fold (P < .01), and the threshold for inducing AF was reduced 3.1-fold (P = .004). Ischemia amplified atrial T-wave alternans (TWAa) and spatiotemporal heterogeneity (TWHa) by 23- and 13-fold, respectively, in inverse correlation to AF threshold (r = 0.74, P <.01; r = 0.61, P = .03). TWAa and TWHa increased by 4.5- and 2-fold shortly before autonomically triggered atrial premature beats and AF. This study used standard electrocatheters to demonstrate that TWAa and TWHa analysis provides means to assess vulnerability to AF without provocative electrical stimuli. These parameters could be evaluated in the clinical electrophysiology laboratory to determine risk for this prevalent arrhythmia and efficacy of contemporary and new agents. Copyright © 2016 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.
Zaman, Junaid A B; Peters, Nicholas S; Narayan, Sanjiv M
Rotors have long been postulated to drive atrial fibrillation, but evidence has been limited to animal models. This changed recently with the demonstration using focal impulse and rotor modulation (FIRM) mapping that rotors act as human atrial fibrillation sources. This mechanistic approach to diagnosing the causes of atrial fibrillation in individual patients has been supported by substantially improved outcomes from FIRM-guided ablation, resulting in increased attention to rotors as therapeutic targets. In this review, we outline the pathophysiology of rotors in animal and in-silico studies of fibrillation, and how this motivated FIRM mapping in humans. We highlight the characteristics of rotors in human atrial fibrillation, now validated by several techniques, with discussion on similar and discrepant findings between techniques. The interventional approaches to eliminate atrial fibrillation rotors are explained and the ablation results in latest studies using FIRM are discussed. We propose that mapping localized sources for human atrial fibrillation, specifically rotors, is moving the field towards a unifying hypothesis that explains several otherwise contradictory observations in atrial fibrillation management. We conclude by suggesting areas of potential research that may reveal more about these critical sites and how these may lead to better and novel treatments for atrial fibrillation.
Berntsson, John; Smith, J Gustav; Nilsson, Peter M; Hedblad, Bo; Melander, Olle; Engström, Gunnar
Background The increasing prevalence of atrial fibrillation and novel therapeutic tools to prevent cardioembolic stroke has increased the need for risk markers. Objectives This study explored the relationship between the midregional sequence of pro-atrial natriuretic peptide (MR-proANP) levels with the risk of atrial fibrillation and stroke, and whether measurement of MR-proANP improves the prediction of these outcomes. Methods MR-proANP was measured in fasting blood samples of 5130 subjects (69% men, mean age 69.2 ± 6.2 years) without a history of atrial fibrillation or stroke from the general population. The incidence of atrial fibrillation and stroke was monitored over a median follow-up of 5.6 years. C-statistics and net reclassification improvement was used to assess the predictive ability of MR-proANP in addition to conventional risk factors. Results Log-normalized MR-proANP was significantly associated with the incidence of atrial fibrillation ( n = 362; hazard ratio (HR); 95% confidence interval (CI) per 1 standard deviation (SD) 2.05, 1.86-2.27) and stroke from all causes ( n = 195; HR 1.30; 95% CI 1.12-1.50). The HR for stroke events related to atrial fibrillation was 1.79 (95% CI 1.25-2.58) per 1 SD. MR-proANP significantly improved the prediction of atrial fibrillation when added to a risk score of conventional risk factors (C statistic 0.69 vs. 0.75), mainly by down-classifying subjects who did not develop atrial fibrillation. A smaller improvement in predictive ability was observed for stroke (C statistic 0.66 vs. 0.68). Conclusion High plasma levels of MR-proANP are associated with the incidence of atrial fibrillation and stroke in the middle-aged and elderly population. MR-proANP may be useful to identify individuals with an increased risk of atrial fibrillation.
Csanádi, Zoltán; Fazekas, Tamás; Varró, András
The authors provide an update on non-pharmacological treatment of atrial fibrillation (AF). They emphasize that although antiarrhythmic drugs continue to be first-line therapy for the arrhythmia considered to be a cardiovascular epidemic, clinical research to develop non-pharmacological means of treatment has been unprecedentally intensified during the last decade. Electrical cardioversion is the most successful non-pharmacological method to restore sinus rhythm, also the efficacy and safety of AV node ablation for palliative ventricular rate-controll is established. "Hybrid" therapeutic procedures, involving combinations of pharmacological and non-pharmacological interventions have gained widespread use. Curative transcatheter ablation for arrhythmia prevention is to be considered in case of clinical suggestions that AF is initiated by a primary regular arrhythmia that is amenable to routine catheter ablation (secondary AF). Despite encouraging results, at this point in time, curative catheter ablation for primary AF may offer significant improvement or even cure only for a small subset of patients, mostly young individuals with normal heart, and paroxysmal AF with frequent, symptomatic episodes refractory to multiple antiarrhythmic drugs. These interventions are to be performed in the settings of a clinical research project in some institutions. Regarding pacemaker therapy in case of bradycardia indication, physiologic pacing (AAI or DDD) is associated with significantly lower incidence of atrial fibrillation than ventricular pacing. Large-scale randomized controlled trials are needed to assess the clinical value of specially designed implantable devices to prevent atrial fibrillation in patients with no conventional bradycardia indication. Also, technical optimization and proper clinical evaluation is needed for implantable atrioverters and implantable cardioverter defibrillators capable of atrial cardioversion therapy.
Today management of atrial fibrillation (AF) centers on restoration and maintenance of normal sinus rhythm or control of the ventricular rate response to AF. Current guidelines state that rhythm and rate control strategies should be considered therapeutically equivalent, but recognize that no "one size fits all," an approach consistent with growing recognition of the heterogeneity of AF. As data from the Sotalol Amiodarone Atrial Fibrillation Efficacy Trial clearly demonstrate, conventional antiarrhythmics have a role in highly symptomatic AF accompanied by decreased quality of life. However, for many AF patients such drugs lack efficacy, have potentially serious side effects, and are poorly tolerated. In parallel with the development of more effective and safer antiarrhythmics, nontraditional approaches to prevention and treatment of AF are being explored. Treatments not considered "antiarrhythmic" that may prevent or forestall AF include aggressive antihypertensive therapy with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and some, but not all, beta-blockers and calcium channel antagonists, especially when used as adjunctive therapy. Other approaches include statins, steroids, and fish oil to reduce atrial fibrosis and inflammation, and pacemakers to prevent bradycardia-mediated AF and as a pacing preventive strategy in selected patients. Ablative techniques with potential to cure AF are gaining popularity, but are not yet simple, straightforward, and risk-free procedures. In the future, treatment of AF will progress beyond today's focus on AF as a purely electrocardiographic disease toward a patient and context-specific management strategy involving multiple treatment modalities.
Siontis, Konstantinos C; Oral, Hakan
The landscape of the invasive management of atrial fibrillation, the most common sustained arrhythmia in humans, has changed dramatically in the last decade owing to numerous advances in arrhythmia mapping and ablation technologies. The current review critically appraises novel interventional strategies for the treatment of atrial fibrillation with a focus on clinical effectiveness and safety. PMID:27403294
Cervigón, Raquel; Moreno, Javier; Millet, José; Pérez-Villacastín, Julián; Castells, Francisco
Since the cardiac activity during atrial fibrillation (AF) may be influenced by autonomic modulations, in this study, a novel method to quantify the effects of the most common anesthetic agent (propofol) in AF ablation procedures is introduced. This study has two main objectives: first, to assess whether the sedation earlier to radio frequency ablation affects the arrhythmia itself, and second, to provide new information that contributes to a better understanding of the influence of the autonomic nervous system on AF. The methodology presented is based on the measurement of synchronization and delay indexes between two atrial activations at adjacent intracavitary electrodes. These parameters aim to estimate whether two activations at different sites may be caused by the same propagating wavefront, or otherwise, are the consequence of independent wavefronts. The results showed that the mentioned indexes have a different behavior at both atria: the right atrium becomes more synchronized with propofol administration, whereas the synchronization index decreases at the left atrium.
Patients with valvular heart disease frequently have atrial fibrillation(AF) due to elevated pressure and dilatation of the left and right atria and pulmonary veins. Guidelines for valvular heart disease and AF recommend that surgical treatment for the valvular heart disease should be performed concomitantly with AF surgery. The Full-Maze procedure has evolved into the gold standard of treatment for medically refractory AF. In addition to the pulmonary vein isolation, the right and left atrial incisions of the Full-Maze procedure are designed to block potential macroreentrant pathways. According to the mechanisms of AF with valvular heart disease, the Full-Maze procedure is more effective for the patients than the pulmonary vein isolation alone.
Bachmann, Justin M; Majmudar, Maulik; Tompkins, Christine; Blumenthal, Roger S; Marine, Joseph E
Atrial fibrillation (AF) is a common cardiac arrhythmia with significant morbidity and public health cost. Because of limitations of efficacy and safety of conventional antiarrhythmic agents, alternative therapies for AF are needed. The potential antiarrhythmic properties of lipid-altering therapy, including the 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors and fish oils, are increasingly recognized, particularly in light of their potential anti-inflammatory properties. This review examines the known effects of lipid-altering therapy on atrial arrhythmias in both experimental and clinical settings. Inflammatory states, such as post-cardiac surgery and AF of recent onset, show promise as targets. In contrast, lipid-lowering therapy is less likely to affect longstanding persistent AF. Current recommendations for the use of lipid-altering therapy for prevention and treatment of AF are summarized.
Verma, Atul; Jiang, Chen-yang; Betts, Timothy R; Chen, Jian; Deisenhofer, Isabel; Mantovan, Roberto; Macle, Laurent; Morillo, Carlos A; Haverkamp, Wilhelm; Weerasooriya, Rukshen; Albenque, Jean-Paul; Nardi, Stefano; Menardi, Endrj; Novak, Paul; Sanders, Prashanthan
Catheter ablation is less successful for persistent atrial fibrillation than for paroxysmal atrial fibrillation. Guidelines suggest that adjuvant substrate modification in addition to pulmonary-vein isolation is required in persistent atrial fibrillation. We randomly assigned 589 patients with persistent atrial fibrillation in a 1:4:4 ratio to ablation with pulmonary-vein isolation alone (67 patients), pulmonary-vein isolation plus ablation of electrograms showing complex fractionated activity (263 patients), or pulmonary-vein isolation plus additional linear ablation across the left atrial roof and mitral valve isthmus (259 patients). The duration of follow-up was 18 months. The primary end point was freedom from any documented recurrence of atrial fibrillation lasting longer than 30 seconds after a single ablation procedure. Procedure time was significantly shorter for pulmonary-vein isolation alone than for the other two procedures (P<0.001). After 18 months, 59% of patients assigned to pulmonary-vein isolation alone were free from recurrent atrial fibrillation, as compared with 49% of patients assigned to pulmonary-vein isolation plus complex electrogram ablation and 46% of patients assigned to pulmonary-vein isolation plus linear ablation (P=0.15). There were also no significant differences among the three groups for the secondary end points, including freedom from atrial fibrillation after two ablation procedures and freedom from any atrial arrhythmia. Complications included tamponade (three patients), stroke or transient ischemic attack (three patients), and atrioesophageal fistula (one patient). Among patients with persistent atrial fibrillation, we found no reduction in the rate of recurrent atrial fibrillation when either linear ablation or ablation of complex fractionated electrograms was performed in addition to pulmonary-vein isolation. (Funded by St. Jude Medical; ClinicalTrials.gov number, NCT01203748.).
Müssigbrodt, A; Weber, A; Mandrola, J; van Belle, Y; Richter, S; Döring, M; Arya, A; Sommer, P; Bollmann, A; Hindricks, G
An interesting and still not well-understood example for old medical wisdom "Sola dosis facit venenum" is the increased prevalence of atrial fibrillation (AF) in athletes. Numerous studies have shown a fourfold to eightfold increased risk of AF in athletes compared to the normal population. Analysis of the existing data suggests a dose-dependent effect of exercise. Moderate exercise seems to have a protective effect and decreases the risk of AF, whereas excessive exercise seems to increase the risk of AF. The described cases illustrate clinical manifestations within the spectrum of AF in elderly athletes, that is, exercise-induced AF, vagal AF, chronic AF, and atrial flutter. As the arrhythmia worsened quality of life and exercise capacity in all patients, recovery of sinus rhythm was desired in all described cases. As the atrial disease was advanced on different levels, different treatment regimes were applied. Lifestyle modification and temporary anti-arrhythmic drug therapy could stabilize sinus rhythm in one patient, whereas others needed radiofrequency ablation to achieve a stable sinus rhythm. The patient with the most advanced atrial disease necessitated anti-arrhythmic drug therapy and another left atrial ablation. All described patients remained in sinus rhythm during the long-term follow-up. © 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.
Tarver, William J.
Concerns about heart dysrhythmia have been present since the earliest days of the US manned space program. While information about an astronaut's health is general kept private, one of the original seven American astronaut's health status was played out in a very public forum. Donald "Deke" Slayton was removed from the second manned space flight when it was discovered he had idiopathic atrial fibrillation. Referencing the original medical documents, details of how this was discovered and managed from the medical perspective will be reviewed. This is NASA's first heart dysrhythmia case in an astronaut and it proves quite interesting when placed in historic perspective.
Mahida, Saagar; Sacher, Frederic; Derval, Nicolas; Berte, Benjamin; Yamashita, Seigo; Hooks, Darren; Denis, Arnaud; Amraoui, Sana; Hocini, Meleze; Haissaguerre, Michel; Jais, Pierre
Over the past few decades, significant progress has been made in understanding the mechanistic basis of atrial fibrillation (AF). One of the most important discoveries in this context has been that pulmonary veins (PV) play a prominent role in the pathogenesis of AF. PV isolation has since become the most widely used technique for treatment of paroxysmal AF. Multiple studies have demonstrated that the electrophysiological and anatomical characteristics of PVs create a proarrhythmogenic substrate. The following review discusses the mechanistic links between PVs and AF. PMID:26835098
Cha, Myung-Jin; Park, Hyo Eun; Lee, Min-Ho; Cho, Youngjin; Choi, Eue-Keun; Oh, Seil
Varied silent ischemic stroke (SS) prevalence occurs in patients with atrial fibrillation (AF). Stroke history is worth 2 points in the CHADS2 scoring system. An unknown proportion of patients with AF with a CHADS2 score of 0 or 1 have been undertreated for stroke prevention. We investigated SS risk factors using magnetic resonance imaging and estimated SS impact on clinical outcomes in patients with AF. We analyzed a total of 1,200 patients (400 with AF and 800 with sinus rhythm) who had brain magnetic resonance imaging performed for routine health checkups. Clinical outcomes including symptomatic stroke, dementia, and cognitive disorder were also evaluated in patients with AF (follow-up duration: 66.7 ± 35.9 months; range 10 to 162). SS was observed in 113 patients with AF (28.3%), which was significantly higher than that in 53 subjects (6.6%) with sinus rhythm (p <0.001, odds ratio [OR] 5.549). Independent risk factors for SS in patients with AF were age (OR 1.049), hypertension (OR 2.086), dyslipidemia (OR 2.073), and valvular AF (OR 3.157). Symptomatic stroke incidence during the follow-up was significantly greater in patients with AF with SS than without SS (5.6% vs 2.7% per year, respectively; p = 0.022, hazard ratio 1.787, 95% confidence interval 1.089 to 2.933). Using current scoring systems without correcting for subclinical stroke, clinicians have likely underestimated the stroke risk in low-risk patients with AF; thus many patients with AF might not receive optimal anticoagulation treatment. In conclusion, a screening tool for detecting SS could be considered for stroke risk evaluation in patients with AF, especially those with valvular AF, elderly patients, and patients with dyslipidemia or hypertension. Copyright © 2014 Elsevier Inc. All rights reserved.
Hergens, Maria-Pia; Galanti, Rosaria; Hansson, Jenny; Fredlund, Peeter; Ahlbom, Anders; Alfredsson, Lars; Bellocco, Rino; Eriksson, Marie; Fransson, Eleonor I; Hallqvist, Johan; Jansson, Jan-Håkan; Knutsson, Anders; Pedersen, Nancy; Lagerros, Ylva Trolle; Ostergren, Per-Olof; Magnusson, Cecilia
Snus is a smokeless tobacco product, widely used among Swedish men and increasingly so elsewhere. There is debate as to whether snus is an acceptable "harm-reduction" tobacco product. Since snus use delivers a dose of nicotine equivalent to cigarettes, and has been implicated in cardiac arrhythmia because of associations with sudden cardiovascular death, a relation with atrial fibrillation is plausible and important to investigate. To assess the relation between use of snus and risk of atrial fibrillation, we carried out a pooled analysis of 7 prospective Swedish cohort studies. In total, 274,882 men, recruited between 1978 and 2004, were followed via the National Patient Register for atrial fibrillation. Primary analyses were restricted to 127,907 never-smokers. Relative risks were estimated using Cox proportional hazard regression. The prevalence of snus use was 25% among never-smokers. During follow-up, 3,069 cases of atrial fibrillation were identified. The pooled relative risk of atrial fibrillation was 1.07 (95% confidence interval = 0.97-1.19) in current snus users, compared with nonusers. Findings from this large national pooling project indicate that snus use is unlikely to confer any important increase in risk of atrial fibrillation.
Gomes da Silva, Ananília Medeiros; Silbiger, Vivian Nogueira
Atrial fibrillation (AF) is a highly prevalent arrhythmia with pronounced morbidity and mortality. Genetics analysis has established electrophysiological substrates, which determine individual vulnerability to AF occurrence and maintenance. MicroRNAs (miRNAs) found in virtually all organisms function as negative regulators of protein-coding genes. Several studies have suggested a role for miRNAs in the regulation of cardiac excitability and arrhythmogenesis. This review is based on 18 studies conducted between 2009 and 2013 to investigate the association of miRNAs with AF. miRNAs are discussed here as candidate biomarkers for AF in blood and cardiac tissues and as potential targets for AF therapy.
Heck, Patrick M; Lee, Justin M S; Kistler, Peter M
Atrial fibrillation (AF) is an important and often-underrecognized cause of cardiovascular morbidity and mortality. It is an arrhythmia that is commonly seen in the older patient; the median age of patients with AF in early studies was 75 years. Heart failure (HF) is also more frequently seen in the older patient with an approximate doubling of HF prevalence with each decade of life. There is clear interaction between AF and HF, with evidence that HF can lead to AF and AF exacerbates HF. This review focuses on the specific aspect of AF management in elderly patients with HF.
Raphael, Claire E.
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia seen in clinical practice with prevalence in excess of 33 million worldwide. Although often asymptomatic and until recently considered a “benign” arrhythmia, it is now appreciated that thromboembolism resulting from AF results in significant morbidity and mortality predominantly due to stroke. Although an arrhythmia more commonly affecting the elderly, AF can also occur in the young. This review focuses on the impact of AF in the younger population and discusses the dilemmas of managing younger patients with AF. PMID:25922764
Ros, E; Mota, S; Toro, F J; Díaz, A F; Fernández, F J
The objective of the paper is to describe an automatic algorithm for Paroxysmal Atrial Fibrillation (PAF) Detection, based on parameters extracted from ECG traces with no atrial fibrillation episode. The modular automatic classification algorithm for PAF diagnosis is developed and evaluated with different parameter configurations. The database used in this study was provided by Physiobank for The Computers in Cardiology Challenge 2001. Each ECG file in this database was translated into a 48 parameter vector. The modular classification algorithm used for PAF diagnosis was based on the nearest K-neighbours. Several configuration options were evaluated to optimize the classification performance. Different configurations of the proposed modular classification algorithm were tested. The uni-parametric approach achieved a top classification rate value of 76%. A multi-parametric approach was configured using the 5 parameters with highest discrimination power, and a top classification rate of 80% was achieved; different functions to typify the parameters were tested. Finally, two automatic parametric scanning strategies, Forward and Backward methods, were adopted. The results obtained with these approaches achieved a top classification rate of 92%. A modular classification algorithm based on the nearest K-neighbours was designed. The classification performance of the algorithm was evaluated using different parameter configurations, typification functions and number of K-neighbors. The automatic parametric scanning techniques achieved much better results than previously tested configurations.
Thomas, S P; Boyd, A C; Aggarwal, G; Jin, Y; Ross, D L
Transvenous catheter ablation for the treatment of atrial fibrillation is an evolving technique. The purpose of this study was to identify subgroups of patients most likely to benefit from pulmonary vein electrical isolation. Patients with symptomatic atrial fibrillation resistant to pharmacological therapy were studied. Mapping-guided segmental application of radio-frequency energy was used to electrically isolate the pulmonary veins in 74 patients. Ischaemic or dilated cardiomyopathy was present in 34% of patients. Atrial fibrillation had been present for a mean time (+/- standard deviation) of 6.6 +/- 6.1 years. It was paroxysmal in 53 patients (72%). The mean number of procedures was 1.6/patient. After 6 +/- 6 months, 73% of patients (54/74) were in sinus rhythm. Thirteen of those in sinus rhythm were using anti-arrhythmic medications (25%). Recurrence of atrial fibrillation soon after pulmonary vein isolation occurred in 50%. Patients with persistent/permanent atrial fibrillation were less likely to be in sinus rhythm at follow up (11/21 (52%) vs 43/53 (81%); P = 0.01). However, the rate of early recurrence was similar in the intermittent and the persistent/permanent groups (26/53 (49%) vs 11/21(52%), respectively; P-value not significant). Patients with persistent atrial fibrillation were more likely to experience a recurrence of atrial fibril-lation (89%; P = 0.04). No other baseline factors predicted procedural success. Cardiac tamponade occurred in two patients and moderate pulmonary vein stenosis (>50% diameter narrowing) occurred in three patients. Pulmonary vein isolation is an effective curative treatment for a broad group of patients with atrial fibrillation. However, the procedure is only suitable for patients with problematic atrial fibrillation resistant to other therapies because of the small risk of serious complications.
... Treatment of Atrial Fibrillation; Guidance for Industry and Food and Drug Administration Staff; Availability... Ablation Devices for Treatment of Atrial Fibrillation.'' This guidance provides FDA's recommendations on clinical trial designs for surgical ablation devices intended for the treatment of atrial...
Ogunsua, Adedotun A; Shaikh, Amir Y; Ahmed, Mohamed; McManus, David D
Atrial fibrillation (AF) is an increasingly prevalent condition and the most common sustained arrhythmia encountered in ambulatory and hospital practice. Several clinical risk factors for AF include age, sex, valvular heart disease, obesity, sleep apnea, heart failure, and hypertension (HTN). Of all the risk factors, HTN is the most commonly encountered condition in patients with incident AF. Hypertension is associated with a 1.8-fold increase in the risk of developing new-onset AF and a 1.5-fold increase in the risk of progression to permanent AF. Hypertension predisposes to cardiac structural changes that influence the development of AF such as atrial remodeling. The renin angiotensin aldosterone system has been demonstrated to be a common mechanistic link in the pathogenesis of HTN and AF. Importantly, HTN is one of the few modifiable AF risk factors, and guideline-directed management of HTN may reduce the incidence of AF.
Floria, Mariana; Drug, Vasile Liviu
We have read with interest the paper by Roman C. and colleagues discussing the relationship between gastroesophageal reflux disease and atrial fibrillation. The review is presenting the available evidence for the common pathogenic mechanisms. However, from a cardiologist perspective, some available data were not highlighted in the review, cardiovascular involvement in gastroesophageal reflux is less assessed. Hypertension, obesity or diabetes mellitus are substrate for left atrial remodeling that initiate and sustained atrial fibrillation development. One of the pathophysiologic mechanisms in atrial fibrillation is the presence of a trigger. Gastroesophageal reflux could be only a trigger for this arrhythmia. We believe that atrial fibrillation should be considered as possible extraesophageal syndrome in the gastroesophageal reflux classification.
Olesen, Jonas Bjerring; Gislason, Gunnar Hilmar; Torp-Pedersen, Christian; Lip, Gregory Y H
This article provides an overview of (i) the risk of stroke associated with vascular disease (acute coronary syndromes and peripheral artery disease) in patients with atrial fibrillation, (ii) the frequent coexistence of vascular disease in patients with atrial fibrillation and, (iii) the cardiovascular risk associated with the coexisting of the two diseases. The literature on this topic is relatively sparse, and we discuss results from both clinical trials and observational studies. There is a clear indication of an increased stroke risk associated with vascular disease in patients with atrial fibrillation. Indeed, patients with atrial fibrillation often had coexisting vascular disease (around 18%), and the combination of the two diseases substantially increases the risk of future cardiovascular events. The increased risk associated with peripheral artery disease in atrial fibrillation is even more pronounced. Patients with atrial fibrillation and stable vascular disease should be treated with oral anticoagulation only, although when these patients present with acute coronary syndrome and/or undergo coronary stenting, concomitant treatment with antiplatelet drugs is indicated. To guide antithrombotic management in patients with atrial fibrillation, several stroke and bleeding risk prediction schemes have been developed. © 2012 Wiley Periodicals, Inc.
Safaei, Nasser; Montazerghaem, Hossein; Azarfarin, Rasoul; Alizadehasl, Azin; Alikhah, Hossein
Atrial Fibrillation (AF) is the most common cardiac arrhythmia which represents a major public health problem. The main purpose of this research is to evaluate the Radiofrequency (RF) ablation effects in the patients with chronic AF scheduled for cardiac surgery because of different heart diseases. The descriptive and prospective study was conducted on 60 patients with AF scheduled for surgery along with RF ablation. The data were collected by questionnaire and included: patients' age, sex, NYHA class, operation type, past medical history, type and cause of valvular heart disease, preoperative ECG (electrocardiogram), duration of surgery, clamping time, cardiopulmonary bypass, and RF ablation time. RF ablation was followed by the main operation. The follow up examination, ECG, and echocardiography were performed 3 and 6 months after operation. The mean age of patients was 48±10 years (18-71 years). Forty one patients had permanent AF and 19 had the persistent AF. The left ventricular ejection fraction was 48.27±9.75 percent before operation, and reached to 56.27±7.87 percent after the surgery (P<0.001). The mean NYHA class before the surgery was 2.83±0.68 which decreased to 1.34±0.46 6 months after the surgery with RF ablation (P<0.001). One patient (1.6%) died after surgery. Complete relief and freedom from AF recurrence was observed in 70% of patients in the mean follow up in 7 months after the surgery. The sinus rhythm with efficient atrial contraction was established in 100% of discharged patients. RF ablation is an effective procedure to cure atrial fibrillation in patients undergoing cardiac surgeries.
Atrial fibrillation (AF) remains the most common cardiac arrhythmia, affecting nearly 2% of the general population worldwide. Minimally invasive surgical ablation remains one of the most dynamically evolving fields of modern cardiac surgery. While there are more than a dozen issues driving this development, two seem to play the most important role: first, there is lack of evidence supporting percutaneous catheter based approach to treat patients with persistent and long-standing persistent AF. Paucity of this data offers surgical community unparalleled opportunity to challenge guidelines and change indications for surgical intervention. Large, multicenter prospective clinical studies are therefore of utmost importance, as well as honest, clear data reporting. Second, a collaborative methodology started a long-awaited debate on a Heart Team approach to AF, similar to the debate on coronary artery disease and transcatheter valves. Appropriate patient selection and tailored treatment options will most certainly result in better outcomes and patient satisfaction, coupled with appropriate use of always-limited institutional resources. The aim of this review, unlike other reviews of minimally invasive surgical ablation, is to present medical professionals with two distinctly different, approaches. The first one is purely surgical, Standalone surgical isolation of the pulmonary veins using bipolar energy source with concomitant amputation of the left atrial appendage—a method of choice in one of the most important clinical trials on AF—The Atrial Fibrillation Catheter Ablation Versus Surgical Ablation Treatment (FAST) Trial. The second one represents the most complex approach to this problem: a multidisciplinary, combined effort of a cardiac surgeon and electrophysiologist. The Convergent Procedure, which includes both endocardial and epicardial unipolar ablation bonds together minimally invasive endoscopic surgery with electroanatomical mapping, to deliver best of
Wijesurendra, Rohan S.; Casadei, Barbara
Atrial fibrillation (AF) is the most common sustained clinical arrhythmia and is associated with significant morbidity, mostly secondary to heart failure and stroke, and an estimated two-fold increase in premature death. Efforts to increase our understanding of AF and its complications have focused on unravelling the mechanisms of electrical and structural remodelling of the atrial myocardium. Yet, it is increasingly recognized that AF is more than an atrial disease, being associated with systemic inflammation, endothelial dysfunction, and adverse effects on the structure and function of the left ventricular myocardium that may be prognostically important. Here, we review the molecular and in vivo evidence that underpins current knowledge regarding the effects of human or experimental AF on the ventricular myocardium. Potential mechanisms are explored including diffuse ventricular fibrosis, focal myocardial scarring, and impaired myocardial perfusion and perfusion reserve. The complex relationship between AF, systemic inflammation, as well as endothelial/microvascular dysfunction and the effects of AF on ventricular calcium handling and oxidative stress are also addressed. Finally, consideration is given to the clinical implications of these observations and concepts, with particular reference to rate vs. rhythm control. PMID:25587048
Wijesurendra, Rohan S; Casadei, Barbara
Atrial fibrillation (AF) is the most common sustained clinical arrhythmia and is associated with significant morbidity, mostly secondary to heart failure and stroke, and an estimated two-fold increase in premature death. Efforts to increase our understanding of AF and its complications have focused on unravelling the mechanisms of electrical and structural remodelling of the atrial myocardium. Yet, it is increasingly recognized that AF is more than an atrial disease, being associated with systemic inflammation, endothelial dysfunction, and adverse effects on the structure and function of the left ventricular myocardium that may be prognostically important. Here, we review the molecular and in vivo evidence that underpins current knowledge regarding the effects of human or experimental AF on the ventricular myocardium. Potential mechanisms are explored including diffuse ventricular fibrosis, focal myocardial scarring, and impaired myocardial perfusion and perfusion reserve. The complex relationship between AF, systemic inflammation, as well as endothelial/microvascular dysfunction and the effects of AF on ventricular calcium handling and oxidative stress are also addressed. Finally, consideration is given to the clinical implications of these observations and concepts, with particular reference to rate vs. rhythm control. © The Author 2015. Published by Oxford University Press on behalf of the European Society of Cardiology.
Petrėnas, Andrius; Sörnmo, Leif; Lukoševičius, Arūnas; Marozas, Vaidotas
This work introduces a novel approach to the detection of brief episodes of paroxysmal atrial fibrillation (PAF). The proposed detector is based on four parameters which characterize RR interval irregularity, P-wave absence, f-wave presence, and noise level, of which the latter three are determined from a signal produced by an echo state network. The parameters are used for fuzzy logic classification where the decisions involve information on prevailing signal quality; no training is required. The performance is evaluated on a large set of test signals with brief episodes of PAF. The results show that episodes with as few as five beats can be reliably detected with an accuracy of 0.88, compared to 0.82 for a detector based on rhythm information only (the coefficient of sample entropy); this difference in accuracy increases when atrial premature beats are present. The results also show that the performance remains essentially unchanged at noise levels up to [Formula: see text] RMS. It is concluded that the combination of information on ventricular activity, atrial activity, and noise leads to substantial improvement when detecting brief episodes of PAF.
Kamel, Hooman; Okin, Peter M.; Longstreth, W. T.; Elkind, Mitchell S.V.; Soliman, Elsayed Z.
Atrial fibrillation (AF) has long been associated with a heightened risk of ischemic stroke and systemic thromboembolism, but recent data require a re-evaluation of our understanding of the nature of this relationship. New findings about the temporal connection between AF and stroke, alongside evidence linking markers of left atrial abnormalities with stroke in the absence of apparent AF, suggest that left atrial thromboembolism may occur even without AF. These observations undermine the hypothesis that the dysrhythmia that defines AF is necessary and sufficient to cause thromboembolism. In this commentary, we instead suggest that the substrate for thromboembolism may often be the anatomic and physiological atrial derangements associated with AF. Therefore, our understanding of cardioembolic stroke may be more complete if we shift our representation of its origin from AF to the concept of atrial cardiopathy. PMID:26021638
Delanaye, Pierre; Bouquegneau, Antoine; Dubois, Bernard E; Sprynger, Muriel; Mariat, Christophe; Krzesinski, Jean-Marie; Lancellotti, Patrizio
Cardiovascular mortality of hemodialysis patients remains a major problem. The prevalence and incidence of atrial fibrillation in this population are more important than in the general population. The indication of antivitamin K therapy (AVK) in this context of atrial fibrillation must be weighted against the increased risk of bleeding. Unfortunately, and contrary to the general population, an indication of anticoagulation based on embolic or hemorrhagic risk scores is not as clearly established in the hemodialysis population. No prospective randomized study has investigated the benefit/risk balance of anticoagulant treatment in hemodialysis subjects. This article is a review of the current literature on this topic, showing the prevalence of thromboembolic but also bleeding events in the hemodialysis population. The impact of AVK treatment in this specific population is also reviewed. To the best of our knowledge, the indication of treatment must be individualized. Copyright © 2016 Association Société de néphrologie. Published by Elsevier Masson SAS. All rights reserved.
Hussein, Ayman A.; Saliba, Walid I.; Barakat, Amr; Bassiouny, Mohammed; Chamsi-Pasha, Mohammed; Al-Bawardy, Rasha; Hakim, Ali; Tarakji, Khaldoun; Baranowski, Bryan; Cantillon, Daniel; Dresing, Thomas; Tchou, Patrick; Martin, David O.; Varma, Niraj; Bhargava, Mandeep; Callahan, Thomas; Niebauer, Mark; Kanj, Mohamed; Chung, Mina; Natale, Andrea; Lindsay, Bruce D.; Wazni, Oussama M.
Background Various ablation strategies of persistent atrial fibrillation (PersAF) have had disappointing outcomes, despite concerted clinical and research efforts, which could reflect progressive atrial fibrillation–related atrial remodeling. Methods and Results Two-year outcomes were assessed in 1241 consecutive patients undergoing first-time ablation of PersAF (2005–2012). The time intervals between the first diagnosis of PersAF and the ablation procedures were determined. Patients had echocardiograms and measures of B-type natriuretic peptide and C-reactive protein before the procedures. The median diagnosis-to-ablation time was 3 years (25th–75th percentiles 1–6.5). With longer diagnosis-to-ablation time (based on quartiles), there was a significant increase in recurrence rates in addition to an increase in B-type natriuretic peptide levels (P=0.01), C-reactive protein levels (P<0.0001), and left atrial size (P=0.03). The arrhythmia recurrence rates over 2 years were 33.6%, 52.6%, 57.1%, and 54.6% in the first, second, third, and fourth quartiles, respectively (Pcategorical<0.0001). In Cox Proportional Hazard analyses, B-type natriuretic peptide levels, C-reactive protein levels, and left atrial size were associated with arrhythmia recurrence. The diagnosis-to-ablation time had the strongest association with the ablation outcomes which persisted in multivariable Cox analyzes (hazard ratio for recurrence per +1Log diagnosis-to-ablation time 1.27, 95% confidence interval 1.14–1.43; P<0.0001; hazard ratio fourth versus first quartile 2.44, 95% confidence interval 1.68–3.65; Pcategorical<0.0001). Conclusions In patients with PersAF undergoing ablation, the time interval between the first diagnosis of PersAF and the catheter ablation procedure had a strong association with the ablation outcomes, such as shorter diagnosis-to-ablation times were associated with better outcomes and in direct association with markers of atrial remodeling. PMID:26763227
De Bortoli, Alessandro; Shi, Li-Bin; Ohm, Ole-Jørgen; Hoff, Per Ivar; Schuster, Peter; Solheim, Eivind; Chen, Jian
We sought to investigate the incidence of atrial fibrillation after catheter ablation for typical atrial flutter and to determine the predictors for symptomatic atrial fibrillation that required a further additional dedicated ablation procedure. 127 patients underwent elective cavotricuspid isthmus ablation with the indication of symptomatic, typical atrial flutter. The occurrence of atrial flutter, atrial fibrillation, cerebrovascular events and the need for additional ablation procedures for symptomatic atrial fibrillation was assessed during long-term follow-up. The majority of patients (70%) manifested atrial fibrillation during a follow-up period of 68 ± 24 months, and a significant proportion (42%) underwent one or multiple atrial fibrillation ablation procedures after an average of 26 months from the index procedure. Recurrence of typical atrial flutter was rare. Ten patients (8%) suffered cerebrovascular events. Earlier documentation of atrial fibrillation (OR 3.53), previous use of flecainide (OR 3.33) and left atrial diameter (OR 2.96) independently predicted occurrence of atrial fibrillation during the follow-up. A combination of pre- and intra-procedural documentation of atrial fibrillation (OR 3.81) and previous use of flecainide (OR 2.43) independently predicted additional atrial fibrillation ablation. Atrial fibrillation occurred in the majority of patients after ablation for typical atrial flutter and 42% of them required an additional dedicated ablation procedure. Pre- and intraprocedural documentation of atrial fibrillation together with previous use of flecainide independently predicted atrial fibrillation occurrence and a need for additional ablation. Anticoagulation treatment should be continued in high-risk patients in spite of clinical disappearance of atrial flutter.
Mead, G E; Elder, A T; Flapan, A D; Kelman, A
Atrial fibrillation increases stroke risk and adversely affects cardiovascular haemodynamics. Electrical cardioversion may, by restoring sinus rhythm, improve cardiovascular haemodynamics, reduce the risk of stroke, and obviate the need for long-term anticoagulation. To assess the effects of electrical cardioversion of atrial fibrillation or flutter on the risk of thromboembolic events, strokes and mortality (primary outcomes), the rate of cognitive decline, quality of life, the use of anticoagulants and the risk of re-hospitalisation (secondary outcomes) in adults (>18 years). We searched the Cochrane CENTRAL Register of Controlled Trials (1967 to May 2004), MEDLINE (1966 to May 2004), Embase (1980 to May 2004), CINAHL (1982 to May 2004), proceedings of the American College of Cardiology (published in Journal of the American College of Cardiology 1983 to 2003), www.trialscentral.org, www.controlled-trials.com and reference lists of articles. We hand-searched the indexes of the Proceedings of the British Cardiac Society published in British Heart Journal (1980 to 1995) and in Heart (1995 to 2002); proceedings of the European Congress of Cardiology and meetings of the Joint Working Groups of the European Society of Cardiology (published in European Heart Journal 1983-2003); scientific sessions of the American Heart Association (published in Circulation 1990-2003). Personal contact was made with experts. Randomised controlled trial or controlled clinical trials of electrical cardioversion plus 'usual care' versus 'usual care' only, where 'usual care' included any combination of anticoagulants, antiplatelet drugs and drugs for 'rate control'. We excluded trials which used pharmacological cardioversion as the first intervention, and trials of new onset atrial fibrillation after cardiac surgery. There were no language restrictions. For dichotomous data, odds ratios were calculated; and for continuous data, the weighted mean difference was calculated. We found three
Patel, Manesh R; Mahaffey, Kenneth W; Garg, Jyotsna; Pan, Guohua; Singer, Daniel E; Hacke, Werner; Breithardt, Günter; Halperin, Jonathan L; Hankey, Graeme J; Piccini, Jonathan P; Becker, Richard C; Nessel, Christopher C; Paolini, John F; Berkowitz, Scott D; Fox, Keith A A; Califf, Robert M
The use of warfarin reduces the rate of ischemic stroke in patients with atrial fibrillation but requires frequent monitoring and dose adjustment. Rivaroxaban, an oral factor Xa inhibitor, may provide more consistent and predictable anticoagulation than warfarin. In a double-blind trial, we randomly assigned 14,264 patients with nonvalvular atrial fibrillation who were at increased risk for stroke to receive either rivaroxaban (at a daily dose of 20 mg) or dose-adjusted warfarin. The per-protocol, as-treated primary analysis was designed to determine whether rivaroxaban was noninferior to warfarin for the primary end point of stroke or systemic embolism. In the primary analysis, the primary end point occurred in 188 patients in the rivaroxaban group (1.7% per year) and in 241 in the warfarin group (2.2% per year) (hazard ratio in the rivaroxaban group, 0.79; 95% confidence interval [CI], 0.66 to 0.96; P<0.001 for noninferiority). In the intention-to-treat analysis, the primary end point occurred in 269 patients in the rivaroxaban group (2.1% per year) and in 306 patients in the warfarin group (2.4% per year) (hazard ratio, 0.88; 95% CI, 0.74 to 1.03; P<0.001 for noninferiority; P=0.12 for superiority). Major and nonmajor clinically relevant bleeding occurred in 1475 patients in the rivaroxaban group (14.9% per year) and in 1449 in the warfarin group (14.5% per year) (hazard ratio, 1.03; 95% CI, 0.96 to 1.11; P=0.44), with significant reductions in intracranial hemorrhage (0.5% vs. 0.7%, P=0.02) and fatal bleeding (0.2% vs. 0.5%, P=0.003) in the rivaroxaban group. In patients with atrial fibrillation, rivaroxaban was noninferior to warfarin for the prevention of stroke or systemic embolism. There was no significant between-group difference in the risk of major bleeding, although intracranial and fatal bleeding occurred less frequently in the rivaroxaban group. (Funded by Johnson & Johnson and Bayer; ROCKET AF ClinicalTrials.gov number, NCT00403767.).
Connolly, Stuart J; Eikelboom, John; Joyner, Campbell; Diener, Hans-Christoph; Hart, Robert; Golitsyn, Sergey; Flaker, Greg; Avezum, Alvaro; Hohnloser, Stefan H; Diaz, Rafael; Talajic, Mario; Zhu, Jun; Pais, Prem; Budaj, Andrzej; Parkhomenko, Alexander; Jansky, Petr; Commerford, Patrick; Tan, Ru San; Sim, Kui-Hian; Lewis, Basil S; Van Mieghem, Walter; Lip, Gregory Y H; Kim, Jae Hyung; Lanas-Zanetti, Fernando; Gonzalez-Hermosillo, Antonio; Dans, Antonio L; Munawar, Muhammad; O'Donnell, Martin; Lawrence, John; Lewis, Gayle; Afzal, Rizwan; Yusuf, Salim
Vitamin K antagonists have been shown to prevent stroke in patients with atrial fibrillation. However, many patients are not suitable candidates for or are unwilling to receive vitamin K antagonist therapy, and these patients have a high risk of stroke. Apixaban, a novel factor Xa inhibitor, may be an alternative treatment for such patients. In a double-blind study, we randomly assigned 5599 patients with atrial fibrillation who were at increased risk for stroke and for whom vitamin K antagonist therapy was unsuitable to receive apixaban (at a dose of 5 mg twice daily) or aspirin (81 to 324 mg per day), to determine whether apixaban was superior. The mean follow up period was 1.1 years. The primary outcome was the occurrence of stroke or systemic embolism. Before enrollment, 40% of the patients had used a vitamin K antagonist. The data and safety monitoring board recommended early termination of the study because of a clear benefit in favor of apixaban. There were 51 primary outcome events (1.6% per year) among patients assigned to apixaban and 113 (3.7% per year) among those assigned to aspirin (hazard ratio with apixaban, 0.45; 95% confidence interval [CI], 0.32 to 0.62; P<0.001). The rates of death were 3.5% per year in the apixaban group and 4.4% per year in the aspirin group (hazard ratio, 0.79; 95% CI, 0.62 to 1.02; P=0.07). There were 44 cases of major bleeding (1.4% per year) in the apixaban group and 39 (1.2% per year) in the aspirin group (hazard ratio with apixaban, 1.13; 95% CI, 0.74 to 1.75; P=0.57); there were 11 cases of intracranial bleeding with apixaban and 13 with aspirin. The risk of a first hospitalization for cardiovascular causes was reduced with apixaban as compared with aspirin (12.6% per year vs. 15.9% per year, P<0.001). The treatment effects were consistent among important subgroups. In patients with atrial fibrillation for whom vitamin K antagonist therapy was unsuitable, apixaban reduced the risk of stroke or systemic embolism without
Ricard, P; Socas, A G; Taramasco, V; Guenoun, M; Lévy, S
The efficacy and safety of low internal cardioversion for the reduction of atrial fibrillation was assessed prospectively in 104 consecutive patients. Sixty-two patients had chronic atrial fibrillation (Group I). 16 patients had paroxysmal atrial fibrillation (Group II) and 26 patients had induced atrial fibrillation (Group III). The average duration of the current episode of atrial fibrillation was 9 +/- 19 months in Group I, 4 +/- 2 days in Group II and 18 +/- 7 minutes in Group III. Two intracardiac defibrillation catheters were used, one (the cathode) in the right atrium and the other in the coronary sinus or left branch of the pulmonary artery (anode). These catheters were connected to an external defibrillator delivering biphasic 3/3 ms shocks with a voltage which could be programmed from 10 to 400 volts. The shocks were synchronised on the R wave. Sinus rhythm was restored in 44 of the 62 patients in Group I (70%), 12 of the 16 patients in Group II (75%) and 20 of the 26 patients in Group III (77%). The average voltages and energies restoring sinus rhythm were 300 +/- 68 volts and 3.5 +/- 1.5 joules respectively in Group I, 245 +/- 72 volts and 2.0 +/- 2.9 joules in Group II, and 270 +/- 67 volts and 2.6 +/- 1.2 joules in Group III. These results show that the energy required to restore sinus rhythm is significantly greater in patients with chronic atrial fibrillation than in patients with paroxysmal or induced atrial fibrillation. There were no ventricular proarrhythmic effects in the 686 shocks synchronised on the R wave. This study shows that internal cardioversion of atrial fibrillation is feasible with low energies under simple sedation. These results support the concept of an implantable atrial defibrillator.
Compostella, Leonida; Russo, Nicola; D’Onofrio, Augusto; Setzu, Tiziana; Compostella, Caterina; Bottio, Tomaso; Gerosa, Gino; Bellotto, Fabio
Introduction Complete denervation of transplanted heart exerts protective effect against postoperative atrial fibrillation; various degrees of autonomic denervation appear also after transection of ascending aorta during surgery for aortic aneurysm. Objective This study aimed to evaluate if the level of cardiac denervation obtained by resection of ascending aorta could exert any effect on postoperative atrial fibrillation incidence. Methods We retrospectively analysed the clinical records of 67 patients submitted to graft replacement of ascending aorta (group A) and 132 with aortic valve replacement (group B); all episodes of postoperative atrial fibrillation occurred during the 1-month follow-up have been reported. Heart Rate Variability parameters were obtained from a 24-h Holter recording; clinical, echocardiographic and treatment data were also evaluated. Results Overall, 45% of patients (group A 43%, group B 46%) presented at least one episode of postoperative atrial fibrillation. Older age (but not gender, abnormal glucose tolerance, ejection fraction, left atrial diameter) was correlated with incidence of postoperative atrial fibrillation. Only among a subgroup of patients with aortic transection and signs of greater autonomic derangement (heart rate variability parameters below the median and mean heart rate over the 75th percentile), possibly indicating more profound autonomic denervation, a lower incidence of postoperative atrial fibrillation was observed (22% vs. 54%). Conclusion Transection of ascending aorta for repair of an aortic aneurysm did not confer any significant protective effect from postoperative atrial fibrillation in comparison to patients with intact ascending aorta. It could be speculated that a limited and heterogeneous cardiac denervation was produced by the intervention, creating an eletrophysiological substrate for the high incidence of postoperative atrial fibrillation observed. PMID:25859868
Gomes, Eva; Campos, Rui; Morais, Renata; Fernandes, Marta
Introdução: A fibrilhação auricular é a arritmia sustentada mais prevalente. Está provada a eficácia da anticoagulação oral na prevenção do acidente vascular cerebral nestes doentes. Contudo, este parece ser um tratamento subutilizado. Objectivos: determinar a prevalência de fibrilhação auricular conhecida numa população dos Cuidados de Saúde Primários; identificar as principais comorbilidades, a terapêutica antitrombótica em curso e avaliar a sua adequação segundo as recomendações da European Society of Cardiology. Material e Métodos: Estudo observacional transversal analítico. População: todos os utentes com idade igual ou superior a 30 anos, inscritos em oito Unidades de Saúde Familiar de Vila Nova de Gaia, com diagnóstico de fibrilhação auricular. Resultados: A prevalência de fibrilhação auricular foi de 1,29% (n = 940), sendo superior no género masculino (p = 0,01) e aumentando com a idade (p < 0,001). As comorbilidades mais frequentes foram a hipertensão arterial (76,4%), a insuficiência cardíaca (32,0%) e a diabetes mellitus (28,2%). Um total de 52% realizava terapêutica anticoagulante, 29% antiagregantes plaquetários e 4% ambas as terapêuticas. Dos utentes com baixo risco trombótico, 63,6% estava a fazer erradamente algum tipo de terapêutica antitrombótica; dos utentes com elevado risco ou doença valvular 56,8% estava adequadamente sob terapêutica anticoagulante. Conclusão: A prevalência de fibrilhação auricular bem como a frequência das principais comorbilidades estão de acordo com a maioria dos estudos. Apesar de a maioria dos doentes se encontrar sob anticoagulação oral, apenas 56,8% dos utentes com fibrilhação auricular fazia terapêutica antitrombótica adequada segundo as recomendações da European Society of Cardiology, verificando-se uma subutilização acentuada deste tratamento.
Zeus, Tobias; Kelm, Malte; Bode, Christoph
Thrombo-embolic prophylaxis is a key element within the therapy of atrial fibrillation/atrial flutter. Besides new oral anticoagulants the concept of left atrial appendage occlusion has approved to be a good alternative option, especially in patients with increased risk of bleeding.
Gourraud, Jean-Baptiste; Andrade, Jason G; Macle, Laurent
The invasive management of atrial fibrillation (AF) has been considerably changed by the identification of major sites of AF initiation and/or maintenance within the pulmonary vein antra. Percutaneous catheter ablation of these targets has become the standard of care for sustained maintenance of sinus rhythm. Long-term failure of ablation is related to an inability to create a durable transmural lesion or to identify all of the non-pulmonary vein arrhythmia triggers. Pharmacological challenges during catheter ablation have been suggested to improve outcomes in both paroxysmal and persistent AF. Herein we review the mechanism and evidence for the use of pharmacological adjuncts during the catheter ablation of AF. PMID:28116081
Alonso, Alvaro; Arenas de Larriva, Antonio P.
Atrial fibrillation (AF) is a common cardiac arrhythmia. Growing evidence supports a role for AF as a risk factor for cognitive decline and dementia. In this review, we summarize epidemiologic observations linking AF with cognitive outcomes, describe potential mechanisms, and explore the impact of AF treatments on cognitive decline and dementia. Community-based, observational studies show a consistent higher rate of cognitive decline and risk of dementia in persons with AF. These associations are partly due to the increased risk of clinical stroke in AF, but other mechanisms, including incidence of silent cerebral infarcts, microbleeds, and cerebral hypoperfusion, are likely additional contributors. Adequate oral anticoagulation and improved management of the overall cardiovascular risk profile in persons with AF offer the promise of reducing the impact of AF on cognitive decline and dementia. PMID:27547248
Sra, Jasbir; Akhtar, Masood
Atrial fibrillation (AF) is a common arrhythmia. Although significant work still needs to be done, recent advances in understanding the mechanism of AF have led to the development of elegant catheter mapping techniques for ablation of AF. These improved mapping techniques are complemented by an evolution in various imaging and navigational technologies, several of which can now be combined in a process called registration, so that the physician no longer needs to rely solely on a mental image of the anatomy of the left atrium and the pulmonary vein while attempting to ablate the region. Ongoing advances in mapping technique will increase safety and efficacy and it is likely that AF ablation will become the first-line therapy in most patients with this complicated arrhythmia.
How, Choon How
Anticoagulation therapy is effective in preventing primary and secondary thromboembolic events due to atrial fibrillation. Warfarin, which was approved by the United States in 1954, was the only long-term oral anticoagulation therapy till the approval of dabigatran in 2010, and of rivaroxaban and other direct factor Xa inhibitors from 2011, forming a group known as novel oral anticoagulants (NOAC). NOAC have fewer food and drug interactions compared to warfarin; hence, the patient will require fewer clinic visits. However, the short half-life of NOAC means that twice-a-day dosing is needed and there is higher risk of a prothrombotic state when doses are missed. Other disadvantages are the lack of long-term data on NOAC, their high cost and the current lack of locally available antidotes. PMID:26702159
Non-vitamin K antagonist (VKA) oral anticoagulants (NOACs) have emerged as alternatives to VKAs for the prevention of stroke in patients with non-valvular atrial fibrillation. Four NOACS: dabigatran, apixaban, rivaroxaban and edoxaban, have received regulatory approval in Europe from the European Medicines Agency. Numerous factors can influence the decision to prescribe a NOAC, the most important of which are assessment of stroke and bleeding risks. Given the variation in design of the pivotal phase III clinical trials investigating the efficacy and safety of NOACs, and in the absence of head-to-head comparative data, it is impossible to recommend one NOAC over the other. However, NOACS offer the opportunity for individualised therapy based on factors such as renal function, age or patient/doctor preference for once- or twice-daily dosing regimens. Dose reduction of some NOACS should be considered in at-risk patient populations. PMID:27617088
Wells, Gretchen L.; Morris, Peter E.
Background Although the mortality rate among patients with sepsis is declining, the incidence of both sepsis and sepsis-related deaths is increasing, likely due to its presence in a growing elderly population. As atrial fibrillation is more common in the elderly, we hypothesize that its presence will be associated with greater mortality among patients with sepsis. Methods The Medical Intensive Care Unit (MICU) database of a large tertiary care medical center was queried for sepsis-related codes and atrial fibrillation. Results Atrial fibrillation was associated with older age and a higher mortality in this series of patients with sepsis. Conclusions Whether atrial fibrillation is a marker of disease severity or contributes to mortality is uncertain. Further studies are necessary to determine optimal management.
Littrell, Rachel; Flaker, Greg
Until recently, pharmaceutical options for stroke prevention in atrial fibrillation were restricted to aspirin or vitamin K antagonist therapy. In recent years development has been underway for alternatives. Apixaban, a direct Factor Xa inhibitor, is orally dosed, target selective and has few known drug or food interactions. As such, it is a member of a new generation of anticoagulants expected to revolutionize the way we approach anticoagulation for stroke prevention in atrial fibrillation. Apixaban has been studied in Phase II and Phase III trials for a variety of indications. The AVERROES trial established apixaban as superior to aspirin for stroke reduction in patients with atrial fibrillation for whom vitamin K antagonist therapy is unsuitable. The recent ARISTOTLE trial found apixaban to be superior to warfarin for stroke prevention in a wide range of patients with atrial fibrillation, with significantly lower bleeding risk, and lower risk of all-cause mortality.
da Silva, Rose Mary Ferreira Lisboa
Inflammation markers have been associated with cardiovascular diseases including atrial fibrillation. This arrhythmia is the most frequent, with an incidence of 38/1000 person-years. The aims of this study are to discuss the association between inflammation, atherosclerosis and atrial fibrillation and its clinical implications. Atherosclerosis is a chronic inflammatory disease and inflammation is a triggering factor of atherosclerotic plaque rupture. In addition to coronary artery disease, clinical conditions identified as risk factors for atrial fibrillation (AF) are also associated with the inflammatory state such as obesity, diabetes mellitus, hypertension, heart failure, metabolic syndrome and sedentary lifestyle. Biomarkers of inflammation, oxidative stress, coagulation, and myocardial necrosis have been identified in patients with atrial fibrillation and these traditional risk factors. Some markers of inflammation were identified as predictors of recurrence of this arrhythmia, subsequent myocardial infarction, stroke by embolism, and death. Thus, approaches to manipulate the inflammatory pathways may be therapeutic interventions, benefiting patients with AF and increased inflammatory markers.
The precise mechanisms of clinical effect of antiarrhythmic agents and the ideal "molecular targets" against arrhythmias, in particular atrial fibrillation, are poorly understood. Current antiarrhythmic drug development, particularly for drugs expected to be active against atrial fibrillation, has focused on drugs with multiple ionic mechanisms of action, in particular on those that block multiple potassium channels. Investigation of antiarrhythmic agents is complicated by the diversity of animal-disease models studied, by the potential multiple mechanisms of arrhythmias, and by the incompletely understood relationships between risks and benefits of antiarrhythmic drug therapy. Furthermore, rhythm control strategies in large groups of patients with atrial fibrillation have failed to show substantial clinical benefit. Nevertheless, drugs that block multiple potassium channels and appear to have relatively little organ toxicity, such as tedisamil, may represent an important new avenue in the therapeutic approach to highly symptomatic arrhythmias such as atrial fibrillation.
Gouveia, Miguel; Costa, João; Alarcão, Joana; Augusto, Margarida; Caldeira, Daniel; Pinheiro, Luís; Vaz Carneiro, António; Borges, Margarida
Atrial fibrillation is the most prevalent sustained arrhythmia. This paper estimates the burden and cost of illness attributable to atrial fibrillation in Portugal based on demographic and health statistics. Mortality data by cause of death came from the European Detailed Mortality Database of the World Health Organization (WHO). Hospital data were taken from the Portuguese diagnosis-related groups database. The burden of disease was measured using DALYs (disability-adjusted life years), a metric adopted by the WHO. Costs studied included resource use and lost productivity. The burden and cost of illness are those attributable to atrial fibrillation and its main complication, ischemic stroke. In Portugal, 4070 deaths were attributable to atrial fibrillation in 2010, corresponding to 3.8% of all deaths. In total, the burden of disease attributable to atrial fibrillation was estimated at 23,084 DALYs: 10,521 resulting from premature deaths (1.7% of the total DALYs due to death in 2010 in Portugal), and 12,563 resulting from disability. The total estimated direct costs attributable to atrial fibrillation at 2013 prices were €115 million: €34 million for inpatient care and €81 million for outpatient care. Indirect costs resulting from lost production due to disability were estimated at €25 million. Atrial fibrillation has an important social impact in Portugal due to its associated mortality and morbidity, and was responsible in 2013 for a total cost of €140 million, about 0.08% of gross domestic product. Copyright © 2014. Published by Elsevier España.
Da Poian, Giulia; Liu, Chengyu; Bernardini, Riccardo; Rinaldo, Roberto; Clifford, Gari D
Compressive sensing (CS) approaches to electrocardiogram (ECG) analysis provide efficient methods for real time encoding of cardiac activity. In doing so, it is important to assess the downstream effect of the compression on any signal processing and classification algorithms. CS is particularly suitable for low power wearable devices, thanks to its low-complex digital or hardware implementation that directly acquires a compressed version of the signal through random projections. In this work, we evaluate the impact of CS compression on atrial fibrillation (AF) detection accuracy. We compare schemes with data reconstruction based on wavelet and Gaussian models, followed by a P&T-based identification of beat-to-beat (RR) intervals on the MIT-BIH atrial fibrillation database. A state-of-the-art AF detector is applied to the RR time series and the accuracy of the AF detector is then evaluated under different levels of compression. We also consider a new beat detection procedure which operates directly in the compressed domain, avoiding costly signal reconstruction procedures. We demonstrate that for compression ratios up to 30[Formula: see text] the AF detector applied to RR intervals derived from the compressed signal exhibits results comparable to those achieved when employing a standard QRS detector on the raw uncompressed signals, and exhibits only a 2% accuracy drop at a compression ratio of 60%. We also show that the Gaussian-based reconstruction approach is superior in terms of AF detection accuracy, with a negligible drop in performance at a compression ratio ⩽75%, compared to a wavelet approach, which exhibited a significant drop in accuracy at a compression ratio ⩾65%. The results suggest that CS should be considered as a plausible methodology for both efficient real time ECG compression (at moderate compression rates) and for offline analysis (at high compression rates).
Bayturan, Ozgur; Puri, Rishi; Tuzcu, E Murat; Shao, Mingyuan; Wolski, Kathy; Schoenhagen, Paul; Kapadia, Samir; Nissen, Steven E; Sanders, Prashanthan; Nicholls, Stephen J
Background Despite atrial fibrillation representing an established risk factor for stroke, the association between atrial fibrillation and both progression of coronary atherosclerosis and major adverse cardiovascular events is not well characterized. We assessed the serial measures of coronary atheroma burden and cardiovascular outcomes in patients with and without atrial fibrillation. Methods Data were analyzed from nine clinical trials involving 4966 patients with coronary artery disease undergoing serial intravascular ultrasonography at 18-24 month intervals to assess changes in percent atheroma volume (PAV). Using a propensity weighted analysis, and following adjustment for baseline variables, patients with ( n = 190) or without ( n = 4776) atrial fibrillation were compared with regard to coronary plaque volume and major adverse cardiovascular events (death, myocardial infarction, and stroke). Results Atrial fibrillation patients demonstrated lower baseline PAV (36.0 ± 8.9 vs. 38.1 ± 8.9%, p = 0.002) and less PAV progression (-0.07 ± 0.34 vs. + 0.23 ± 0.34%, p = 0.001) compared with the non-atrial fibrillation group. Multivariable analysis revealed atrial fibrillation to independently predict both myocardial infarction [HR, 2.41 (1.74,3.35), p<0.001] 2.41 (1.74, 3.35), p < 0.00) and major adverse cardiovascular events [HR, 2.2, (1.66, 2.92), p<0.001] 2.20 (1.66, 2.92), p < 0.001]. Kaplan-Meier analysis showed that atrial fibrillation compared with non-atrial fibrillation patients had a significantly higher two-year cumulative incidence of overall major adverse cardiovascular events (4.4 vs. 2.0%, log-rank p = 0.02) and myocardial infarction (3.3 vs. 1.5%, log-rank p = 0.05). Conclusions The presence of atrial fibrillation independently associates with a heightened risk of myocardial infarction despite a lower baseline burden and progression rate of coronary atheroma. Further studies are necessary to define
TANAKA-ESPOSITO, CHRISTINE; CHUNG, MINA K.
When considering anticoagulant therapy for patients with atrial fibrillation, one must balance the reduction in risk of thromboembolism that this therapy offers against the risk of bleeding that it poses. The American Heart Association, American College of Cardiology, and Heart Rhythm Society updated their atrial fibrillation guidelines in 2014. This review outlines a rationale for clinical decision-making based on the new guidelines and summarizes the currently approved drugs. PMID:25552627
Roten, Laurent; Derval, Nicolas; Pascale, Patrizio; Scherr, Daniel; Komatsu, Yuki; Shah, Ashok; Ramoul, Khaled; Denis, Arnaud; Sacher, Frédéric; Hocini, Mélèze; Haïssaguerre, Michel; Jaïs, Pierre
Atrial fibrillation (AF) ablation has evolved to the treatment of choice for patients with drug-resistant and symptomatic AF. Pulmonary vein isolation at the ostial or antral level usually is sufficient for treatment of true paroxysmal AF. For persistent AF ablation, drivers and perpetuators outside of the pulmonary veins are responsible for AF maintenance and have to be targeted to achieve satisfying arrhythmia-free success rate. Both complex fractionated atrial electrogram (CFAE) ablation and linear ablation are added to pulmonary vein isolation for persistent AF ablation. Nevertheless, ablation failure and necessity of repeat ablations are still frequent, especially after persistent AF ablation. Pulmonary vein reconduction is the main reason for arrhythmia recurrence after paroxysmal and to a lesser extent after persistent AF ablation. Failure of persistent AF ablation mostly is a consequence of inadequate trigger ablation, substrate modification or incompletely ablated or reconducting linear lesions. In this review we will discuss these points responsible for AF recurrence after ablation and review current possibilities on how to overcome these limitations. PMID:22920482
German, David M; Kabir, Muammar M; Dewland, Thomas A; Henrikson, Charles A; Tereshchenko, Larisa G
Atrial fibrillation (AF) is the most common arrhythmia in adults and is associated with significant morbidity and mortality. Substantial interest has developed in the primary prevention of AF, and thus the identification of individuals at risk for developing AF. The electrocardiogram (ECG) provides a wealth of information, which is of value in predicting incident AF. The PR interval and P wave indices (including P wave duration, P wave terminal force, P wave axis, and other measures of P wave morphology) are discussed with regard to their ability to predict and characterize AF risk in the general population. The predictive value of the QT interval, ECG criteria for left ventricular hypertrophy, and findings of atrial and ventricular ectopy are also discussed. Efforts are underway to develop models that predict AF incidence in the general population; however, at present, little information from the ECG is included in these models. The ECG provides a great deal of information on AF risk and has the potential to contribute substantially to AF risk estimation, but more research is needed.
Chen, Xiaodong; Chen, Minglong; Wang, Yingying; Yang, Bing; Ju, Weizhu; Zhang, Fengxiang; Cao, Kejiang
Abstract We sought to investigate variation of atrial electromechanical interval after catheter ablation procedure in patients with persistent atrial fibrillation using pulse Doppler (PW) and pulse tissue Doppler imaging (PW-TDI). A total of 25 consecutive in-patients with persistent atrial fibrillation, who restored sinus rhythm after ablation procedure, were recruited in our cardiac center. Echocardiography was performed on each patient at 2 hours, 1 day, 5 days, 1 month and 3 months after the ablation therapy, and atrial electromechanical delay was measured simultaneously by PW and PW-TDI. There was no significant difference between PW and TDI in measuring atrial electromechanical delay. However, at postoperative 2 hours, peak A detection rates were mathematically but nonsignificantly greater by PW-TDI than by PW. Second, there was a significant decreasing trend in atrial electromechanical interval from postoperative 2 hours to 3 months, but only postoperative 2-hour atrial electromechanical interval was significantly greater than atrial electromechanical interval at other time. Lastly, patients without postoperative 2-hour atrial electromechanical interval had a significantly longer duration of atrial fibrillation as compared to those with postoperative 2-hour atrial electromechanical interval, by the PW or by PW-TDI, respectively. In patients with persistent atrial fibrillation, atrial electromechanical interval may decrease significantly within the first 24 hours after ablation but remain consistent later, and was significantly related to patients’ duration of atrial fibrillation. Atrial electromechanical interval, as a potential predicted factor, is recommended to be measured by either PW or TDI after 24 hours, when patients had recovered sinus rhythm by radiofrequency ablation. PMID:27924066
Tenekecioglu, Erhan; Agca, Fahriye Vatansever; Ozluk, Ozlem Arican; Karaagac, Kemal; Demir, Serafettin; Peker, Tezcan; Kuzeytemiz, Mustafa; Senturk, Muhammed; Yılmaz, Mustafa
Background Hypertension is the most prevalent and modifiable risk factor for atrial fibrillation. The pressure overload in the left atrium induces pathophysiological changes leading to alterations in contractile function and electrical properties. Objective In this study our aim was to assess left atrial function in hypertensive patients to determine the association between left atrial function with paroxysmal atrial fibrillation (PAF). Method We studied 57 hypertensive patients (age: 53±4 years; left ventricular ejection fraction: 76±6.7%), including 30 consecutive patients with PAF and 30 age-matched control subjects. Left atrial (LA) volumes were measured using the modified Simpson's biplane method. Three types of LA volume were determined: maximal LA(LAVmax), preatrial contraction LA(LAVpreA) and minimal LA volume(LAVmin). LA emptying functions were calculated. LA total emptying volume = LAVmax−LAVmin and the LA total EF = (LAVmax-LAVmin )/LAVmax, LA passive emptying volume = LAVmax− LAVpreA and the LA passive EF = (LAVmax-LAVpreA)/LAVmax, LA active emptying volume = LAVpreA−LAVmin and LA active EF = (LAVpreA-LAVmin )/LAVpreA. Results The hypertensive period is longer in hypertensive group with PAF. LAVmax significantly increased in hypertensive group with PAF when compared to hypertensive group without PAF (p=0.010). LAAEF was significantly decreased in hypertensive group with PAF as compared to hypertensive group without PAF (p=0.020). A' was decreased in the hypertensive group with PAF when compared to those without PAF (p = 0.044). Conclusion Increased LA volume and impaired LA active emptying function was associated with PAF in untreated hypertensive patients. Longer hypertensive period is associated with PAF. PMID:24676227
Staerk, Laila; Sherer, Jason A; Ko, Darae; Benjamin, Emelia J; Helm, Robert H
The past 3 decades have been characterized by an exponential growth in knowledge and advances in the clinical treatment of atrial fibrillation (AF). It is now known that AF genesis requires a vulnerable atrial substrate and that the formation and composition of this substrate may vary depending on comorbid conditions, genetics, sex, and other factors. Population-based studies have identified numerous factors that modify the atrial substrate and increase AF susceptibility. To date, genetic studies have reported 17 independent signals for AF at 14 genomic regions. Studies have established that advanced age, male sex, and European ancestry are prominent AF risk factors. Other modifiable risk factors include sedentary lifestyle, smoking, obesity, diabetes mellitus, obstructive sleep apnea, and elevated blood pressure predispose to AF, and each factor has been shown to induce structural and electric remodeling of the atria. Both heart failure and myocardial infarction increase risk of AF and vice versa creating a feed-forward loop that increases mortality. Other cardiovascular outcomes attributed to AF, including stroke and thromboembolism, are well established, and epidemiology studies have championed therapeutics that mitigate these adverse outcomes. However, the role of anticoagulation for preventing dementia attributed to AF is less established. Our review is a comprehensive examination of the epidemiological data associating unmodifiable and modifiable risk factors for AF and of the pathophysiological evidence supporting the mechanistic link between each risk factor and AF genesis. Our review also critically examines the epidemiological data on clinical outcomes attributed to AF and summarizes current evidence linking each outcome with AF. © 2017 American Heart Association, Inc.
Kalifa, J; Maixent, JM; Chalvidan, T; Dalmasso, C; Colin, D; Cozma, D; Laurent, P; Deharo, JC; Djiane, P; Cozzone, P; Bernard, M
Background and methods Perturbations in energetic metabolism and impaired atrial contractility may play an important role in the pathogenesis of atrial fibrillation (AF). Besides, atrial stretch is commonly associated with AF. However, the atrial energetics of stretch-related AF are poorly understood. Here, we measured indicators of energy metabolism during acute-stretch related AF. PCr, adenine nucleotides and derivatives concentrations as well as the activity of the F0F1-ATPase and Na,K-ATPase were obtained after one hour of stretch and/or AF in isolated rabbit hearts and compared to control hearts without stretch and AF. Results After one hour of stretch-related AF, the total adenine nucleotides pool was significantly lower (42.2±2.6 versus 63.7±8.3 µmol/g protein in control group, p<0.05) and the PCr/ATP ratio significantly higher (2.3±0.3 vs 1.1± 0.1 in control group p<0.05), because of ATP, ADP and AMP decrease and PCr increase. The sum of high energy phosphate compounds did not change. There were no significant differences in F0F1-ATPase nor Na,K-ATPase activity between the groups. Conclusions Results show that in this experimental model, acute-stretch related AF induces specific modifications of atrial myocytes energetics that may play a pivotal role in the perpetuation of the arrhythmia. PMID:18553177
detection of patients prone to atrial fibrillation (AF), one of the most frequent arrhythmias. It focuses first on the segmentation of the...Keywords : atrial fibrillation , ECG segmentation, P-wave, hidden Markov model, wavelets, ECG database I. INTRODUCTION Atrial fibrillation (AF) is a very... atrial thrombosis, with the subsequent risk of a stroke. The aim of this study is to try to automatically detect patients prone to atrial fibrillation (AF
Rabah, Ali; Wazni, Oussama
Atrial fibrillation and heart failure commonly coexist in the same patient. Each may adversely affect the other. Atrial fibrillation leads to heart failure exacerbation, left ventricular function deterioration and an increase in thrombo-embolic risk. Therapeutic options targeting atrial fibrillation in heart failure patients include pharmacological and non-pharmacological means. Pharmacological therapy is directed at either rate control using nodal blocking agents or rhythm control using anti-arrhythmic agents, of which the options are limited in patients with heart failure. The landmark AF-CHF trial did not show any benefit of rhythm control strategy as opposed to rate control in patients with heart failure and atrial fibrillation. However, patients in this trial as well as in others used mostly amiodarone for rhythm control. This might have negated any positive effects of achieving normal sinus rhythm. Non-pharmacological therapy both for rate and rhythm control is appealing. This includes AV node ablation for rate control, catheter ablation of atrial fibrillation and surgical therapy of atrial fibrillation. This review will address non-pharmacologic treatment of AF in heart failure patients.
Wagdi, Philipp; Salzer, Frank
Life expectancy of the population is steadily increasing world wide. Consequently, the incidence and ultimately the prevalence of atrial fibrillation (AF) and it’s sequelae will be rising proportionately. It is estimated that 3-5% of persons above 65 years of age have chronic AF, 30% of which will suffer at least one stroke. On the other hand, chronic AF is responsible for about 20% of all cerebrovascular accidents. Predictors of stroke in AF have been defined by the CHADS2 score, and in these patients, oral anticoagulation has been the cornerstone of thromboembolic disease prevention. Because elderly patients have an increased risk of bleeding complications even under the newer antagonists of Factor Xa and direct Thrombin inhibitors, percutaneous occlusion of the left atrial appendage (LAA) as the main thrombogenic source offers an attractive alternative to permanent anticoagulation. This promising new therapeutic approach is put into clinical real world perspective.
Khawar, Waqaar; Smith, Nathan; Masroor, Saqib
Patients with atrial fibrillation are at increased risk for thromboembolic stroke originating predominantly in the left atrial appendage. To reduce the risk, the standard of care is anticoagulation. In addition, several devices for exclusion of the left atrial appendage have been developed. PubMed was searched for articles relevant to left atrial appendage management. The resulting articles were reviewed as were relevant articles in their bibliographies. Relevant journals were manually searched for sources. Devices are being used for left atrial appendage exclusion by percutaneous and surgical approaches. Their indications, limitations, and outcomes are reviewed. Excision and exclusion of the left atrial appendage is safe and as effective as medical management of atrial fibrillation for stroke prevention. The choice of treatment should be made based on patients' anatomy, history, and preference informed by an appropriate left atrial appendage management team. Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.
Mathew, Joseph P; Fontes, Manuel L; Tudor, Iulia C; Ramsay, James; Duke, Peter; Mazer, C David; Barash, Paul G; Hsu, Ping H; Mangano, Dennis T
Atrial fibrillation is a common, but potentially preventable, complication following coronary artery bypass graft (CABG) surgery. To assess the nature and consequences of atrial fibrillation after CABG surgery and to develop a comprehensive risk index that can better identify patients at risk for atrial fibrillation. Prospective observational study of 4657 patients undergoing CABG surgery between November 1996 and June 2000 at 70 centers located within 17 countries, selected using a systematic sampling technique. From a derivation cohort of 3093 patients, associations between predictor variables and postoperative atrial fibrillation were identified to develop a risk model, which was assessed in a validation cohort of 1564 patients. New-onset atrial fibrillation after CABG surgery. A total of 1503 patients (32.3%) developed atrial fibrillation after CABG surgery. Postoperative atrial fibrillation was associated with subsequent greater resource use as well as with cognitive changes, renal dysfunction, and infection. Among patients in the derivation cohort, risk factors associated with atrial fibrillation were advanced age (odds ratio [OR] for 10-year increase, 1.75; 95% confidence interval [CI], 1.59-1.93); history of atrial fibrillation (OR, 2.11; 95% CI, 1.57-2.85) or chronic obstructive pulmonary disease (OR, 1.43; 95% CI, 1.09-1.87); valve surgery (OR, 1.74; 95% CI, 1.31-2.32); and postoperative withdrawal of a beta-blocker (OR, 1.91; 95% CI, 1.52-2.40) or an angiotensin-converting enzyme (ACE) inhibitor (OR 1.69; 95% CI, 1.38-2.08). Conversely, reduced risk was associated with postoperative administration of beta-blockers (OR, 0.32; 95% CI, 0.22-0.46), ACE inhibitors (OR, 0.62; 95% CI, 0.48-0.79), potassium supplementation (OR, 0.53; 95% CI, 0.42-0.68), and nonsteroidal anti-inflammatory drugs (OR, 0.49; 95% CI, 0.40-0.60). The resulting multivariable risk index had adequate discriminative power with an area under the receiver operating characteristic (ROC
Cadilhac, Dominique A
Stroke associated with atrial fibrillation may occur in up to one third of people who experience an ischemic event, and results in greater stroke severity and poorer health outcomes. The ageing population in developed and developing countries will lead to an increase in the prevalence of atrial fibrillation in society. Detecting people who have atrial fibrillation and ensuring optimal prevention management is essential for reducing the burden of stroke worldwide. There is evidence that use of anticoagulants is inadequate in primary and secondary prevention of stroke. New anticoagulants that have fewer side effects and population screening tools are available. However, there is little information available about the cost-effectiveness of these new options for atrial fibrillation detection and stroke prevention management over current practice. Since resources for spending in health are limited, it is essential that formal economic analyses are undertaken to ensure there are informed and evidence-based decisions on where to best invest stroke prevention resources. It is essential that renewed efforts in the area of atrial fibrillation and options for stroke prevention are undertaken within the public health research community.
Liew, Aaron; Eikelboom, John W; O'Donnell, Martin
The prevalence of atrial fibrillation is increasing because of an aging population. Vitamin K antagonists have been the standard therapy for stroke prevention in atrial fibrillation but are underutilized and often poorly managed because of their inherent limitations. This study critically reviews the recently completed phase 3 randomized controlled trials of new oral anticoagulants (OACs) for stroke prevention in patients with nonvalvular atrial fibrillation: RE-LY (dabigatran), AVERROES (apixaban), ARISTOTLE (apixaban) and ROCKET-AF (rivaroxaban). On the basis of their favorable pharmacological characteristics and excellent efficacy and safety profile as demonstrated by the results of the randomized controlled trials, the new OACs have the potential to replace vitamin K antagonists as the first-line treatment for stroke prevention in atrial fibrillation, with warfarin reserved for patients with contraindications to the new OACs and those unable to afford them. The new OACs represent a major advance for patients with atrial fibrillation with the potential to reduce morbidity and mortality due to cardioembolic stroke.
Afdala, Adfal; Nuryani, Nuryani; Satriyo Nugroho, Anto
Atrial Fibrillation is one of heart disease, that common characterized by irregularity heart beat. Atrial fibrillation leads to severe complications such as cardiac failure with the subsequent risk of a stroke. A method to detect atrial fibrillation is needed to prevent a risk of atrial fibrillation. This research uses data from physionet in atrial fibrillation database category. The performance of Shannon entropy has the highest accuracy if a threshold is 0.5 with accuracy 89.79%, sensitivity 91.04% and specificity 89.01%. Based on the result we get a conclusion, the ability of Shannon entropy to detect atrial fibrillation is good.
Aparina, O P; Chikhireva, L N; Stukalova, O V; Mironova, N A; Kashtanova, S Iu; Ternovoĭ, S K; Golitsyn, S P
Changes of atrial structure and function are the contributors of atrial fibrillation clinical course, complications and treatment effectiveness. Effects of inflammation and mechanical stretch on atrial structural remodeling leading to atrial fibrillation are reviewed in the article. Contemporary invasive and non-invasive methods of evaluation (including late gadolinium enhancement magnetic resonance imaging) of patients with atrial structural remodeling in atrial fibrillation are also described.
Olsson, Karen M; Nickel, Nils P; Tongers, Jörn; Hoeper, Marius M
Atrial flutter and fibrillation are being increasingly reported in patients with pulmonary hypertension but little is known about their clinical implications. We sought to determine the incidence and clinical impact of these arrhythmias in patients with pulmonary hypertension. In a 5-year, prospective study, we assessed the incidence of new-onset atrial flutter and fibrillation as well as risk factors, clinical consequences, management, and impact on survival in patients with pulmonary arterial hypertension (PAH, n=157) or inoperable chronic thromboembolic pulmonary hypertension (CTEPH, n=82). The cumulative 5-year incidence of new-onset atrial flutter and fibrillation was 25.1% (95% confidence interval, 13.8-35.4%). The development of these arrhythmias was frequently accompanied by clinical worsening (80%) and signs of right heart failure (30%). Stable sinus rhythm was successfully re-established in 21/24 (88%) of patients initially presenting with atrial flutter and in 16/24 (67%) of patients initially presenting with atrial fibrillation. New-onset atrial flutter and fibrillation were an independent risk factor of death (p=0.04, simple Cox regression analysis) with a higher mortality in patients with persistent atrial fibrillation when compared to patients in whom sinus rhythm was restored (estimated survival at 1, 2 and 3 years 64%, 55%, and 27% versus 97%, 80%, and 57%, respectively; p=0.01, log rank analysis). Atrial flutter and fibrillation develop in a sizable number of patients with PAH or inoperable CTEPH and often lead to clinical deterioration and right heart failure. Mortality is high when sinus rhythm cannot be restored. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.
Stewart, G A; Fulton, L J; McKellar, C D
Atrial fibrillation is described in a champion pacer which earlier had been named Australian Harness Horse of the Year as a 3-year-old in 1986-87. Prior to conversion atrial fibrillation had been present for at least 6 weeks, during which the horse had not raced. Successful treatment was achieved with two 10g doses of quinidine sulphate per oesophageal tube, after slow digitalisation with intravenous digoxin over 4d. Four hours after commencement of quinidine therapy the arrhythmia had regressed to atrial flutter and converted to sinus rhythm 10 min later. Considering his age, standard of racing and high reputation the horse's overall performance as a 5-year-old after conversion from atrial fibrillation appeared comparable to his previous performance as a 4-year-old before the disorder occurred. In one of the wins since his return to sinus rhythm, the horse recorded his fastest winning speed and created a new track record at the major Melbourne racetrack. The absence of abnormalities of atrial and atrio-ventricular conduction after the cessation of the arrhythmia, together with the horse's return to successful racing, indicate that this was case of atrial fibrillation occurring as a functional disorder without persistent atrial pathology.
Ricci, Renato Pietro
Device-detected atrial fibrillation (AF) episodes predict poor clinical outcome regardless of symptoms. Potential benefits of remote monitoring are early arrhythmia detection and patient continuous monitoring. Several studies of device remote monitoring consistently demonstrated that AF represents the most common clinical alert and that detailed information on arrhythmia onset, duration, and burden as well as on the ventricular rate may be early available for clinical evaluation. Reaction time to AF alerts was very short in all series involving either pacemakers or defibrillators and action ability of AF alerts was very high. In the Home Guide Registry, in which 1650 patients were enrolled, AF was detected in 16.3% of patients and represented 36% of all cardiovascular events during the follow-up. Timely anticoagulation introduction in asymptomatic patients may impact on the stroke rate. According to the results of repeated Monte Carlo simulations based on a real population of 166 patients, daily monitoring may reduce the 2-year stroke risk by 9-18% with an absolute reduction of 0.2-0.6%, compared with conventional inter-visit intervals of 6-12 months. In the COMPAS trial, the incidence of hospitalizations for atrial arrhythmias and related stroke was significantly higher in the control group than in the remote monitoring group. Major questions will be addressed by the ongoing IMPACT trial in which a remote monitoring guided anticoagulation strategy based on AF detection will be compared with a physician-directed standard strategy. In patients with heart failure, AF early detection combined with other indexes may help prevent hospitalizations.
Prystowsky, E N
Atrial fibrillation (AF) is the most common sustained arrhythmia in humans. The 3 basic tenets of therapy are (1) restoration and maintenance of sinus rhythm; (2) ventricular rate control; and (3) prevention of thromboembolism. Maintenance of sinus rhythm appears preferable to rate control alone in patients with significant symptoms caused by AF. Complete suppression of AF with drug therapy for >6 months is unusual, but it is not the sole criterion of success. As with other chronic cardiac disorders such as angina and heart failure, a marked reduction in frequency and duration of episodes of AF will likely translate into an excellent clinical outcome. The major risk of antiarrhythmic drug therapy is ventricular proarrhythmia, which is seen most frequently in patients with substantial left ventricular dysfunction. Torsade de pointes is the most frequent proarrhythmia that occurs with antiarrhythmic agents that prolong ventricular repolarization and the QT interval. To minimize the risk of proarrhythmia, antiarrhythmic drugs are started in-hospital in patients with significant heart disease, and agents are selected based on certain patient characteristics. For example, the drugs initially selected for patients with heart failure and coronary artery disease are amiodarone and sotalol, respectively. Two approaches may be used to decrease the thromboembolic risk associated with cardioversion of AF to sinus rhythm. In the conventional method, warfarin is given (INR 2.0-3.0) for 3 weeks before and at least 4 weeks after cardioversion. An alternative approach employs transesophageal echocardiography to rule out left atrial thrombi before cardioversion. Both methods appear reasonable and safe, and I prefer the conventional and transesophageal echocardiography-guided approaches for outpatients and in-hospital patients, respectively.
Dalal, Rahul S.; Sabe, Ashraf A.; Elmadhun, Nassrene Y.; Ramlawi, Basel; Sellke, Frank W.
OBJECTIVE Atrial fibrillation and neurocognitive decline are common complications after cardiopulmonary bypass. By utilizing genomic microarrays we investigate whether gene expression is associated with postoperative atrial fibrillation and neurocognitive decline. METHODS Twenty one cardiac surgery patients were prospectively matched and underwent neurocognitive assessments pre-operatively and four days postoperatively. The whole blood collected in the pre-cardiopulmonary bypass, 6 hours after-cardiopulmonary bypass, and on the 4th postoperative day was hybridized to Affymetrix Gene Chip U133 Plus 2.0 Microarrays. Gene expression in patients who developed postoperative atrial fibrillation and neurocognitive decline (n=6; POAF+NCD) was compared with gene expression in patients with postoperative atrial fibrillation and normal cognitive function (n=5; POAF+NORM) and patients with sinus rhythm and normal cognitive function (n=10; SR+NORM). Regulated genes were identified using JMP Genomics 4.0 with a false discovery rate of 0.05 and fold change of >1.5 or <-1.5. RESULTS Eleven patients developed postoperative atrial fibrillation. Six of these also developed neurocognitive decline. Of the 12 patients with sinus rhythm, only 2 developed neurocognitive decline. POAF+NCD patients had unique regulation of 17 named genes preoperatively, 60 named genes six hours after cardiopulmonary bypass, and 34 named genes four days postoperatively (P<0.05) compared with normal patients. Pathway analysis demonstrated that these genes are involved in cell death, inflammation, cardiac remodeling and nervous system function. CONCLUSION Patients who developed postoperative atrial fibrillation and neurocognitive decline after cardiopulmonary bypass may have differential genomic responses compared to normal patients and patients with only postoperative atrial fibrillation, suggesting common pathophysiology for these conditions. Further exploration of these genes may provide insight into the
Tarride, Jean-Eric; Dolovich, Lisa; Blackhouse, Gordon; Guertin, Jason Robert; Burke, Natasha; Manja, Veena; Grinvalds, Alex; Lim, Ting; Healey, Jeff S; Sandhu, Roopinder K
Screening for undiagnosed atrial fibrillation may lead to treatment with oral anticoagulation therapy, which can decrease the risk of ischemic stroke. The objective of this study was to conduct an economic evaluation of the Program for the Identification of 'Actionable' Atrial Fibrillation in the Pharmacy Setting (PIAAF-Pharmacy), which screened 1145 participants aged 65 years or more at 30 community pharmacies in Ontario and Alberta between October 2014 and April 2015. We used a 2-part decision model to evaluate the short- and long-term costs and quality-adjusted life-years (QALYs) of a pharmacy screening program for atrial fibrillation compared to no screening. Data from the PIAAF-Pharmacy study were used for the short-term model, and the relevant literature was used to extrapolate the benefits of the PIAAF-Pharmacy study in the long-term model. Costs and QALYs were calculated from a payer perspective over a lifetime horizon and were discounted at 1.5%/year. Screening for atrial fibrillation in pharmacies was associated with higher costs ($26) and more QALYs (0.0035) compared to no screening, yielding an incremental cost per QALY gained of $7480. Univariate and probabilistic sensitivity analyses confirmed that screening for atrial fibrillation in a pharmacy setting was a cost-effective strategy. Our results support screening for atrial fibrillation in Canadian pharmacies. Given this finding, efforts should be made by provincial governments and pharmacies to implement such programs in Canada. The addition of atrial fibrillation screening alongside screening and management of other cardiovascular conditions may help to reduce the burden of stroke. Copyright 2017, Joule Inc. or its licensors.
Sherman, David G
Atrial fibrillation is a common arrhythmia associated with increased risk for embolic stroke. Restoration of sinus rhythm in patients with atrial fibrillation is a logical strategy to prevent the cardiovascular and thromboembolic complications of this dysrhythmia. The most common strategy for restoration of sinus rhythm is pharmacological antiarrhythmic therapy with or without electrical cardioversion. Five randomized clinical trials compared rhythm to rate-control strategies in patients with atrial fibrillation. These trials examined mortality, thromboembolic complications, exercise tolerance, quality of life, hospital admissions and drug-related adverse reactions. Mortality ranged from 2.9% to 23.8% among the trial subjects randomized to rhythm control versus 1.0% to 21.3% in the rate control subjects. The risk of thromboemboli was greater: 2.9% to 7.9% in the rhythm-control subjects compared with 0% to 5.5% in the rate control subjects. Hospital admissions and drug-related adverse events were increased in the rhythm-control subjects. Stroke and systemic emboli occurred more often in the rhythm-control subjects many of whom had been withdrawn from anticoagulation. Rhythm-control offered no advantage compared with rate control for patients with atrial fibrillation at increased risk for stroke. One explanation for this finding is that those patients thought to have been successfully converted to sinus rhythm in fact had asymptomatic paroxysmal episodes of atrial fibrillation increasing their risk of stroke because they were unprotected by anticoagulation. Pharmacological attempts to restore atrial fibrillation to sinus rhythm do not improve mortality or reduce thromboembolic events. All patients with atrial fibrillation at increased risk for stroke should be continued on long-term anticoagulation even if they appear to have been successfully restored to sinus rhythm.
Laukkanen, Jari A; Zaccardi, Francesco; Karppi, Jouni; Ronkainen, Kimmo; Kurl, Sudhir
There is limited knowledge on the relationship between kidney function and incidence of atrial fibrillation. Thus, this prospective study was designed to evaluate whether various biomarkers of kidney function are associated to the risk of atrial fibrillation. The study population consisted of 1840 subjects (615 women and 1225 men) aged 61-82 years. Cystatin C- and creatinine-based estimation of glomerular filtration rate (eGFRcys and eGRFcreat , respectively) and urinary albumin/creatinine ratio (ACR) were assessed to investigate their relationship with the risk of atrial fibrillation. During a median follow-up of 3.7 years, a total of 159 incident atrial fibrillation cases occurred. After adjustment for potential confounders, the risk of atrial fibrillation was increased (hazard ratio 2.74, 95% confidence interval (CI) 1.56-4.81, P < 0.001) in subjects with reduced kidney function (eGFRcys , 15-59 mL/min per 1.73 m(2) ) compared to subjects with normal kidney function (≥90 mL/min per 1.73 m(2) ). Similar results were also found when comparing the respective groups of subjects defined by their eGRFcreat levels (hazard ratio 2.41, CI 1.09-5.30, P = 0.029). Consistently, subjects with ACR ≥300 mg/g had an increased risk of incident atrial fibrillation (hazard ratio 2.16, CI 1.35-2.82, P < 0.001) compared to those with ACR <30 mg/g. Reduced eGFR and albuminuria were associated with an increased risk of atrial fibrillation.
Gillinov, A Marc; Gelijns, Annetine C; Parides, Michael K; DeRose, Joseph J; Moskowitz, Alan J; Voisine, Pierre; Ailawadi, Gorav; Bouchard, Denis; Smith, Peter K; Mack, Michael J; Acker, Michael A; Mullen, John C; Rose, Eric A; Chang, Helena L; Puskas, John D; Couderc, Jean-Philippe; Gardner, Timothy J; Varghese, Robin; Horvath, Keith A; Bolling, Steven F; Michler, Robert E; Geller, Nancy L; Ascheim, Deborah D; Miller, Marissa A; Bagiella, Emilia; Moquete, Ellen G; Williams, Paula; Taddei-Peters, Wendy C; O'Gara, Patrick T; Blackstone, Eugene H; Argenziano, Michael
Among patients undergoing mitral-valve surgery, 30 to 50% present with atrial fibrillation, which is associated with reduced survival and increased risk of stroke. Surgical ablation of atrial fibrillation has been widely adopted, but evidence regarding its safety and effectiveness is limited. We randomly assigned 260 patients with persistent or long-standing persistent atrial fibrillation who required mitral-valve surgery to undergo either surgical ablation (ablation group) or no ablation (control group) during the mitral-valve operation. Patients in the ablation group underwent further randomization to pulmonary-vein isolation or a biatrial maze procedure. All patients underwent closure of the left atrial appendage. The primary end point was freedom from atrial fibrillation at both 6 months and 12 months (as assessed by means of 3-day Holter monitoring). More patients in the ablation group than in the control group were free from atrial fibrillation at both 6 and 12 months (63.2% vs. 29.4%, P<0.001). There was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrial maze procedure (61.0% and 66.0%, respectively; P=0.60). One-year mortality was 6.8% in the ablation group and 8.7% in the control group (hazard ratio with ablation, 0.76; 95% confidence interval, 0.32 to 1.84; P=0.55). Ablation was associated with more implantations of a permanent pacemaker than was no ablation (21.5 vs. 8.1 per 100 patient-years, P=0.01). There were no significant between-group differences in major cardiac or cerebrovascular adverse events, overall serious adverse events, or hospital readmissions. The addition of atrial fibrillation ablation to mitral-valve surgery significantly increased the rate of freedom from atrial fibrillation at 1 year among patients with persistent or long-standing persistent atrial fibrillation, but the risk of implantation of a permanent pacemaker
Gillinov, A. Marc; Gelijns, Annetine C.; Parides, Michael K.; DeRose, Joseph J.; Moskowitz, Alan J.; Voisine, Pierre; Ailawadi, Gorav; Bouchard, Denis; Smith, Peter K.; Mack, Michael J.; Acker, Michael A.; Mullen, John C.; Rose, Eric A.; Chang, Helena L.; Puskas, John D.; Couderc, Jean-Philippe; Gardner, Timothy J.; Varghese, Robin; Horvath, Keith A.; Bolling, Steven F.; Michler, Robert E.; Geller, Nancy L.; Ascheim, Deborah D.; Miller, Marissa A.; Bagiella, Emilia; Moquete, Ellen G.; Williams, Paula; Taddei-Peters, Wendy C.; O’Gara, Patrick T.; Blackstone, Eugene H.; Argenziano, Michael
Background Among patients undergoing mitral-valve surgery, 30 to 50% present with atrial fibrillation, which is associated with reduced survival and increased risk of stroke. Surgical ablation of atrial fibrillation has been widely adopted, but evidence regarding its safety and effectiveness is limited. Methods We randomly assigned 260 patients with persistent or long-standing persistent atrial fibrillation who required mitral-valve surgery to undergo either surgical ablation (ablation group) or no ablation (control group) during the mitral-valve operation. Patients in the ablation group underwent further randomization to pulmonary-vein isolation or a biatrial maze procedure. All patients underwent closure of the left atrial appendage. The primary end point was freedom from atrial fibrillation at both 6 months and 12 months (as assessed by means of 3-day Holter monitoring). Results More patients in the ablation group than in the control group were free from atrial fibrillation at both 6 and 12 months (63.2% vs. 29.4%, P<0.001). There was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrial maze procedure (61.0% and 66.0%, respectively; P = 0.60). One-year mortality was 6.8% in the ablation group and 8.7% in the control group (hazard ratio with ablation, 0.76; 95% confidence interval, 0.32 to 1.84; P = 0.55). Ablation was associated with more implantations of a permanent pacemaker than was no ablation (21.5 vs. 8.1 per 100 patient-years, P = 0.01). There were no significant between-group differences in major cardiac or cerebrovascular adverse events, overall serious adverse events, or hospital readmissions. Conclusions The addition of atrial fibrillation ablation to mitral-valve surgery significantly increased the rate of freedom from atrial fibrillation at 1 year among patients with persistent or long-standing persistent atrial fibrillation, but the
Earon, Allison; Handorf, Anna; Fahey, Nisha; Talati, Kandarp; Bostrom, John; Chon, Ki; Napolitano, Craig; Chin, Michael; Sullivan, John; Raithatha, Shyamsundar; Goldberg, Robert; Nimbalkar, Somashekhar; Allison, Jeroan; Thanvi, Sunil; McManus, David
Background Atrial fibrillation, the world’s most common arrhythmia, is a leading risk factor for stroke, a disease striking nearly 1.6 million Indians annually. Early detection and management of atrial fibrillation is a promising opportunity to prevent stroke but widespread screening programs in limited resource settings using conventional methods is difficult and costly. Objective The objective of this study is to screen people for atrial fibrillation in rural western India using a US Food and Drug Administration-approved single-lead electrocardiography device, Alivecor. Methods Residents from 6 villages in Anand District, Gujarat, India, comprised the base population. After obtaining informed consent, a team of trained research coordinators and community health workers enrolled a total of 354 participants aged 50 years and older and screened them at their residences using Alivecor for 2 minutes on 5 consecutive days over a period of 6 weeks beginning June, 2015. Results Almost two-thirds of study participants were 55 years or older, nearly half were female, one-third did not receive any formal education, and more than one-half were from households earning less than US $2 per day. Twelve participants screened positive for atrial fibrillation yielding a sample prevalence of 5.1% (95% CI 2.7-8.7). Only one participant had persistent atrial fibrillation throughout all of the screenings, and 9 screened positive only once. Conclusions Our study suggests a prevalence of atrial fibrillation in this Indian region (5.1%) that is markedly higher than has been previously reported in India and similar to the prevalence estimates reported in studies of persons from North America and Europe. Historically low reported burden of atrial fibrillation among individuals from low and middle-income countries may be due to a lack of routine screening. Mobile technologies may help overcome resource limitations for atrial fibrillation screening in underserved and low-resource settings
Xie, Ruiqin; Yang, Yingtao; Cui, Wei; Yin, Hongning; Zheng, Hongmei; Zhang, Jidong; You, Ling
The objective of this study was to study the functional changes of the left atrium after radiofrequency ablation treatment for atrial fibrillation and the therapeutic effect of atorvastatin. Fifty-eight patients undergoing radiofrequency ablation for atrial fibrillation were randomly divided into non-atorvastatin group and atorvastatin group. Patients in the atorvastatin group were treated with atorvastatin 20 mg p.o. per night in addition to the conventional treatment of atrial fibrillation; patients in the non-atorvastatin group received conventional treatment of atrial fibrillation only. Echocardiography was performed before radiofrequency ablation operation and 1 week, 2 weeks, 3 weeks, and 4 weeks after operation. Two-dimensional ultrasound speckle tracking imaging system was used to measure the structural indexes of the left atrium. Results indicated that there was no significant change for indexes representing the structural status of the left atrium within a month after radiofrequency ablation (P > 0.05); however, there were significant changes for indexes representing the functional status of the left atrium. There were also significant changes in indexes reflecting left atrial strain status: the S and SRs of atorvastatin group were higher than those of non-atorvastatin group (P < 0.05). In summary, atorvastatin could improve left atrial function and shorten the duration of atrial stunning after radiofrequency ablation of atrial fibrillation.
von Bodman, G; Brömsen, J; Kopf, C; Füller, M; Block, M
Two young patients with documented episodes of symptomatic paroxysmal atrial fibrillation have been referred for pulmonary vein isolation. Both patients had a history of concomitant regular tachycardia. in both cases pulmonaryvein isolation has not been performed but in each patient a supraventricular tachycardia (right focal atrial tachycardia/atrioventricular reentry tachycardia) could be induced and ablated instead. Concomitant supraventricular tachycardia acting as a trigger arrhythmia is frequent in young patients with atrial fibrillation without underlying cardiacdisease. In these patients a concomitant supra-ventricular tachycardia should beexcluded by electrophysiological study or ablated before pulmonary vein isolation or initiating an antiarrhythmic drug therapy. In most cases ablation of supraventricular tachycardia is safe and successful whereas the risks of ablative therapy of atrial fibrillation can not be neglected and success is moderate.
McCarthy, P M; Castle, L W; Trohman, R G; Simmons, T W; Maloney, J D; Klein, A L; White, R D; Cox, J L
Although atrial fibrillation is well tolerated by most patients, in some patients the consequences may be severe. The Maze procedure is a new open-heart operation that creates a carefully designed maze of incisions in the atrial myocardium; this maze then acts as an electrical conduit to channel atrial impulses from the sinoatrial node to the atrioventricular node. The Maze procedure has been shown to restore sinus rhythm and atrial systole (thus reducing the risk of thromboembolism), improve hemodynamics, alleviate palpitations, and eliminate the need for antiarrhythmic and anticoagulant drugs. We describe our first patient to undergo this operation.
Veltkamp, R; Hacke, W
Atrial fibrillation (AF) causes at least 20% of all ischemic strokes. In large randomized trials of primary and secondary stroke prevention, anticoagulation with vitamin K antagonists (VKA) protected much more efficiently than antiplatelet agents against stroke. Because of the problematic pharmacological properties of VKA only part of the AF patients are currently being treated with oral anticoagulants (OAK). The targeted development of specific oral inhibitors of the central coagulation factors thrombin and factor Xa allows reliable anticoagulation without regular coagulation monitoring. In the present review, pharmacological properties of the different agents are compared. Of the four large randomized phase 3 studies in AF (RELY, ROCKET-AF, ARISTOTLE, ENGAGE-AF) with the primary efficacy endpoint stroke and systemic embolism, the published data from the RELY trial indicate a superior efficacy of dabigatran etexilate (2 × 150 mg/day) and a lower risk of intracranial hemorrhage compared to warfarin. Favorable preliminary results have been demonstrated for the factor Xa inhibitor rivaroxaban. Apixaban was more efficacious than ASA and had a similar risk of hemorrhage in the AVERROES study. Thus, the available data suggest a favorable benefit-risk ratio for the new substances in addition to improved patient comfort. Currently unresolved issues relate to the verification of patient adherence by suitable coagulation tests and to the emergency coagulation diagnostics and therapy in acute ischemic or hemorrhagic strokes under the new OAC.
Pankaala, Mikko; Koivisto, Tero; Lahdenoja, Olli; Kiviniemi, Tuomas; Saraste, Antti; Vasankari, Tuija; Airaksinen, Juhani
In this paper we study the feasibility of seismocardiography (SCG) for the detection of Atrial Fibrillation (AF). In this preclinical study, data acquired from one patient having paroxysmal AF (no other heart diseases) is used to introduce specific changes in SCG signal due to AF. Observed changes and phenomena create a foundation for the development of SCG-based AF detection algorithms. SCG data was recorded from the sternum of an AF patient in dorso-ventral direction while at rest in a supine position using a three-axis high precision MEMS accelerometer simultaneously with a one-lead ECG. In contrast to ECG, the magnitude of beats registered with SCG varies considerably from beat to beat during AF. We show that the magnitude of the beats is not random but is in relation to beat intervals. It is shown that extra indicators for detecting AF become available when SCG data is combined with electrocardiographical (ECG) data; there is a certain behavior in the electromechanical delay characteristic of the AF. It is discussed how all this information can be taken advantage of in the detection of AF. Today electrocardiography (ECG) is the primary method for diagnosing arrhythmias, but there is a growing need for simpler and more convenient method for detecting asymptomatic AF. Given the very small dimensions of modern MEMS accelerometers (2mm×2mm), a reliable MEMS based measurement may provide totally new venues for arrhythmia detection.
Alonso, Alvaro; Norby, Faye L.
Atrial fibrillation (AF) is a common cardiac arrhythmia associated with an increased risk of stroke and other complications. Identifying individuals at higher risk of developing AF in the community is now possible using validated predictive models that take into account clinical variables and circulating biomarkers. These models have shown adequate performance in racially and ethnically diverse populations. Similarly, risk stratification schemes predict incidence of ischemic stroke in persons with AF, assisting clinicians and patients in decisions regarding oral anticoagulation use. Complementary schemes have been developed to predict the risk of bleeding in AF patients taking vitamin K antagonists. However, major gaps in our ability to predict AF and its complications exist. Additional research should refine models for AF prediction and determine their value to improve population health and clinical outcomes, advance our ability to predict stroke and other complications in AF patients, and develop predictive models for bleeding events and other adverse effects in patients using non-vitamin K oral anticoagulants. PMID:27008924
Metzner, Andreas; Wissner, Erik; Lin, Tina; Ouyang, Feifan; Kuck, Karl-Heinz
Ablation of atrial fibrillation (AF) is an established treatment option for symptomatic patients refractory to antiarrhythmic medication. In patients with paroxysmal AF, ablation can be offered as first-line therapy when performed in an experienced centre. The accepted cornerstone for all ablation strategies is isolation of the pulmonary veins. However, it is still challenging to achieve contiguous, transmural, permanent lesions using radio-frequency current (RFC) based catheters in conjunction with a three-dimensional mapping system and the learning curve remains long. These limitations have kindled interest in developing and evaluating novel catheter designs that incorporate alternative energy sources. Novel catheters include balloon-based ablation systems, incorporating different energy modalities such as laser (Heartlight(™), CardioFocus, Marlborough, MA, US), RFC (Hot Balloon Catheter, Hayama Arrhythmia Institute, Kanagawa, Japan) and cryo-energy (ArcticFront, Medtronic, Inc., Minneapolis, MN, US). While the cryoballoon (CB) and the radiofrequency hot balloon (RHB) are single-shot devices, the endoscopic ablation system (EAS) allows for point-by-point ablation. The CB and EAS are well established as safe, time-efficient and effective ablation tools. Initial studies using the RHB could also demonstrate promising results. However, more data are required.
Hijazi, Ziad; Oldgren, Jonas; Siegbahn, Agneta; Granger, Christopher B; Wallentin, Lars
Assessment of atrial fibrillation (AF)-associated stroke risk is at present mainly based on clinical risk scores such as CHADS2 and CHA2DS2-VASc, although these scores provide only modest discrimination of risk for individual patients. Biomarkers derived from the blood may help refine risk assessment in AF for stroke outcomes and for mortality. Recent studies of biomarkers in AF have shown that they can substantially improve risk stratification. Cardiac biomarkers, such as troponin and natriuretic peptides, significantly improve risk stratification in addition to current clinical risk stratification models. Similar findings have recently been described for markers of renal function, coagulation, and inflammation in AF populations based on large randomized prospective clinical trials or large community-based cohorts. These new findings may enable development of novel tools to improve clinical risk assessment in AF. Biomarkers in AF may also improve the understanding of the pathophysiology of AF further as well as potentially elucidate novel treatment targets. This review will highlight novel associations of biomarkers and outcomes in AF as well as recent progress in the use of biomarkers for risk stratification.
Ovadia, Marc; Duque, Kristin S
A novel indication for (123)I-mIBG has recently been proposed to risk stratify patients with atrial fibrillation. This review puts into perspective the utility and importance of such a risk stratification modality, in the setting of the epidemic of atrial fibrillation, which also relates to the prevalence of heart failure, obesity, hypertension, and stroke. The authors argue that the epic cost of care for patients with paroxysmal and more advanced forms of atrial fibrillation-including catheter ablation, heart failure, and stroke management-coupled with the poor efficacy of all treatment modalities in advanced atrial fibrillation, make necessary a paradigm shift where only paroxysmal atrial fibrillation that demonstrably will turn into permanent fibrillation should be targeted aggressively. If this premise is accepted, then (123)I-mIBG nuclear imaging for risk stratification becomes a vital tool for the care of the individual patient, as well as for disease control and cost containment in the population, since (123)I-mIBG scanning alone can predict (with hazard ratios of the order of 3.0-5.0) the future occurrence of permanent atrial fibrillation or heart failure.
Saengklub, Nakkawee; Limprasutr, Vudhiporn; Sawangkoon, Suwanakiet; Hamlin, Robert L.; Kijtawornrat, Anusak
Atrial fibrillation (AF) is a supraventricular arrhythmia that leads to a decrease in cardiac output and impairs cardiac function and quality of life. Dronedarone has an atrial-selective property and has been used for management of AF in humans, but limited information is available in dogs. This study was designed to evaluate efficacy of dronedarone in attenuating the duration of AF in dog model of sustained AF. Six beagle dogs were anesthetized with isoflurane and instrumented to measure atrial action potential duration (aAPD) and atrial effective refractory period (AERP). Then AF was induced by rapid right atrial pacing (20 V, 40 Hz) simultaneously with infusion of phenylephrine (2 µg/kg/min, intravenously) for 20 min. The duration of sustained AF was recorded, and the animals were allowed to recover. Dronedarone was given at a dose of 20 mg/kg, BID, orally for 7 days. On the last day, the dogs were anesthetized again to record aAPD and AERP, and AF was induced with the same procedure as described above. The results showed that after dronedarone administration the aAPD was lengthened significantly from 76.4 ± 4.2 ms to 91.2 ± 3.9 ms (P<0.05) and AERP was prolonged significantly from 97.5 ± 2.8 ms to 120 ± 4.8 ms (P<0.05). The duration of sustained AF was also significantly attenuated after receipt of dronedarone (P<0.05). It can be suggested that oral dronedarone attenuates the duration of sustained AF in a dog model of AF by extending the AERP more than the aAPD, causing post-repolarization refractoriness. Hence, dronedarone may be useful for management of AF in dogs. PMID:28381818
Starek, Zdenk; Lehar, Frantisek; Jez, Jiri; Wolf, Jiri; Novák, Miroslav
Atrial fibrillation is the most common sustained arrhythmia. Because of the sub-optimal outcomes and associated risks of medical therapy as well as the recent advances in non-pharmacologic strategies, a multitude of combined (hybrid) algorithms have been introduced that improve efficacy of standalone therapies while maintaining a high safety profile. Antiarrhythmic administration enhances success rate of electrical cardioversion. Catheter ablation of antiarrhythmic drug-induced typical atrial flutter may prevent recurrent atrial fibrillation. Through simple ablation in the right atrium, suppression of atrial fibrillation may be achieved in patients with previously ineffective antiarrhythmic therapy. Efficacy of complex catheter ablation in the left atrium is improved with antiarrhythmic drugs. Catheter ablation followed by permanent pacemaker implantation is an effective and safe treatment option for selected patients. Additional strategies include pacing therapies such as atrial pacing with permanent pacemakers, preventive pacing algorithms, and/or implantable dual-chamber defibrillators are available. Modern hybrid strategies combining both epicardial and endocardial approaches in order to create a complex set of radiofrequency lesions in the left atrium have demonstrated a high rate of success and warrant further research. Hybrid therapy for atrial fibrillation reviews history of development of non-pharmacological treatment strategies and outlines avenues of ongoing research in this field.
Stárek, Zdeněk; Lehar, František; Jež, Jiří; Wolf, Jiří; Novák, Miroslav
Atrial fibrillation is the most common sustained arrhythmia. Because of the sub-optimal outcomes and associated risks of medical therapy as well as the recent advances in non-pharmacologic strategies, a multitude of combined (hybrid) algorithms have been introduced that improve efficacy of standalone therapies while maintaining a high safety profile. Antiarrhythmic administration enhances success rate of electrical cardioversion. Catheter ablation of antiarrhythmic drug-induced typical atrial flutter may prevent recurrent atrial fibrillation. Through simple ablation in the right atrium, suppression of atrial fibrillation may be achieved in patients with previously ineffective antiarrhythmic therapy. Efficacy of complex catheter ablation in the left atrium is improved with antiarrhythmic drugs. Catheter ablation followed by permanent pacemaker implantation is an effective and safe treatment option for selected patients. Additional strategies include pacing therapies such as atrial pacing with permanent pacemakers, preventive pacing algorithms, and/or implantable dual-chamber defibrillators are available. Modern hybrid strategies combining both epicardial and endocardial approaches in order to create a complex set of radiofrequency lesions in the left atrium have demonstrated a high rate of success and warrant further research. Hybrid therapy for atrial fibrillation reviews history of development of non-pharmacological treatment strategies and outlines avenues of ongoing research in this field. PMID:25028165
Bloomfield, Gerald S.; Temu, Tecla; Akwanalo, Constantine O.; Chen, Peng-Sheng; Emonyi, Wilfred; Heckbert, Susan R.; Koech, Myra M.; Manji, Imran; Shen, Changyu; Vatta, Matteo; Velazquez, Eric J.; Wessel, Jennifer; Kimaiyo, Sylvester; Inui, Thomas S.
Background There is an urgent need to understand genetic associations with atrial fibrillation in ethnically diverse populations. There are no such data from sub-Saharan Africa, despite the fact that atrial fibrillation is one of the fastest-growing diseases. Moreover, patients with valvular heart disease are under-represented in studies of the genetics of atrial fibrillation. Methods We designed a case-control study of patients with and without a history of atrial fibrillation in Kenya. Cases with atrial fibrillation included those with and without valvular heart disease. Patients underwent clinical phenotyping and will have laboratory analysis and genetic testing of >240 candidate genes associated with cardiovascular diseases. A 12-month follow-up assessment will determine the groups’ morbidity and mortality. The primary analyses will describe genetic and phenotypic associations with atrial fibrillation. Results We recruited 298 participants: 72 (24%) with non-valvular atrial fibrillation, 78 (26%) with valvular atrial fibrillation and 148 (50%) controls without atrial fibrillation. The mean age of cases and controls were 53 and 48 years, respectively. Most (69%) participants were female. Controls more often had hypertension (45%) than those with valvular atrial fibrillation (27%). Diabetes and current tobacco smoking were uncommon. A history of stroke was present in 25% of cases and in 5% of controls. Conclusion This is the first study determining genetic associations in valvular and non-valvular atrial fibrillation in sub-Saharan Africa with a control population. The results advance knowledge about atrial fibrillation and will enhance international efforts to decrease atrial fibrillation-related morbidity. PMID:26385028
Bloomfield, Gerald S; Temu, Tecla M; Akwanalo, Constantine O; Chen, Peng-Sheng; Emonyi, Wilfred; Heckbert, Susan R; Koech, Myra M; Manji, Imran; Shen, Changyu; Vatta, Matteo; Velazquez, Eric J; Wessel, Jennifer; Kimaiyo, Sylvester; Inui, Thomas S
There is an urgent need to understand genetic associations with atrial fibrillation in ethnically diverse populations. There are no such data from sub-Saharan Africa, despite the fact that atrial fibrillation is one of the fastest growing diseases. Moreover, patients with valvular heart disease are underrepresented in studies of the genetics of atrial fibrillation. We designed a case-control study of patients with and without a history of atrial fibrillation in Kenya. Cases with atrial fibrillation included those with and without valvular heart disease. Patients underwent clinical phenotyping and will have laboratory analysis and genetic testing of >240 candidate genes associated with cardiovascular diseases. A 12-month follow-up assessment will determine the groups' morbidity and mortality. The primary analyses will describe genetic and phenotypic associations with atrial fibrillation. We recruited 298 participants: 72 (24%) with nonvalvular atrial fibrillation, 78 (26%) with valvular atrial fibrillation, and 148 (50%) controls without atrial fibrillation. The mean age of cases and controls were 53 and 48 years, respectively. Most (69%) participants were female. Controls more often had hypertension (45%) than did those with valvular atrial fibrillation (27%). Diabetes and current tobacco smoking were uncommon. A history of stroke was present in 25% of cases and in 5% of controls. This is the first study determining genetic associations in valvular and nonvalvular atrial fibrillation in sub-Saharan Africa with a control population. The results advance knowledge about atrial fibrillation and will enhance international efforts to decrease atrial fibrillation-related morbidity. Copyright © 2015 Elsevier Inc. All rights reserved.
Lalani, Gautam G.; Schricker, Amir; Gibson, Michael; Rostamian, Armand; Krummen, David E.; Narayan, Sanjiv M.
Objectives The aim of this study was to determine whether onset sites of human atrial fibrillation (AF) exhibit conduction slowing, reduced amplitude, and/or prolonged duration of signals (i.e., fractionation) immediately before AF onset. Background Few studies have identified functional determinants of AF initiation. Because conduction slowing is required for reentry, we hypothesized that AF from pulmonary vein triggers might initiate at sites exhibiting rate-dependent slowing in conduction velocity (CV restitution) or local slowing evidenced by signal fractionation. Methods In 28 patients with AF (left atrial size 43 ± 5 mm; n = 13 persistent) and 3 control subjects (no AF) at electrophysiological study, we measured bi-atrial conduction time (CT) electrogram fractionation at 64 or 128 electrodes with baskets in left (n = 17) or both (n = 14) atria during superior pulmonary vein pacing at cycle lengths (CL) accelerating from 500 ms (120 beats/min) to AF onset. Results Atrial fibrillation initiated in 19 of 28 AF patients and no control subjects. During rate acceleration, conduction slowed in 23 of 28 AF patients (vs. no control subjects, p = 0.01) at the site of AF initiation (15 of 19) or latest activated site (20 of 28). The CT lengthened from 79 ± 23 ms to 107 ± 39 ms (p < 0.001) on acceleration, in a spectrum from persistent AF (greatest slowing) to control subjects (least slowing; p < 0.05). Three patterns of CV restitution were observed: 1) broad (gradual CT prolongation, 37% patients); 2) steep (abrupt prolongation, at CL 266 ± 62 ms, 42%); and 3) flat (no prolongation, 21% AF patients, all control subjects). The AF initiation was more prevalent in patients with CV restitution (17 of 23 vs. 2 of 8; p = 0.03) and immediately followed abrupt reorientation of the activation vector in patients with broad but not steep CV restitution (p < 0.01). Patients with broad CV restitution had larger atria (p = 0.03) and were more likely to have persistent AF (p = 0
Montenegro, Márcio José; Quintella, Edgard Freitas; Damonte, Aníbal; Sabino, Hugo de Castro; Zajdenverg, Ricardo; Laufer, Gustavo Pinaud; Amorim, Bernardo; Estrada, André Pereira Duque; Armas, Cristian Paul Yugcha; Sterque, Aline
Atrial fibrillation is associated with embolic strokes that often result in death or disability. Effective in reducing these events, anticoagulation has several limitations and has been widely underutilized. Over 90% of thrombi identified in patients with atrial fibrillation without valvular disease originate in the left atrial appendage, whose occlusion is investigated as an alternative to anticoagulation. To determine the feasibility of percutaneous occlusion of the left atrial appendage in patients at high risk of embolic events and limitations to the use of anticoagulation. We report our initial experience with Amplatzer Cardiac Plug™ (St. Jude Medical Inc., Saint Paul, Estados Unidos) in patients with nonvalvular atrial fibrillation. We selected patients at high risk of thromboembolism, major bleeding, contraindications to the use or major instability in response to the anticoagulant. The procedures were performed percutaneously under general anesthesia and transesophageal echocardiography. The primary outcome was the presence of periprocedural complications and follow-up program included clinical and echocardiographic review within 30 days and by telephone contact after nine months. In five selected patients it was possible to occlude the left atrial appendage without periprocedural complications. There were no clinical events in follow-up. Controlled clinical trials are needed before percutaneous closure of the left atrial appendage should be considered an alternative to anticoagulation in nonvalvular atrial fibrillation. But the device has shown to be promissory in patients at high risk of embolism and restrictions on the use of anticoagulants.
Shamoun, Fadi; Obeid, Hiba; Ramakrishna, Harish
Atrial fibrillation continues to be a significant source of morbidity and mortality worldwide. Effective anticoagulation remains the cornerstone of outpatient and inpatient treatment. The use of the new generation of anticoagulants (NOACs) continues to grow. Recently published data indicate their cost-effectiveness and overall safety in stroke prevention; compared to vitamin K antagonists, they can be prescribed in fixed doses for long-term therapy without the need for coagulation monitoring. Both United States and European Guidelines recommend NOACs for stroke prevention in patients with atrial fibrillation. This review discusses each of the NOACs, along with their efficacy and safety data. It explores the most recent guidelines regarding their perioperative use in atrial fibrillation patients. It also discusses bleeding complications, perioperative management, and reversal agents. PMID:26221593
Kaiser, Stefanie; Kirst, Malte; Kunze, Christophe
Two versions of a new detector for automatic real-time detection of atrial fibrillation in non-invasive ECG signals are introduced. The methods are based on beat to beat variability, tachogram analysis and simple signal filtering. The implementation on mobile devices is made possible due to the low demand on computing power of the employed analysis procedures. The proposed algorithms correctly identified 436 of 440 five minute episodes of atrial fibrillation or flutter and also correctly identified up to 302 of 342 episodes of no atrial fibrillation, including normal sinus rhythm as well as other cardiac arrhythmias. These numbers correspond to a sensitivity of 99.1 % and a specificity of 88.3%.
Weitz, Jeffrey I; Eikelboom, John
The non-vitamin K antagonist oral anticoagulants (NOACs) are replacing warfarin for stroke prevention in many patients with nonvalvular atrial fibrillation. Edoxaban, an oral factor Xa inhibitor, is the newest entrant in this class. Results of the Effective Anticoagulation with Factor Xa Next Generation in Atrial Fibrillation (ENGAGE AF) study demonstrate that edoxaban is noninferior to warfarin for prevention of stroke and systemic embolic events, and is associated with significantly less major bleeding, including intracranial bleeding, and reduced cardiovascular mortality. With a net clinical benefit over warfarin, edoxaban is well positioned as a choice among the NOACs, which include dabigatran, rivaroxaban, and apixaban. But how will clinicians choose amongst them? The purpose of this paper is to (a) place the ENGAGE AF trial results into context with results of the studies with the other NOACs, and (b) aid clinicians in selection of the right anticoagulant for the right atrial fibrillation patient.
Hajhosseiny, Reza; Matthews, Gareth K; Lip, Gregory Y H
The prevalence of atrial fibrillation (AF) and AF-related stroke is set to increase dramatically in coming decades, with developing regions such as Latin America experiencing the greatest impact. These trends are primarily driven by aging populations and by the increasing prevalence of the metabolic syndrome. The metabolic syndrome describes an association between diabetes, hypertension, obesity, and dyslipidemia and an increased risk of cardiovascular disease. It is in large part the result of unbalanced diet and sedentary lifestyle. These essentially modifiable risk factors are becoming more prevalent with the widespread adoption of so-called Western lifestyles. This review examines the physiology underlying the link between the metabolic syndrome and AF. Next, it highlights the importance of addressing lifestyle-related risk factors to mitigate the trend toward increasing AF prevalence. It then goes on to discuss the importance of stroke prevention therapy in patients with established AF, focusing on the relative merits of various available options for anticoagulation. Given the recent availability of comprehensive data on the 4 currently available non-vitamin K antagonist oral anticoagulant drugs, this review concludes by discussing the relative merits of specific agents in individual patient groups.
Lin Md, Tina; Wissner Md, Erik; Tilz Md, Roland; Rillig Md, Andreas; Mathew Md, Shibu; Rausch Md, Peter; Rausch Md, Peter; Lemes Md, Christine; Deiss Md, Sebastian; Kamioka Md, Masashi; Bucur Md, Tudor; Ouyang Md, Feifan; Kuck Md, Karl-Heinz; Metzner Md, Andreas
Atrial fibrillation (AF) is the most common cardiac arrhythmia worldwide and is associated with significant morbidity and mortality. Its prevalence increases with increasing age, and is one of the leading causes of thromboembolism, including ischemic stroke. The prevalence of cognitive dysfunction also increases with increasing age. Although several studies have shown a strong correlation between AF and cognitive dysfunction in patients with and without overt stroke, a direct causative link has yet to be established. Rhythm vs rate control and anticoagulation regimens have been extensively investigated, particularly with the introduction of the novel anticoagulants. With catheter ablation becoming more prevalent for the management of AF and the ongoing development of various new energy sources and catheters, an additional thromboembolism risk is introduced. As cognitive dysfunction decreases the patient's ability to self-care and manage a complex disease such as AF, this increases the burden to our healthcare system. Therefore as the prevalence of AF increases in the general population, it becomes more imperative that we strive to optimize our methods to preserve cognitive function. This review gives an overview of the current evidence behind the association of AF with cognitive dysfunction, and discusses the most up-to-date medical and procedural treatment strategies available for decreasing thromboembolism associated with AF and its treatment, which may lead to preserving cognitive function.
Karim, R.; Mohiaddin, R.; Rueckert, D.
Segmentation of the left atrium is vital for pre-operative assessment of its anatomy in radio-frequency catheter ablation (RFCA) surgery. RFCA is commonly used for treating atrial fibrillation. In this paper we present an semi-automatic approach for segmenting the left atrium and the pulmonary veins from MR angiography (MRA) data sets. We also present an automatic approach for further subdividing the segmented atrium into the atrium body and the pulmonary veins. The segmentation algorithm is based on the notion that in MRA the atrium becomes connected to surrounding structures via partial volume affected voxels and narrow vessels, the atrium can be separated if these regions are characterized and identified. The blood pool, obtained by subtracting the pre- and post-contrast scans, is first segmented using a region-growing approach. The segmented blood pool is then subdivided into disjoint subdivisions based on its Euclidean distance transform. These subdivisions are then merged automatically starting from a seed point and stopping at points where the atrium leaks into a neighbouring structure. The resulting merged subdivisions produce the segmented atrium. Measuring the size of the pulmonary vein ostium is vital for selecting the optimal Lasso catheter diameter. We present a second technique for automatically identifying the atrium body from segmented left atrium images. The separating surface between the atrium body and the pulmonary veins gives the ostia locations and can play an important role in measuring their diameters. The technique relies on evolving interfaces modelled using level sets. Results have been presented on 20 patient MRA datasets.
Lubitz, Steven A.; Weng, Lu-Chen; Christophersen, Ingrid E.; Boerwinkle, Eric; Gibbs, Richard A.; Cupples, L. Adrienne; Mohler, Peter J.; Nickerson, Deborah A.; Muzny, Donna; Psaty, Bruce M.; Soliman, Elsayed Z.; Sotoodehnia, Nona; Lunetta, Kathryn L.; Heckbert, Susan R.; Arking, Dan E.; Ellinor, Patrick T.
Atrial fibrillation (AF) is a morbid and heritable arrhythmia. Over 35 genes have been reported to underlie AF, most of which were described in small candidate gene association studies. Replication remains lacking for most, and therefore the contribution of coding variation to AF susceptibility remains poorly understood. We examined whole exome sequencing data in a large community-based sample of 1,734 individuals with and 9,423 without AF from the Framingham Heart Study, Cardiovascular Health Study, Atherosclerosis Risk in Communities Study, and NHLBI-GO Exome Sequencing Project and meta-analyzed the results. We also examined whether genetic variation was enriched in suspected AF genes (N = 37) in AF cases versus controls. The mean age ranged from 59 to 73 years; 8,656 (78%) were of European ancestry. None of the 99,404 common variants evaluated was significantly associated after adjusting for multiple testing. Among the most significantly associated variants was a common (allele frequency = 86%) missense variant in SYNPO2L (rs3812629, p.Pro707Leu, [odds ratio 1.27, 95% confidence interval 1.13–1.43, P = 6.6x10-5]) which lies at a known AF susceptibility locus and is in linkage disequilibrium with a top marker from prior analyses at the locus. We did not observe significant associations between rare variants and AF in gene-based tests. Individuals with AF did not display any statistically significant enrichment for common or rare coding variation in previously implicated AF genes. In conclusion, we did not observe associations between coding genetic variants and AF, suggesting that large-effect coding variation is not the predominant mechanism underlying AF. A coding variant in SYNPO2L requires further evaluation to determine whether it is causally related to AF. Efforts to identify biologically meaningful coding variation underlying AF may require large sample sizes or populations enriched for large genetic effects. PMID:27589061
Carter, Lindsey; Gardner, Martin; Magee, Kirk; Fearon, Ann; Morgulis, Inna; Doucette, Steve; Sapp, John L; Gray, Chris; Abdelwahab, Amir; Parkash, Ratika
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia resulting in mortality and morbidity. Gaps in oral anticoagulation and education of patients regarding AF have been identified as areas that require improvement. A before-and-after study of 433 patients with newly diagnosed AF in the 3 emergency departments in Nova Scotia from January 1, 2011 until January 31, 2014 was performed. The "before" phase underwent the usual-care pathway for AF management; the "after" phase was enrolled in a nurse-run, physician-supervised AF clinic. The primary outcome was a composite of death, cardiovascular hospitalization, and AF-related emergency department visits. A propensity analysis was performed to account for differences in baseline characteristics. A total of 185 patients were enrolled into the usual-care group, and 228 patients were enrolled in the AF clinic group. The mean age was 64±15 years and 44% were women. In a propensity-matched analysis, the primary outcome occurred in 44 (26.2%) patients in the usual-care group and 29 (17.3%) patients in the AF clinic group (odds ratio 0.71; 95% CI [0.59, 1]; P=0.049) at 12 months. Prescription of oral anticoagulation was increased in the CHADS2 ≥2 group (88.4% in the AF clinic versus 58.5% in the usual-care group, P<0.01). Adoption of this integrated management approach for the burgeoning population of AF may provide an overall benefit to cardiovascular morbidity and mortality. © 2016 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.
Lau, Dennis H; Middeldorp, Melissa E; Brooks, Anthony G; Ganesan, Anand N; Roberts-Thomson, Kurt C; Stiles, Martin K; Leong, Darryl P; Abed, Hany S; Lim, Han S; Wong, Christopher X; Willoughby, Scott R; Young, Glenn D; Kalman, Jonathan M; Abhayaratna, Walter P; Sanders, Prashanthan
Recent community-based research has linked aortic stiffness to the development of atrial fibrillation. We posit that aortic stiffness contributes to adverse atrial remodeling leading to the persistence of atrial fibrillation following catheter ablation in lone atrial fibrillation patients, despite the absence of apparent structural heart disease. Here, we aim to evaluate aortic stiffness in lone atrial fibrillation patients and determine its association with arrhythmia recurrence following radio-frequency catheter ablation. We studied 68 consecutive lone atrial fibrillation patients who underwent catheter ablation procedure for atrial fibrillation and 50 healthy age- and sex-matched community controls. We performed radial artery applanation tonometry to obtain central measures of aortic stiffness: pulse pressure, augmentation pressure and augmentation index. Following ablation, arrhythmia recurrence was monitored at months 3, 6, 9, 12 and 6 monthly thereafter. Compared to healthy controls, lone atrial fibrillation patients had significantly elevated peripheral pulse pressure, central pulse pressure, augmentation pressure and larger left atrial dimensions (all P<0.05). During a mean follow-up of 2.9±1.4 years, 38 of the 68 lone atrial fibrillation patients had atrial fibrillation recurrence after initial catheter ablation procedure. Neither blood pressure nor aortic stiffness indices differed between patients with and without atrial fibrillation recurrence. However, patients with highest levels (≥75(th) percentile) of peripheral pulse pressure, central pulse pressure and augmentation pressure had higher atrial fibrillation recurrence rates (all P<0.05). Only central aortic stiffness indices were associated with lower survival free from atrial fibrillation using Kaplan-Meier analysis. Aortic stiffness is an important risk factor in patients with lone atrial fibrillation and contributes to higher atrial fibrillation recurrence following catheter ablation procedure.
Paventi, S; Parafati, M A; Pellegrino, C A; Bevilacqua, U; Paggi, A
Normal atrial mechanic function may not return immediately after the successful cardioversion of atrial fibrillation. It has been suggested that the delayed recovery of atrial contraction (atrial stunning) might be due to: 1. the energy delivered during direct current cardioversion 2. the time from the onset of atrial fibrillation 3. the left atrial size 4. the associated cardiac disease. This study evaluates "atrial stunning" in patients pharmacologically treated, with atrial fibrillation of recent onset, normal atrial size and without heart disease. Doppler echocardiography is well suited for assessment of atrial function due to the ability of recording the peak velocity of atrial contraction (A wave). Twenty-five patients with no evidence of heart disease and M-mode left atrial dimension less than 40 mm underwent successful pharmacologic cardioversion (pro-paphenon or flecainide 2 mg/kg/10 min) of atrial fibrillation of recent onset (less than 48 hours). After cardioversion an echocardiographic study was performed within 12 hours (ECO 1), on day 3 (ECO 2), on day 12 (ECO 3), and on day 30 (ECO 4). No significant difference of both left atrial size (37 +/- 3.9 mm; 38.22 +/- 3.8 mm; 38.02 +/- 4.7 mm; 38.2 +/- 4.14 mm) and peak E velocity (57.97 +/- 18.3 mm/sec; 59.4 +/- 18.3 mm/sec; 59.0 +/- 16 mm/sec; 59.07 +/- 16.7 mm/sec) was demonstrated among serial echocardiographic evaluations. Both peak A velocity (mm/sec) and E/A ratio were significantly different in ECO 1 (60.29 +/- 12.3-1.0 +/- 0.37) than in ECO 2 (73.1 +/- 10.7, p < 0.005-0.82 +/- 0.27, p < 0.05); no statistical difference was found between ECO 2 and ECO 3 (76.31 +/- 12-0.78 +/- 0.24 mm/sec)--ECO 4 (76.91 +/- 14.8-0.78 +/- 0.21 mm/sec). This study suggests that patients with atrial fibrillation of recent onset have a delayed recovery of normal atrial systolic function after pharmacologic cardioversion.
Rienstra, Michiel; Van Gelder, Isabelle C
In the last few years, there has been a major shift in the treatment of atrial fibrillation (AF) in the setting of hear failure (HF), from rhythm to ventricular rate control in most patients with both conditions. In this article, the authors focus on ventricular rate control and discuss the indications; the optimal ventricular rate-control target, including detailed results of the Rate Control Efficacy in Permanent Atrial Fibrillation: a Comparison Between Lenient versus Strict Rate Control II (RACE II) study; and the pharmacologic and nonpharmacologic options to control the ventricular rate during AF in the setting of HF. Copyright © 2013 Elsevier Inc. All rights reserved.
Wilde, Sandra; Wiltink, Jörg; Wild, Philipp S.; Sinning, Christoph R.; Lubos, Edith; Ojeda, Francisco M.; Zeller, Tanja; Munzel, Thomas; Blankenberg, Stefan; Beutel, Manfred E.
Background Initial evidence suggests that depressive symptoms are more frequent in patients with atrial fibrillation. Data from the general population are limited. Methods and Results In 10,000 individuals (mean age 56±11 years, 49.4% women) of the population-based Gutenberg Health Study we assessed depression by the Patient Health Questionnaire (PHQ-9) and a history of depression in relation to manifest atrial fibrillation (n = 309 cases). The median (25th/75th percentile) PHQ-9 score of depressive symptoms was 4 (2/6) in atrial fibrillation individuals versus 3 (2/6) individuals without atrial fibrillation, . Multivariable regression analyses of the severity of depressive symptoms in relation to atrial fibrillation in cardiovascular risk factor adjusted models revealed a relation of PHQ-9 values and atrial fibrillation (odds ratio (OR) 1.04, 95% confidence interval (CI) 1.01–1.08; P = 0.023). The association was stronger for the somatic symptom dimension of depression (OR 1.08, 95% CI 1.02–1.15; P = 0.0085) than for cognitive symptoms (OR 1.05, 95% CI 0.98–1.11; P = 0.15). Results did not change markedly after additional adjustment for heart failure, partnership status or the inflammatory biomarker C-reactive protein. Both, self-reported physical health status, very good/good versus fair/bad, (OR 0.54, 95% CI 0.41–0.70; P<0.001) and mental health status (OR 0.61 (0.46–0.82); P = 0.0012) were associated with atrial fibrillation in multivariable-adjusted models. Conclusions In a population-based sample we observed a higher burden of depressive symptoms driven by somatic symptom dimensions in individuals with atrial fibrillation. Depression was associated with a worse perception of physical or mental health status. Whether screening and treatment of depressive symptoms modulates disease progression and outcome needs to be shown. PMID:24324579
Gorenek, Bulent; Kudaiberdieva, Gulmira
Atrial fibrillation is the most common arrhythmia associated with increased mortality and morbidity. Its management requires high healthcare expenditures; 52%-70% of expenses for AF care are constituted by hospitalization costs. The current management strategies of pharmacological rhythm control and pharmacological or invasive rate control show no difference in impact on major outcomes in patients with AF. Radiofrequency catheter ablation (RFA) has been shown to reduce the risk of AF recurrence, improve quality of life and reduce hospitalization rate as compared to pharmacological rhythm control and rate control strategies. This review summarizes current knowledge on cost and cost-effectiveness analysis of RFA for patients with atrial fibrillation.
Yadava, Mrinal; Hughey, Andrew B; Crawford, Thomas Christopher
Atrial fibrillation is the most commonly encountered arrhythmia after cardiac surgery. Although usually self-limiting, it represents an important predictor of increased patient morbidity, mortality, and health care costs. Numerous studies have attempted to determine the underlying mechanisms of postoperative atrial fibrillation (POAF) with varied success. A multifactorial pathophysiology is hypothesized, with inflammation and postoperative β-adrenergic activation recognized as important contributing factors. The management of POAF is complicated by a paucity of data relating to the outcomes of different therapeutic interventions in this population. This article reviews the literature on epidemiology, mechanisms, and risk factors of POAF, with a subsequent focus on the therapeutic interventions and guidelines regarding management.
Khabchabov PhD, Rustam; Rg PhD, Khabchabov; Er PhD, Makhmudova
Resume In accordance with modern concepts, one of the leading roles in the development of paroxysmal atrial fibrillation and flutter, belongs - the restructuring of the myocardium, in second place - sick sinus syndrome and in third place - the presence of accessory pathways and hormonal disorders. The development of atrial fibrillation and flutter in the structural pathology, primarily begins with of drugs if it does not work, we have to carry out ablation. Providing proper, effective and important combination therapy - is the main challenge in cardiology.
Nührich, Jana M; Geisler, Anne C; Steven, Daniel; Hoffmann, Boris A; Schäffer, Benjamin; Lund, Gunnar; Stehning, Christian; Radunski, Ulf K; Sultan, Arian; Schwarzl, Michael; Adam, Gerhard; Willems, Stephan; Muellerleile, Kai
Extensive and repeated substrate modification (SM) is frequently performed as an ablation strategy in persistent atrial fibrillation (persAF). The effect of these extended ablation strategies on atrial function has not been investigated sufficiently so far. The purpose was to assess atrial function by cardiac magnetic resonance (CMR) and its association with left atrial (LA) scar burden by electroanatomical voltage-mapping after multiple persAF ablation procedures. We included 16 persAF patients who had ≥2 SM procedures and a control group (CG) of 21 persAF patients without prior ablation. CMR was performed in sinus rhythm at least 4 weeks after the last cardioversion. Active left and right (RA) atrial emptying fractions (AEF) as well as peak active left atrial appendage (LAA) emptying velocities were obtained by CMR flow measurements. Furthermore, LA scar burden was quantified on electroanatomical voltage maps by the portion of points with local voltage amplitude <0.2 mV. We found median LA-AEF to be lower (13 [9-22] vs 32 [26-36] %, P < 0.001) and median LA scar burden to be higher (40 [20-68] vs nine [3-18] %, P < 0.05) in the SM group compared with the CG. Furthermore, a significant correlation was found between mean LA voltage and LA-AEF (r(2) = 0.62, P < 0.001). No significant differences were detected with respect to median RA-AEF (41 [28-48] vs 47 [35-50] %, P = 0.43) and median peak LAA emptying velocities (30 [16-40] vs 17 [13-28] cm/s, P = 0.07). Active LA function is preserved but significantly impaired and associated with ablation-related LA scar burden after multiple extensive persAF ablations. ©2016 Wiley Periodicals, Inc.
Ahmed, Amar; Calvert, Melanie; Lencioni, Mauro; Terwee, Caroline B.; Lane, Deirdre A.
Background Atrial fibrillation is a large and growing burden across all types of healthcare. Both incidence and prevalence are expected to double in the next 20 years, with huge impact on hospital admissions, costs and patient quality of life. Patient wellbeing determines the management strategy for atrial fibrillation, including the use of rhythm control therapy and the clinical success of heart rate control. Hence, evaluation of quality of life is an emerging and important part of the assessment of patients with atrial fibrillation. Although a number of questionnaires to assess quality of life in atrial fibrillation are available, a comprehensive overview of their measurement properties is lacking. Methods and Results We performed a systematic review of the measurement properties of atrial fibrillation-specific health-related quality of life questionnaires. Methodological quality was assessed using the Consensus based Standards for selection of health Measurement Instruments (COSMIN) checklist, with measurement properties rated for quality against optimal criteria and levels of evidence. We screened 2,216 articles, of which eight articles describing five questionnaires were eligible for inclusion: Atrial Fibrillation 6 (AF6), Atrial Fibrillation Effect on QualiTy-of-Life (AFEQT), Atrial Fibrillation Quality of Life Questionnaire (AFQLQ), Atrial Fibrillation Quality of Life (AFQoL), and Quality of Life in Atrial Fibrillation (QLAF). Good reliability (internal consistency and test-retest reliability) was demonstrated for AF6, AFEQT, AFQLQ and AFQoL. Content, construct and criterion validity were positively rated only in AFEQT. Responsiveness was positively rated only in AFEQT, but with limited evidence. Overall, AFEQT showed strong positive evidence for 2 of 9 measurement properties, compared to one for AFQoL and none for the remaining questionnaires. Interpretation Given the low ratings for many measurement properties, no single questionnaire can be recommended
Gladstone, David J; Dorian, Paul; Spring, Melanie; Panzov, Val; Mamdani, Muhammad; Healey, Jeff S; Thorpe, Kevin E
Many ischemic strokes or transient ischemic attacks are labeled cryptogenic but may have undetected atrial fibrillation (AF). We sought to identify those most likely to have subclinical AF. We prospectively studied patients with cryptogenic stroke or transient ischemic attack aged ≥55 years in sinus rhythm, without known AF, enrolled in the intervention arm of the 30 Day Event Monitoring Belt for Recording Atrial Fibrillation After a Cerebral Ischemic Event (EMBRACE) trial. Participants underwent baseline 24-hour Holter ECG poststroke; if AF was not detected, they were randomly assigned to 30-day ECG monitoring with an AF auto-detect external loop recorder. Multivariable logistic regression assessed the association between baseline variables (Holter-detected atrial premature beats [APBs], runs of atrial tachycardia, age, and left atrial enlargement) and subsequent AF detection. Among 237 participants, the median baseline Holter APB count/24 h was 629 (interquartile range, 142-1973) among those who subsequently had AF detected versus 45 (interquartile range, 14-250) in those without AF (P<0.001). APB count was the only significant predictor of AF detection by 30-day ECG (P<0.0001), and at 90 days (P=0.0017) and 2 years (P=0.0027). Compared with the 16% overall 90-day AF detection rate, the probability of AF increased from <9% among patients with <100 APBs/24 h to 9% to 24% in those with 100 to 499 APBs/24 h, 25% to 37% with 500 to 999 APBs/24 h, 37% to 40% with 1000 to 1499 APBs/24 h, and 40% beyond 1500 APBs/24 h. Among older cryptogenic stroke or transient ischemic attack patients, the number of APBs on a routine 24-hour Holter ECG was a strong dose-dependent independent predictor of prevalent subclinical AF. Those with frequent APBs have a high probability of AF and represent ideal candidates for prolonged ECG monitoring for AF detection. URL: http://www.clinicaltrials.gov. Unique identifier: NCT00846924. © 2015 American Heart Association, Inc.
Matusik, Paweł; Woznica, Natalia; Lelakowsk, Jacek
Atrial fibrillation (AF) is a frequent problem of patients with pacemakers, and depends not only on disease but also on stimulation method. The aim of the study was to estimate the prevalence of AF before and after pacemaker implantation as well as to assess the influence of VVI and DDD cardiac pacing on onset of AF in patients with complete atrioventricularblock (AVB). We included 155 patients controlled between 2000 and 2008 in Pacemaker Clinic because of AVB III degree, treated with VVI or DDD pacemaker implantation. Information about the health status of the patients was gathered from medical documentation and analysis of clinical ambulatory electrocardiograms. The study group comprised of 68 women and 87 men, mean age 68.7 +/- 13.9 years during implantation. 69% of patients had VVI pacemaker. There were 72.3% of patients with sinus rhythm before pacemaker implantation. During follow-up 4 +/- 2.8 years in 19.6% cases onset of atrial fibrillation de novo was diagnosed (in 31.3% in VVI mode vs. 2.2% in DDD mode; p = 0.00014). Mean time to AF since implantation was approximately 2.5 years. In VVI group (21 persons) amounted 32.1 months, while in 1 patient with DDD pacemaker 18 months. Between group with AF after implantation and with sinus rhythm preserved there was no statistically significant difference in age or gender (p = 0.89512 and p = 0.1253, respectively). Prevalence of atrial fibrillation after pacemaker implantation increased to 40%. Atrial fibrillation is frequent in patients before and after pacemaker implantation, especially in patients stimulated in VVI mode. Major possibility of atrial fibrillation onset after pacemaker implantation should result in more attention during routine ECG examination.
Sudlow, M; Thomson, R; Kenny, R A; Rodgers, H
BACKGROUND: Anticoagulants are effective in preventing stroke in those with atrial fibrillation, but most patients remain untreated. AIM: To investigate the prevalence of disability, cognitive impairment, and problems with compliance in a representative sample of the elderly with atrial fibrillation, and to determine whether they would want treatment and how they would like services to be arranged. METHOD: In a survey of a random sample of 4843 elderly subjects, those with atrial fibrillation were identified using electrocardiograms. Views on treatment were obtained using a structured interview. Disability was assessed using the Office of Population Censuses and Surveys Disability Scale and cognitive status using the Mini Mental State Examination. General practitioners were asked, via questionnaire, for their views on each subject's compliance. RESULTS: Two hundred and seven elderly people with atrial fibrillation were identified. Almost all subjects expressed a willingness to undertake treatment to prevent stroke and preferred blood testing performed outside of hospital. Disability (82.7%), cognitive impairment (25.7%), and problems with compliance (25.0%) were common, but the prevalence of these difficulties was not substantially different from the general elderly population, and in many cases they could be overcome (e.g. only 10% of subjects had problems with compliance and no-one who could help them to comply). CONCLUSIONS: Most elderly people with atrial fibrillation would accept treatment to prevent stroke. Disability, cognitive impairment, and problems with compliance may make it difficult to treat this patient group. An increase in the use of anticoagulants should be accompanied by the development of services appropriate to this frail population. PMID:10198488
Barbati, Giovanni; De Domenico, Renato; Rossi, Stefania; Vecchiato, Elena; Zeppellini, Roberto
Oral anticoagulant therapy (OAT) is a mainstay of atrial fibrillation (AF) pharmacological treatment. Left atrial appendage closure is a possible treatment, when feasible, in patients with intracerebral hemorrhage during OAT. We report a case of right atrial appendage thrombosis in a patient with chronic AF admitted for syncope due to diuretic-induced orthostatic hypotension. Two years previously, he had undergone left atrial appendage closure with the Amplatzer Cardiac Plug device because of intracerebral hemorrhage during OAT. After neurological consult, OAT was resumed with apixaban 5 mg twice daily, and transesophageal echocardiography performed two months later showed complete resolution of the right atrial appendage thrombosis. This particular case underlines the importance of searching for a possible right atrial appendage thrombosis in patients affected by AF, and suggests that left atrial appendage closure in AF patients not suitable for OAT does not fully eliminate the risk of thromboembolism.
Nagy, Zsófia; Kis, Zsuzsanna; Som, Zoltán; Földesi, Csaba; Kardos, Attila
Contact force sensing radiofrequency ablation and the new generation cryoballoon ablation are prevalent techniques for the treatment of paroxysmal atrial fibrillation. The authors aimed to compare the procedural and 1-year outcome of patients after radiofrequency and cryoballoon ablation. 96 patients with paroxysmal atrial fibrillation (radiofrequency ablation: 58, cryoballoon: 38 patients; 65 men and 31 women aged 28-70 years) were enrolled. At postprocedural 1, 3, 6 and 12 months ECG, Holter monitoring and telephone interviews were performed. Procedure and fluorosocopy time were: radiofrequency ablation, 118.5 ± 15 min and 15.8 ± 6 min; cryoballoon, 73.5 ± 16 min (p<0.05) and 13.8 ± 4.,1 min (p = 0.09), respectively. One year later freedom from atrial fibrillation was achieved in 76.5% of patients who underwent radiofrequency ablation and in 81% of patients treated with cryoballoon. Temporary phrenic nerve palsy occurred in two patients and pericardial tamponade developed in one patient. In this single center study freedom from paroxysmal atrial fibrillation was similar in the two groups with significant shorter procedure time in the cryoballoon group.
Wakili, Reza; Voigt, Niels; Kääb, Stefan; Dobrev, Dobromir; Nattel, Stanley
Atrial fibrillation (AF) is an extremely common cardiac rhythm disorder that causes substantial morbidity and contributes to mortality. The mechanisms underlying AF are complex, involving both increased spontaneous ectopic firing of atrial cells and impulse reentry through atrial tissue. Over the past ten years, there has been enormous progress in understanding the underlying molecular pathobiology. This article reviews the basic mechanisms and molecular processes causing AF. We discuss the ways in which cardiac disease states, extracardiac factors, and abnormal genetic control lead to the arrhythmia. We conclude with a discussion of the potential therapeutic implications that might arise from an improved mechanistic understanding. PMID:21804195
Massaro, Ayrton R.; Lippp, Gregory Y. H.
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, with an estimated prevalence of 1-2% in North America and Europe. The increased prevalence of AF in Latin America is associated with an ageing general population, along with poor control of key risk factors, including hypertension. As a result, stroke prevalence and associated mortality have increased dramatically in the region. Therefore, the need for effective anticoagulation strategies in Latin America is clear. The aim of this review is to provide a contemporary overview of anticoagulants for stroke prevention. The use of vitamin K antagonists (VKAs, eg, warfarin) and aspirin in the prevention of stroke in patients with AF in Latin America remains common, although around one fifth of all AF patients receive no anticoagulation. Warfarin use is complicated by a lack of access to effective monitoring services coupled with an unpredictable pharmacokinetic profile. The overuse of aspirin is associated with significant bleeding risks and reduced efficacy for stroke prevention in this patient group. The non-VKA oral anticoagulants (NOACbs) represent a potential means of overcoming many limitations associated with VKA and aspirin use, including a reduction in the need for monitoring and a reduced risk of hemorrhagic events. The ultimate decision of which anticoagulant drug to utilize in AF patients depends on a multitude of factors. More research is needed to appreciate the impact of these factors in the Latin American population and thereby reduce the burden of AF-associated stroke in this region. PMID:27533256
McBane, Robert D; Hodge, David O; Wysokinski, Waldemar E
Although infrequent, embolic occlusion to non-cerebral arteries may result in limb loss, organ failure, and death. The aim of this study was to define clinical and echocardiographic characteristics determining thromboembolism destination in non-valvular atrial fibrillation. An inception cohort of individuals (n=72) were identified with incident peripheral embolism in the setting of non-valvular atrial fibrillation (1995-2005). A randomly selected group of atrial fibrillation related stroke patients (n=100) were identified for comparison. Arteries of the extremities were the most common site of embolism (85%); lower extremity involvement was twice as common compared with the upper extremity. Clinical features distinguishing peripheral embolism from stroke included age>75, heart failure and hypertension. Severe left ventricular dysfunction, spontaneous echo contrast and left atrial thrombus were 2-3 fold more common in peripheral embolism patients. Mean CHADS-2 scores were low and comparable for both groups. By multivariate analysis, age>5 years (hazard ratio [HR] 2.3, 95% confidence interval [CI] 1.3-3.9; p=0.05) was predictive of peripheral embolism. After adjustment for age>75 years, severe left atrial enlargement (HR 1.8, 95% CI 0.99-3.1; p=0.055) and CHADS score (HR 1.2, 95% CI 0.99-1.6; p=0.06) were of borderline significance. In conclusion, several clinical and echocardiographic measures distinguish the clinical presentation of thromboembolism in non-valvular atrial fibrillation. Small emboli are destined to lodge in the cerebral circulation as a result of hydrodynamic, anatomic, and physical factors. Advanced age, atrial enlargement and other co-morbidities may increase the propensity for the formation of larger thrombi which may bypass the carotid orifice merely as a function of size.
Tsutsui, Kenta; Ajiki, Kohsuke; Fujiu, Katsuhito; Imai, Yasushi; Hayami, Noriyuki; Murakawa, Yuji
Atrial tachycardia (AT) and atrial fibrillation (AF) were observed in a 21-year old male who had a history of patch closure for an atrial septal defect (ASD) at the age of 5 and a persistent left superior vena cava (LSVC). During electrophysiologic study, atrial extrastimuli reproducibly induced AT which spontaneously terminated or changed into AF. Electroanatomical mapping revealed focal AT arising from the floor of the proximal LSVC. Radio- frequency applications within LSVC targeted to the earliest activation site of AT as well as the complex fractionated potential eliminated both AT and AF without trans-septal puncture.
Goldberger, Jeffrey J.; Arora, Rishi; Green, David; Greenland, Philip; Lee, Daniel C.; Lloyd-Jones, Donald M.; Markl, Michael; Ng, Jason; Shah, Sanjiv J.
Atrial disease or myopathy forms the substrate for atrial fibrillation (AF) and underlies the potential for atrial thrombus formation and subsequent stroke. Current diagnostic approaches in patients with AF focus on identifying clinical predictors with evaluation of left atrial size by echocardiography serving as the sole measure specifically evaluating the atrium. Although the atrial substrate underlying AF is likely developing for years prior to the onset of AF, there is no current evaluation to identify the pre-clinical atrial myopathy. Atrial fibrosis is one component of the atrial substrate that has garnered recent attention based on newer MRI techniques that have been applied to visualize atrial fibrosis in humans with prognostic implications regarding success of treatment. Advanced ECG signal processing, echocardiographic techniques, and MRI imaging of fibrosis and flow provide up-to-date approaches to evaluate the atrial myopathy underlying AF. While thromboembolic risk is currently defined by clinical scores, their predictive value is mediocre. Evaluation of stasis via imaging and biomarkers associated with thrombogenesis may provide enhanced approaches to assess risk for stroke in patients with AF. Better delineation of the atrial myopathy that serves as the substrate for AF and thromboembolic complications might improve treatment outcomes. Furthermore, better delineation of the pathophysiologic mechanisms underlying the development of the atrial substrate for AF, particularly in its earlier stages, could help identify blood and imaging biomarkers that could be useful to assess risk for developing new onset AF and suggest specific pathways that could be targeted for prevention. PMID:26216085
Fox, Henrik; Bitter, Thomas; Horstkotte, Dieter; Oldenburg, Olaf
Sleep-disordered breathing (SDB), in particular obstructive sleep apnoea, is associated with an increased risk of onset or recurrence of atrial fibrillation (AF) and atrial flutter. This prospective study investigated the relationship between restoration of sinus rhythm and SDB in patients with AF or atrial flutter. 138 consecutive patients (age 67.8 ± 10.3 years, 67.4 % male) with AF (86.2 %) or atrial flutter (13.8 %) were enrolled and underwent multichannel cardiorespiratory polygraphy the night before and immediately after electrical cardioversion (CV). None of the patients was treated with ventilation therapy before or during the study. Overall prevalence of SDB [apnoea-hypopnoea index (AHI) ≥5/h] was 92 % and prevalence of moderate-to-severe SDB (AHI) ≥15/h was 64 %. Within the first night after CV, AHI decreased from 23.4 ± 16.3 to 16.3 ± 11.5/h, p < 0.001. This was due to a significant decrease in central respiratory events, with a total reduction of patients showing central sleep apnoea (n = 53 at baseline vs n = 23 immediately after CV; p < 0.001). In conclusion, SDB represents a highly prevalent comorbidity in patients with atrial arrhythmias. Through cardioversion, an immediate reduction of SDB can be detected due to a significant reduction in central respiratory events.
Cengel, Atiye; Sahinarslan, Asife; Biberoğlu, Gursel; Hasanoğlu, Alev; Tavil, Yusuf; Tulmaç, Murat; Ozdemir, Murat
Atrial fibrillation (AF) is known to be related with increased risk of thromboembolic events. Asymmetrical dimethylarginine (ADMA), which is an endogenous inhibitor of nitric oxide synthase (NOS), can cause endothelial dysfunction by decreasing nitric oxide (NO) and lead to increased risk of thrombosis. In the present study our aim was to compare plasma levels of ADMA in patients with acute onset (< 24 hours) and chronic AF (> 1 year) to determine the risk of thrombosis. 17 patients with the first detected attack of AF within the first 24 hours of presentation (group 1), 25 patients who had permanent chronic AF lasting at least 1 year or more (group II) and 18 healthy persons as the control group (group III) were included in the study. For each patient the plasma ADMA, L-arginine, symmetrical dimethylarginine (SDMA) concentrations were measured by high-performance liquid chromatography in venous blood samples collected before cardioversion. We compared the plasma ADMA, L-arginine and SDMA concentrations between the groups. Plasma L-arginine (78.18 +/- 28.29 vs. 73.14 +/- 14.11 vs. 71.03 +/- 21.31, P = 0.549) and plasma SDMA concentrations (0.38 +/-0.18 vs. 0.42 +/- 0.21 vs. 0.32 +/- 0.24, P = 0.224) were similar in all groups. There was a significant difference between plasma ADMA concentrations (0.76 +/- 0.27 vs. 0.50 +/- 0.26 vs. 0.36 +/- 0.20, P < 0.001) among the groups. When we compared plasma ADMA levels between the subgroups, we also found a significant difference (P = 0.002 when comparing group I and group II, P < 0.001 when comparing of group I and group III, P = 0.042 when compareng of group II and group III). ADMA levels in patients with acute onset AF were significantly increased when compared with patients with chronic AF and the healthy control group indicating the presence of endothelial dysfunction and a prothrombotic state even in a very early phase of AF.
Urtubia Palacios, A; Usieto López, L; Fernández Esteban, M I; Puértolas Ortega, M
Torsade de pointes is a frequent cause of sudden death of cardiac origin, with uncertain mechanisms of actions and very diverse origins. A case is presented of a patient with a bronchial condition on pharmacological treatment with macrolides, and who, as well as having atrial fibrillation, suffered an episode of self-limiting torsade de pointes that abated spontaneously with no associated clinical complications.
Calvo Romero, J M
In clinical practice, low-molecular-weight heparins are used relatively frequently in patients with atrial fibrillation to prevent embolic events. In this article, it is revised the available evidence in the following clinical situations: rapid onset of anticoagulation, bridging therapy (replacing long-term oral anticoagulant therapy around an invasive procedure) and transesophageal echocardiography-guided cardioversion.
Brick, Alexandre Visconti; Braile, Domingo Marcolino
Surgical ablation, concomitant with other operations, is an option for treatment in patients with chronic atrial fibrillation. The aim of this study is to present a literature review on surgical ablation of atrial fibrillation in patients undergoing cardiac surgery, considering energy sources and return to sinus rhythm. A comprehensive survey was performed in the literature on surgical ablation of atrial fibrillation considering energy sources, sample size, study type, outcome (early and late), and return to sinus rhythm. Analyzing studies with immediate results (n=5), the percentage of return to sinus rhythm ranged from 73% to 96%, while those with long-term results (n=20) (from 12 months on) ranged from 62% to 97.7%. In both of them, there was subsequent clinical improvement of patients who underwent ablation, regardless of the energy source used. Surgical ablation of atrial fibrillation is essential for the treatment of this arrhythmia. With current technology, it may be minimally invasive, making it mandatory to perform a procedure in an attempt to revert to sinus rhythm in patients requiring heart surgery.
Brick, Alexandre Visconti; Braile, Domingo Marcolino
Surgical ablation, concomitant with other operations, is an option for treatment in patients with chronic atrial fibrillation. The aim of this study is to present a literature review on surgical ablation of atrial fibrillation in patients undergoing cardiac surgery, considering energy sources and return to sinus rhythm. A comprehensive survey was performed in the literature on surgical ablation of atrial fibrillation considering energy sources, sample size, study type, outcome (early and late), and return to sinus rhythm. Analyzing studies with immediate results (n=5), the percentage of return to sinus rhythm ranged from 73% to 96%, while those with long-term results (n=20) (from 12 months on) ranged from 62% to 97.7%. In both of them, there was subsequent clinical improvement of patients who underwent ablation, regardless of the energy source used. Surgical ablation of atrial fibrillation is essential for the treatment of this arrhythmia. With current technology, it may be minimally invasive, making it mandatory to perform a procedure in an attempt to revert to sinus rhythm in patients requiring heart surgery. PMID:26934404
Diener, Hans-Christoph; Weber, Ralph; Lip, Gregory Y H; Hohnloser, Stefan H
Oral anticoagulation with vitamin K antagonists (warfarin, phenprocoumon) is successful in both primary and secondary stroke prevention in patients with atrial fibrillation, yielding a 60-70% relative reduction in stroke risk compared with placebo, as well as a mortality reduction of 26%. However, these agents have a number of well documented shortcomings. Acetylsalicylic acid (ASA) reduces the relative risk of stroke by a nonsignificant 19% compared with placebo, and increased bleeding risk offsets any therapeutic gain from the combination of ASA with clopidogrel. This review describes the current landscape and developments in stroke prevention in patients with atrial fibrillation, with special reference to secondary prevention. A number of new drugs for oral anticoagulation that do not exhibit the limitations of vitamin K antagonists are under investigation. These include direct factor Xa inhibitors and direct thrombin inhibitors. Recent studies (RE-LY, ROCKET-AF, AVERROES, ARISTOTLE) provide promising results for new agents, including higher efficacy and significantly lower incidences of intracranial bleeds compared with warfarin. The new substances show similar results in secondary as in primary stroke prevention in patients with atrial fibrillation. New anticoagulants add to the therapeutic options for patients with atrial fibrillation, and offer a number of advantages over warfarin, for both the clinician and patient, including a favourable bleeding profile and convenience of use. Consideration of these new anticoagulants will improve clinical decision making.
Rawles, J M; Rowland, E
The belief that there is total irregularity of the pulse in atrial fibrillation has been re-examined. In a computerised analysis of R-R intervals and pulse volumes, 100-500 (mean 237) consecutive cycles were examined in 74 patients with atrial fibrillation, of whom 36 were on digoxin and 38 were not taking any antiarrhythmic treatment. A Doppler ultrasound technique was used to assess pulse volumes, against which R-R intervals were correlated. Although the sequence of consecutive R-R intervals was random in 52 (70%), patients there was a significant correlation between consecutive intervals in 22 (30%), the correlation coefficient being negative in 11 and positive in 11. In 43 (58%) cases the sequence of consecutive pulse volumes was significantly non-random; 34 (46%) showed pulsus alternans, indicated by a negative correlation between consecutive volumes. The proportion of patients with a non-random sequence of R-R intervals or pulse volumes was the same whether or not they were taking digoxin. Thus patients with atrial fibrillation often have patterns of regularity of the pulse, with the ventricular rhythm being non-random in almost one third and the sequence of pulse volumes being non-random in over a half. Contrary to classic teaching, in many patients with atrial fibrillation the pulse is not irregularly irregular. PMID:3730206
Bauer, Peter A.; Polk, J. D.
This presentation will explore the clinical and administrative conundrums faced by the flight surgeon upon discovering asymptomatic paroxysmal atrial fibrillation seven months prior to scheduled long duration spaceflight. The presenter will discuss the decision-making process as well as the clinical and operational outcomes.
Rordorf, Roberto; Savastano, Simone; Gandolfi, Edoardo; Vicentini, Alessandro; Petracci, Barbara; Landolina, Maurizio
Catheter ablation has been proven to be an effective treatment for patients with drug-resistant atrial fibrillation. Nevertheless its efficacy is limited to 60-80% of patients in different studies. Whether the use of pharmacological therapy after catheter ablation of atrial fibrillation might increase the procedural success rate is still a matter of debate. There is general agreement that antiarrhythmic drugs (AADs) are useful in the management of arrhythmias occurring in the very early period after catheter ablation (blanking period). On the contrary, limited data are available on the efficacy of AADs over a longer period. Some patients remain free of arrhythmia recurrences by the use of AADs that were ineffective before catheter ablation: whether this latter situation is to be considered a partial success of catheter ablation or a treatment failure, thus demanding a redo procedure, is still an open question. Some studies have also investigated the role of non-AADs [angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers, statins and corticosteroids] in preventing atrial fibrillation recurrences after catheter ablation, reporting conflicting results. Whereas there is a general consensus on the use of anticoagulation therapy in the first phase after catheter ablation, no definite data are available on the proper long-term management of anticoagulation therapy after catheter ablation. This review focuses on the still open issue of what is the optimal pharmacological treatment of patients after catheter ablation of atrial fibrillation.
Donahue, J Kevin
Atrial fibrillation is a prominent cause of morbidity and mortality in developed countries. Treatment strategies center on controlling atrial rhythm or ventricular rate. The need for anticoagulation is an independent decision from the rate versus rhythm control debate. This review discusses novel biological strategies that have potential utility in the management of atrial fibrillation. Rate controlling strategies predominately rely on G-protein gene transfer to enhance cholinergic or suppress adrenergic signaling pathways in the atrioventricular node. Calcium channel blocking gene therapy and fibrosis enhancing cell therapy have also been reported. Rhythm controlling strategies focus on disrupting reentry by enhancing conduction or suppressing repolarization. Efforts to suppress inflammation and apoptosis are also under study. Resistance to blood clot formation has been shown with thrombomodulin. These strategies are in various stages of preclinical development.
Abstract This paper reviews the simulations of catheter ablation in computer models of the atria, from the first attempts to the most recent anatomical models. It describes how postulated substrates of atrial fibrillation can be incorporated into mathematical models, how modelling studies can be designed to test ablation strategies, what their current trade‐offs and limitations are, and what clinically relevant lessons can be learnt from these simulations. Drawing a parallel between clinical and modelling studies, six ablation targets are considered: pulmonary vein isolation, linear ablation, ectopic foci, complex fractionated atrial electrogram, rotors and ganglionated plexi. The examples presented for each ablation target illustrate a major advantage of computer models, the ability to identify why a therapy is successful or not in a given atrial fibrillation substrate. The integration of pathophysiological data to create detailed models of arrhythmogenic substrates is expected to solidify the understanding of ablation mechanisms and to provide theoretical arguments supporting substrate‐specific ablation strategies. PMID:26846178
Lisa Gracia, M; Córdoba Alonso, A; Hernández Hernández, J L; Pérez Montes, R; Napal Lecumberri, J J
To analyse the importance of cardiovascular risk factors, ultrasound findings in the supra-aortic trunk and the presence of anticoagulated nonvalvular atrial fibrillation (NVAF) in patients with retinal vein occlusion (RVO) and in a control group. A cross-sectional study was conducted of all patients with RVO consecutively referred to the office of internal medicine, comparing them with a control group. We analysed clinical, electrocardiographic and ultrasound variables. We studied 212 patients (114 men and 98 women) with RVO and 212 controls (95 men and 117 women) of similar ages. Arterial hypertension, dyslipidaemia and diabetes mellitus were significantly more prevalent in the patients with RVO than in the controls (73.6 vs. 50%, 64.6 vs. 48.6% and 27.8 vs. 12.3%, respectively). We observed arteriosclerotic lesions in the supra-aortic trunk in 55% of the patients with RVO. The patients with RVO and NVAF had a greater burden of cardiovascular risk factors than the controls with NVAF. There were no differences in terms of the international normalised ratio or in the use of direct anticoagulants between the cases and controls with NVAF. Cardiovascular risk factors (especially arterial hypertension) and arteriosclerotic involvement of the supra-aortic trunk are highly prevalent in RVO. Anticoagulation does not appear to be effective in preventing RVO. Copyright © 2016 Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI). All rights reserved.
Kanda, Takashi; Masuda, Masaharu; Sunaga, Akihiro; Fujita, Masashi; Iida, Osamu; Okamoto, Shin; Ishihara, Takayuki; Watanabe, Tetsuya; Takahara, Mitsuyoshi; Sakata, Yasushi; Uematsu, Masaaki
Recurrence after catheter ablation of persistent atrial fibrillation (AF) remains an unsolved issue. This study aimed to explore the association between the left atrial appendage peak flow velocity (LAAV) and AF recurrence after ablation in persistent AF patients. Fifty-three consecutive patients who underwent an initial catheter ablation of persistent AF were enrolled [age, 65±10 years; male, 42 (79%)]. The LAAV was obtained by transesophageal echocardiography before ablation. All the patients underwent pulmonary vein isolation and were followed up for 12 months. The LAAV and other clinical factors (AF duration, CHA2DS2VASc score, left atrial diameter, left atrial volume, and left ventricular ejection fraction) were tested using a Cox proportional hazards regression analysis as predictors of AF recurrence during the 1-year follow-up. AF recurrence occurred in 16 (30%) patients. The patients with AF recurrences had lower LAAVs (23.3±7.2cm/s vs. 33.3±15.1cm/s, p=0.002) than those without AF recurrence. In the multivariable analysis, a low LAAV independently predicted AF recurrence (hazard ratio, 3.04; 95% confidence interval, 1.05-8.79; p=0.040). A Kaplan-Meier analysis also demonstrated a lower survival rate free from AF recurrence in the low LAAV group than in the high LAAV group (p=0.030). A low LAAV was associated with AF recurrence after the initial catheter ablation of persistent AF. Copyright © 2015. Published by Elsevier Ltd.
Providência, Rui; Gonçalves, Lino; Ferreira, Maria João
Cerebrovascular disease has long been the leading cause of death in Portugal. Despite improvements in the treatment of hypertension and the resulting decrease in associated mortality, the progressive aging of the population and increased prevalence of atrial fibrillation have prevented the incidence of stroke from falling as much as desired. The authors review the evidence on the situation in Portugal and propose an intervention plan.
Mehta, Rupal; Cai, Xuan; Lee, Jungwha; Scialla, Julia J.; Bansal, Nisha; Sondheimer, James H.; Chen, Jing; Hamm, L. Lee; Ricardo, Ana C.; Navaneethan, Sankar D.; Deo, Rajat; Rahman, Mahboob; Feldman, Harold I.; Go, Alan S.; Isakova, Tamara; Wolf, Myles
Importance Levels of fibroblast growth factor 23 (FGF23) are elevated in chronic kidney disease (CKD) and strongly associated with left ventricular hypertrophy, heart failure, and death. Whether FGF23 is an independent risk factor for atrial fibrillation in CKD is unknown. Objective To investigate the association of FGF23 with atrial fibrillation in CKD. Design, Setting, and Participants Prospective cohort study of 3876 individuals with mild to severe CKD who enrolled in the Chronic Renal Insufficiency Cohort Study between June 19, 2003, and September 3, 2008, and were followed up through March 31, 2013. Exposures Baseline plasma FGF23 levels. Main Outcomes and Measures Prevalent and incident atrial fibrillation. Results The study cohort comprised 3876 participants. Their mean (SD) age was 57.7 (11.0) years, and 44.8% (1736 of 3876) were female. Elevated FGF23 levels were independently associated with increased odds of prevalent atrial fibrillation (n = 660) after adjustment for cardiovascular and CKD-specific factors (odds ratio of highest vs lowest FGF23 quartile, 2.30; 95% CI, 1.69-3.13; P < .001 for linear trend across quartiles). During a median follow-up of 7.6 years (interquartile range, 6.3-8.6 years), 247 of the 3216 participants who were at risk developed incident atrial fibrillation (11.9 events per 1000 person-years). In fully adjusted models, elevated FGF23 was independently associated with increased risk of incident atrial fibrillation after adjustment for demographic, cardiovascular, and CKD-specific factors, and other markers of mineral metabolism (hazard ratio of highest vs lowest FGF23 quartile, 1.59; 95% CI, 1.00-2.53; P = .02 for linear trend across quartiles). The results were unchanged when further adjusted for ejection fraction, but individual adjustments for left ventricular mass index, left atrial area, and interim heart failure events partially attenuated the association of elevated FGF23 with incident atrial fibrillation. Conclusions and
Mirza, Mahek; Shen, Win-Kuang; Sofi, Aamir; Tran, Canh; Jahangir, Ahad; Sultan, Sulaiman; Khan, Uzma; Viqar, Maria; Cho, Chi; Jahangir, Arshad
Sleep apnea has been recognized as a factor predisposing to atrial fibrillation recurrence and progression. The effect of other sleep-disturbing conditions on atrial fibrillation progression is not known. We sought to determine whether frequent periodic leg movement during sleep is a risk factor for progression of atrial fibrillation. In this retrospective study, patients with atrial fibrillation and a clinical suspicion of restless legs syndrome who were referred for polysomnography were divided into two groups based on severity of periodic leg movement during sleep: frequent (periodic movement index >35/h) and infrequent (≤35/h). Progression of atrial fibrillation to persistent or permanent forms between the two groups was compared using Wilcoxon rank-sum test, chi-square tests and logistic regression analysis. Of 373 patients with atrial fibrillation (77% paroxysmal, 23% persistent), 108 (29%) progressed to persistent or permanent atrial fibrillation during follow-up (median, 33 months; interquartile range, 16-50). Compared to patients with infrequent periodic leg movement during sleep (n=168), patients with frequent periodic leg movement during sleep (n=205) had a higher rate of atrial fibrillation progression (23% vs. 34%; p=0.01). Patients with frequent periodic leg movement during sleep were older and predominantly male; however, there were no significant differences at baseline in clinical factors that promote atrial fibrillation progression between both groups. On multivariate analysis, independent predictors of atrial fibrillation progression were persistent atrial fibrillation at baseline, female gender, hypertension and frequent periodic leg movement during sleep. In patients with frequent periodic leg movement during sleep, dopaminergic therapy for control of leg movements in patients with restless legs syndrome reduced risk of atrial fibrillation progression. Frequent leg movement during sleep in patients with restless legs syndrome is associated
Hatem, Stéphane N; Redheuil, Alban; Gandjbakhch, Estelle
The amount of adipose tissue that accumulates around the atria is associated with the risk, persistence, and severity of atrial fibrillation (AF). A strong body of clinical and experimental evidence indicates that this relationship is not an epiphenomenon but is the result of complex crosstalk between the adipose tissue and the neighbouring atrial myocardium. For instance, epicardial adipose tissue is a major source of adipokines, inflammatory cytokines, or reactive oxidative species, which can contribute to the fibrotic remodelling of the atrial myocardium. Fibro-fatty infiltrations of the subepicardium could also contribute to the functional disorganization of the atrial myocardium. The observation that obesity is associated with distinct structural and functional remodelling of the atria has opened new perspectives of treating AF substrate with aggressive risk factor management. Advances in cardiac imaging should lead to an improved ability to visualize myocardial fat depositions and to localize AF substrates.
... Atrial Fibrillation AGENCY: Agency for Healthcare Research and Quality (AHRQ), HHS. ACTION: Request for... scientific information submissions from manufacturers of atrial fibrillation medical devices. Scientific... Fibrillation, which is currently being conducted by the Evidence-based Practice Centers for the AHRQ...
Nam, Gi-Byoung; Jin, Eun-Sun; Choi, HyungOh; Song, Hae-Geun; Kim, Sung-Hwan; Kim, Ki-Hun; Hwang, Eui-Seock; Park, Kyoung-Min; Kim, Jun; Rhee, Kyoung-Suk; Choi, Kee-Joon; Kim, You-Ho
Catheter ablation of atrial fibrillation that targets complex fractionated electrogram sites has been widely applied in the management of persistent atrial fibrillation. The clinical outcomes of pulmonary vein isolation alone and pulmonary vein isolation plus the use of complex fractionated electrogram-guided ablation (CFEA) have not been fully compared in patients with paroxysmal atrial fibrillation. This prospective study included 70 patients with symptomatic paroxysmal atrial fibrillation that remained inducible after pulmonary vein isolation. For radio-frequency catheter ablation, patients were nonrandomly assigned to a control group (pulmonary vein isolation alone, Group 1, n=35) or a CFEA group (pulmonary vein isolation plus additional CFEA, Group 2, n=35). The times to first recurrence of atrial tachyarrhythmias were compared between the 2 groups. In Group 2, CFEA rendered atrial fibrillation noninducible in 16 patients (45.7%) and converted inducible atrial fibrillation into inducible atrial flutters in 12 patients (34.3%). Atrial fibrillation remained inducible in 7 patients (20%) after the combined ablation procedures. After a mean follow-up of 23 months, freedom from recurrence of atrial tachyarrhythmias was significantly higher in Group 2 than in Group 1 (P=0.037). In Group 1, all of the recurrent tachyarrhythmias were atrial fibrillation, whereas regular tachycardia was the major mechanism of recurrent arrhythmias in Group 2 (atrial tachycardia or atrial flutter in 5 of 6 patients and atrial fibrillation in 1 patient). We found that CFEA after pulmonary vein isolation significantly reduced recurrent atrial tachyarrhythmia and might modify the pattern of arrhythmia recurrence in patients with paroxysmal atrial fibrillation. PMID:22719147
Sheikh, Azfar; Patel, Nileshkumar J; Nalluri, Nikhil; Agnihotri, Kanishk; Spagnola, Jonathan; Patel, Aashay; Asti, Deepak; Kanotra, Ritesh; Khan, Hafiz; Savani, Chirag; Arora, Shilpkumar; Patel, Nilay; Thakkar, Badal; Patel, Neil; Pau, Dhaval; Badheka, Apurva O; Deshmukh, Abhishek; Kowalski, Marcin; Viles-Gonzalez, Juan; Paydak, Hakan
Atrial fibrillation (AF) is the most prevalent arrhythmia worldwide and the most common arrhythmia leading to hospitalization. Due to a substantial increase in incidence and prevalence of AF over the past few decades, it attributes to an extensive economic and public health burden. The increasing number of hospitalizations, aging population, anticoagulation management, and increasing trend for disposition to a skilled facility are drivers of the increasing cost associated with AF. There has been significant progress in AF management with the release of new oral anticoagulants, use of left atrial catheter ablation, and novel techniques for left atrial appendage closure. In this article, we aim to review the trends in epidemiology, hospitalization, and cost of AF along with its future implications on public health.
McDowell, Kathleen S; Vadakkumpadan, Fijoy; Blake, Robert; Blauer, Joshua; Plank, Gernot; MacLeod, Rob S; Trayanova, Natalia A
Personalized computational cardiac models are emerging as an important tool for studying cardiac arrhythmia mechanisms, and have the potential to become powerful instruments for guiding clinical anti-arrhythmia therapy. In this article, we present the methodology for constructing a patient-specific model of atrial fibrosis as a substrate for atrial fibrillation. The model is constructed from high-resolution late gadolinium-enhanced magnetic resonance imaging (LGE-MRI) images acquired in vivo from a patient suffering from persistent atrial fibrillation, accurately capturing both the patient's atrial geometry and the distribution of the fibrotic regions in the atria. Atrial fiber orientation is estimated using a novel image-based method, and fibrosis is represented in the patient-specific fibrotic regions as incorporating collagenous septa, gap junction remodeling, and myofibroblast proliferation. A proof-of-concept simulation result of reentrant circuits underlying atrial fibrillation in the model of the patient's fibrotic atrium is presented to demonstrate the completion of methodology development. Copyright © 2012 Elsevier Inc. All rights reserved.
Masè, M; Marini, M; Disertori, M; Ravelli, F
The causal relationship between atrial and ventricular activities during human atrial fibrillation (AF) is poorly understood. This study analyzed the effects of an increase in atrial rate on the link between atrial and ventricular activities during AF. Atrial and ventricular time series were determined in 14 patients during the spontaneous acceleration of the atrial rhythm at AF onset. The dynamic relationship between atrial and ventricular activities was quantified in terms of atrioventricular (AV) coupling by AV synchrogram analysis. The technique identified n:m coupling patterns (n atrial beats in m ventricular cycles), quantifying their percentage, maximal length, and conduction ratio (= m/n). Simulations with a difference-equation AV model were performed to correlate the observed dynamics to specific atrial/nodal properties. The atrial rate increase significantly affected AV coupling and ventricular response during AF. The shortening of atrial intervals from 185 ± 32 to 165 ± 24 ms (P < 0.001) determined transitions toward AV patterns with progressively decreasing m/n ratios (from conduction ratio = 0.34 ± 0.09 to 0.29 ± 0.08, P < 0.01), lower occurrence (from percentage of coupled beats = 27.1 ± 8.0 to 21.8 ± 6.9%, P < 0.05), and higher instability (from maximal length = 3.9 ± 1.5 to 2.8 ± 0.7 s, P < 0.01). Advanced levels of AV block and coupling instability at higher atrial rates were associated with increased ventricular interval variability (from 123 ± 52 to 133 ± 55 ms, P < 0.05). AV pattern transitions and coupling instability in patients were predicted, assuming the filtering of high-rate irregular atrial beats by the slow recovery of nodal excitability. These results support the role of atrial rate in determining AV coupling and ventricular response and may have implications for rate control in AF.
Lau, Chu-Pak; Gbadebo, T David; Connolly, Stuart J; Van Gelder, Isabelle C; Capucci, Alessandro; Gold, Michael R; Israel, Carsten W; Morillo, Carlos A; Siu, Chung-Wah; Abe, Haruhiko; Carlson, Mark; Tse, Hung-Fat; Hohnloser, Stefan H; Healey, Jeff S
Atrial fibrillation (AF) is suggested to be less common among black and Asian individuals, which could reflect bias in symptom reporting and access to care. In the Asymptomatic AF and Stroke Evaluation in Pacemaker Patients and the AF Reduction Atrial Pacing Trial (ASSERT), patients with hypertension but no history of AF had AF recorded via an implanted pacemaker or defibrillator, thus allowing both symptomatic and asymptomatic AF incidence to be determined without ascertainment bias. The ASSERT enrolled 2,580 patients in 23 countries in North America, Europe, and Asia. AF was defined as device-recorded AF episodes >190/min, lasting either for >6 minutes or >6 hours in duration. All ethnic groups with >50 patients were enrolled. Ethnic groups studied include Europeans (n = 1900), black Africans (n = 73), Chinese (n = 89), and Japanese (n = 105) patients. Compared to Europeans, black Africans had more risk factors for AF such as heart failure (27.8 vs 14.6%) and diabetes (41.7 vs 26.3%). At 2.5 years follow-up, all 3 non-European races had a lower incidence of AF (8.3%, 10.1%, and 9.5% vs 18.0%, respectively, for AF>6 minutes, P < 0.006). When adjusted for baseline difference, Chinese had a lower incidence of AF > 6 minutes (P < 0.007), and Japanese and black Africans had a lower incidence of AF > 6 hours (P < 0.04 and P = 0.057, respectively). Black Africans, Chinese, and Japanese had lower incidence of AF compared to Europeans. In the case of black Africans, this is despite an increased prevalence of AF risk factors. © 2013 Wiley Periodicals, Inc.
Kik, Charles; Bogers, Ad J.J.C.
Atrial fibrillation may result in significant symptoms, (systemic) thrombo-embolism, as well as tachycardia-induced cardiomyopathy with cardiac failure, and consequently be associated with significant morbidity and mortality. Nowadays symptomatic atrial fibrillation can be treated with catheter-based ablation, surgical ablation or hybrid approaches. In this setting a fairly large number of surgical approaches and procedures are described and being practised. It should be clear that the Cox-maze procedure resulted from building up evidence and experience in different steps, while some of the present surgical approaches and techniques are being based only on technical feasibility with limited experience, rather than on a process of consequent methodology. Some of the issues still under debate are whether or not the maze procedure can be limited to the left atrium or even to isolation of the pulmonary veins or that bi-atrial procedures are indicated, whether or not cardiopulmonary bypass is to be applied and which route of exposure facilitates an optimal result. In addition, maze procedures are not procedures guide by electrophysiological mapping. At least in theory not in all patients all lesions of the maze procedures are necessary. A history and aspects of current practise in surgical treatment of atrial fibrillation is presented.
Trigo, Paula; Fischer, Gregory W
Atrial fibrillation is the most commonly seen arrhythmia in the geriatric population and is associated with increased cardiovascular morbidity and mortality. Treatment of the elderly with atrial fibrillation remains challenging for physicians, because this unique subpopulation is characterized by multiple comorbidities requiring chronic use of numerous medications, which can potentially lead to severe drug interactions. Furthermore, age-related changes in the cardiovascular system as well as other physiological changes result in altered drug pharmacokinetics. Dronedarone is a new drug recently approved for the treatment of arrhythmias, such as atrial fibrillation and/or atrial flutter. Dronedarone is a benzofuran amiodarone analog which lacks the iodine moiety and contains a methane sulfonyl group that decreases its lipophilicity. These differences in chemical structure are responsible for making dronedarone less toxic than amiodarone which, in turn, results in fewer side effects. Adverse events for dronedarone include gastrointestinal side effects and rash. No dosage adjustments are required for patients with renal impairment. However, the use of dronedarone is contraindicated in the presence of severe hepatic dysfunction.
Dakay, Katarina; Chang, Andrew D; Hemendinger, Morgan; Cutting, Shawna; McTaggart, Ryan A; Jayaraman, Mahesh V; Chu, Antony; Panda, Nikhil; Song, Christopher; Merkler, Alexander; Gialdini, Gino; Kummer, Benjamin; Lerario, Michael P; Kamel, Hooman; Elkind, Mitchell S V; Furie, Karen L; Yaghi, Shadi
Despite anticoagulation therapy, ischemic stroke risk in atrial fibrillation (AF) remains substantial. We hypothesize that left atrial enlargement (LAE) is more prevalent in AF patients admitted with ischemic stroke who are therapeutic, as opposed to nontherapeutic, on anticoagulation. We included consecutive patients with AF admitted with ischemic stroke between April 1, 2015, and December 31, 2016. Patients were divided into two groups based on whether they were therapeutic (warfarin with an international normalized ratio ≥ 2.0 or non-vitamin K oral anticoagulant with uninterrupted use in the prior 2 weeks) versus nontherapeutic on anticoagulation. Univariable and multivariable models were used to estimate associations between therapeutic anticoagulation and clinical factors, including CHADS2 score and LAE (none/mild versus moderate/severe). We identified 225 patients during the study period; 52 (23.1%) were therapeutic on anticoagulation. Patients therapeutic on anticoagulation were more likely to have a larger left atrial diameter in millimeters (45.6 ± 9.2 versus 42.3 ± 8.6, P = .032) and a higher CHADS2 score (2.9 ± 1.1 versus 2.4 ± 1.1, P = .03). After adjusting for the CHADS2 score, patients who had a stroke despite therapeutic anticoagulation were more likely to have moderate to severe LAE (odds ratio, 2.05; 95% confidence interval, 1.01-4.16). LAE is associated with anticoagulation failure in AF patients admitted with an ischemic stroke. This provides indirect evidence that LAE may portend failure of anticoagulation therapy in patients with AF; further studies are needed to delineate the significance of this association and improve stroke prevention strategies. Copyright © 2017 National Stroke Association. Published by Elsevier Inc. All rights reserved.
Ejima, Koichiro; Shoda, Morio; Tanizaki, Kohei; Kasanuki, Hiroshi
Irregular tachycardias mimicking atrial fibrillation (AF) have previously been described. We report a case of a 60-year-old man with an antiarrhythmic drug-resistant atrial tachycardia (AT) mimicking AF. The tachycardia consisted of two distinct ATs with interference of one repetitive AT with another sustained AT. Radiofrequency (RF) ablation of two distinct right atrial foci eliminated the irregular tachycardia. Although catheter-based pulmonary vein isolation has become a popular therapeutic approach for patients with symptomatic AF, careful evaluation of the intracardiac recordings in the patients undergoing RF ablation for AF is important.
Lichten, Catherine A.; Castle-Clarke, Sophie; Manville, Catriona; Horvath, Veronika; Robin, Enora; Krapels, Joachim; Parks, Sarah; Sim, Megan; van Zijverden, Olga; Chataway, Joanna
Abstract Atrial fibrillation (AF) is the most common type of cardiac arrhythmia, affecting approximately 1–2 per cent of the population worldwide. Those who suffer from AF have a five times higher risk of stroke. AF prevalence increases with age and it affects roughly 18 per cent of the population over 85. Consequently, as populations age, AF is becoming an increasingly significant public health issue. Over recent years there have been developments in treatment and management options, both for treating the arrhythmia directly, and assessing and reducing the risk of AF-related stroke, but there is a need to ensure that available knowledge is applied optimally to benefit patients so that opportunities to prevent AF-related stroke are not missed. The aims of this project were to assess the current landscape and explore the direction of future developments in AF management in Europe, with a focus on the use of anticoagulants in the prevention of AF-related stroke. Through rapid evidence assessment, key informant interviews, PESTLE analysis and the development and exploration of future scenarios, we have developed sets of shorter- and longer-term recommendations for improving AF-related patient outcomes. The short-term recommendations are: i) improve AF awareness among the public and policymakers; ii) support education about AF management for healthcare professionals and patients; and iii) maintain engagement in AF-related research across the health services. PMID:28083378
Kotecha, Dipak; Piccini, Jonathan P
Heart failure (HF) and atrial fibrillation (AF) are two conditions that are likely to dominate the next 50 years of cardiovascular (CV) care. Both are increasingly prevalent and associated with high morbidity, mortality, and healthcare cost. They are closely inter-related with similar risk factors and shared pathophysiology. Patients with concomitant HF and AF suffer from even worse symptoms and poorer prognosis, yet evidence-based evaluation and management of this group of patients is lacking. In this review, we evaluate the common mechanisms for the development of AF in HF patients and vice versa, focusing on the evidence for potential treatment strategies. Recent data have suggested that these patients may respond differently than those with HF or AF alone. These results highlight the clear clinical need to identify and treat according to best evidence, in order to prevent adverse outcomes and reduce the huge burden that HF and AF are expected to have on global healthcare systems in the future. We propose an easy-to-use clinical mnemonic to aid the initial management of newly discovered concomitant HF and AF, the CAN-TREAT HFrEF + AF algorithm (Cardioversion if compromised; Anticoagulation unless contraindication; Normalize fluid balance; Target initial heart rate <110 b.p.m.; Renin-angiotensin-aldosterone modification; Early consideration of rhythm control; Advanced HF therapies; Treatment of other CV disease).
Hahne, Kathrin; Mönnig, Gerold; Samol, Alexander
Atrial fibrillation (AF) is the most common cardiac arrhythmia, with a projected number of 1 million affected subjects in Germany. Changes in age structure of the Western population allow for the assumption that the number of concerned people is going to be doubled, maybe tripled, by the year 2050. Large epidemiological investigations showed that AF leads to a significant increase in mortality and morbidity. Approximately one-third of all strokes are caused by AF and, due to thromboembolic cause, these strokes are often more severe than those caused by other etiologies. Silent brain infarction is defined as the presence of cerebral infarction in the absence of corresponding clinical symptomatology. Progress in imaging technology simplifies diagnostic procedures of these lesions and leads to a large amount of diagnosed lesions, but there is still no final conclusion about frequency, risk factors, and clinical relevance of these infarctions. The prevalence of silent strokes in patients with AF is higher compared to patients without AF, and several studies reported high incidence rates of silent strokes after AF ablation procedures. While treatment strategies to prevent clinically apparent strokes in patients with AF are well investigated, the role of anticoagulatory treatment for prevention of silent infarctions is unclear. This paper summarizes developments in diagnosis of silent brain infarction and its context to AF. PMID:27022272
Ferreira, Cátia; Providência, Rui; Ferreira, Maria João; Gonçalves, Lino Manuel
Atrial fibrillation (AF) is the most common cardiac arrhythmia and is associated with an unfavorable prognosis, increasing the risk of stroke and death. Although traditionally associated with cardiovascular diseases, there is increasing evidence of high incidence of AF in patients with highly prevalent noncardiovascular diseases, such as cancer, sepsis, chronic obstructive pulmonary disease, obstructive sleep apnea and chronic kidney disease. Therefore, considerable number of patients has been affected by these comorbidities, leading to an increased risk of adverse outcomes. The authors performed a systematic review of the literature aiming to better elucidate the interaction between these conditions. Several mechanisms seem to contribute to the concomitant presence of AF and noncardiovascular diseases. Comorbidities, advanced age, autonomic dysfunction, electrolyte disturbance and inflammation are common to these conditions and may predispose to AF. The treatment of AF in these patients represents a clinical challenge, especially in terms of antithrombotic therapy, since the scores for stratification of thromboembolic risk, such as the CHADS2 and CHA2DS2VASc scores, and the scores for hemorrhagic risk, like the HAS-BLED score have limitations when applied in these conditions. The evidence in this area is still scarce and further investigations to elucidate aspects like epidemiology, pathogenesis, prevention and treatment of AF in noncardiovascular diseases are still needed. PMID:26577719
Tucker, Nathan R.; Ellinor, Patrick T.
Atrial fibrillation (AF) is the most common arrhythmic disorder, and currently affects nearly 3 million Americans, 8.8 million Europeans, and an estimated 30 million individuals worldwide. The clinical risk factors for AF are numerous, with age, sex, hypertension, obesity, and ischemic heart disease among the most prevalent. Over the last ten years, a preponderance of evidence also suggests a large genetic contribution to AF. The earliest report of familial AF dates to the early 1940s1. Since then, it has become apparent that AF in referral populations2,3 and in the community is heritable4,5. Indeed, having a family member with AF is associated with a 40% increased risk for the arrhythmia6. Once the heritability was recognized, traditional genetics techniques for the discovery of rare, monogenic causes of AF were used to identify the initial AF genes. These studies in turn, informed candidate gene screening in AF cohorts. To identify additional sources of heritability for AF, large-scale analyses of common variation through genome wide association studies (GWAS) has recently yielded data identifying risk loci in many regions of the genome. In spite of these advances, the combination of these techniques has, as yet, failed to completely identify the heritability of AF in the population. It is the goal of this review to examine the previous studies on rare variants, address the findings of the recent GWAS studies, and describe future avenues towards defining the heritability of AF. PMID:24763465
Large, Stephen R; Nashef, Samer A M
Surgery to correct a structural heart valve problem can restore sinus rhythm in approximately one-fifth of patients with atrial fibrillation (AF), and the addition of a maze procedure will increase this proportion. Evidence shows that the maze procedure may restore atrial function in some patients and may have beneficial effects on functional symptoms and prognosis. The role of the maze procedure as an isolated treatment for lone AF in the context of heart failure with no structurally correctable cause is unknown. Future progress will determine the appropriate indications for treatment and the risks and benefits of any intervention.
The mechanisms underlying atrial fibrillation (AF) in humans are poorly understood. In particular, we simply do not understand how atrial AF becomes persistent or permanent. The objective of this brief review is to address the most important factors involved in the mechanism of AF perpetuation, including structural remodeling in the form of fibrosis and electrical remodeling secondary to ion channel expression changes. In addition, I discuss the possibility that both fibrosis and electrical remodeling might be preventable when intervening pharmacologically early enough before the remodeling process reaches a point of no return.
Robertson, Jason O.; Lawrance, Christopher P.; Maniar, Hersh S.; Damiano, Ralph J.
The use of surgical lesion sets for the treatment of atrial fibrillation has been increasing, particularly in patients with complicated anatomical substrates and those undergoing concomitant surgery. Preferences in terms of lesion set, surgical approach and ablation technology vary by center. This review discusses both the surgical techniques and the outcomes for the most commonly performed procedures in the context of recent consensus guidelines. The Cox-Maze IV, pulmonary vein isolation, extended left atrial lesion sets, the hybrid approach and ganglionated plexus ablation are each reviewed in an attempt to provide insight into current clinical practice and patient selection PMID:23823731
Pacifico, Antonio; Henry, Philip D
During the past 10 years numerous studies on the treatment of paroxysmal atrial fibrillation (AF) by right and left atrial ablation procedures have been published. The results of studies based on follow-up periods of a few months have been repeatedly interpreted as providing evidence for curative therapy. However, insufficient focus on the variability of the natural history of paroxysmal AF, the inadequate detection of silent arrhythmic events, the eclectic post-interventional use of antiarrhythmic drugs, and the lack of appropriate control groups make the reports unconvincing. Randomized controlled trials are needed to confirm postulated long-term cure rates for AF.
Xie, Xudong; Liu, Yanrong; Gao, Shilong; Wu, Bifeng; Hu, Xiaosheng; Chen, Junzhu
Chronic atrial fibrillation (AF) is characterized by a remodeling process with prominent atrial fibrosis. Fibrocytes, a bone marrow-derived population of fibroblast-like cells, have been placed at the center of a number of fibrosing conditions. The purpose of this study was to evaluate the contribution of fibrocytes to atrial fibrosis in patients with chronic AF and the possible mechanisms. We enrolled 22 consecutive valvular heart disease patients with chronic AF (>6 months: CAF group) and 15 valvular heart disease patients in sinus rhythm served as controls (SR group). Left atrial tissue samples were obtained during cardiac surgery. The infiltration of fibrocytes into the atrial interstitium was observed by confocal microscopy. The number of atrial fibrocytes was approximately three-fold higher in the CAF group compared with the SR controls, and positively correlated with both the atrial collagen volume fraction (r=0.713; P=0.0002) and the left atrial volume index (r=0.631; P=0.002). In the peripheral blood samples collected before the operation, approximately 2.5-fold higher percentage of circulating fibrocytes was identified in the CAF group. These fibrocytes showed a stronger proliferative capacity (≍2.5-fold) and higher level expression of collagen I and α-SMA (≍2-fold and 4-fold, respectively) compared with the SR controls. The results suggested that fibrocytes may be involved in atrial fibrosis in chronic AF through enhanced profibrotic characteristics.
Folla, Cynthia de Oliveira; Melo, Cinthia Cristina de Santana; Silva, Rita de Cassia Gengo E
To analyze predictive demographic and perioperative variables of postoperative atrial fibrillation in patients who underwent exclusively coronary artery bypass grafting. This was a retrospective cohort. We randomly selected 105 medical records of patients who underwent exclusively coronary artery bypass grafting in 2014. Demographic, clinical (preoperative and immediate postoperative) data and related with surgical procedure were collected from medical records. The occurrence of postoperative atrial fibrillation was considered until the third day after the surgery. Variables were analyzed using descriptive and inferential statistics. To identify predictive factors of postoperative atrial fibrillation we used a decision tree model with Classification and Regression Trees algorithm. Atrial fibrillation incidence was 19.0% (n=20). Patients with left atrial >40.5mm and aged >64.5 years were more likely to develop the arrhythmia during the post-surgical period. Left atrial diameter and advanced age were predictive factors of atrial fibrillation in patients who underwent exclusively coronary artery bypass grafting. Analisar as variáveis demográficas e perioperatórias preditivas de fibrilação atrial pós-operatória em pacientes brasileiros submetidos exclusivamente à cirurgia de revascularização do miocárdio. Trata-se de coorte retrospectiva. A amostra foi constituída de 105 prontuários de pacientes submetidos exclusivamente à revascularização do miocárdio no ano de 2014, selecionados aleatoriamente. Dados demográficos, clínicos (préoperatórios e do pós-operatório imediato) e relacionados ao procedimento cirúrgico foram coletados por meio de consulta ao prontuário. A ocorrência de fibrilação atrial no pós-operatório foi considerada até o terceiro dia após a cirurgia. As variáveis foram analisadas por estatística descritiva e inferencial. Para identificar os fatores preditivos de fibrilação atrial no pós-operatório, utilizou-se um
Ros, E; Mota, S; Fernández, F J; Toro, F J; Bernier, J L
Paroxysmal atrial fibrillation (PAF) is one of the most common heart arrhythmias. It is very difficult to detect unless an explicit Atrial Fibrillation episode occurs during the exploration. The present paper describes a number of low level parameters extracted from ECG traces where no Atrial Fibrillation process is present. The ability of this parameter set to characterize PAF patients is studied and discussed. Based on these parameters a modular automatic classification algorithm for PAF diagnosis is developed and evaluated.
Bridge, Francesca; Thijs, Vincent
The introduction of insertable cardiac monitoring devices has dramatically altered our understanding of the role of intermittent atrial fibrillation in cryptogenic stroke. In this narrative review we discuss the incidence, timing and relationship between atrial fibrillation and cryptogenic stroke, how to select patients for monitoring and the value and limitations of different monitoring strategies. We also discuss the role of empirical anticoagulation, and atrial fibrillation burden as a means of tailoring anticoagulation in patients at high risk of bleeding. PMID:27283276
Lee, S H; Ahn, H J; Yeon, S M; Yang, M; Kim, J A; Jung, D M; Park, J H
Atrial fibrillation is the most frequent arrhythmia after thoracic surgery and is associated with increased hospital costs, morbidity and mortality. In this study, we aimed to identify potentially modifiable risk factors for postoperative atrial fibrillation following lung resection surgery and to suggest possible measures to reduce risk. We retrospectively reviewed the medical records of 4731 patients who underwent lobectomy or more major lung resection over a 6-year period. Patients who developed atrial fibrillation postoperatively and required treatment were included in the postoperative atrial fibrillation group, while the remaining patients were assigned to the non-postoperative atrial fibrillation group. Risk factors for postoperative atrial fibrillation were analysed by multivariate analysis and propensity score matching. Overall, 12% of patients developed postoperative atrial fibrillation. Potentially modifiable risk factors for postoperative atrial fibrillation were excessive alcohol consumption (odds ratio (OR) = 1.48, 95% CI 1.08-2.02, p = 0.0140), red cell transfusion (2.70(2.13-3.43), p < 0.0001), use of inotropes (1.81(1.42-2.31), p < 0.0001) and open (vs. thoracoscopic) surgery (1.59(1.23-2.05), p < 0.0001). Compared with inotrope use, vasopressor administration was not related to postoperative atrial fibrillation. Use of steroids or thoracic epidural anaesthesia did not reduce the incidence of postoperative atrial fibrillation. We conclude that high alcohol consumption, red cell transfusion, use of inotropes and open surgery are potentially modifiable risk factors for postoperative atrial fibrillation. Pre-operative alcohol consumption needs to be addressed. Avoiding red cell transfusion and performing lung resection via video-assisted thoracoscopic surgery may reduce the incidence of postoperative atrial fibrillation and the administration of vasopressors rather than inotropes is preferred.
Ogata, Toshiyasu; Yasaka, Masahiro
The patients with cardioembolic stroke sometimes suffer from severe neurological deficit and from recurrent strokes. Since atrial fibrillation, especially non-valvular atrial fibrillation (NVAF) is associated with over half of the cardioembolic strokes, the prevention of cardioembolic stroke in patients with NVAF is important. There have been some reports about how to prevent stroke. They have indicated that the best medication for preventing from stroke was anticoagulation by warfarin. Therefore, the guidelines recommended the patients with NVAF to take warfarin. In case with the older patients under 70 years, prothrombin international normalized ratio (PT-INR) should be kept from 2.0 to 3.0. On the other hand, if the patients with NVAF are over 70 years, PT-INR has to be controlled from 1.6 to 2.6. Before extraction of a tooth, anticoagulation should not be call off.
Marcotte, Christopher D.; Grigoriev, Roman O.
While spiral wave breakup has been implicated in the emergence of atrial fibrillation, its role in maintaining this complex type of cardiac arrhythmia is less clear. We used the Karma model of cardiac excitation to investigate the dynamical mechanisms that sustain atrial fibrillation once it has been established. The results of our numerical study show that spatiotemporally chaotic dynamics in this regime can be described as a dynamical equilibrium between topologically distinct types of transitions that increase or decrease the number of wavelets, in general agreement with the multiple wavelets' hypothesis. Surprisingly, we found that the process of continuous excitation waves breaking up into discontinuous pieces plays no role whatsoever in maintaining spatiotemporal complexity. Instead, this complexity is maintained as a dynamical balance between wave coalescence—a unique, previously unidentified, topological process that increases the number of wavelets—and wave collapse—a different topological process that decreases their number.
Briongos Figuero, Sem; García Santos-Gallego, Carlos; Badimón, Juan José
For the last decades vitamin K antagonists have been the most effective anticoagulant treatment of atrial fibrillation. New molecules are being designed, mainly due to the great amount of disadvantages in the management of conventional anticoagulation. Dabigatran, rivaroxaban and apixaban will soon be available as an alternative to warfarin/acenocumarol. All of them have demonstrated to be non-inferior to warfarin in preventing stroke and systemic embolism, with even dabigatran 150 mg bid and apixaban being superior. They have also a lower risk of bleeding, especially regarding severe/fatal and intracranial hemorrhages. This is a real revolution. The advance of these new anticoagulants will be limited only by the higher cost, and will progressively become the protagonists of oral anticoagulation in patients with nonvalvular atrial fibrillation.
Korantzopoulos, Panagiotis; Li, Guangping
Atrial fibrillation (AF) is the most common sustained arrhythmia in clinical practice, representing a major public health problem. Recent evidence suggests oxidative stress may play an important role in the pathogenesis and perpetuation of AF. In the past few years, experimental data and clinical evidence have tested the concept of antioxidant therapies to prevent AF. Besides statins, ACE-inhibitors (ACEIs) and/or angiotensin-receptor blockers (ARBs), and omega-3 polyunsaturated fatty acids, several other interventions with antioxidant properties, such as Vitamin C and E, thiazolidinediones, N-acetylcysteine, probucol, nitric oxide donors or precursors, NADPH oxidase inhibitors, Xanthine oxidase inhibitors have emerged as novel strategies for the management of AF. We aim to review recent evidence regarding antioxidant therapies in the prevention and treatment of atrial fibrillation. PMID:24282730
Nguyen, Tuan; Jolly, Umjeet; Sidhu, Kiran; Yee, Raymond; Leong-Sit, Peter
Atrial fibrillation (AF) is an increasing global issue leading to increased hospitalizations, adverse health related events and mortality. This review focuses on the management of atrial fibrillation, in particular in the past decade, comparing two major strategies, rate or rhythm control. We evaluate the evidence for each strategy, pharmacological options and the increasing utilization of invasive techniques, in particular catheter ablation and use of implantable cardiac pacing devices. Pharmacological comparative trials evaluating both strategies have shown rate control being non-inferior to rhythm control for clinical outcomes of mortality and other cardiovascular events (including stroke). Catheter ablation techniques, involving radiofrequency ablation and recently cryoablation, have shown promising results in particular with paroxysmal AF. However, persistent AF provides ongoing challenges and will be a particular focus of continued research.
Gucuk Ipek, Esra; Marine, Joseph E; Habibi, Mohammadali; Chrispin, Jonathan; Lima, Joao; Rickard, Jack; Spragg, David; Zimmerman, Stefan L; Zipunnikov, Vadim; Berger, Ronald; Calkins, Hugh; Nazarian, Saman
Symptomatic left atrial (LA) flutter (LAFL) is common after atrial fibrillation (AF) ablation. The purpose of this study was to examine the association of baseline LA function with incident LAFL after AF ablation. The source cohort included 216 patients with cardiac magnetic resonance (CMR) before initial AF ablation between 2010 and 2013. Patients who underwent cryoballoon or laser ablation, patients with AF during CMR, and those with suboptimal CMR, or missing follow-up data were excluded. Baseline LA volume and function were assessed by feature-tracking CMR analysis. The final cohort included 119 patients (mean age 58.9 ± 11 years; 76.5% men; 70.6% patients with paroxysmal AF). During a median follow-up of 421 days (interquartile range 235-751 days), 22 patients (18.5%) had incident LAFL. Baseline LA volume was similar between the 2 groups. In contrast, baseline reservoir, conduit, and contractile function of the LA were significantly impaired in patients with incident LAFL. Baseline global peak longitudinal atrial strain (PLAS) <22.65% predicted incident LAFL with 86% sensitivity and 68% specificity (C statistic 0.76). In a multivariable model adjusting for age, heart failure, and LA volume, PLAS (hazard ratio 0.9 per % increase in PLAS; P = .003) and LA linear lesions (hazard ratio 2.94; P = .020) were independently associated with incident LAFL. The coexistence of PLAS <22.65% and linear lesions was associated with 9-fold increased hazard of incident LAFL. Baseline LA function and linear lesions were independently associated with incident LAFL after AF ablation. Linear lesions should be limited to selected cases, especially in patients with impaired LA function. Copyright © 2016 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia in people with significant morbidity and mortality. There is a strong association between atrial fibrosis and AF. Transforming growth factor B1 (TGF-B1) is an essential mediator of atrial fibrosis in animal models and human pat...
Zhang, Peide; Wang, Wei; Wang, Xin; Wang, Xu; Song, Yunhu; Han, Yong; Zhang, Jing; Zhao, Hui
Atrial fibrosis, as a hallmark of atrial structure remodeling, plays an important role in maintenance of chronic atrial fibrillation, but interrelationship of atrial fibrosis and atrial fibrillation is uncertain. Label-free proteomics can implement high throughput screening for finding and analyzing pivotal proteins related to the disease.. Therefore, we used label-free proteomics to explore and analyze differentially proteins in chronic atrial fibrillation patients with mitral valve disease. Left and right atrial appendages obtained from patients with mitral valve disease were both in chronic atrial fibrillation (CAF, AF≥6 months, n = 6) and in sinus rhythm (SR, n = 6). One part of the sample was used for histological analysis and fibrosis quantification; other part were analyzed by label-free proteomic combining liquid chromatography with mass spectrometry (LC-MS), we utilized bioinformatics analysis to identify differential proteins. Degree of atrial fibrosis was higher in CAF patients than that of SR patients. 223 differential proteins were detected between two groups. These proteins mainly had vital functions such as cell proliferation, stress response, focal adhesion apoptosis. We evaluated that serine/threonine protein kinase N2 (PKN2), dermatopontin (DP), S100 calcium binding protein B (S100B), protein tyrosine kinase 2 (PTK2) and discoidin domain receptor tyrosine kinase 2 (DDR2) played important roles in fibrotic process related to atrial fibrillation. The study presented differential proteins responsible for atrial fibrosis in chronic atrial fibrillation patients through label-free proteomic analysis. We assessed some vital proteins including their characters and roles. These findings may open up new realm for mechanism research of atrial fibrillation.
Estrada, Amara H; Pariaut, Romain; Moïse, N Sydney
Electrical cardioversion of atrial fibrillation is now commonly performed in veterinary medicine. Successful timing of the delivery of energy is important in order to avoid ventricular fibrillation. This brief communication describes how to ensure that proper energy delivery is performed.
Atrial fibrillation (AF) is a common arrhythmia of substantial public health importance. Recent evidence demonstrates a heritable component underlying AF, and genetic discoveries have identified common variants associated with the arrhythmia. Ultimately one hopes that the consideration of genetic variation in clinical practice may enhance care and improve health outcomes. In this review we explore areas of potential clinical utility in AF management including those relating to pharmacogenetics and risk prediction. PMID:23210687
Pirson, Magali; Di Pierdomenico, Lionel; Gusman, Julie; Baré, Benoît; Fontaine, David; Motte, Serge
The number of hospitalizations for atrial fibrillation has increased dramatically. This increase, in the number of hospital stays will continue, given the growth projections based on epidemiological data, and will contribute to significantly increase expenses for the social security system.The objective of this study was to evaluate the length of hospital stay, the average cost borne by social security, and the types of hospital stay expenditures for patients admitted through the emergency department for atrial fibrillation. Patients were identified by using the minimal clinical summaries of seven general hospitals in Belgium in 2008. Only hospitalized patients having as primary diagnosis code ICD-9-CM 42731 'atrial fibrillation'were selected for this study. Hospital billing files were analysed in order to isolate the costs borne by social security. Outliers were isolated in order not to have results influenced by patients having an atypical length of stay. Results show that the mean length of stay was 8.6 days and the mean cost charged to social security was euro 3,066.02 per hospital stay.The mean cost of care was strongly associated with the degree of severity index related to the APR-DRG. Approximately 85% of the total cost was related to the cost of hospital days and medical procedures with medical imaging and laboratory tests being the two main cost inductors. 18% of patients had cardioversion during their hospital stay, including 4% who had only that treatment. 19% of patients used amiodarone. Flecainide and propafenone were also used, but less frequently. The mean cost of care for AF patients admitted via the emergency department is strongly associated with the degree of severity. Approximately 85% of the total cost is related to the cost of hospital days and medical procedures. Hypertension is the most common secondary diagnosis. An optimal treatment of this risk factor could help to reduce the risk of atrial fibrillation, and thereby reduce the morbidity
Bohnker, B K; Feeks, E F; McEwen, G
A patient is presented with new-onset atrial fibrillation. While being air-evacuated, he cardioverted during the acceleration associated with aircraft carrier catapult launch. This case suggests a possible myocardial response to the kinetic energy produced by the acceleration force, similar to the electrical energy commonly used for cardioversion. Cardioversion using acceleration forces is probably not a clinically useful modality; however, this case demonstrates the importance of acceleration forces on patients during medical evacuation from aircraft carriers.
Joseph, Jubin; Wong, Kelvin C K; Ginks, Matthew R; Bashir, Yaver; Betts, Timothy R; Rajappan, Kim
Steerable sheaths have been shown to reduce procedure time in the catheter ablation of atrial fibrillation (AF), where catheter positioning and stability is typically challenging. This review critically addresses and highlights the recent developments in design of sheaths used to manipulate the ablation catheter and how these developments may impact on the ablation procedure itself, in particular the likelihood of first-time success. Patents relating to steerable sheaths are reviewed and discussed to gauge potential future developments in this area.
Luckie, M; Jenkins, N P; Davidson, N C; Chauhan, A
Dressler's syndrome, characterized by features of fever, pericarditis and pericardial effusion typically occurs in the weeks to months following a myocardial infarction. The syndrome has also been described following several other myocardial and pericardial pathologies, including two reports of Dressler's syndrome following radio-frequency ablation. We describe a case of Dressler's syndrome following a pulmonary vein isolation procedure, which is being performed with increasing frequency as a treatment strategy for atrial fibrillation.
Anticoagulation is vital for stroke and systemic embolism prevention in patients with atrial fibrillation. Current therapy with the vitamin K inhibitor warfarin has many inherent limitations in clinical practice. With the potential of broadening anticoagulation therapy to a larger population, new classes of anticoagulants have recently emerged with the potential for improved efficacy, safety and convenience. Direct thrombin inhibitor and Factor Xa inhibitor classes are showing promise for both patients and clinicians. PMID:23251767
Sullivan, Renee M; Olshansky, Brian
Introduction: Dronedarone, a benzofuran derivative with a structure similar to amiodarone, has been developed as a potential therapy for patients with atrial fibrillation. Aim: To review the published evidence regarding the efficacy and safety of dronedarone use in patients with atrial fibrillation. Evidence review: Available evidence suggests that dronedarone 400 mg orally twice daily can lengthen the time to and decrease the overall recurrence of atrial fibrillation compared with placebo. Dronedarone may reduce risk of mortality and cardiovascular hospitalization. Patients with atrial fibrillation receiving dronedarone had improved ventricular rate control compared with patients receiving placebo. Dronedarone is associated with few serious adverse events except, notably, in patients with decompensated heart failure. Place in therapy: Dronedarone may have a role in rate and rhythm control for patients with atrial fibrillation. Dronedarone can reduce unique, but potentially serious, end points in patients with atrial fibrillation. Despite this, the exact role of dronedarone in the management of patients with atrial fibrillation continues to emerge. It remains uncertain if dronedarone should be considered a primary treatment strategy for atrial fibrillation. Dronedarone should not be administered to patients with decompensated heart failure. Conclusion: Dronedarone is a unique drug that may serve a key role to treat patients with atrial fibrillation. PMID:21042542
Atrial Fibrillation; Medication Adherence; Blood Coagulation Tests; Anticoagulants; Circulating, Hemorrhagic Disorder; Drug Effect; Drug Use; Drug Toxicity; Drug Intolerance; Blood Clot; Blood Coagulation Disorder; Laboratory Problem; Bleeding; Thrombosis
Doggrell, Sheila A
Subjects with atrial fibrillation are at risk of thromboembolic events. The vitamin K antagonists (e.g., warfarin) are useful at preventing coagulation in atrial fibrillation, but are difficult to use. One of the FXa inhibitors, oral apixaban, has been tested as an anticoagulant in atrial fibrillation. In ARISTOTLE (Apixaban for reduction in stroke and other thromboembolic events in atrial fibrillation) apixaban was compared to warfarin in subjects with atrial fibrillation, and shown to cause a lower rate of stroke or systemic embolism and of major bleeding, than warfarin. In the AVERROES (Apixaban versus acetylsalicylic acid [ASA] to prevent stroke in atrial fibrillations patients who have failed or are unsuitable for vitamin K antagonist treatment) trial, stroke or systemic embolism occurred less often with apixaban than aspirin, whereas the occurrence of major bleeding was similar in the groups. Apixaban is much easier for subjects with atrial fibrillation to use than warfarin, as it does not require regular monitoring by a health professional, with dosage adjustment. In addition to replacing warfarin in subjects with atrial fibrillation who are unable or not prepared to use warfarin, apixaban has the potential to replace warfarin more widely in the prevention of thromboembolism in subjects with atrial fibrillation.
Pinho-Gomes, Ana C; Amorim, Mário J; Oliveira, Sílvia M; Azevedo, Luís; Almeida, Jorge; Monteiro, Vítor; Maciel, Maria Júlia; Pinho, Paulo; Leite-Moreira, Adelino F
We present the experience of our centre with radiofrequency ablation of atrial fibrillation concomitantly with cardiac surgery Methods: 170 patients underwent atrial fibrillation ablation with uni/bipolar-radiofrequency. They were followed for 3-months and then as appropriate for the cardiac disease. In 2013, patients still alive underwent rhythm monitoring with ECG and 24-hour tape if in sinus rhythm Mean age was 65 years old and 42% of the patients were male. Paroxysmal AF was rare (7%). Most patients had preserved ejection fraction and dilated left atria (diameter 53.2±7.5 mm). The most common indication for cardiac surgery was valve disease. More than 75% of the patients underwent prophylactic closure of the left atrial appendage. Pulmonary vein isolation was performed in all patients, followed by other left atrial ablation lines. Overall, surgical complications were rare, being the most frequent pacemaker implantation (15%). Median length of stay was 9 days (p25-p75:7-14). At discharge, 69% of the patients were in sinus rhythm, being 90% on anticoagulation and 69% on amiodarone. In-hospital mortality was less than 3% (5 patients), none of them related to the ablation procedure. At 3 months, 50% of the patients were in sinus rhythm, being 92% on anticoagulation and 75% on antiarrhythmic drugs. Direct current cardioversion was successful in 8 of 12 patients. In the multivariate analysis, being in sinus rhythm at discharge was the single independent predictor of maintaining sinus rhythm at 3 months. In 2013 (469 patients-year), 40% of the patients were in sinus rhythm, being 80% on anticoagulation and 45% on antiarrhythmic drugs. Concurrent atrial fibrillation ablation with radiofrequency achieves satisfactory and stable recovery of sinu rhythm without adding significant operative risk and post-operative complications.
Sargento-Freitas, Joao; Silva, Fernando; Koehler, Sebastian; Isidoro, Luís; Mendonça, Nuno; Machado, Cristina; Cordeiro, Gustavo; Cunha, Luís
Cardioembolism due to atrial fibrillation assumes a dominant etiologic role in cerebrovascular diseases due to its growing incidence, high embolic risk and particular aspects of clinical events caused. Our objectives are to analyze the frequency of atrial fibrillation in patients with ischemic stroke, study the vital and functional impact of stroke due to different etiologies and evaluate antithrombotic options before and after stroke. We conducted a retrospective study including patients admitted in a central hospital due to ischemic stroke in 2010 (at least one year of follow-up). Etiology of stroke was defined using the Trial of ORG 10172 in Acute Stroke (TOAST) classification, and functional outcome by modified Rankin scale. We performed a descriptive analysis of different stroke etiologies and antithrombotic medication in patients with atrial fibrillation. We then conducted a cohort study to evaluate the clinical impact of antithrombotic options in secondary prevention after cardioembolic stroke. In our population (n = 631) we found superior frequency of cardioembolism (34.5%) to that reported in the literature. Mortality, morbidity and antithrombotic options are similar to other previous series, confirming the severity of cardioembolic strokes and the underuse of vitamin K antagonists. Oral anticoagulation was effective in secondary prevention independently from post-stroke functional condition. Despite unequivocal recommendations, oral anticoagulation is still underused in stroke prevention. This study confirms the clinical efficacy of vitamin K antagonists in secondary prevention independently from residual functional impairment.
Arotaritei, D.; Rotariu, C.
In this paper we present a novel method to develop an atrial fibrillation (AF) based on statistical descriptors and hybrid neuro-fuzzy and crisp system. The inference of system produce rules of type if-then-else that care extracted to construct a binary decision system: normal of atrial fibrillation. We use TPR (Turning Point Ratio), SE (Shannon Entropy) and RMSSD (Root Mean Square of Successive Differences) along with a new descriptor, Teager- Kaiser energy, in order to improve the accuracy of detection. The descriptors are calculated over a sliding window that produce very large number of vectors (massive dataset) used by classifier. The length of window is a crisp descriptor meanwhile the rest of descriptors are interval-valued type. The parameters of hybrid system are adapted using Genetic Algorithm (GA) algorithm with fitness single objective target: highest values for sensibility and sensitivity. The rules are extracted and they are part of the decision system. The proposed method was tested using the Physionet MIT-BIH Atrial Fibrillation Database and the experimental results revealed a good accuracy of AF detection in terms of sensitivity and specificity (above 90%).
Filos, D; Chouvarda, I; Dakos, G; Vassilikos, V; Maglaveras, N
Atrial fibrillation (AF) is a complex phenomenon, related with a multitude of factors, including the electrical properties of the atrial substrate. The purpose of this work is to present a method that highlights electrocardiographic differences between normal subjects and patients with paroxysmal AF episodes (PAF), potentially related with substrate differences. Vectorcardiography recordings are considered and, for each lead (X-Y-Z), on a beat by beat basis, a steady window before QRS, corresponding to the atrial activity, is analysed via continuous wavelet transform. Wavelet-based parameters are calculated and compared between the normal and AF group, with the beat to beat variation of wavelet energy as the most important feature showing a significantly higher variability in the AF group.
Lau, Y-F; Yiu, K-H; Siu, C-W; Tse, H-F
Hypertension is one of the most important risk factors associated with atrial fibrillation (AF) and increased the risk of cardiovascular events in patients with AF. However, the pathophysiological link between hypertension and AF is unclear. Nevertheless, this can be explained by the hemodynamic changes of the left atrium secondary to long standing hypertension, resulting in elevated left atrium pressure and subsequently left atrial enlargement. Moreover, the activation of renin-angiotensin-aldosterone system (RAAS) activation in patients with hypertension induces left atrial fibrosis and conduction block in the left atrium, resulting in the development of AF. Accordingly, recent studies have shown that effective blockage of RAAS by angiotensin converting enzyme inhibitors or angiotensin receptor antagonist may be effective in both primary and secondary prevention of AF in patients with hypertension, although with controversies. In addition, optimal antithrombotic therapy, blood pressure control as well as rate control for AF are key to the management of patients with AF.
Mody, Behram P.; Raza, Anoshia; Jacobson, Jason; Iwai, Sei; Frenkel, Daniel; Rojas, Rhadames
Atrial fibrillation (AF) is the most commonly encountered arrhythmia in the clinical setting affecting nearly 6 million people in United States and the numbers are only expected to rise as the population continues to age. Broadly it is classified into paroxysmal, persistent and longstanding persistent AF. Electrical, structural and autonomic remodeling are some of the diverse pathophysiological mechanisms that contribute to the persistence of AF. Our review article emphasizes particularly on long standing persistent atrial fibrillation (LSPAF) aspect of the disease which poses a great challenge for electrophysiologists. While pulmonary vein isolation (PVI) has been established as a successful ablation strategy for paroxysmal AF, same cannot be said for LSPAF owing to its long duration, complexity of mechanisms, multiple triggers and substrate sites that are responsible for its perpetuation. The article explains different approaches currently being adopted to achieve freedom from atrial arrhythmias. These mainly include ablation techniques chiefly targeting complex fractionated atrial electrograms (CFAE), rotors, linear lesions, scars and even considering hybrid approaches in a few cases while exploring the role of delayed enhancement magnetic resonance imaging (deMRI) in the pre-procedural planning to improve the overall short and long term outcomes of catheter ablation. PMID:28856145
Tse, Hung-Fat; Wang, Yong-Jun; Ahmed Ai-Abdullah, Moheeb; Pizarro-Borromeo, Annette B; Chiang, Chern-En; Krittayaphong, Rungroj; Singh, Balbir; Vora, Amit; Wang, Chun-Xue; Zubaid, Mohammad; Clemens, Andreas; Lim, Paul; Hu, Dayi
Despite relatively lower prevalence of atrial fibrillation (AF) in Asians (~1%) than in Caucasians (~2%), Asia has a much higher overall disease burden because of its proportionally larger aged population. For example, on the basis of reported age-adjusted prevalence rates and projected population figures in China, there will be an estimated 5.2 million men and 3.1 million women with AF older than 60 years by year 2050. Stroke is a disabling complication of AF that is of increasing cause for concern in Asians patients. Implementing consensus expert recommendations for managing stroke risk in patients with AF can considerably reduce stroke rates. However, caution is necessary when aligning management of Asian patients with AF to that of their Caucasian counterparts. Current international guidelines and risk stratification tools for AF management are based on findings in predominantly Caucasian populations and may therefore have limited relevance, in certain respects, to Asian patients. Oral anticoagulants play an important role in preventing AF-related stroke. The vitamin K antagonist warfarin is recommended for reducing the risk of stroke and thromboembolism in high-risk patients with nonvalvular AF; however, warfarin interacts with many drugs and food ingredients, which may pose significant challenges in administration and monitoring among Asian patients. Further research is needed to inform specific guidance on the implications of different stroke and bleeding profiles in Asians vs Caucasians. Moreover, there is scope to improve physician perceptions and patient knowledge, as well as considering alternative new oral anticoagulants, for example, direct thrombin inhibitors or factor Xa inhibitors. Copyright © 2013 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.
Friberg, L; Hammar, N; Rosenqvist, M
Recent studies of patients with heart failure and of patients receiving intensive care indicate that digoxin may increase mortality if the patient has atrial fibrillation (AF). Objective To study which patients receive digoxin treatment for AF and what the prognosis is for patients given this treatment. 2824 patients with AF were studied prospectively for a mean of 4.6 years. Information about medication was obtained from the local hospital registry. Information about diagnoses, hospitalisations and deaths was obtained from national registries. Propensity score matching and Cox regression was used to account for confounding. Factors associated with digoxin use were permanent AF (hazard ratio (HR) = 3.2, confidence interval (CI) 2.7 to 3.9), absence of pacemaker (HR = 2.3, CI 1.6 to 3.2), history of heart failure (HR = 2.0, CI 1.7 to 2.5), treatment in an internal medicine ward rather than a cardiology ward (HR = 1.6, CI 1.3 to 2.0), female sex (HR = 1.6, CI 1.3 to 1.9) and age >or=80 years (HR = 1.4, CI 1.1 to 1.7). More patients with than without digoxin died (51% vs 31%, p<0.001). After adjustment for covariates, however, no disadvantages related to digoxin use could be found for all-cause mortality, myocardial infarction, ischaemic stroke, time to readmission to hospital or days at hospital/year at risk. The only end point significantly associated with digoxin use was pacemaker implantations, which were more common in digoxin-treated patients (HR = 2.0, CI 1.2 to 3.4). Digoxin is mainly given to an elderly and frailer subset of patients with AF and is thus associated with an increased mortality. When differences in patient characteristics are accounted for digoxin use seems to have a neutral effect on mortality and major cardiovascular events in patients with AF.
Yamazaki, Masatoshi; Mironov, Sergey; Taravant, Clément; Brec, Julien; Vaquero, Luis M.; Bandaru, Krishna; Avula, Uma Mahesh R; Honjo, Haruo; Kodama, Itsuo; Berenfeld, Omer; Kalifa, Jérôme
Aims Atrial dilatation and myocardial stretch are strongly associated with atrial fibrillation (AF). However, the mechanisms by which the three-dimensional (3D) atrial architecture and heterogeneous stretch contribute to AF perpetuation are incompletely understood. We compared AF dynamics during stretch-related AF (pressure: 12cmH2O) in normal sheep hearts (n = 5) and in persistent AF (PtAF, n = 8)-remodelled hearts subjected to prolonged atrial tachypacing. We hypothesized that, in the presence of stretch, meandering 3D atrial scroll waves (ASWs) anchor in regions of large spatial gradients in wall thickness. Methods and results We implemented a high-resolution optical mapping set-up that enabled simultaneous epicardial- and endoscopy-guided endocardial recordings of the intact atria in Langendorff-perfused normal and PtAF (AF duration: 21.3 ± 11.9 days) hearts. The numbers and lifespan of long-lasting ASWs (>3 rotations) were greater in PtAF than normal (lifespan 0.9 ± 0.5 vs. 0.4 ± 0.2 s/(3 s of AF), P< 0.05). Than normal hearts, focal breakthroughs interacted with ASWs at the posterior left atrium and left atrial appendage to maintain AF. In PtAF hearts, ASW filaments seemed to span the atrial wall from endocardium to epicardium. Numerical simulations using 3D atrial geometries (Courtemanche-Ramirez-Nattel human atrial model) predicted that, similar to experiments, filaments of meandering ASWs stabilized at locations with large gradients in myocardial thickness. Moreover, simulations predicted that ionic remodelling and heterogeneous distribution of stretch-activated channel conductances contributed to filament stabilization. Conclusion The heterogeneous atrial wall thickness and atrial stretch, together with ionic and anatomic remodelling caused by AF, are the main factors allowing ASW and AF maintenance. PMID:22227155
Xu, Zhen-Xing; Zhong, Jing-Quan; Zhang, Wei; Yue, Xin; Rong, Bing; Zhu, Qing; Zheng, Zhaotong; Zhang, Yun
This study aimed to assess whether intra- and inter-atrial conduction delay could predict atrial fibrillation (AF) for paroxysmal supraventricular tachycardia (PSVT) patients after successful treatment by radiofrequency catheter ablation (RFCA). Echocardiography examination was performed on 524 consecutive PSVT patients (15 patients were excluded). Left atrial dimension, right atrial diameter and intra- and inter-atrial conduction delay were measured before ablation. Patients were divided into group A (n = 32): occurrence of AF after the ablation and group B (n = 477): remained in sinus rhythm during follow-up. Receiver operating characteristic (ROC) curve analysis was performed to estimate the predictive value of intra- and inter-atrial conduction delay. Both intra- and inter-atrial conduction delay were higher in group A than in group B (4.79 ± 0.30 msec vs. 4.56 ± 0.32 msec; 21.98 ± 1.32 msec vs. 20.01 ± 1.33; p < 0.05). Binary logistic regression analysis showed that intra- and inter-atrial conduction were significant influential factors for the occurrence of AF (odds ratio [OR] = 13.577, 95% confidence interval [CI], 3.469-48.914; OR = 2.569, 95% CI, 1.909-3.459, p < 0.05). The ROC cure analysis revealed that intra-atrial conduction delay ≥ 4.45 msec and inter-atrial conduction delay ≥ 20.65 were the most optimal cut-off value for predicting AF in PSVT patients after RFCA. In conclusion, this is the first study to show that the intra- and inter-atrial conduction delay could effectively predict AF in post-ablation PSVT patients.
Berisso, Massimo Zoni; Fabbri, Gianna; Gonzini, Lucio; Caruso, Davide; Fontanella, Andrea; Pellegrini, Francesco; Silvestri, Nunzia; Vincenti, Antonio; Mathieu, Giovanni; Di Pasquale, Giuseppe
To provide insights on the antiarrhythmic management of atrial fibrillation among patients enrolled in the Antithrombotic Agents in Atrial Fibrillation (ATA-AF) study, and to assess the adherence of the Italian cardiologists and internists to guidelines recommendations. The ATA-AF study is a multicenter, observational study with prospective data collection on the management and treatment of patients with atrial fibrillation. From March to July 2010, 6910 patients with atrial fibrillation were recruited in 164 Italian Cardiology (Card) and 196 Internal Medicine (IMed) centers. Permanent atrial fibrillation was diagnosed in 50.8%, persistent atrial fibrillation in 24.4%, paroxysmal in 15.5%, and first-detected atrial fibrillation in 9.3% of the patients. Rhythm control (rhyC) strategy was pursued in 27.5% (39.6% Card vs. 12.9% IMed; P < 0.0001) and rate control (raC) in 51.4% (43.7% Card vs. 60.7% IMed; P < 0.0001); in 21.1% the antiarrhythmic strategy was not defined. Patients assigned to rhyC were younger and with less comorbidities than those assigned to raC. Adjusted multivariable analysis showed that atrial fibrillation type, setting of management, age and site of patient discharge were the most important independent predictors of rhyC assignment. The severity of atrial fibrillation-related symptoms was not associated with rhyC assignment. At discharge, beta-blockers, amiodarone and class 1c antiarrhythmic drugs were the drugs mainly used in the Card centers; and beta-blockers, digitalis, amiodarone and diltiazem/verapamil were used in the IMed centers. Amiodarone was overused in both Card and IMed centers. In the present study, rhyC was the strategy mainly pursued by cardiologists and raC by internists; treatment strategy assignment and antiarrhythmic therapy often do not agree with the guideline recommendations.
Accuracy of diagnosing atrial fibrillation on electrocardiogram by primary care practitioners and interpretative diagnostic software: analysis of data from screening for atrial fibrillation in the elderly (SAFE) trial.
Mant, Jonathan; Fitzmaurice, David A; Hobbs, F D Richard; Jowett, Sue; Murray, Ellen T; Holder, Roger; Davies, Michael; Lip, Gregory Y H
To assess the accuracy of general practitioners, practice nurses, and interpretative software in the use of different types of electrocardiogram to diagnose atrial fibrillation. Prospective comparison with reference standard of assessment of electrocardiograms by two independent specialists. 49 general practices in central England. 2595 patients aged 65 or over screened for atrial fibrillation as part of the screening for atrial fibrillation in the elderly (SAFE) study; 49 general practitioners and 49 practice nurses. All electrocardiograms were read with the Biolog interpretative software, and a random sample of 12 lead, limb lead, and single lead thoracic placement electrocardiograms were assessed by general practitioners and practice nurses independently of each other and of the Biolog assessment. Sensitivity, specificity, and positive and negative predictive values. General practitioners detected 79 out of 99 cases of atrial fibrillation on a 12 lead electrocardiogram (sensitivity 80%, 95% confidence interval 71% to 87%) and misinterpreted 114 out of 1355 cases of sinus rhythm as atrial fibrillation (specificity 92%, 90% to 93%). Practice nurses detected a similar proportion of cases of atrial fibrillation (sensitivity 77%, 67% to 85%), but had a lower specificity (85%, 83% to 87%). The interpretative software was significantly more accurate, with a specificity of 99%, but missed 36 of 215 cases of atrial fibrillation (sensitivity 83%). Combining general practitioners' interpretation with the interpretative software led to a sensitivity of 92% and a specificity of 91%. Use of limb lead or single lead thoracic placement electrocardiograms resulted in some loss of specificity. Many primary care professionals cannot accurately detect atrial fibrillation on an electrocardiogram, and interpretative software is not sufficiently accurate to circumvent this problem, even when combined with interpretation by a general practitioner. Diagnosis of atrial fibrillation in
Kuck, Karl-Heinz; Brugada, Josep; Fürnkranz, Alexander; Metzner, Andreas; Ouyang, Feifan; Chun, K R Julian; Elvan, Arif; Arentz, Thomas; Bestehorn, Kurt; Pocock, Stuart J; Albenque, Jean-Paul; Tondo, Claudio
Current guidelines recommend pulmonary-vein isolation by means of catheter ablation as treatment for drug-refractory paroxysmal atrial fibrillation. Radiofrequency ablation is the most common method, and cryoballoon ablation is the second most frequently used technology. We conducted a multicenter, randomized trial to determine whether cryoballoon ablation was noninferior to radiofrequency ablation in symptomatic patients with drug-refractory paroxysmal atrial fibrillation. The primary efficacy end point in a time-to-event analysis was the first documented clinical failure (recurrence of atrial fibrillation, occurrence of atrial flutter or atrial tachycardia, use of antiarrhythmic drugs, or repeat ablation) following a 90-day period after the index ablation. The noninferiority margin was prespecified as a hazard ratio of 1.43. The primary safety end point was a composite of death, cerebrovascular events, or serious treatment-related adverse events. A total of 762 patients underwent randomization (378 assigned to cryoballoon ablation and 384 assigned to radiofrequency ablation). The mean duration of follow-up was 1.5 years. The primary efficacy end point occurred in 138 patients in the cryoballoon group and in 143 in the radiofrequency group (1-year Kaplan-Meier event rate estimates, 34.6% and 35.9%, respectively; hazard ratio, 0.96; 95% confidence interval [CI], 0.76 to 1.22; P<0.001 for noninferiority). The primary safety end point occurred in 40 patients in the cryoballoon group and in 51 patients in the radiofrequency group (1-year Kaplan-Meier event rate estimates, 10.2% and 12.8%, respectively; hazard ratio, 0.78; 95% CI, 0.52 to 1.18; P=0.24). In this randomized trial, cryoballoon ablation was noninferior to radiofrequency ablation with respect to efficacy for the treatment of patients with drug-refractory paroxysmal atrial fibrillation, and there was no significant difference between the two methods with regard to overall safety. (Funded by Medtronic; FIRE
Obremska, Marta; Zyśko, Dorota; Nowicki, Rafał; Goździk, Anna; Rachwalik, Maciej; Grzebieniak, Tomasz; Kustrzycki, Wojciech
Chronic atrial fibrillation may temporarily resolve after cardiac surgery. Prolongation of the ventricular repolarization period may be the electrophysiological background for this phenomenon. The aim of the study was to assess the association between resolution of atrial fibrillation and changes in the duration of the ventricular repolarization period in patients with pre-operative chronic atrial fibrillation who underwent cardiac surgery. A retrospective analysis of the medical recordings of patients with chronic atrial fibrillation who underwent cardiac surgery was performed. After exclusions the study group comprised 51 patients with chronic atrial fibrillation who underwent surgery in the Cardiac Surgery Department of Wrocław Medical University in 2008 and 2009. The 12-lead EKGs performed before and after the surgery were assessed and the QT and R-R intervals were measured. The patients were divided into Group 1, in whom atrial fibrillation persisted after the cardiac surgery, and Group 2, whose atrial fibrillation resolved after the surgery. In 31 patients (60.8%) atrial fibrillation disappeared during the first 24 hours after cardiac surgery. A significant prolongation of the QT interval after the surgery was found in Group 2 that was not observed in Group 1. Multiple regression analysis revealed that QT interval duration after surgery is related to the resolution of atrial fibrillation independently from the duration of the R-R interval duration and the need for cardiac pacing. Spontaneous temporary resolution of atrial fibrillation is a common finding after cardiac surgery in patients with chronic atrial fibrillation. This phenomenon is related to a prolonged QT interval, therefore it may have an electrophysiological basis rather than a hemodynamic background. Further studies are required to assess the clinical importance of the prolongation of the QT interval after cardiac surgery.
Hald, Erin M; Enga, Kristin F; Løchen, Maja-Lisa; Mathiesen, Ellisiv B; Njølstad, Inger; Wilsgaard, Tom; Braekkan, Sigrid K; Hansen, John-Bjarne
Pulmonary embolism (PE) may trigger atrial fibrillation through increased right atrial pressure and subsequent atrial strain, but the degree of evidence is low. In this study, we wanted to investigate the impact of incident venous thromboembolism (VTE) on future risk of atrial fibrillation in a prospective population-based study. The study included 29 974 subjects recruited from the Tromsø study (1994-1995, 2001-2002, 2007-2008). Incident VTE and atrial fibrillation events were registered from date of enrolment to end of follow-up, December 31, 2010. Cox proportional hazard regression models using age as time-scale and VTE as a time-dependent variable were used to estimate crude and multivariable hazard ratios (HRs) for atrial fibrillation with 95% confidence intervals (CIs). During 16 years of follow up, 540 (1.8%) subjects had an incident VTE event, and 1662 (5.54%) were diagnosed with atrial fibrillation. Among those with VTE, 50 (9.3%) developed subsequent atrial fibrillation. Patients with VTE had 63% higher risk of atrial fibrillation compared to subjects without VTE (multivariable-adjusted HR: 1.63, 95% CI: 1.22 to 2.17). The risk of atrial fibrillation was particularly high during the first 6 months after the VTE event (HR 4.00, 95% CI: 2.21 to 7.25) and among those with PE (HR 1.78, 95% CI: 1.13 to 2.80). We found that incident VTE was associated with future risk of atrial fibrillation. Our findings support the hypothesis that PE may lead to cardiac dysfunctions that, in turn, could trigger atrial fibrillation.
Rho, Robert W; Page, Richard L
Cardioversion of atrial fibrillation (AF) using traditional monophasic shock waveform is unsuccessful in up to 20% of cases, and often requires several shocks of up to 360 J. Based on the success with biphasic shock waveform in converting ventricular fibrillation, it was postulated that biphasic shocks would allow cardioversion with lower energy. In a international multicenter, double-blind, randomized trial of 203 patients, damped sine wave monophasic shocks were compared with impedance-compensated truncated exponential biphasic waveform shocks. Patients received up to five shocks: 100 J, 150 J, 200 J, a fourth shock at maximum output for the initial waveform (200 J biphasic, 360 J monophasic) and a final cross-over shock at maximum output of the alternate waveform. For each energy level, the biphasic waveform compared favorably to the monophasic waveform in successful cardioversion (100 J: 60% versus 22%, P < 0.0001; 150 J: 77% versus 44%, p < 0.0001; 200 J: 90% versus 53%, p < 0.0001). Success with 200 J biphasic was equivalent to 360 J monophasic shock (91% versus 85%, p = 0.29). Patients randomized to biphasic waveform required fewer shocks and lower total energy delivered; in addition, this waveform was associated with less dermal injury and no blistering. Biphasic shocks converted AF present for less than 48 hours with 80% efficacy, but conversion of AF present for more than 48 hours and more than 1 year the success rate was only 63 and 20%, respectively. The results of this study is similar to other investigations comparing biphasic and monophasic shock waveforms for conversion of atrial fibrillation. We recommend starting with biphasic energy of 100 J for atrial fibrillation of less than 48 hours duration, but using higher energies (150 J, 200 J or greater) when AF has been present for longer periods.
Kume, Osamu; Teshima, Yasushi; Abe, Ichitaro; Ikebe, Yuki; Oniki, Takahiro; Kondo, Hidekazu; Saito, Shotaro; Fukui, Akira; Yufu, Kunio; Miura, Masahiro; Shimada, Tatsuo; Takahashi, Naohiko
Monocyte chemoattractant protein-1 (MCP-1)-mediated inflammatory mechanisms have been shown to play a crucial role in atrial fibrosis induced by pressure overload. In the present study, we investigated whether left atrial endothelial cells would quickly respond structurally and functionally to pressure overload to trigger atrial fibrosis and fibrillation. Six-week-old male Sprague-Dawley rats underwent suprarenal abdominal aortic constriction (AAC) or a sham operation. By day 3 after surgery, macrophages were observed to infiltrate into the endocardium. The expression of MCP-1 and E-selectin in atrial endothelium and the expression of intercellular adhesion molecule-1, vascular cell adhesion molecule-1, and ED1 in left atrial tissue were enhanced. Atrial endothelial cells were irregularly hypertrophied with the disarrangement of lines of cells by scanning electron microscopy. Various-sized gap formations appeared along the border in atrial endothelial cells, and several macrophages were located just in the endothelial gap. Along with the development of heterogeneous interstitial fibrosis, interatrial conduction time was prolonged and the inducibility of atrial fibrillation by programmed extrastimuli was increased in the AAC rats compared to the sham-operated rats. Atrial endothelium responds rapidly to pressure overload by expressing adhesion molecules and MCP-1, which induce macrophage infiltration into the atrial tissues. These processes could be an initial step in the development of atrial remodeling for atrial fibrillation. Copyright © 2016 Elsevier Inc. All rights reserved.
Pandit, Sandeep V.; Workman, Antony J.
Heart failure (HF) causes complex, chronic changes in atrial structure and function, which can cause substantial electrophysiological remodeling and predispose the individual to atrial fibrillation (AF). Pharmacological treatments for preventing AF in patients with HF are limited. Improved understanding of the atrial electrical and ionic/molecular mechanisms that promote AF in these patients could lead to the identification of novel therapeutic targets. Animal models of HF have identified numerous changes in atrial ion currents, intracellular calcium handling, action potential waveform and conduction, as well as expression and signaling of associated proteins. These studies have shown that the pattern of electrophysiological remodeling likely depends on the duration of HF, the underlying cardiac pathology, and the species studied. In atrial myocytes and tissues obtained from patients with HF or left ventricular systolic dysfunction, the data on changes in ion currents and action potentials are largely equivocal, probably owing mainly to difficulties in controlling for the confounding influences of multiple variables, such as patient’s age, sex, disease history, and drug treatments, as well as the technical challenges in obtaining such data. In this review, we provide a summary and comparison of the main animal and human electrophysiological studies to date, with the aim of highlighting the consistencies in some of the remodeling patterns, as well as identifying areas of contention and gaps in the knowledge, which warrant further investigation. PMID:27812293
Altman, Robert K.; Proietti, Riccardo; Barrett, Conor D.; Paoletti Perini, Alessandro; Santangeli, Pasquale; Danik, Stephan B.; Di Biase, Luigi
Over the past two decades, invasive techniques to treat atrial fibrillation (AF) including catheter-based and surgical procedures have evolved along with our understanding of the pathophysiology of this arrhythmia. Surgical treatment of AF may be performed on patients undergoing cardiac surgery for other reasons (concomitant surgical ablation) or as a stand-alone procedure. Advances in technology and technique have made surgical intervention for AF more widespread. Despite improvements in outcome of both catheter-based and surgical treatment for AF, recurrence of atrial arrhythmias following initial invasive therapy may occur.Atrial arrhythmias may occur early or late in the post-operative course after surgical ablation. Early arrhythmias are generally treated with prompt electrical cardioversion with or without antiarrhythmic therapy and do not necessarily represent treatment failure. The mechanism of persistent or late occurring atrial arrhythmias is complex, and these arrhythmias may be resistant to antiarrhythmic drug therapy. The characterization and management of recurrent atrial arrhythmias following surgical ablation of AF are discussed below. PMID:24516805
Massaro, Ayrton R; Lip, Gregory Y H
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, with an estimated prevalence of 1-2% in North America and Europe. The increased prevalence of AF in Latin America is associated with an ageing general population, along with poor control of key risk factors, including hypertension. As a result, stroke prevalence and associated mortality have increased dramatically in the region. Therefore, the need for effective anticoagulation strategies in Latin America is clear. The aim of this review is to provide a contemporary overview of anticoagulants for stroke prevention. The use of vitamin K antagonists (VKAs, eg, warfarin) and aspirin in the prevention of stroke in patients with AF in Latin America remains common, although around one fifth of all AF patients receive no anticoagulation. Warfarin use is complicated by a lack of access to effective monitoring services coupled with an unpredictable pharmacokinetic profile. The overuse of aspirin is associated with significant bleeding risks and reduced efficacy for stroke prevention in this patient group. The non-VKA oral anticoagulants (NOACbs) represent a potential means of overcoming many limitations associated with VKA and aspirin use, including a reduction in the need for monitoring and a reduced risk of hemorrhagic events. The ultimate decision of which anticoagulant drug to utilize in AF patients depends on a multitude of factors. More research is needed to appreciate the impact of these factors in the Latin American population and thereby reduce the burden of AF-associated stroke in this region. Resumo A fibrilação atrial (FA) é a arritmia cardíaca sustentada mais comum, com uma prevalência estimada de 1-2% na América do Norte e Europa. O aumento da prevalência da FA na América Latina está associado com o envelhecimento da população geral, juntamente com um mal controle dos principais fatores de risco, incluindo a hipertensão arterial. Como resultado, a prevalência do acidente
Matějková, Adéla; Šteiner, Ivo
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia. For long time it was considered as pure functional disorder, but in recent years, there were identified atrial locations, which are involved in the initiation and maintenance of this arrhythmia. These structural changes, so called remodelation, start at electric level and later they affect contractility and morphology. In this study we attempted to find a possible relation between morphological (scarring, amyloidosis, left atrial (LA) enlargement) and electrophysiological (ECG features) changes in patients with AF. We examined grossly and histologically 100 hearts of necropsy patients - 54 with a history of AF and 46 without AF. Premortem ECGs were evaluated. The patients with AF had significantly heavier heart, larger LA, more severely scarred myocardium of the LA and atrial septum, and more severe amyloidosis in both atria. Severity of amyloidosis was higher in LAs vs. right atria (RAs). Distribution of both fibrosis and amyloidosis was irregular. The most affected area was in the LA anterior wall. Patients with a history of AF and with most severe amyloidosis have more often abnormally long P waves. Finding of long P wave may contribute to diagnosis of a hitherto undisclosed atrial fibrillation.
Crowson, Cynthia S.; Roger, Véronique L.; Gabriel, Sherine E.; Matteson, Eric L.
Objective. To investigate the incidence of atrial fibrillation (AF) among patients with rheumatoid arthritis (RA) compared to the general population. Methods. A population-based inception cohort of Olmsted County, Minnesota, residents with incident RA in 1980–2007 and a cohort of non-RA subjects from the same population base were assembled and followed until 12/31/2008. The occurrence of AF was ascertained by medical record review. Results. The study included 813 patients with RA and 813 non-RA subjects (mean age 55.9 (SD:15.7) years, 68% women in both cohorts). The prevalence of AF was similar in the RA and non-RA cohorts at RA incidence/index date (4% versus 3%; P = 0.51). The cumulative incidence of AF during follow-up was higher among patients with RA compared to non-RA subjects (18.3% versus 16.3% at 20 years; P = 0.048). This difference persisted after adjustment for age, sex, calendar year, smoking, and hypertension (hazard ratio: 1.46; 95% CI: 1.07, 2.00). There was no evidence of a differential impact of AF on mortality in patients with RA compared to non-RA subjects (hazard ratio 2.5 versus 2.8; interaction P = 0.31). Conclusion. The incidence of AF is increased in patients with RA, even after adjustment for AF risk factors. AF related mortality risk did not differ between patients with and without RA. PMID:25815336
Danelich, Ilya M; Reed, Brent N; Hollis, Ian B; Cook, Abigail M; Rodgers, Jo E
Atrial fibrillation (AF) is a cardiac arrhythmia associated with significant morbidity and mortality, affecting more than 3 million people in the United States and 1-2% of the population worldwide. Its estimated prevalence is expected to double within the next 50 years. During the past decade, there have been significant advances in the treatment of AF. Studies have demonstrated that a rate control strategy, with a target resting heart rate between 80 and 100 beats/minute, is recommended over rhythm control in the vast majority of patients. The CHA2 DS2 ≥ (congestive heart failure, hypertension, age ≥ 65 yrs, diabetes mellitus, stroke or transient ischemic attack, vascular disease, female gender) scoring system is a potentially useful stroke risk stratification tool that incorporates additional risk factors to the commonly used CHADS2 (congestive heart failure, hypertension, age ≥ 75 years, diabetes mellitus, stroke transient ischemic attack) scoring tool. Similarly, a convenient scheme, termed HAS-BLED (hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile international normalized ratio, elderly, drugs/alcohol concomitantly), to assess bleeding risk has emerged that may be useful in select patients. Furthermore, new antithrombotic strategies have been developed as potential alternatives to warfarin, including dual-antiplatelet therapy with clopidogrel plus aspirin and the development of new oral anticoagulants such as dabigatran, rivaroxaban, and apixaban. Vernakalant has emerged as another potential option for pharmacologic conversion of AF, whereas recent trials have better defined the role of dronedarone in the maintenance of sinus rhythm. Finally, catheter ablation represents another alternative to manage AF, whereas upstream therapy with inhibitors of the renin-angiotensin-aldosterone system, statins, and polyunsaturated fatty acids could potentially prevent the occurrence of AF. Despite substantial progress
Lee, Geraldine A; Stub, Dion; Ling, Han
Atrial fibrillation (AF) is the most commonly seen arrhythmia and its prevalence increases with age. In the general population, rates of 1-2% are reported but in older patients, the rates increase to over 10% (in those aged 85years or older). Many older patients present to the emergency department (ED) with complaints that could be caused or associated with AF including valvular heart disease, hypertension, heart failure, an underlying infection (urinary or chest) and thyroid disorder. The most devastating complication of AF is stroke and early detection of AF and initiation of treatment (specifically the use of anti-coagulant medication) can significantly reduce the risk. AF is associated with high healthcare costs and has significant impacts on disability and quality of life especially if a stroke occurs. This review aims to describe the aetiology and treatment options for patients with newly diagnosed and previously diagnosed AF with an emphasis on how ED staff can manage older patients with AF and ensure optimal care is given. The treatment of AF has three main considerations (i) appropriateness for thromboembolic prophylaxis, (ii) rate control (including anti-arrhythmics, cardiac glycosides, B blockers and calcium channel blockers) and (iii) rhythm control with traditional cardioversion (either electrically or pharmacologically) or utilising interventional means to maintain sinus rhythm with cardiac surgery and more recently radio-frequency ablation. As anti-coagulation is widely implemented, the risks and benefits associated with warfarin and the newer agents will be described. Given that more than half of those with AF are over 75years and 30% of AF is diagnosed incidentally, there is an imperative for prompt diagnosis to reduce the risk of debilitating complications especially stroke. AF should not be viewed as yet another concomitant "benign" condition. Emergency staff are well placed to detect AF and ensure appropriate treatment is commenced to reduce the
Atrial fibrillation (AF), the most common clinically relevant arrhythmia, affects 2.2 million individuals in the USA and 4.5 million in Europe, resulting in significant morbidity and mortality. Pharmacotherapy aimed at controlling both heart rate and rhythm is employed to relieve AF symptoms, though debate continues about which approach is preferable. AF prevalence rises with age from 0.4% to 1% in the general population to 11% in those aged >70 years. AF is associated with a pro-thrombotic state and other comorbidities; age, hypertension, heart failure and diabetes mellitus all play a key role in AF pathogenesis. Anti-coagulation is essential for stroke prevention in patients with AF and is recommended for patients with one or more risk factors for stroke. Used within the recommended therapeutic range, warfarin and other vitamin K antagonists decrease the incidence of stroke and mortality in AF patients. Warfarin remains under-used, however, because of the perceived high risk of haemorrhage, narrow therapeutic window and need for regular monitoring. Several novel anti-coagulants show promise in AF-related stroke prevention. In particular, the novel, oral, direct thrombin inhibitor, dabigatran etexilate, recently licensed by the US Food and Drug Administration (FDA) and Health Canada has shown improved efficacy and safety compared with warfarin for stroke prevention in AF, and has the potential to replace warfarin in this indication. The increasing number of new therapeutic options, including improved anti-arrhythmic agents, novel anti-coagulants and more accessible ablation techniques, are likely to deliver better care for AF patients in the near future. PMID:21816811
Tu, Karen; Nieuwlaat, Robby; Cheng, Stephanie Y; Wing, Laura; Ivers, Noah; Atzema, Clare L; Healey, Jeff S; Dorian, Paul
Identifying patients with atrial fibrillation (AF) using administrative data is important for epidemiologic and outcomes research. Although administrative data cover large populations, it is necessary to assess their validity in identifying AF patients. We used Ontario family physician electronic medical records from the Electronic Medical Record Administrative data Linked Database (EMRALD) as a reference standard to assess the accuracy of administrative data algorithms in identifying patients with AF. From a random sample of 7500 adult patients, patients with AF as recorded in family physician records were identified. The optimal algorithm consisted of any of: hospitalization or an emergency room code for AF or prescription for an AF-specific antiarrhythmic agent or billing code for cardioversion, or prescription for an anticoagulant that was accompanied by a physician billing code. for arrhythmia. The algorithm sensitivity was 80.7% (95% confidence interval [CI], 75.1-86.3), specificity 99.1% (95% CI, 98.9-99.3), positive predictive value 71.1% (95% CI, 65.1-77.1), and negative predictive value 99.5% (95% CI, 99.3-99.7). This algorithm, applied to the Ontario population, resulted in a calculated increase in AF prevalence from 1.68% to 2.36% over the years 2000-2014. Anticoagulation rates for AF patients increased from 53% in 2011 to 60% in 2014. Among AF patients receiving anticoagulants, novel oral anticoagulant utilization increased from < 5% in 2011 to > 50% in 2014. Identifying patients with AF can be done using administrative data, and the algorithm can be used to assess trends in disease burden over time and patterns of care in large populations. Copyright Â© 2016 The Authors. Published by Elsevier Inc. All rights reserved.
Kuo, Chang-Fu; Grainge, Matthew J; Mallen, Christian; Zhang, Weiya; Doherty, Michael
To examine the risk of atrial fibrillation (AF) at the time of first diagnosis of gout compared with matched controls and to follow incident gout patients and their matched controls after diagnosis to compare their subsequent risk of AF. From the UK Clinical Practice Research Data-link, 45 378 incident gout patients and 45 378 age-, sex-, practice-, registration year- and index year-matched controls were identified. Index dates were initial diagnosis date for gout patients and their matched controls. The risk of AF at diagnosis [odds ratios (ORs), using conditional logistic regression] and after the diagnosis of gout [hazard ratios (HRs), using Cox proportional models] were estimated, adjusted for BMI, smoking, alcohol consumption, ischaemic heart disease, heart failure, heart valve disease, hyperthyroidism and other comorbidities and medications. The prevalence of AF at index date in gout patients (male, 72.3%; mean age, 62.4 ± 15.1 years) was 7.42% (95% CI 7.18, 7.66%) and in matched controls 2.83% (95% CI 2.67, 2.98%). The adjusted OR (95% CI) was 1.45 (1.29, 1.62). The cumulative probability of AF at 1, 2, 5 and 10 years after index date was 1.08, 2.03, 4.77 and 9.68% in gout patients and 0.43, 1.08, 2.95 and 6.33% in controls, respectively (log-rank test, P < 0.001). The adjusted HR (95% CIs) was 1.09 (1.03, 1.16). This population-based study indicates that gout is independently associated with a higher risk of AF at diagnosis and the risk is also higher after the diagnosis. © The Author 2015. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: email@example.com.
Enga, K F; Rye-Holmboe, I; Hald, E M; Løchen, M-L; Mathiesen, E B; Njølstad, I; Wilsgaard, T; Braekkan, S K; Hansen, J-B
Whether atrial fibrillation is related to risk of venous thromboembolism (VTE) has not been extensively studied. Therefore, we investigated the association between atrial fibrillation and future risk of VTE in a population-based cohort. In total, 29,975 subjects were recruited from three surveys of the Tromsø study and followed from enrollment (1994-1995, 2001-2002 and 2007-2008) up to 2010. Incident events of atrial fibrillation and VTE during follow-up were recorded. Information on potential confounders was obtained at baseline. Cox-regression models with atrial fibrillation as time-dependent variable were used to calculate hazard ratios (HRs) for VTE with 95% confidence intervals (CIs). During 16 years of median follow-up, 1604 subjects were diagnosed with atrial fibrillation and 614 with incident VTE. The risk of VTE was substantially increased during the first 6 months after diagnosis of atrial fibrillation (HR, 8.44; 95% CI, 5.61-12.69), and remained increased throughout the study period (HR, 1.43; 95% CI, 1.43-1.99) compared with those without atrial fibrillation. Atrial fibrillation displayed higher risk estimates for pulmonary embolism (HR, 11.84; 95% CI, 6.80-20.63) than for deep vein thrombosis (HR, 6.20; 95% CI, 3.37-11.39) during the first 6 months, and was still associated with pulmonary embolism (HR, 1.96; 95% CI, 1.24-3.10) but not with deep vein thrombosis (HR, 1.08; 95% CI, 0.66-1.75) more than 6 months after diagnosis. Atrial fibrillation was associated with increased risk of VTE, and pulmonary embolism in particular. Our findings support the concept that isolated pulmonary embolism may originate from right atrial thrombi due to atrial fibrillation. © 2014 International Society on Thrombosis and Haemostasis.
McCarthy, P M; Castle, L W; Maloney, J D; Trohman, R G; Simmons, T W; White, R D; Klein, A L; Cosgrove, D M
From January 1991 until May 1992, a total of 14 patients (mean age 48 years) underwent the maze procedure for refractory atrial fibrillation (mean duration, 7 years; mean number of antiarrhythmic medications, six). Three patients had had embolic events, one patient had had a cardiac arrest from flecainide, one had pulmonary fibrosis from amiodarone, and six of ten who were employed were temporarily disabled. Two patients underwent successful mitral valve repair in which the maze procedure was added as a secondary goal of the operation. Postoperative fluid retention was a problem in five patients (36%). Six patients (43%) were temporarily treated with an antiarrhythmic medication. Two patients (14%) with preoperative sick sinus syndrome required pacemakers. One patient was discharged from the hospital but died suddenly less than 1 month after the operation (7% operative mortality) of hyperkalemia caused by acute renal failure. All patients beyond 3 postoperative months (100% "cure") are receiving no antiarrhythmic medications, have sinus rhythm, or have p-wave tracking with ventricular pacing. Atrial contraction has been documented by cinegraphic magnetic resonance imaging studies and by Doppler echocardiography performed when sinus rhythm had resumed. The maze procedure is an extensive operation but is indicated for selected patients who have the severe sequelae of atrial fibrillation.
Hu, Xiaoliang; Jiang, Jingzhou; Ma, Yuedong; Tang, Anli
Background Circumferential pulmonary vein isolation (CPVI) is a widely used treatment for paroxysmal atrial fibrillation (AF). Several P wave duration (PWD) parameters have been suggested to predict post-ablation recurrence, but their use remains controversial. This study aimed to identify novel P wave indices that predict post-ablation AF recurrence. Material/Methods We selected 171 consecutive patients undergoing CPVI for paroxysmal AF. Electrocardiography (ECG) recordings were obtained at the beginning and the end of ablation. PWD was measured in all 12 leads. The PWD variation was calculated by subtracting the pre-ablation PWD from the post-ablation PWD. Results PWD was significantly shortened in leads II, III, aVF, and V1 after ablation. During a mean follow-up of 19.96±4.32 months, AF recurrence occurred in 32 (18.7%) patients. No significant differences in baseline characteristics or pre- or post-ablation PWD were observed between the AF recurrence and non-recurrence groups. Patients with AF recurrence exhibited a smaller PWD variation in leads II (1.21(−0.56, 2.40) vs. −5.77(−9.10, −4.06) ms, P<0.001), III (−5.92(−9.87, 3.27) vs. −9.44(−11.89, −5.57) ms, P=0.001) and V1 (−4.43(−6.64, −3.13) vs. −6.33(−8.19,−4.59) ms, P=0.003). Multivariable logistic regression analysis demonstrated that smaller PWD variations in lead II and III were independent risk factors for AF recurrence. PWD variation ≥−2.21 ms in lead II displayed the highest combined sensitivity and specificity (85.29% and 83.94%, respectively) for predicting post-ablation AF recurrence. A PWD variation ≥0 ms displayed the best practical value in predicting AF recurrence. Conclusions PWD variation in lead II is an effective predictor of post-ablation AF recurrence. PMID:27450644
Lubitz, Steven A.; Yin, Xiaoyan; Fontes, João D.; Magnani, Jared W.; Rienstra, Michiel; Pai, Manju; Villalon, Mark L.; Vasan, Ramachandran S.; Pencina, Michael J.; Levy, Daniel; Larson, Martin G.; Ellinor, Patrick T.; Benjamin, Emelia J.
Context Although the heritability of atrial fibrillation (AF) is established, the contribution of familial AF to predicting new-onset AF remains unknown. Objective To determine whether familial occurrence of AF is associated with new-onset AF beyond established risk factors. Design, Setting, and Participants The Framingham Heart Study, a prospective population-based cohort study started in 1948. Original and Offspring Cohort participants were age at least 30 years, free of AF at the baseline examination, and had at least one parent or sibling enrolled in the study. Main outcome measures The incremental predictive value of incorporating different features of familial AF (any familial AF, premature familial AF [onset ≤65 years], number of affected relatives, and youngest age of onset in a relative) into a risk model for new-onset AF. Results Of 4421 participants (11971 person-examinations, mean age 54±13 years, 54% women), 440 developed AF during follow-up. Familial AF occurred in 1185 participants (26.8%) and premature familial AF occurred in 351 (7.9%) participants. AF occurred more frequently among participants with familial AF than without familial AF (unadjusted absolute event rates of 5.8% and 3.1%, respectively). The association was not attenuated by adjustment for AF risk factors (multivariable-adjusted HR 1.40, 95% CI 1.13–1.74) or reported AF-related genetic variants. Among the different features of familial AF examined, premature familial AF was associated with improved discrimination beyond traditional risk factors to the greatest extent (c-statistic 0.842; 95% CI, 0.826–0.858 to 0.846; 95%CI, 0.831–0.862; P=.004). Modest changes in integrated discrimination improvement were observed with premature familial AF (2.1%). Net reclassification improvement (assessed using eight-year risk thresholds of <5%, 5–10%, >10%) did not change significantly with premature familial AF (0.011; 95% CI, −0.021–0.042; P=.51), although category-less net
Mazurek, Michał; Shantsila, Eduard; Lane, Deirdre A; Wolff, Andreas; Proietti, Marco; Lip, Gregory Y H
Although patients with atrial fibrillation (AF) who experienced an acute stroke are at high risk for recurrence, many patients are untreated or treated suboptimally for stroke prevention. The objective of this study is to compare clinical outcomes of AF patients with versus without previous stroke in relation to guideline-adherent antithrombotic treatment in a contemporary primary care population. Community cohort of 105 000 patients from 11 general practices in Darlington, England, was used to assess AF stroke prevention strategies against 2014 National Institute for Health and Care Excellence guidelines. Overall, 2259 (2.15%) patients with AF were identified, of which 18.9% constituted a secondary prevention cohort. For secondary prevention, antithrombotic treatment was guideline adherent in 56.3%, 18.9% were overtreated, and 24.8% undertreated; corresponding proportions for primary prevention were 49.5%, 11.7%, and 38.8%, respectively. One-year stroke rates were 8.6% and 1.6% for secondary and primary prevention, respectively (P<0.001); corresponding all-cause mortality rates were 9.8% and 9.4%, respectively (P=0.79). On multivariable analysis, lack of antithrombotic treatment guideline adherence was associated with increased stroke risk for primary prevention (odds ratio, 2.95; 95% confidence interval, 1.26-6.90; P=0.013 for undertreatment); for secondary prevention, lack of guideline adherence was associated with increased risk of recurrent stroke (odds ratio, 2.80; 95% confidence interval, 1.25-6.27; P=0.012 for overtreatment) and all-cause death (odds ratio, 2.75; 95% confidence interval, 1.33-5.69; P=0.006 for undertreatment). Only approximately half of eligible patients with AF are prescribed oral anticoagulation in line with guidelines. Guideline-adherent antithrombotic treatment significantly reduces the risk of stroke among primary prevention patients and both risk of recurrent stroke and death in patients with previous stroke. © 2017 American Heart
Lee, Hsiu-Hao; Chen, Yueh-Chung; Chen, Jien-Jiun; Lo, Shih-Hsiang; Guo, Yue-Liang; Hu, Hsiao-Yun
Background Although advancements in the treatment of atrial fibrillation have improved patient prognosis for this persistent condition, interest in atrial fibrillation development is growing. Of note is the fact that additional attention is being focused on the accompanying effect of insomnia. The aim of the study was to investigate the effects of insomnia on the risk of atrial fibrillation development. Methods This was a nationwide population-based retrospective cohort study using data from the Taiwan National health Insurance Research Database. We analyzed 64,421 insomnia cases and 128,842 matched controls without insomnia from January 1, 2000, to December 31, 2010. A Cox regression model was used to estimate the adjusted hazard ratios (HRs) and 95% confidence intervals (CI) for atrial fibrillation development. Results During the follow-up period, the incidence of atrial fibrillation development was significantly higher in the insomnia cases than in the comparison cohort (2.6% vs. 2.3%, p < 0.001). Insomnia was associated with an increased risk of atrial fibrillation (HR = 1.08, 95% CI: 1.01-1.14). Males, those > 65 years of age, and patients with peripheral artery disease who have insomnia had a higher rate of atrial fibrillation development. Conclusions The findings of this nationwide analysis support the hypothesis that insomnia is associated with a significant risk of atrial fibrillation development. PMID:28344420
Kohno, Hiroki; Ueda, Hideki; Matsuura, Kaoru; Tamura, Yusaku; Watanabe, Michiko; Matsumiya, Goro
Background Atrial fibrillation is a common complication after cardiac surgery, but the risk factors and long-term outcome after primary isolated aortic valve replacement remains to be clarified. Methods A single-center retrospective study was conducted on 157 patients who underwent first-time isolated aortic valve replacement between April 1999 and February 2015. Fifty-eight patients developed new-onset atrial fibrillation within 6 months postoperatively, and they were compared with patients who remained in sinus rhythm. Multivariate analyses, which incorporated the propensity score patient matching technique, were conducted to evaluate the long-term outcome of new-onset postoperative atrial fibrillation and identify patients at risk of developing this arrhythmia. Results At a mean follow-up of 52.4 months (range 8.4-200.7 months), mortality was significantly higher in patients who developed atrial fibrillation compared to those who remained in sinus rhythm (2.8%/patient-year vs. 0.2%/patient-year, respectively; p < 0.05). Patients developing atrial fibrillation were also at an independently increased risk of stroke and readmission during follow-up. Risk analysis revealed that advanced age (>70 years) and absence of a postoperative β-blocker were predictors of atrial fibrillation. Conclusions New-onset atrial fibrillation after first-time isolated aortic valve replacement correlated significantly with late morbidity and mortality. Advanced age and absence of a postoperative β-blocker may increase the incidence of atrial fibrillation.
Carasso, Shemy; Kuperstein, Rafael; Konen, Eli; Glikson, Michael; Feinberg, Micha S
We present two patients with a large left atrial (LA) thrombus following invasive treatment for atrial fibrillation and inadequate anticoagulation. Case 1: A 30-year-old woman, with a one-year history of symptomatic paroxysmal atrial fibrillation resistant to medical therapy, underwent catheter ablation for atrial fibrillation. Three days after the procedure the patient presented with dizziness, fatigue, rapid atrial fibrillation with a sub-therapeutic INR. Transesophageal echocardiography (TEE) revealed a large LA thrombus. Case 2: A 59-year-old male, with severe mitral regurgitation and chronic atrial fibrillation, underwent mitral valve repair and Cox-Maze procedure. Three months later, while asymptomatic, a follow-up transthoracic echocardiography a large posterior LA thrombus was imaged. His INR was also sub-therapeutic. Both patients were treated by enhancing anticoagulation and close echocardiographic follow-up. So far both patients have remained asymptomatic two months following discharge. Large LA thrombi detected by transthoracic echocardiography are a rare complication of the Cox-Maze procedure and radio-frequency ablation for atrial fibrillation, which may occur even in patients with restored normal sinus rhythm receiving inadequate anticoagulation therapy.
Tamargo Menéndez, Juan
Atrial fibrillation starts in the left atrium and from there the activity invades the atrial tissues and causes an inhomogeneous shortening the duration of atrial action potential duration and refractoriness. The purpose of this study was to compare the voltage-dependent potassium currents in human cells isolated from the right and left atria and to determine whether electrical remodeling produced by chronic atrial fibrillation (CAF) differentially affects voltage-dependent potassium currents involved in atrial repolarization in each atrium as compared to sinus rhythm (SR). The currents were recorded using the whole-cell configuration of the patch-clamp technique. We found that in atrial cardiomyocytes of patients both in SR and in CAF there are three types of cells according to their main voltage-dependent repolarizing potassium current: the Ca(2+)-independent 4-aminopyridine sensitive component of the transient outward current (I(to1)) and the ultrarapid (I(Kur)), rapid (I(Kr)) and slow (I(Ks)) components of the delayed rectifier current. CAF differentially modified the proportion of these 3 types of cells on each atrium: CAF reduced the I(to1) more markedly in the left than in the right atria, while I(Kur) was more markedly reduced in the right than in the left atria. Interestingly, in both atria, CAF markedly increased the I(Ks). This increase was enhanced by isoproterenol and suppressed by atenolol. These changes produce a non-uniform shortening of atrial repolarization that facilitates the reentry of the cardiac impulse and the perpetuation of the arrhythmia.
Mont, Lluís; Elosua, Roberto; Brugada, Josep
Although the benefits of regular exercise in controlling cardiovascular risk factors have been extensively proven, little is known about the long-term cardiovascular effects of regular and extreme endurance sport practice, such as jogging, cycling, rowing, swimming, etc. Recent data from a small series suggest a relationship between regular, long-term endurance sport practice and atrial fibrillation (AF) and flutter. Reported case control studies included less than 300 athletes, with mean age between 40 and 50. Most series recruited only male patients, or more than 70% males, who had been involved in intense training for many years. Endurance sport practice increases between 2 and 10 times the probability of suffering AF, after adjusting for other risk factors. The possible mechanisms explaining the association remain speculative. Atrial ectopic beats, inflammatory changes, and atrial size have been suggested. Some of the published studies found that atrial size was larger in athletes than in controls, and this was a predictor for AF. It has also been shown that the left atrium may be enlarged in as many as 20% of competitive athletes. Other proposed mechanisms are increased vagal tone and bradycardia, affecting the atrial refractory period; however, this may facilitate rather than cause the arrhythmia. In summary, recent data suggest an association between endurance sport practice and atrial fibrillation and flutter. The underlying mechanism explaining this association is unclear, although structural atrial changes (dilatation and fibrosis) are probably present. Larger longitudinal studies and mechanistic studies are needed to further characterize the association to clarify whether a threshold limit for the intensity and duration of physical activity may prevent AF, without limiting the cardiovascular benefits of exercise.
D'Ascenzi, Flavio; Cameli, Matteo; Ciccone, Marco M; Maiello, Maria; Modesti, Pietro A; Mondillo, Sergio; Muiesan, Maria L; Scicchitano, Pietro; Novo, Salvatore; Palmiero, Pasquale; Saba, Pier S; Pedrinelli, Roberto
Atrial fibrillation is the most common clinically significant arrhythmia observed both in the general population and in competitive athletes. The most important risk factors are all preventable by regular physical activity. However, although the benefits of moderate physical activity in controlling cardiovascular risk factors and decreasing the risk of atrial fibrillation have been extensively proved, concerns have arisen about the potential negative effects of vigorous exercise, particularly in endurance athletes. Furthermore, in a subset of patients with atrial fibrillation younger than 60 years, routine evaluation does not reveal any cardiovascular disease or any other known causal factor. This condition is called 'lone atrial fibrillation', and the potential mechanisms underlying this condition are speculative and remain to be clarified. Atrial ectopy, increased vagal tone, changes in electrolytes, left atrial dilatation, and fibrosis have been proposed among others as potential mechanisms. However, no convincing data still exist. Particularly, the increase in left atrial size represents in athletes a physiological adaptation to exercise conditioning and the presence of biatrial fibrosis has not been demonstrated in humans. Thus, contrary to patients with cardiovascular disorders, the atrial substrate seems to play a secondary role in healthy athletes. This review article analyzes the controversial relationship between atrial fibrillation and physical activity, with a particular attention on the pathophysiological mechanisms that could be responsible for atrial fibrillation in the athletic population.
Yoshida, Kuniko; Obokata, Masaru; Kurosawa, Koji; Sorimachi, Hidemi; Kurabayashi, Masahiko; Negishi, Kazuaki
Embolic stroke in atrial fibrillation is more prevalent in women than in men, yet the basis for this difference remains unclear. This study seeks to elucidate whether there are any sex differences in the relationships between stroke risk (CHADS2 score, CHA2DS2-VASc score without a sex category, and estimated stroke rate) and left atrial (LA) anatomy or mechanics in patients with atrial fibrillation. LA emptying fraction and global peak atrial longitudinal strain were assessed in 414 subjects with paroxysmal or persistent atrial fibrillation (156 women and 258 men). Linear regression models with an interaction term were performed to test the effect of sex difference on associations between the embolic risk and LA function or anatomy. Sensitivity analyses were performed in 228 age, heart rate, and rhythm-matched subjects (114 women and men). Women were older and had larger LA volumes and lower LA mechanics than men. Significant negative association between the CHADS2 score and LA emptying fraction was only demonstrated in women with a significant interaction between sexes. Similar significant interactions were found in global peak atrial longitudinal strain but not in LA volume. These findings were corroborated in the comparisons against CHA2DS2-VASc score without a sex category and the estimated stroke rate. Sensitivity analyses in the matched subgroup also confirmed the robustness of these sex differences in LA emptying fraction, but less so in global peak atrial longitudinal strain. Significant sex interactions on the association between global LA function and risk stratification schemes exist, which may be a reason for the higher prevalence of embolic stroke in women. © 2016 American Heart Association, Inc.
de Figueiredo, Marcelo Marinho; Rodrigues, Ana Clara Tude; Alves, Monique Bueno; Neto, Miguel Cendoroglo; Silva, Gisele Sampaio
OBJECTIVE: Atrial fibrillation is a common arrhythmia that increases the risk of stroke by four- to five-fold. We aimed to establish a profile of patients with atrial fibrillation from a population of patients admitted with acute ischemic stroke or transient ischemic attack using clinical and echocardiographic findings. METHODS: We evaluated patients consecutively admitted to a tertiary hospital with acute ischemic stroke or transient ischemic attack. Subjects were divided into an original set (admissions from May 2009 to October 2010) and a validation set (admissions from November 2010 to April 2013). The study was designed as a cohort, with clinical and echocardiographic findings compared between patients with and without atrial fibrillation. A multivariable model was built, and independent predictive factors were used to produce a predictive grading score for atrial fibrillation (Acute Stroke AF Score-ASAS). RESULTS: A total of 257 patients were evaluated from May 2009 to October 2010 and included in the original set. Atrial fibrillation was diagnosed in 17.5% of these patients. Significant predictors of atrial fibrillation in the multivariate analysis included age, National Institutes of Health Stroke Scores, and the presence of left atrial enlargement. These predictors were used in the final logistic model. For this model, the area under the receiver operating characteristic curve was 0.79. The score derived from the logistic regression analysis was The model developed from the original data set was then applied to the validation data set, showing the preserved discriminatory ability of the model (c statistic = 0.76). CONCLUSIONS: Our risk score suggests that the individual risk for atrial fibrillation in patients with acute ischemic stroke can be assessed using simple data, including age, National Institutes of Health Stroke Scores at admission, and the presence of left atrial enlargement. PMID:24714831
Bosomworth, N John
To review the evidence on the effects of various levels of physical activity (PA) on the incidence of atrial fibrillation (AF) in both the general population and in endurance athletes. A PubMed search was done initially using the MeSH headings or text words (with the search-field descriptor TIAB [title and abstract]) atrial fibrillation and exercise or physical activity or athlet* or sport*, without additional filters. Conclusions regarding quality and strength of evidence were based on the GRADE (grading of recommendations, assessment, development, and evaluation) system. No interventional studies were available. Observational studies were therefore considered acceptable, and, although larger long-term prospective cohort studies were preferred, case-control or cross-sectional trials were also included in this review. Available evidence suggests a dose-response association linking increased exercise levels with reduced incident AF in women. The same is true in men at low and moderate levels of exertional activity. In men only, high levels of PA are associated with increased risk of AF in most, but not all, studies. This risk is moderate, with a hazard ratio of 1.29 in one of the better studies. The risk of AF for most people who exercise regularly is lower than that of a matched sedentary population. Atrial fibrillation is probably less common as PA increases, with a demonstrable dose-response relationship. Exercise at any level should be promoted for its effect on physical well-being and mortality reduction. In men exercising at high levels, beneficial effects on AF might be lost and risk might exceed that of the sedentary population; however, the evidence is neither robust nor consistent. These men should be made aware of this modest increase in risk should they choose to continue to engage in high levels of PA. Copyright© the College of Family Physicians of Canada.
Pazianas, Michael; Cooper, Cyrus; Wang, Yiting; Lange, Jeff L; Russell, R Graham G
Background: Epidemiological studies investigating a possible association between bisphosphonates and atrial fibrillation (AF) have reported conflicting findings. The objective of our study was to determine whether exposure to oral nitrogen-containing bisphosphonates alendronate and risedronate are associated with increased incidence of atrial fibrillation. Methods: In a retrospective cohort study we analyzed data from three large independent databases, two from the United States (MarketScan® and Ingenix®) and one from the United Kingdom (THIN). 144,548 women, age 50–89, bisphosphonate users during 2002–2005 were compared to 668,891 sex- and age-matched controls (1:4). Our primary outcome measure was new incident atrial fibrillation for up to three years; Cox models adjusted for disease and drug history were used to estimated relative risks. Results: We identified a total of 8,001, 1,984, and 817 AF cases in oral bisphosphonate users and nonusers during 744,340 (MarketScan), 243,898 (Ingenix), and 148,779 (THIN) person-years of follow-up, respectively. Compared to nonusers, overall adjusted relative risk (adjRR) (95% confidence interval [CI]) for AF in oral bisphosphonates users was 0.92 (0.85–0.99; MarketScan), 1.00 (0.87–1.16; Ingenix), and 0.97 (0.79–1.20; THIN); overall adjRR (95% CI) for any cardiac dysrrhythmia for MarketScan was 1.01 (0.98–1.05), Ingenix 1.06 (0.99–1.13), and THIN 0.97 (0.79–1.20). Conclusions: In all three databases from the two countries, the risk of AF or cardiac dysrrhythmia was not increased in postmenopausal women treated for up to three years with oral alendronate or risedronate. PMID:21479144
Chao, Tze-Fan; Liu, Chia-Jen; Tuan, Ta-Chuan; Chen, Su-Jung; Wang, Kang-Ling; Lin, Yenn-Jiang; Chang, Shih-Lin; Lo, Li-Wei; Hu, Yu-Feng; Chen, Tzeng-Ji; Chiang, Chern-En; Chen, Shih-Ann
Current American and European guidelines emphasize the importance of rate-control treatments in treating atrial fibrillation with a Class I recommendation, although data on the survival benefits of rate control are lacking. The goal of the present study was to investigate whether patients receiving rate-control drugs had a better prognosis compared with those without rate-control treatment. This study used the National Health Insurance Research Database in Taiwan. There were 43 879, 18 466, and 38 898 patients with atrial fibrillation enrolled in the groups receiving β-blockers, calcium channel blockers, and digoxin, respectively. The reference group consisted of 168 678 subjects who did not receive any rate-control drug. The clinical end point was all-cause mortality. During a follow-up of 4.9±3.7 years, mortality occurred in 88 263 patients (32.7%). After adjustment for baseline differences, the risk of mortality was lower in patients receiving β-blockers (adjusted hazard ratio=0.76; 95% confidence interval=0.74-0.78) and calcium channel blockers (adjusted hazard ratio=0.93; 95% confidence interval=0.90-0.96) compared with those who did not receive rate-control medications. On the contrary, the digoxin group had a higher risk of mortality with an adjusted hazard ratio of 1.12 (95% confidence interval=1.10-1.14). The results were observed consistently in subgroup analyses and among the cohorts after propensity matching. In this nationwide atrial fibrillation cohort, the risk of mortality was lower for patients receiving rate-control treatment with β-blockers or calcium channel blockers, and the use of β-blockers was associated with the largest risk reduction. Digoxin use was associated with greater mortality. Prospective, randomized trials are necessary to confirm these findings. © 2015 American Heart Association, Inc.
Synopsis Atrial fibrillation (AF) is a complex arrhythmia with multiple possible mechanisms. It requires a trigger for initiation and a favorable substrate for maintenance. Pulmonary vein myocardial sleeves have the potential to generate spontaneous activity, and such arrhythmogenic activity is surfaced by modulation of intracellular calcium dynamics. Direct autonomic nerve recordings in canine models demonstrate that simultaneous sympathovagal discharges are the most common triggers of paroxysmal atrial tachycardia and paroxysmal AF. Autonomic modulation as a potential therapeutic strategy has been targeted clinically and experimentally, but its effectiveness as an adjunctive therapeutic modality to catheter ablation of AF has been inconsistent. Further studies are warranted before application can be widely implied for therapies of clinical AF. PMID:19111762
Duytschaever, Mattias; Danse, Peter; Allessie, Maurits
Recent studies with the implantable atrial cardioverter have shown that atrial fibrillation (AF) recurs almost immediately after successful cardioversion in about 27% of cases. In the present study, we determined the electrophysiologic properties of the caprine atrium immediately after spontaneous termination of AF both before and after 48 hours of AF-induced electrical remodeling. In eight goats, atrial effective refractory period (AERP), intra-atrial conduction velocity, and atrial wavelength were measured during sinus rhythm both before (t = 0) and after 48 hours (t = 48) of electrically maintained AF (baseline). After baseline, a 5-minute paroxysm of AF was induced, during which the refractory period (RPAF) was determined. AERP, conduction velocity, and atrial wavelength also were measured immediately after spontaneous restoration of sinus rhythm (post-AF values). Both in normal and remodeled atria, immediately after AF, AERP and conduction velocity were markedly decreased compared with baseline (P < 0.01). In normal atria, post-AF AERP (107+/-14 msec) gradually prolonged from its AF value (114+/-17 msec) to its baseline value (138+/-13 msec). Conduction velocity decreased from 130+/-9 cm/sec to 117+/-9 cm/sec. After 48 hours of AF, AERP had shortened to 74+/-8 msec. RPAF was 89+/-9 msec. Surprisingly, immediately after termination of AF, AERP shortened further to 58+/-6 msec (P < 0.01). Post-AF conduction velocity decreased from 136+/-11 cm/sec to 122+/-10 cm/sec (P < 0.01). As a result, the post-AF atrial wavelength became as short as 7.1+/-1 cm. These changes were transient, and all parameters gradually returned to baseline within 1 to 2 minutes after conversion of AF. Due to a combined decrease in AERP and conduction velocity, marked shortening of the atrial wavelength occurs during the first minutes after conversion of AF. In electrically remodeled atria, this results in a transient ultrashort value of AERP (<60 msec) and atrial wavelength (7.1 cm). These
Myrstad, Marius; Nystad, Wenche; Graff-Iversen, Sidsel; Thelle, Dag S; Stigum, Hein; Aarønæs, Marit; Ranhoff, Anette H
Emerging evidence suggests that endurance exercise increases the risk for atrial fibrillation (AF) in men, but few studies have investigated the dose-response relation between exercise and risk for atrial arrhythmias. Both exposure to exercise and reference points vary among studies, and previous studies have not differentiated between AF and atrial flutter. The aim of this study was to assess the risk for atrial arrhythmias by cumulative years of regular endurance exercise in men. To cover the range from physical inactivity to long-term endurance exercise, the study sample in this retrospective cohort study was based on 2 distinct cohorts: male participants in a long-distance cross-country ski race and men from the general population, in total 3,545 men aged ≥ 53 years. Arrhythmia diagnoses were validated by electrocardiograms during review of medical records. Regular endurance exercise was self-reported by questionnaire. A broad range of confounding factors was available for adjustment. The adjusted odds ratios per 10 years of regular endurance exercise were 1.16 (95% confidence interval 1.06 to 1.29) for AF and 1.42 (95% confidence interval 1.20 to 1.69) for atrial flutter. In stratified analyses, the associations were significant in cross-country skiers and in men from the general population. In conclusion, cumulative years of regular endurance exercise were associated with a gradually increased risk for AF and atrial flutter. Copyright © 2014 Elsevier Inc. All rights reserved.
Xie, Jun; Chen, Yuhan; Hu, Chuanxian; Pan, Quanhua; Wang, Bingjian; Li, Xueling; Geng, Jin; Xu, Biao
Premature senescence is associated with atrial fibrosis and has an antifibrotic effect in mice. However, the role of senescence in atrial fibrillation (AF) remains unclear. Here, we investigated the association of premature senescence with fibrosis and also determined the role of senescence in the recurrence of AF after surgery ablation. Western blot, Sirius red staining, SA-β-gal staining and immunohistochemistry were performed to detect the degree of atrial fibrosis ,the expression of TGF-β and collagens, and also the senescence markers in 72 tissue specimens of left atrial appendage in this study. Then the patients undergoing successful surgical ablation were followed up for 12 months. The expression of collagens and TGF-β was paralleled by a high level of atrial fibrosis and were increased in AF group, especially in the persistent AF group. Western blotting of P16 and SA-β-gal staining showed an increased premature senescence in the sinus rhythm, paroxysmal AF and persistent AF groups. In addition, positive area of senescence markers, SA-β-gal and P16, was correlated positively with fibrotic lesions. We also found a lower ratio of P16/TGF-β in patients with recurrence of AF than in patients without recurrent AF. In conclusion, premature senescence is associated with atrial fibrosis in AF, and may have an antifibrotic role in AF.
Stähli, Barbara E; Gebhard, Cathérine; Gick, Michael; Mashayekhi, Kambis; Ferenc, Miroslaw; Buettner, Heinz Joachim; Neumann, Franz-Josef; Toma, Aurel
Successful CTO recanalization has been associated with clinical benefit. Outcomes of patients with atrial fibrillation undergoing CTO PCI have not been investigated, yet. This study sought to evaluate the association between atrial fibrillation and outcomes after percutaneous coronary intervention (PCI) for chronic total occlusions (CTO). Consecutive patients undergoing CTO PCI between January 2005 and December 2013 were divided into patients with and without atrial fibrillation, and propensity-matched models used to adjust for baseline differences between groups. The primary outcome was all-cause mortality at a median follow-up of 3.2 (interquartile range 3.1-4.5) years. Of 2002 patients undergoing CTO PCI, atrial fibrillation was present in 169 (8.4%) patients. Patients with atrial fibrillation were older, and more frequently had hypertension, left ventricular systolic dysfunction, and chronic kidney disease. Before matching, all-cause mortality was 39.6 and 14.5% in the atrial fibrillation and the sinus rhythm groups (HR 2.92, 95% CI 2.23-3.82, p < 0.001). In the propensity-matched model, atrial fibrillation remained associated with an increased risk of mortality (HR 1.62, 95% CI 1.06-2.47, p = 0.03). In the unmatched patient cohort, all-cause mortality was significantly reduced in patients with procedural success, both in the atrial fibrillation (34.9 versus 55.0%, adjusted HR 0.99, 95% CI 0.97-1.00, p = 0.02) and the sinus rhythm groups (12.8 versus 23.0%, adjusted HR 0.70, 95% CI 0.53-0.92, p = 0.01). Although atrial fibrillation is independently associated with mortality after CTO PCI, substantial survival benefit of successful CTO recanalization is observed in both patients with and without atrial fibrillation.
Ren, W D; Visentin, P; Nicolosi, G L; Canterin, F A; Dall'Aglio, V; Lestuzzi, C; Mimo, R; Pavan, D; Sparacino, L; Cervesato, E
The effect of atrial fibrillation on pulmonary venous flow patterns is still not well known. Twenty-four patients in atrial fibrillation and 21 patients in sinus rhythm were studied by transoesophageal echocardiography. In ninety-five percent (20/21) of sinus rhythm patients, the early systolic wave due to atrial relaxation or reverse wave due to atrial contraction could be distinguished on pulsed Doppler tracings by transoesophageal echocardiography. However, there was no early systolic wave and/or reverse at the end of diastole in any atrial fibrillation patients. In atrial fibrillation patients without mitral regurgitation (n = 14), the onset of systolic flow was delayed (165 +/- 38 vs 50 +/- 46 ms, P < 0.05), and systolic peak velocities, time-velocity integrals and systolic fractions were reduced (31 +/- 13 vs 54 +/- 17 cm.s-1, P < 0.05; 5 +/- 2 vs 13 +/- 6 cm, P < 0.05 and 36 +/- 8 vs 61 +/- 15%, P < 0.05, respectively) as compared to those in sinus rhythm. Significant mitral regurgitation (n = 10) reduced systolic velocity parameters considerably in atrial fibrillation patients but the diastolic flow parameters were not significantly different between sinus rhythm and atrial fibrillation patients. Stepwise multiple regression analysis identified atrial fibrillation as an important independent predictor for changes in systolic flow parameters. The R-R interval is also an important factor for diastolic flow parameters. Thus, the present study demonstrates that atrial fibrillation significantly modifies pulmonary venous flow pattern and is an important factor for systolic flow parameters. Significant mitral regurgitation can further modify systolic flow pattern in atrial fibrillation patients.
Mendes, Fernanda de Souza Nogueira Sardinha; Atié, Jacob; Garcia, Marcelo Iorio; Gripp, Eliza de Almeida; de Sousa, Andréa Silvestre; Feijó, Luiz Augusto; Xavier, Sergio Salles
Background Studies on atrial fibrillation (AF) in decompensated heart failure (DHF) are scarce in Brazil. Objectives To determine AF prevalence, its types and associated factors in patients hospitalized due to DHF; to assess their thromboembolic risk profile and anticoagulation rate; and to assess the impact of AF on in-hospital mortality and hospital length of stay. Methods Retrospective, observational, cross-sectional study of incident cases including 659 consecutive hospitalizations due to DHF, from 01/01/2006 to 12/31/2011. The thromboembolic risk was assessed by using CHADSVASc score. On univariate analysis, the chi-square, Student t and Mann Whitney tests were used. On multivariate analysis, logistic regression was used. Results The prevalence of AF was 40%, and the permanent type predominated (73.5%). On multivariate model, AF associated with advanced age (p < 0.0001), non-ischemic etiology (p = 0.02), right ventricular dysfunction (p = 0.03), lower systolic blood pressure (SBP) (p = 0.02), higher ejection fraction (EF) (p < 0.0001) and enlarged left atrium (LA) (p < 0.0001). The median CHADSVASc score was 4, and 90% of the cases had it ≥ 2. The anticoagulation rate was 52.8% on admission and 66.8% on discharge, being lower for higher scores. The group with AF had higher in-hospital mortality (11.0% versus 8.1%, p = 0.21) and longer hospital length of stay (20.5 ± 16 versus 16.3 ± 12, p = 0.001). Conclusions Atrial fibrillation is frequent in DHF, the most prevalent type being permanent AF. Atrial fibrillation is associated with more advanced age, non-ischemic etiology, right ventricular dysfunction, lower SBP, higher EF and enlarged LA. Despite the high thromboembolic risk profile, anticoagulation is underutilized. The presence of AF is associated with longer hospital length of stay and high mortality. PMID:25352505
Kalantarian, Shadi; Ay, Hakan; Gollub, Randy L; Lee, Hang; Retzepi, Kallirroi; Mansour, Moussa; Ruskin, Jeremy N
Atrial fibrillation (AF) is a common cause of stroke. Silent cerebral infarctions (SCIs) are known to occur in the presence and absence of AF, but the association between these disorders has not been well-defined. To estimate the association between AF and SCIs and the prevalence of SCIs in stroke-free patients with AF. Searches of MEDLINE, PsycINFO, Cochrane Library, CINAHL, and EMBASE from inception to 8 May 2014 without language restrictions and manual screening of article references. Observational studies involving adults with AF and no clinical history of stroke or prosthetic valves who reported SCIs. Study characteristics and study quality were assessed in duplicate. Eleven studies including 5317 patients with mean ages from 50.0 to 83.6 years reported on the association between AF and SCIs. Autopsy studies were heterogeneous and low-quality; therefore, they were excluded from the meta-analysis of the risk estimates. When computed tomography (CT) and magnetic resonance imaging (MRI) studies were combined, AF was associated with SCIs in patients with no history of symptomatic stroke (odds ratio, 2.62 [95% CI, 1.81 to 3.80]; I(2) = 32.12%; P for heterogeneity = 0.118). This association was independent of AF type (paroxysmal vs. persistent). The results were not altered significantly when the analysis was restricted to studies that met at least 70% of the maximum possible quality score (odds ratio, 3.06 [CI, 2.24 to 4.19]). Seventeen studies reported the prevalence of SCIs. The overall prevalence of SCI lesions on MRI and CT among patients with AF was 40% and 22%, respectively. Most studies were cross-sectional, and autopsy studies were heterogeneous and not sufficiently sensitive to detect small lesions. Atrial fibrillation is associated with more than a 2-fold increase in the odds for SCI. Deane Institute for Integrative Research in Atrial Fibrillation and Stroke, Massachusetts General Hospital.
Melby, Spencer J.; Schuessler, Richard B.; Damiano, Ralph J.
The Cox maze procedure for the surgical treatment of atrial fibrillation has been simplified from its original cut-and-sew technique. Various energy sources now exist which create linear lines of ablation that can be used to replace the original incisions, greatly facilitating the surgical approach. This review article describes the anatomy of the atria that must be considered in choosing a successful energy source. Furthermore the device characteristics, safety profile, mechanism of tissue injury, and ability to create transmural lesions of the various energy sources that have been used in the Cox maze procedure, along with the strengths and weaknesses of each device is discussed. PMID:23995989
da Silva, Ananília Medeiros Gomes; de Araújo, Jéssica Nayara Góes; de Freitas, Renata Caroline Costa
Atrial fibrillation (AF) is the most common supraventricular arrhythmia in the population. MicroRNAs (small endogenous noncoding RNAs) are attractive candidates as biomarkers for AF, especially considering that miRNAs are stable and are detected within easily accessible biofluids such as blood. In this review, we selected twelve studies (2012 to 2016) that were classified according to the sample type. We aimed to provide an overview of the role of circulating miRNAs in AF and to discuss the variability of the results, seeking to improve the perspective of the use of miRNAs as potential noninvasive biomarkers for this heart disease. PMID:28349066
Yang, Felix; Chou, Denise; Schweitzer, Paul; Hanon, Sam
Warfarin is commonly used to prevent stroke in patients with atrial fibrillation; however, patients on haemodialysis may not derive the same benefit from warfarin as the general population. There are no randomized controlled studies in dialysis patients which demonstrate the efficacy of warfarin in preventing stroke. In fact, warfarin places the dialysis patient at increased risk for haemorrhagic stroke and possibly ischaemic stroke. Additionally, warfarin increases the risk of major bleeding and has been associated with vascular calcification. Routine use of warfarin in dialysis for stroke prevention should be discouraged, and therapy should only be reserved for dialysis patients at high risk for thrombo-embolic stroke and carefully monitored if implemented.
Frontera, Antonio; Wilson, D G; Sekhon, H; Duncan, E R; Thomas, G
Hypertrophic cardiomyopathy (HCM) is one of the most common genetic cardiac conditions. Atrial fibrillation (AF) has been demonstrated to be the most frequent arrhythmia encountered in HCM patients. Research focusing on AF and embolic stroke in HCM patients has been sparse and the sample size of most studies is small. The prognostic significance of AF in HCM patients is still not well known. The aim of this article is to provide further understanding of the anti-coagulation requirement of HCM patients with AF.
Voukalis, Christos; Lip, Gregory Y H; Shantsila, Eduard
Ischaemic strokes resulting from atrial fibrillation (AF) constitute a devastating condition for patients and their carers with huge burden on health care systems. Prophylactic treatment against systemic embolization and ischaemic strokes is the cornerstone for the management of AF. Effective stroke prevention requires the use of the vitamin K antagonists or non-vitamin K oral anticoagulants (NOACs). This article summarises the latest developments in the field of stroke prevention in AF and aims to assist physicians with the choice of oral anticoagulant for patients with non-valvular AF with different risk factor profile.
Weiss, James N; Qu, Zhilin; Shivkumar, Kalyanam
Although considerable progress has been made in developing ablation approaches to cure atrial fibrillation (AF), outcomes are still suboptimal, especially for persistent and long-lasting persistent AF. In this topical review, we review the arrhythmia mechanisms, both reentrant and nonreentrant, that are potentially relevant to human AF at various stages/settings. We describe arrhythmia mapping techniques used to distinguish between the different mechanisms, with a particular focus on the detection of rotors. We discuss which arrhythmia mechanisms are likely to respond to ablation, and the challenges and prospects for improving upon current ablation strategies to achieve better outcomes.
Connolly, Stuart J; Camm, A John; Halperin, Jonathan L; Joyner, Campbell; Alings, Marco; Amerena, John; Atar, Dan; Avezum, Álvaro; Blomström, Per; Borggrefe, Martin; Budaj, Andrzej; Chen, Shih-Ann; Ching, Chi Keong; Commerford, Patrick; Dans, Antonio; Davy, Jean-Marc; Delacrétaz, Etienne; Di Pasquale, Giuseppe; Diaz, Rafael; Dorian, Paul; Flaker, Greg; Golitsyn, Sergey; Gonzalez-Hermosillo, Antonio; Granger, Christopher B; Heidbüchel, Hein; Kautzner, Josef; Kim, June Soo; Lanas, Fernando; Lewis, Basil S; Merino, Jose L; Morillo, Carlos; Murin, Jan; Narasimhan, Calambur; Paolasso, Ernesto; Parkhomenko, Alexander; Peters, Nicholas S; Sim, Kui-Hian; Stiles, Martin K; Tanomsup, Supachai; Toivonen, Lauri; Tomcsányi, János; Torp-Pedersen, Christian; Tse, Hung-Fat; Vardas, Panos; Vinereanu, Dragos; Xavier, Denis; Zhu, Jun; Zhu, Jun-Ren; Baret-Cormel, Lydie; Weinling, Estelle; Staiger, Christoph; Yusuf, Salim; Chrolavicius, Susan; Afzal, Rizwan; Hohnloser, Stefan H
Dronedarone restores sinus rhythm and reduces hospitalization or death in intermittent atrial fibrillation. It also lowers heart rate and blood pressure and has antiadrenergic and potential ventricular antiarrhythmic effects. We hypothesized that dronedarone would reduce major vascular events in high-risk permanent atrial fibrillation. We assigned patients who were at least 65 years of age with at least a 6-month history of permanent atrial fibrillation and risk factors for major vascular events to receive dronedarone or placebo. The first coprimary outcome was stroke, myocardial infarction, systemic embolism, or death from cardiovascular causes. The second coprimary outcome was unplanned hospitalization for a cardiovascular cause or death. After the enrollment of 3236 patients, the study was stopped for safety reasons. The first coprimary outcome occurred in 43 patients receiving dronedarone and 19 receiving placebo (hazard ratio, 2.29; 95% confidence interval [CI], 1.34 to 3.94; P=0.002). There were 21 deaths from cardiovascular causes in the dronedarone group and 10 in the placebo group (hazard ratio, 2.11; 95% CI, 1.00 to 4.49; P=0.046), including death from arrhythmia in 13 patients and 4 patients, respectively (hazard ratio, 3.26; 95% CI, 1.06 to 10.00; P=0.03). Stroke occurred in 23 patients in the dronedarone group and 10 in the placebo group (hazard ratio, 2.32; 95% CI, 1.11 to 4.88; P=0.02). Hospitalization for heart failure occurred in 43 patients in the dronedarone group and 24 in the placebo group (hazard ratio, 1.81; 95% CI, 1.10 to 2.99; P=0.02). Dronedarone increased rates of heart failure, stroke, and death from cardiovascular causes in patients with permanent atrial fibrillation who were at risk for major vascular events. Our data show that this drug should not be used in such patients. (Funded by Sanofi-Aventis; PALLAS ClinicalTrials.gov number, NCT01151137.).
Voukalis, Christos; Lip, Gregory Y.H.; Shantsila, Eduard
Ischaemic strokes resulting from atrial fibrillation (AF) constitute a devastating condition for patients and their carers with huge burden on health care systems. Prophylactic treatment against systemic embolization and ischaemic strokes is the cornerstone for the management of AF. Effective stroke prevention requires the use of the vitamin K antagonists or non-vitamin K oral anticoagulants (NOACs). This article summarises the latest developments in the field of stroke prevention in AF and aims to assist physicians with the choice of oral anticoagulant for patients with non-valvular AF with different risk factor profile. PMID:26981569
Uslar, Thomas; Anabalón, Jaime
For most atrial fibrillation patients oral anticoagulation constitutes the standard treatment to prevent stroke. However, they carry a risk of bleeding, which is why alternative treatments have been put into practice, such as percutaneous closure of the left atrial appendage. It is not clear whether this is as effective as the conventional treatment with anticoagulants. Searching in Epistemonikos database, which is maintained by screening 30 databases, we identified three systematic reviews including only one pertinent randomized controlled trial. We combined the evidence and generated a summary of findings following the GRADE approach. We concluded that percutaneous left atrial appendage occlusion may decrease stroke and mortality, but the certainty of the evidence is low. The effect on other outcomes is not clear because the certainty of the evidence is very low.
Opacic, Dragan; van Bragt, Kelly A; Nasrallah, Hussein M; Schotten, Ulrich; Verheule, Sander
Atrial fibrillation (AF) is the most common tachyarrhythmia in clinical practice. Over decades of research, a vast amount of knowledge has been gathered about the causes and consequences of AF related to cellular electrophysiology and features of the tissue structure that influence the propagation of fibrillation waves. Far less is known about the role of myocyte metabolism and tissue perfusion in the pathogenesis of AF. However, the rapid rates of electrical activity and contraction during AF must present an enormous challenge to the energy balance of atrial myocytes. This challenge can be met by scaling back energy demand and by increasing energy supply, and there are several indications that both phenomena occur as a result of AF. Still, there is ample evidence that these adaptations fall short of redressing this imbalance, which may represent a driving force for atrial electrical as well as structural remodelling. In addition, several 'metabolic diseases' such as diabetes, obesity, and abnormal thyroid function precipitate some well-known 'culprits' of the AF substrate such as myocyte hypertrophy and fibrosis, while some other AF risk factors, such as heart failure, affect atrial metabolism. This review provides an overview of metabolic and vascular alterations in AF and their involvement in its pathogenesis.
Elikowski, Waldemar; Wróblewski, Dariusz; Małek-Elikowska, Małgorzata; Mazurek, Andrzej; Foremska-Iciek, Joanna; Łazowski, Stanisław
Atrial fibrillation and heart failure are factors predisposing to locally formed intracardiac thrombosis, which is usually localized in left-sided chambers. A case report. The authors present a case of a 50-year-old male with permanent atrial fibrillation and dilated cardiomyopathy in whom recurrent right atrial thrombus was observed. Initially, the lesion was detected in echocardiography while he was hospitalized due to extensive right-sided pneumonia. The thrombus was successfully treated with heparin, followed by warfarin. Even though the patient continued warfarin use properly, there was recurrence of the thrombus two years later during a new episode of heart failure exacerbation. Because the thrombus was resistant to intensified anticoagulation, cardiac surgery was needed. A large (30 x 25 mm) pedunculated thrombus, as well as two smaller ones (each of 10 x 10 mm) attached closely to the atrial wall and previously not detected either by echocardiography or by magnetic resonance imaging, were excited. A partially organized pattern of the thrombi in histological examination can explain lack of anticoagulation effectiveness.
Benjamin, Emelia J; Rice, Kenneth M; Arking, Dan E; Pfeufer, Arne; van Noord, Charlotte; Smith, Albert V; Schnabel, Renate B; Bis, Joshua C; Boerwinkle, Eric; Sinner, Moritz F; Dehghan, Abbas; Lubitz, Steven A; D'Agostino, Ralph B; Lumley, Thomas; Ehret, Georg B; Heeringa, Jan; Aspelund, Thor; Newton-Cheh, Christopher; Larson, Martin G; Marciante, Kristin D; Soliman, Elsayed Z; Rivadeneira, Fernando; Wang, Thomas J; Eiríksdottir, Gudny; Levy, Daniel; Psaty, Bruce M; Li, Man; Chamberlain, Alanna M; Hofman, Albert; Vasan, Ramachandran S; Harris, Tamara B; Rotter, Jerome I; Kao, W H Linda; Agarwal, Sunil K; Stricker, Bruno H Ch; Wang, Ke; Launer, Lenore J; Smith, Nicholas L; Chakravarti, Aravinda; Uitterlinden, André G; Wolf, Philip A; Sotoodehnia, Nona; Köttgen, Anna; van Duijn, Cornelia M; Meitinger, Thomas; Mueller, Martina; Perz, Siegfried; Steinbeck, Gerhard; Wichmann, H-Erich; Lunetta, Kathryn L; Heckbert, Susan R; Gudnason, Vilmundur; Alonso, Alvaro; Kääb, Stefan; Ellinor, Patrick T; Witteman, Jacqueline C M
We conducted meta-analyses of genome-wide association studies for atrial fibrillation (AF) in participants from five community-based cohorts. Meta-analyses of 896 prevalent (15,768 referents) and 2,517 incident (21,337 referents) AF cases identified a new locus for AF (ZFHX3, rs2106261, risk ratio RR = 1.19; P = 2.3 x 10(-7)). We replicated this association in an independent cohort from the German AF Network (odds ratio = 1.44; P = 1.6 x 10(-11); combined RR = 1.25; combined P = 1.8 x 10(-15)).
De Potter, Tom; Cresti, Alberto; Severi, Silva; Breithardt, Günter
Atrial fibrillation (AF) remains the most frequent sustained cardiac arrhythmia worldwide and its incidence increases with ageing, cardiovascular risk factors and comorbidities. Prevalence of diabetes mellitus (DM) is growing fast and is assuming pandemic proportions mostly due to overnutrition and sedentary habits. Experimental and clinical evidences suggest that DM and AF are strongly interconnected. The present review addresses in detail new molecular pathways implicated in the etiology of AF and their relevance for mechanism-based therapeutic strategies in this setting. Advances in risk stratification, drug therapy (i.e., novel anticoagulants) and catheter ablation are also described. PMID:26543823
Vadmann, Henrik; Grønlund, Jens; Andreasen, Jan Jesper
The prevalence of atrial fibrillation in the general population is 1-2% and ablation procedures have been introduced among some symptomatic patients on order to obtain sinus rythm. A surgical thoracoscopic procedure may be offered to patients in whom percutaneous procedures were unsuccessful. This paper describes the procedure and initial results from 21 patients operated at Aalborg University Hospital, Denmark. Six months post-operatively 15 of 20 patients had obtained sinus rythm. Systematic follow-up is missing in local hospitals, indicating the need for systematic reporting to a clinical database.
Huang, Shih-Yu; Chen, Yi-Ann; Chen, Shih-Ann; Chen, Yi-Jen; Lin, Yung-Kuo
Atrial fibrillation (AF) is the most common cardiac arrhythmia. Chronic kidney disease (CKD) is associated with a high prevalence of AF, and uremic toxins are an important risk factor for cardiovascular diseases associated with CKD. Uremic toxins can produce pro-fibrotic, pro-hypertrophic, and pro-inflammatory effects on cardiac tissues and enhance oxidative stress or neurohormonal phenomena of cardiovascular injury, which are recognized as arrhythmogenic factors of AF. This article reviews the clinical, molecular, and electrophysiological data of uremic toxins in CKD considered to induce AF through multiple mechanisms on structural and electrical remodeling of the cardiovascular system. PMID:27274165
Safaie, Naser; Maghamipour, Nasrollah; Jodati, Ahmad Reza; Mahmoodpoor, Ata; Dashtaki, Leila; Hakimzadeh, Masoud
Patients with valvular heart disease suffer from atrial fibrillation for more than 12 months after valve surgery and have a low probability of remaining in sinus rhythm. We performed an intra-operative procedure similar to surgical maze ІІІ procedure for conversion of this arrhythmia to sinus rhythm. We did this study to evaluate the efficacy of this procedure to restore the sinus rhythm in patients with valvular heart disease. 28 patients with valvular heart disease and chronic persistent atrial fibrillation underwent different combinations of valve surgery and concomitant reduction of left and right atrial size and resection of both atrial auricles in Shahid Madani cardiothoracic center from September 2004 to October 2008. The procedure for atrial fibrillation treatment was performed with cardiopulmonary bypass and after mitral valve replacement. There was one in-hospital death postoperatively because of respiratory failure, but no other complication till 6 months after the operation. Out of 28 patients, 23 were in sinus rhythm one week after the operation, one patient had junctional rhythm after the operation that restored to sinus rhythm and 4 patients had persistent atrial fibrillation. During the 12-month follow up, atrial fibrillation was corrected in 82.14%. Doppler echocardiography in these patients with sinus rhythm demonstrated good atrial contractility. This procedure on both atria is effective and less invasive than the original maze procedure to eliminate the atrial fibrillation, and can be performed in patients with valvular heart disease without increasing the risk of operation.
Heijman, Jordi; Erfanian Abdoust, Pegah; Voigt, Niels; Nattel, Stanley; Dobrev, Dobromir
The complexity of the heart makes an intuitive understanding of the relative contribution of ion channels, transporters and signalling pathways to cardiac electrophysiology challenging. Computational modelling of cardiac cellular electrophysiology has proven useful to integrate experimental findings, extrapolate results obtained in expression systems or animal models to other systems, test quantitatively ideas based on experimental data and provide novel hypotheses that are experimentally testable. While the bulk of computational modelling has traditionally been directed towards ventricular bioelectricity, increasing recognition of the clinical importance of atrial arrhythmias, particularly atrial fibrillation, has led to widespread efforts to apply computational approaches to understanding atrial electrical function. The increasing availability of detailed, atrial-specific experimental data has stimulated the development of novel computational models of atrial-cellular electrophysiology and Ca(2+) handling. To date, more than 300 studies have employed mathematical simulations to enhance our understanding of atrial electrophysiology, arrhythmogenesis and therapeutic responses. Future modelling studies are likely to move beyond current whole-cell models by incorporating new data on subcellular architecture, macromolecular protein complexes, and localized ion-channel regulation by signalling pathways. At the same time, more integrative multicellular models that take into account regional electrophysiological and Ca(2+) handling properties, mechano-electrical feedback and/or autonomic regulation will be needed to investigate the mechanisms governing atrial arrhythmias. A combined experimental and computational approach is expected to provide the more comprehensive understanding of atrial arrhythmogenesis that is required to develop improved diagnostic and therapeutic options. Here, we review this rapidly expanding area, with a particular focus on Ca(2+) handling, and
Yujing, Wang; Congxin, Huang; Shaning, Yang; Lijun, Jin; Xiaojun, Hu; Gang, Wu; Qiang, Xie
This study was designed to investigate whether administration of digitalis could improve mechanical function of left atrial appendage (LAA) and left atrium prospectively in patients with atrial stunning. Fifty-four consecutive patients in whom atrial stunning was observed immediately after cardioversion of chronic atrial fibrillation (AF) were randomized into digitalis or control group for 1 week following cardioversion. Transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) were performed prior to, immediately following, 1 day after and 1 week after cardioversion to measure transmitral flow velocity and LAA flow velocity. Electrical cardioversion of AF elicited significantly slower left atrial appendage peak emptying velocity (LAA-PEV) and peak filling velocity (LAA-PFV) immediately following cardioversion in both groups. 1 day post cardioversion, there were no significant differences in transmitral E wave, A wave, E/A ratio, LAA-PEV, LAA-PFV or left atrial appendage ejection fraction (LAA-EF) between digitalis and control groups. 1 week post cardioversion, no significant differences were found in transmitral E wave, A wave, E/A ratio, LAA-PEV, LAA-PFV or LAA-EF between the two groups. The occurrence rates of spontaneous echo contrast were not significantly different between digitalis and control groups one day and one week post cardioversion. In conclusion, digitalis did not improve left atrial and appendage mechanical dysfunction following cardioversion of chronic AF. Digitalis did not prevent the development of spontaneous echo contrast in left atrial chamber and appendage. This may be due to the fact that digitalis aggravates intracellular calcium overload induced by chronic AF and has a negative effect on ventricular rate.
Prevalence, Patterns, and Clinical Predictors of Left Ventricular Late Gadolinium Enhancement in Patients Undergoing Cardiac Magnetic Resonance Prior to Pulmonary Vein Antral Isolation for Atrial Fibrillation: A Cross-Sectional Observational Study.
Nance, John W; Khurram, Irfan M; Nazarian, Saman; DeWire, Jane; Calkins, Hugh; Zimmerman, Stefan L
Cardiac magnetic resonance (CMR) imaging is increasingly used to evaluate patients with atrial fibrillation (AF) before pulmonary vein antral isolation (PVAI). The purpose of this study was to assess the incidence and pattern of left ventricular (LV) late gadolinium enhancement (LGE) in patients undergoing CMR before PVAI and compare the clinical and demographic differences of patients with and without LV LGE. Clinical and demographic data on 62 patients (mean age 61 ± 7.9, 69% male) undergoing CMR before PVAI for AF were collected. Two observers, masked to clinical histories, independently recorded the prevalence, extent (number of myocardial segments), and pattern (subendocardial, midmyocardial, or subepicardial) of LV LGE in each patient. Clinical and demographic predictors of LV LGE were determined using logistic regression. Twenty-three patients (37%) demonstrated LV LGE affecting a mean of 3.0 ± 2.1 myocardial segments. There was no difference in LV ejection fraction between patients with and without LGE, and most (65%) patients with LGE had normal wall motion. Only age (P = 0.04) and a history of congestive heart failure (P = .03) were statistically significant independent predictors of LGE. The most common LGE pattern was midmyocardial, seen in 17 of 23 (74%) patients. Only 4 of 23 (17%) patients had LGE in an "expected" pattern based on clinical history. Of the remaining 19 patients, 4 had known congestive heart failure, 5 nonischemic cardiomyopathy, 4 known coronary artery disease, and 2 prior aortic valve replacement. Six of 23 (26%) patients had no known coronary artery, valvular, or myocardial disease. There is a high prevalence of unexpected LV scar in patients undergoing CMR before PVAI for AF, with most patients demonstrating a nonischemic pattern of LV LGE and no wall motion abnormalities (ie, subclinical disease). The high prevalence of unexpected LGE in these patients may argue for CMR as the modality of choice for imaging
Gialdini, Gino; Nearing, Katherine; Bhave, Prashant D.; Bonuccelli, Ubaldo; Iadecola, Costantino; Healey, Jeff S.; Kamel, Hooman
IMPORTANCE Clinically apparent atrial fibrillation increases the risk of ischemic stroke. In contrast, perioperative atrial fibrillation may be viewed as a transient response to physiological stress, and the long-term risk of stroke after perioperative atrial fibrillation is unclear. OBJECTIVE To examine the association between perioperative atrial fibrillation and the long-term risk of stroke. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study using administrative claims data on patients hospitalized for surgery (as defined by surgical diagnosis related group codes), and discharged alive and free of documented cerebrovascular disease or preexisting atrial fibrillation from nonfederal California acute care hospitals between 2007 and 2011. Patients undergoing cardiac vs other types of surgery were analyzed separately. MAIN OUTCOMES AND MEASURES Previously validated diagnosis codes were used to identify ischemic strokes after discharge from the index hospitalization for surgery. The primary predictor variable was atrial fibrillation newly diagnosed during the index hospitalization, as defined by previously validated present-on-admission codes. Patients were censored at postdischarge emergency department encounters or hospitalizations with a recorded diagnosis of atrial fibrillation. RESULTS Of 1 729 360 eligible patients, 24 711 (1.43%; 95% CI, 1.41%–1.45%) had new-onset perioperative atrial fibrillation during the index hospitalization and 13 952 (0.81%; 95% CI, 0.79%–0.82%) experienced a stroke after discharge. In a Cox proportional hazards analysis accounting for potential confounders, perioperative atrial fibrillation was associated with subsequent stroke both after noncardiac and cardiac surgery. Type of SurgeryCumulative Rate of Stroke 1 Year AfterHospitalization, % (95% CI)Hazard Ratio (95% CI)PerioperativeAtrial FibrillationNo PerioperativeAtrial FibrillationNoncardiac1.47 (1.24–1.75)0.36 (0.35–0.37)2.0 (1.7–2.3)Cardiac0.99 (0.81–1
Gullón, Alejandra; Suárez, Carmen; Díez-Manglano, Jesús; Formiga, Francesc; Cepeda, José María; Pose, Antonio; Camafort, Miguel; Castiella, Jesús; Rovira, Eduardo; Mostaza, José María
The prevalence of non-valvular atrial fibrillation (NVAF) increases with the patient's age and is associated with high morbi-mortality rates. The main goal of this study was to describe the characteristics of hospitalized elderly patients with NVAF and to identify the clinical and functional factors which determine the use of different antithrombotic strategies. Observational, prospective, multicentre study carried out on patients with NVAF over the age of 75, who had been admitted for any medical condition to Internal Medicine departments. We evaluated 804 patients with a mean age of 85 years (range 75-101), of which 53.9% were females. The prevalence of risk factors and cardiovascular disease was high: hypertension (87.6%), heart failure (65.4%), ischemic cardiomyopathy (24.4%), cerebrovascular disease (22.4%) and chronic kidney disease (45%). Among those cases with previous diagnoses of NVAF, antithrombotic treatment was prescribed in 86.2% of patients: anticoagulants (59.7%), antiplatelet medication (17.8%) and double therapy (8.7%). The factors associated with the use of antithrombotic treatment were history of acute coronary syndrome and atrial fibrillation progression longer than one year. Older age, atrial fibrillation for less than one year, higher HAS-BLED scores and severe cognitive impairment were associated with the use of anti-platelet drugs. Permanent atrial fibrillation favoured the use of anticoagulants. Hospitalized patients older than 75 years old with NVAF showed numerous comorbidities. The percentage of anticoagulation was small and 18% received only anti-platelet therapy. The patient's age, atrial fibrillation's progression time and the severity of the cognitive impairment influenced this therapy choice. Copyright © 2016 Elsevier España, S.L.U. All rights reserved.
Tzikas, Apostolos; Karagounis, Lambros; Bouktsi, Maria; Drevelegas, Antonios; Parcharidou, Despina; Ioannidis, Stathis; Krasopoulos, George; Giannakoulas, George
Left atrial appendage (LAA) occlusion has been introduced into clinical practice as a valuable alternative to oral anticoagulation for stroke prevention in patients with non-valvular atrial fibrillation. In this case presentation we describe the first LAA occlusion in Greece using the Amplatzer Amulet device. We also briefly discuss issues related to procedural safety and multimodality imaging for LAA occlusion.
Vos, M; Golitsyn, S; Stangl, K; Ruda, M; Van Wijk, L; Harry, J; Perry, K; Touboul, P; Steinbeck, G; Wellens, H
Objective—To compare the efficacy and safety of a single dose of ibutilide, a new class III antiarrhythmic drug, with that of DL-sotalol in terminating chronic atrial fibrillation or flutter in haemodynamically stable patients. Design—Double blind, randomised study. Setting—43 European hospitals. Patients—308 patients (mean age 60 years, 70% men, 48% with heart disease) with sustained atrial fibrillation (n = 251) or atrial flutter (n = 57) (duration three hours to 45 days) were randomised to three groups to receive a 10 minute infusion of 1 mg ibutilide (n = 99), 2 mg ibutilide (n = 106), or 1.5 mg/kg DL-sotalol (n = 103). Infusion was discontinued at termination of the arrhythmia. Main outcome measure—Successful conversion of atrial fibrillation or flutter, defined as termination of arrhythmia within one hour of treatment. Results—Both drugs were more effective against atrial flutter than against atrial fibrillation. Ibutilide was superior to DL-sotalol for treating atrial flutter (70% and 56% v 19%), while the high dose of ibutilide was more effective for treating atrial fibrillation than DL-sotalol (44% v 11%) and the lower dose of ibutilide (44% v 20%, p < 0.01). The mean (SD) time to arrhythmia termination was 13 (7) minutes with 2 mg ibutilide, 19 (15) minutes with 1 mg ibutilide, and 25 (17) minutes with DL-sotalol. In all patients, the duration of arrhythmia before treatment was a predictor of arrhythmia termination, although this was less obvious in the group that received 2 mg ibutilide. This dose converted almost 48% of atrial fibrillation that was present for more than 30 days. Concomitant use of digitalis or nifedipine and prolongation of the QTc interval were not predictive of arrhythmia termination. Bradycardia (6.5%) and hypotension (3.7%) were more common side effects with DL-sotalol. Of 211 patients given ibutilide, two (0.9%) who received the higher dose developed polymorphic ventricular tachycardia
Wolowacz, S E; Samuel, M; Brennan, V K; Jasso-Mosqueda, J-G; Van Gelder, I C
Atrial fibrillation (AF) is the most common cardiac arrhythmia, its prevalence increasing markedly with age. Atrial fibrillation is strongly associated with increased risk of morbidity, including stroke and thromboembolism. There is growing awareness of the economic burden of AF due to ageing populations and constrained public finances. A systematic review was performed (1990-2009). Cost studies for AF or atrial flutter were included; acute-onset and post-operative AF were excluded. Total, direct, and indirect costs were extracted. Of 875 records retrieved, 37 studies were included. The cost of managing individual AF patients is high. Direct-cost estimates ranged from $2000 to 14,200 per patient-year in the USA and from €450 to 3000 in Europe. This is comparable with other chronic conditions such as diabetes. The direct cost of AF represented 0.9-2.4% of the UK health-care budget in 2000 and had almost doubled over the previous 5 years. Inpatient care accounted for 50-70% of annual direct costs. In the USA, AF hospitalizations alone cost ∼$6.65 billion in 2005. In this first systematic review of the economic burden of AF, hospitalizations consistently represented the major cost driver. Costs and hospitalizations attributable to AF have increased markedly over recent decades and are expected to increase in future due to ageing populations.
Alegret, Josep M; Viñolas, Xavier; Sagristá, Jaume; Hernández-Madrid, Antonio; Berruezo, Antonio; Moya, Angel; Martínez Sande, José L; Pastor, Agustín
The objectives were to investigate the treatment and clinical characteristics of patients referred for cardioversion in Spain and to compare them with those reported in the AFFIRM (Atrial Fibrillation Follow-up Investigation of Rhythm Management) and RACE (RAte Control versus Electrical cardioversion) studies. The prospective study involved 1515 consecutive patients with persistent atrial fibrillation who were referred for cardioversion at 96 Spanish hospitals. Half of the patients were being treated with Vaughan-Williams group-I or -III antiarrhythmic drugs. The most frequently used approach to anticoagulation was to administer dicoumarins 34 weeks before and after cardioversion. Our patients were younger than those in the AFFIRM and RACE studies. Compared with AFFIRM patients, our patients had a lower prevalence of previous embolism, ischemic heart disease, hypertension, diabetes, and systolic dysfunction. Compared with RACE patients, our patients had a lower prevalence of ischemic heart disease and previous embolism, but a slightly higher prevalence of hypertension and diabetes. We conclude that patients referred for cardioversion in Spain clearly had a lower cardiovascular risk profile than those in the AFFIRM study, and appeared to have a lower risk profile than those in the RACE study.
da Silva, Rose M.F.L.
Atrial fibrillation is the most frequent arrhythmia in clinical practice, reaching 2% of the people in the world and is associated with systemic embolism. Thus, the use of anticoagulants is indicated if CHA2DS2-VASc score ≥2 or in patients with previous transient ischemic attack or stroke. For decades, warfarin, a vitamin K antagonist, was the only choice for chronic oral anticoagulation. Recently, novel oral anticoagulants (NOACs) have been introduced, offering similar (or better) effectiveness, safety, and convenience to the vitamin K antagonists. Dabigatran was the first NOAC approved and is a direct thrombin inhibitor. Rivaroxaban and apixaban are factor Xa inhibitors. They display rapid onset of action, more predictable of pharmacological profile, less interactions with other drugs, lack of significant effects in the diet, and less risk of intracranial hemorrhage than warfarin. Despite that dose adjustment is necessary for patients with chronic kidney disease or according to body weight, these new drugs do not require regular monitoring. There are recommendations for the start and follow-up therapy with NOACs, planning for cardioversion, ablation and surgical interventions and the management of bleeding. This article is a review of the major studies of the NOACs. The clinical use of these drugs in patients with non-valvular atrial fibrillation is presented. PMID:25470147
Poposka, Lidija; Boskov, Vladimir; Risteski, Dejan; Taleski, Jane; Georgievska-Ismail, Ljubica
INTRODUCTION: In patients with an implanted pacemaker, asymptomatic atrial fibrillation (AF) is associated with an increased risk of thrombo-embolic complications. There is still no consensus which duration of episodes of atrial fibrillation should be taken as an indicator for inclusion of oral anticoagulation therapy (OAC). MATERIAL AND METHODS: A total of 104 patients who had no AF episodes in the past and have an indication for permanent pacing were included in the study. RESULTS: During an average follow-up of 18 months, 33 of the patients developed episodes of AF. Inclusion of OAC was performed in 17 patients, in whom AF was recorded, although in all patients CHA2DS2-VASc score was ≥ 1. The inclusion of OAC showed a statistically significant correlation with increasing duration of episodes of AF (r = 0.502, p = 0.003). During the follow-up period none of the patients developed thrombo-embolic complication. CONCLUSION: Considering that our group of patients had no thrombo-embolic events, we could conclude that dividing the AF episodes in less than 1% in 24 hours and longer than 1% within 24 hours could be an indicator for decision-making to include OAK if the CHA2DS2-VASc score is ≥ 1. PMID:27335594
Lawrance, Christopher P.; Henn, Matthew C.; Damiano, Ralph J.
Purpose of review The aim of this review is to focus specifically on the indications, evolution of technique, and results of surgical ablation for atrial fibrillation. Recent findings With the introduction of the Cox-Maze IV procedure utilizing bipolar radiofrequency ablation and cryoablation, long-term studies have demonstrated a significant decrease in aortic cross-clamp times and major complications with a comparable rate of restoration of sinus rhythm. New hybrid approaches utilizing both catheter-based ablation and minimally invasive surgical approaches have been developed, but have not been standardized. Early studies have demonstrated reasonable success rates of hybrid procedures, with advantages that include confirmation of conduction block, decreased surgical morbidity, and possibly reduced morbidity. However, hybrid approaches have the disadvantage of significantly increased operative times. Summary The Cox-Maze IV is currently the gold standard for surgical treatment of atrial fibrillation. New hybrid approaches have potential advantages with promising early results, but a standard lesion set, improvement in operative times, and long-term results still need to be evaluated. PMID:25389650
Peshko, Igor; Rubtsov, Vladimir; Vesselov, Leonid; Sigal, Gennady; Laks, Hillel
A fiber photo-catheter has been developed for surgical treatment of atrial fibrillation with laser radiation. Atrial fibrillation (AF) is a heart rhythm abnormality that involves irregular and rapid heartbeats. Recent studies demonstrate the superiority of treating AF disease with optical radiation of the near infrared region. To produce long continuous transmural lesions, solid-state lasers and laser diodes, along with end-emitting fiber catheters, have been used experimentally. The absence of side-emitting flexible catheters with the ability to produce long continuous lesions limits the further development of this technology. In this research, a prototype of an optical catheter, consisting of a flexible 10-cm fiber diffuser has been used to make continuous photocoagulation lesions for effective maze procedure treatments. The system also includes: a flexible optical reflector; a series of openings for rapid self-attachment to the tissue; and an optional closed-loop irrigating chamber with circulating saline to cool the optical diffuser and irrigate the tissue. PMID:19587838
Kate, Mahesh; Gioia, Laura; Buck, Brian; Sivakumar, Leka; Jeerakathil, Thomas; Shuaib, Ashfaq; Butcher, Kenneth
Acute ischemic stroke patients are at risk of early recurrence. We tested the feasibility and safety of initiating dabigatran in patients, within 24 hours of minor stroke in patients without atrial fibrillation. Minor stroke patients (National Institutes of Health Stroke Scale score ≤3) without atrial fibrillation and evidence of acute infarction on magnetic resonance imaging were treated with dabigatran. Treatment began within 24 hours of onset and was continued for 30 days. The primary end point was symptomatic hemorrhagic transformation. A total of 53 patients with median (interquartile range) age of 68 (57-77) years and National Institutes of Health Stroke Scale score of 1 (0-2) were enrolled. Baseline diffusion-weighted imaging volume was 0.8 (0.3-2.4) mL. No patients experienced symptomatic hemorrhagic transformation. Three patients had evidence of asymptomatic petechial hemorrhagic transformation on day 7, which remained stable at day 30, while continuing dabigatran. Dabigatran treatment within 24 hours of minor stroke is feasible. A larger randomized trial is required to confirm the safety and efficacy of this treatment approach. URL: http://www.clinicaltrials.gov. Unique identifier: NCT 01769703. © 2015 American Heart Association, Inc.
Lappe, Jason M; Cutler, Michael J; Day, John D; Bunch, T Jared
Persistent atrial fibrillation (AF) is a prevalent condition that can be difficult to treat medically, and an ablation strategy is often sought. Currently, the cornerstone of AF ablation strategies is pulmonary vein isolation (PVI). Unfortunately, the single procedure success rates are limited, particularly when long-term outcomes (>1 year) are considered. As a result, the most recent consensus statement recommends that in patients with persistent AF a more extensive ablation be considered. Many additive procedural approaches to PVI have been investigated. These include electrical compartmentalization of the atria with linear lesions (LLs), ablation of complex fractionated atrial electrograms (CFAEs), ablation of the dominant frequency (DF) signals, and focal impulse and rotor modulation (FIRM) ablation. Each of these approaches has demonstrated degrees of additive success when performed with a PVI in patients with persistent AF. This review provides an in-depth discussion of these techniques, their successes in treating persistent AF, and their shortcomings.
Tozzi, Piergiorgio; Hayoz, Daniel; Thévenaz, Pierrick; Roulet, Jean-Yves; Salchli, Francois; von Segesser, Ludwig K
Chronic atrial fibrillation affects millions of people worldwide. Its surgical treatment often fails to restore the transport function of the atrium. This study first introduces the concept of an atrial assist device (AAD) to restore the pump function of the atrium. The AAD is developed to be totally implantable in the human body with a transcutaneous energy transfer system to recharge the implanted battery. The ADD consists of a motorless pump based on artificial muscle technology, positioned on the external surface of the atrium to compress it and restore its muscular activity. A bench model reproduces the function of a fibrillating atrium to assess the circulatory support that this pump can provide. Atripump (Nanopowers SA, Switzerland) is a dome-shaped silicone-coated nitinol actuator 5 mm high, sutured on the external surface of the atrium. A pacemaker-like control unit drives the actuator that compresses the atrium, providing the mechanical support to the blood circulation. Electrical characteristics: the system is composed of one actuator that needs a minimal tension of 15 V and has a maximum current of 1.5 A with a 50% duty cycle. The implantable rechargeable battery is made of a cell having the following specifications: nominal tension of a cell: 4.1 V, tension after 90% of discharge: 3.5 V, nominal capacity of a cell: 163 mA h. The bench model consists of an open circuit made of latex bladder 60 mm in diameter filled with water. The bladder is connected to a vertically positioned tube that is filled to different levels, reproducing changes in cardiac preload. The Atripump is placed on the outer surface of the bladder. Pressure, volume and temperature changes were recorded. The contraction rate was 1 Hz with a power supply of 12 V, 400 mA for 200 ms. Preload ranged from 15 to 21 cm H(2)O. Maximal silicone membrane temperature was 55 degrees C and maximal temperature of the liquid environment was 35 degrees C. The pump produced a maximal work of 16 x 10
Koskinen, P; Kupari, M; Leinonen, H; Luomanmäki, K
The aetiological role of alcohol in new onset atrial fibrillation was evaluated in a case-control study of 100 consecutive patients aged 21-64 years. Clinical examination, routine diagnostic tests, and echocardiography revealed an underlying disease or other identifiable factor for atrial fibrillation in 65 patients (group 1); 35 patients had idiopathic atrial fibrillation (group 2). The most common diseases associated with atrial fibrillation were ischaemic heart disease (21%), hypertension (13%), and cardiomyopathy (8%). Data on alcohol consumption were obtained by interviewing the patients and their age and sex matched controls on admission. The mean daily alcohol intake of group 2 patients during the week preceding atrial fibrillation was significantly larger than that of either controls or group 1 patients. Compared with controls significantly more patients in both groups with atrial fibrillation had consumed alcohol within two days of the onset of the arrhythmia. Significantly more patients had onset of arrhythmia on Wednesday, Thursday, or Friday than on any other weekday, including patients with high alcohol intake. This study establishes alcohol as an important precipitating factor for new onset atrial fibrillation. PMID:3593617
Pagonas, Nikolaos; Schmidt, Sven; Eysel, Jörg; Compton, Friederike; Hoffmann, Clemens; Seibert, Felix; Hilpert, Justus; Tschöpe, Carsten; Zidek, Walter; Westhoff, Timm H
The introduction of automated oscillometric blood pressure monitors was the basis for today's widespread use of blood pressure self-measurement. However, in atrial fibrillation, there is a controversial debate on the use of oscillometry because there is a high variability of heart rate and stroke volume. To date, the accuracy of oscillometric blood pressure monitoring in atrial fibrillation has only been investigated using auscultatory sphygmomanometry as reference method, which may be biased by arrhythmia as well. We performed a cross-sectional study in 102 patients (52 sinus rhythm, 50 atrial fibrillation) assessing the accuracy of an automated and validated oscillometric upper arm (M5 Professional, Omron) and wrist device (R5 Professional, Omron) to invasively assessed arterial pressure. Blood pressure values were calculated as the mean of 3 consecutive measurements. Systolic and diastolic blood pressure did not significantly differ in patients with sinus rhythm and atrial fibrillation, independent of the method of measurement (P>0.05 each). The within-subject variability of the oscillometric measurements was higher in patients with atrial fibrillation compared with sinus rhythm (P<0.01 each). The biases of systolic and diastolic blood pressure, however, did not significantly differ in presence or absence of atrial fibrillation in Bland-Altmann analysis (P>0.05 each). In conclusion, atrial fibrillation did not significantly affect the accuracy of oscillometric measurements, if 3 repeated measurements were performed.
Jović, A.; Troskot, R.
OBJECTIVE: To evaluate the time course of the recovery of atrial mechanical function after pharmacological cardioversion of chronic atrial fibrillation to sinus rhythm. PATIENTS AND METHODS: 21 patients (12 male, 9 female, aged 37-77 years) with chronic atrial fibrillation (< 6 months) were followed up by serial transmitral pulsed Doppler echocardiography. Echocardiographic studies were performed within the first 24 hours and on day 8, 15, and 30 after cardioversion. RESULTS: There was a significant increase (mean (SD)) in the peak A-wave velocity (from 0.35 (0.10) on day 1 to 0.50 (1.73) on day 8, and thereafter a gradual increase to 0.61 (0.14) m/s on day 30). Similarly, integrated late atrial velocities increased from 4.50 (1.46) on day 1 to 5.61 (1.73) on day 8 and 5.97 (1.47) cm/s2 on day 30. The atrial contribution to total transmitral flow increased significantly from 26 (7)% immediately after conversion of atrial fibrillation to sinus rhythm to 34 (7)% on day 30, indicating the haemodynamic benefit of the restoration of sinus rhythm. Left atrial diameter decreased but not significantly, from 4.11 (0.37) to 3.98 (0.34) cm (P < 0.005). CONCLUSIONS: These results suggest that restoration of atrial mechanical function after pharmacological cardioversion in patients with chronic atrial fibrillation is slow and gradual, as it is after electrical DC restoration of sinus rhythm. This time course may have important implications for determining how long treatment with anticoagulants and antiarrhythmic agents needs to continue in individual patients. It will also influence the clinical assessment of the haemodynamic benefit of restoring sinus rhythm in patients with chronic atrial fibrillation. Images PMID:9038694
Xu, H F; He, Y M; Qian, Y X; Zhao, X; Li, X; Yang, X J
Atrial fibrillation is the most common significant cardiac arrhythmia in clinical practice, but its risk factors remain to be clarified. We have hypothesized that left ventricular posterior wall thickness is an independent risk factor for paroxysmal atrial fibrillation (PAF). A total of 166 consecutive patients with paroxysmal atrial fibrillation were included in this study. Another 166 healthy check-up people, strictly age and sex-matched, were enrolled as controls in the same period. Univariable analysis and multivariable conditional logistic stepwise regression analysis were conducted. Receiver operating characteristic (ROC) curve analysis was performed on those significant indices obtained from the multivariable logistic regression analysis. The multivariable stepwise analysis identified left ventricular posterior wall thickness, left atrial diameter tricuspid insufficiency and residence (countryside) as independent predictors for paroxysmal atrial fibrillation. Receiver operating characteristic curve analysis demonstrated the cutoff values of those risk factors aforementioned. In this strictly age and sex-matched population-based sample, left ventricular posterior wall thickness, left atrial diameter, tricuspid insufficiency and residence were predictive risks for paroxysmal atrial fibrillation. This study offers novel information therapeutically beyond that provided by traditional clinical atrial fibrillation risk factors.
Murin, Jan; Naditch-Brûlé, Lisa; Brette, Sandrine; Chiang, Chern-En; O’Neill, James; Steg, P. Gabriel
Background Atrial fibrillation can be categorized into nonpermanent and permanent atrial fibrillation. There is less information on permanent than on nonpermanent atrial fibrillation patients. This analysis aimed to describe the characteristics and current management, including the proportion of patients with successful atrial fibrillation control, of these atrial fibrillation subsets in a large, geographically diverse contemporary sample. Methods and Results Data from RealiseAF, an international, observational, cross-sectional survey of 10,491 patients with atrial fibrillation, were used to characterize permanent atrial fibrillation (N = 4869) and nonpermanent atrial fibrillation (N = 5622) patients. Permanent atrial fibrillation patients were older, had a longer time since atrial fibrillation diagnosis, a higher symptom burden, and were more likely to be physically inactive. They also had a higher mean (SD) CHADS2 score (2.2 [1.3] vs. 1.7 [1.3], p<0.001), and a higher frequency of CHADS2 score ≥2 (67.3% vs. 53.0%, p<0.001) and comorbidities, most notably heart failure. Physicians indicated using a rate-control strategy in 84.2% of permanent atrial fibrillation patients (vs. 27.5% in nonpermanent atrial fibrillation). Only 50.2% (N = 2262/4508) of permanent atrial fibrillation patients were controlled. These patients had a longer time since atrial fibrillation diagnosis, a lower symptom burden, less obesity and physical inactivity, less severe heart failure, and fewer hospitalizations for acute heart failure than uncontrolled permanent atrial fibrillation patients, but with more arrhythmic events. The most frequent causes of hospitalization in the last 12 months were acute heart failure and stroke. Conclusion Permanent atrial fibrillation is a high-risk subset of atrial fibrillation, representing half of all atrial fibrillation patients, yet rate control is only achieved in around half. Since control is associated with lower symptom burden and heart
Zhang, Huijuan; Nan, Qun; Liu, Youjun
The aim of this study is to investigate the effects of ablation parameters on thermal distribution during microwave atrial fibrillation catheter ablation, such as ablation time, ablation power, blood condition and antenna placement, and give proper ablative parameters to realise transmural ablation. In this paper, simplified 3D antenna-myocardium-blood finite element method models were built to simulate the endocardial ablation operation. Thermal distribution was obtained based on the coupled electromagnetic-thermal analysis. Under different antenna placement conditions and different microwave power inputs within 60 s, the lesion dimensions (maximum depth, maximum width) of the ablation zones were analysed. The ablation width and depth increased with the ablation time. The increase rate significantly slowed down after 10 s. The maximum temperature was located in 1 mm under the antenna tip when perpendicular to the endocardium, while 1.5 mm away from the antenna axis and 26 mm along the antenna (with antenna length about 30 mm) in the myocardium when parallel to the endocardium. The maximum temperature in the ablated area decreased and the effective ablation area (with the temperature raised to 50°C) shifted deeper into the myocardium due to the blood cooling. The research validated that the microwave antenna can provide continuous long and linear lesions for the treatment of atrial fibrillation. The dimensions of the created lesion widths were all larger than those of the depths. It is easy for the microwave antenna to produce transmural lesions for an atrial wall thickness of 2-6 mm by adjusting the applied power and ablation time.
Budeus, Marco; Felix, Oliver; Hennersdorf, Marcus; Wieneke, Heinrich; Erbel, Raimund; Sack, Stefan
Paroxysmal atrial fibrillation (PAF) transits to permanent atrial fibrillation (PEAF). The current study was to determine whether a P wave-triggered P wave signal averaged electrocardiogram (P-SAECG) and chemoreflexsensitivity (CHRS) are useful to predict a conversion to PEAF in patients with PAF. The filtered P wave duration (FPD) and the root mean square voltage of the last 20 ms of the P wave (RMS 20) were measured by P-SAECG. The ratio between the difference of RR intervals in the ECG and venous pO2 before and after 5-minutes oxygen inhalation is measured (ms/mmHg) for the determination of CHRS. A total of 180 patients with PAF were enrolled and followed for a mean of 22.5 months. PEAF occurred in 38 patients (21%) and these patients had a significantly larger left atrial size (43.2 +/- 4.9 vs. 41.0 +/- 5.4 mm, P = 0.021), a significantly longer FPD (158.8 +/- 18.2 vs. 136.7 +/- 16.6 ms, P < 0.0001), and a significantly lower CHRS (1.96 +/- 0.99 vs. 2.44 +/- 1.19 ms/mmHg, P = 0.024) than patients with PAF. Patients with PEAF tended to have a lower RMS 20 (2.38 +/- 0.65 vs. 2.75 +/- 1.18 microV, P = 0.067) than patients with PAF. The chi(2) test showed that the combination of FPD > or = 145 ms, RMS 20 < or = 3.0 microV, left atrial size > or = 41 mm, and CHRS < or = 2.0 ms/mmHg had the best predictive power for PEAF. Patients who fulfilled these criteria had a 12-fold increased risk for a conversion from PAF to PEAF. Our results show that a P-SAECG, an analysis of CHRS, and left atrial enlargement are clinical predictors of a progression from PAF to PEAF.
Zhang, Youhua; Dedkov, Eduard I.; Teplitsky, Diana; Weltman, Nathan Y.; Pol, Christine J.; Rajagopalan, Viswanathan; Lee, Bianca; Gerdes, A. Martin
Background Evidence indicates that cardiac hypothyroidism may contribute to heart failure (HF) progression. It is also known that HF is associated with an increased risk of atrial fibrillation (AF). While it is established that hyperthyroidism increases AF incidence, the effect of hypothyroidism on AF is unclear. This study investigated the effects of different thyroid hormone levels, ranging from hypothyroidism to hyperthyroidism on AF inducibility in thyroidectomized rats. Methods and Results Thyroidectomized rats with serum confirmed hypothyroidism 1 month after surgery were randomized into hypothyroid (n=9), euthyroid (n=9) and hyperthyroid (n=9) groups. Rats received placebo, 3.3mg L-thyroxine (T4), or 20 mg T4 pellets (60 day release form) for 2 months, respectively. At the end of treatment, hypothyroid, euthyroid and hyperthyroid status was confirmed. Hypothyroid animals showed cardiac atrophy and reduced cardiac systolic and diastolic function, while hyperthyroid rats exhibited cardiac hypertrophy and increased cardiac function. Hypothyroidism and hyperthyroidism produced opposite electrophysiological changes in heart rates and atrial effective refractory period, but both significantly increased AF susceptibility. AF incidence was 78% in hypothyroid, 67% in hyperthyroid, and the duration of induced AF was also longer, compared with 11% in the euthyroid group (all p<0.05). Hypothyroidism increased atrial interstitial fibrosis, but connexin 43 was not affected. Conclusions Both hypothyroidism and hyperthyroidism lead to increased AF vulnerability in a rat thyroidectomy model. Our results stress that normal thyroid hormone levels are required to maintain normal cardiac electrophysiology and prevent cardiac arrhythmias and AF. PMID:24036190
Vidaurri, A; Pastelín, G; Méndez, R; Cárdenas, M
Quinidine gluconate was administered slowly by intravenous infusion to 20 patients with atrial fibrillation. Nineteen of them had rheumatic heart disease and the other one had Ebstein's disease. The first ten patients received 0.027 mg/kg/min during 6 hs or less if they returned to normal sinus rhythm (SR). The other ten received 0.041 mg/kg/min with the same protocol. Plasma quinidine concentrations were determined in all patients. Atrial functional refractory period was measured in five of the patients returning to normal sinus rhythm. Six patients in the first group were returned to SR. The required time of infusion was 4.2 hs. The maximal quinidine plasma level was 1.91 ug/ml. In the Second group; five patients returned to normal sinus rhythm, four of them in a mean time of 4.75 hs ofinfusion and the other one spontaneously 11 hs after the infusion was finished. The maximal quinidine plasma level in this group was 4.7 ug/ml. Side effects were observed in five patients. Diarrhea in one, vomiting in one, hypotension in two atrial flutter with 1: 1 A-V conduction in one.
Risom, Signe S; Zwisler, Ann-Dorthe; Johansen, Pernille P; Sibilitz, Kirstine L; Lindschou, Jane; Gluud, Christian; Taylor, Rod S; Svendsen, Jesper H; Berg, Selina K
Exercise-based cardiac rehabilitation may benefit adults with atrial fibrillation or those who had been treated for atrial fibrillation. Atrial fibrillation is caused by multiple micro re-entry circuits within the atrial tissue, which result in chaotic rapid activity in the atria. To assess the benefits and harms of exercise-based rehabilitation programmes, alone or with another intervention, compared with no-exercise training controls in adults who currently have AF, or have been treated for AF. We searched the following electronic databases; CENTRAL and the Database of Abstracts of Reviews of Effectiveness (DARE) in the Cochrane Library, MEDLINE Ovid, Embase Ovid, PsycINFO Ovid, Web of Science Core Collection Thomson Reuters, CINAHL EBSCO, LILACS Bireme, and three clinical trial registers on 14 July 2016. We also checked the bibliographies of relevant systematic reviews identified by the searches. We imposed no language restrictions. We included randomised controlled trials (RCT) that investigated exercise-based interventions compared with any type of no-exercise control. We included trials that included adults aged 18 years or older with atrial fibrillation, or post-treatment for atrial fibrillation. Two authors independently extracted data. We assessed the risk of bias using the domains outlined in the Cochrane Handbook for Systematic Reviews of Interventions. We assessed clinical and statistical heterogeneity by visual inspection of the forest plots, and by using standard Chi² and I² statistics. We performed meta-analyses using fixed-effect and random-effects models; we used standardised mean differences where different scales were used for the same outcome. We assessed the risk of random errors with trial sequential analysis (TSA) and used the GRADE methodology to rate the quality of evidence, reporting it in the 'Summary of findings' table. We included six RCTs with a total of 421 patients with various types of atrial fibrillation. All trials were
Martínez-Sellés, Manuel; Massó-van Roessel, Albert; Álvarez-García, Jesús; García de la Villa, Bernardo; Cruz-Jentoft, Alfonso J; Vidán, María Teresa; López Díaz, Javier; Felix Redondo, Francisco Javier; Durán Guerrero, Juan Manuel; Bayes-Genis, Antoni; Bayes de Luna, Antonio
Data are lacking on the characteristics of atrial activity in centenarians, including interatrial block (IAB). The aim of this study was to describe the prevalence of IAB and auricular arrhythmias in subjects older than 100 years and to elucidate their clinical implications. We studied 80 centenarians (mean age 101.4 ± 1.5 years; 21 men) with follow-ups of 6-34 months. Of these 80 centenarians, 71 subjects (88.8%) underwent echocardiography. The control group comprised 269 septuagenarians. A total of 23 subjects (28.8%) had normal P wave, 16 (20%) had partial IAB, 21 (26%) had advanced IAB, and 20 (25.0%) had atrial fibrillation/flutter. The IAB groups exhibited premature atrial beats more frequently than did the normal P wave group (35.1% vs 17.4%; P < .001); also, other measurements in the IAB groups frequently fell between values observed in the normal P wave and the atrial fibrillation/flutter groups. These measurements included sex preponderance, mental status and dementia, perceived health status, significant mitral regurgitation, and mortality. The IAB group had a higher previous stroke rate (24.3%) than did other groups. Compared with septuagenarians, centenarians less frequently presented a normal P wave (28.8% vs 53.5%) and more frequently presented advanced IAB (26.3% vs 8.2%), atrial fibrillation/flutter (25.0% vs 10.0%), and premature atrial beats (28.3 vs 7.0%) (P < .01). Relatively few centenarians (<30%) had a normal P wave, and nearly half had IAB. Our data suggested that IAB, particularly advanced IAB, is a pre-atrial fibrillation condition associated with premature atrial beats. Atrial arrhythmias and IAB occurred more frequently in centenarians than in septuagenarians. Copyright © 2016 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.
Lowres, Nicole; Krass, Ines; Neubeck, Lis; Redfern, Julie; McLachlan, Andrew J; Bennett, Alexandra A; Freedman, S Ben
Atrial fibrillation guidelines advocate screening to identify undiagnosed atrial fibrillation. Community pharmacies may provide an opportunistic venue for such screening. To explore the experience of implementing an atrial fibrillation screening service from the pharmacist's perspective including: the process of study implementation; the perceived benefits; the barriers and enablers; and the challenges for future sustainability of atrial fibrillation screening within pharmacies. Setting Interviews were conducted face-to-face in the pharmacy or via telephone, according to pharmacist preference. The 'SEARCH-AF study' screened 1000 pharmacy customers aged ≥65 years using an iPhone electrocardiogram, identifying 1.5 % with undiagnosed atrial fibrillation. Nine pharmacists took part in semi-structured interviews. Interviews were transcribed in full and thematically analysed. Qualitative analysis of the experience of implementing an AF screening service from the pharmacist's perspective. Four broad themes relating to service provision were identified: (1) interest and engagement in atrial fibrillation screening by pharmacists, customers, and doctors with the novel, easy-to-use electrocardiogram technology serving as an incentive to undergo screening and an education tool for pharmacists to use with customers; (2) perceived benefits to the pharmacist including increased job satisfaction, improvement in customer relations and pharmacy profile by fostering enhanced customer care and the educational role of pharmacists; (3) implementation barriers including managing workflow, and enablers such as personal approaches for recruitment, and allocating time to discuss screening process and fears; and, (4) potential for sustainable future implementation including remuneration linked to government or pharmacy incentives, combined cardiovascular screening, and automating sections of risk-assessments using touch-screen technology. Atrial fibrillation screening in pharmacies is well
Kalil, Carlos; Bartholomay, Eduardo; Borges, Anibal; Gazzoni, Guilherme; de Lima, Edimar; Etchepare, Renata; Moraes, Rafael; Sussenbach, Carolina; Andrade, Karina; Kalil, Renato
Background Radiofrequency catheter ablation guided by electroanatomical mapping is currently an important therapeutic option for the treatment of atrial fibrillation. The complexity of the procedure, the several techniques used and the diversity of the patients hinder the reproduction of the results and the indication for the procedure. Objective To evaluate the efficacy and factors associated with recurrence of atrial fibrillation. Methods Prospective cohort study with consecutive patients submitted to atrial fibrillation ablation treatment guided by electroanatomical mapping. The inclusion criteria were as follows: minimum age of 18 years; presence of paroxysmal, pers