The total atrial conduction time (TACT) is an independent predictor of atrial fibrillation (AF). A new transthoracic echocardiographic tool to determine TACT by tissue Doppler imaging (PA-TDI (the ...time from the initiation of the P wave on the ECG (lead II) to the A' wave on the lateral left atrial tissue Doppler tracing)) has been developed recently.
To test the hypothesis that measurement of PA-TDI enables prediction of new-onset AF.
249 Patients without a history of AF were studied. All patients underwent an echocardiogram and the PA-TDI interval was measured. Patient characteristics and rhythm at follow-up were recorded.
During a mean (SD) follow-up of 680 (290) days, 15 patients (6%) developed new-onset AF. These patients had a longer PA-TDI interval than patients who remained in sinus rhythm (172 (25) ms vs 150 (20) ms, p = 0.001). Furthermore, the patients developing AF were older, more often had a history of heart failure or chronic obstructive pulmonary disease, more often used alpha blockers, had enlarged left atria and more frequently mitral incompetence on the echocardiogram. After adjusting for potential confounders, Cox regression showed that PA-TDI was independently associated with new-onset AF (OR = 1.375; 95% CI 1.037 to 1.823; p = 0.027). The 2-year incidence of AF was 33% in patients with a PA-TDI interval >190 ms versus 0% in patients with a PA-TDI interval <130 ms (p = 0.002).
A prolonged PA-TDI interval may predict the development of new-onset AF. This measure may be used to identify patients at risk in future strategies to prevent the development or complications of AF.
Patients with asymptomatic and undiagnosed atrial fibrillation (AF) are at increased risk of heart failure and ischaemic stroke. In this study, we validated a new diagnostic device, the ...MyDiagnostick, for detection of AF by general practitioners and patients. It records and stores a Lead I electrocardiogram (ECG) which is automatically analysed for the presence of AF.
In total, 192 patients (age 69.4 ± 12.6 years) were asked to hold the MyDiagnostick for 1 min, immediately before a routine 12-lead ECG was recorded. Atrial fibrillation detection and ECGs stored by the MyDiagnostick were compared with the cardiac rhythm on the 12-lead ECG. In a second part of the study, the MyDiagnostick was used to screen for AF during influenza vaccination in the general practitioner's office. Atrial fibrillation was present in 53 out of the 192 patients (27.6%). All AF patients were correctly detected by the MyDiagnostick (sensitivity 100%; 95% confidence interval 93-100%). MyDiagnostick AF classification in 6 out of 139 patients in sinus rhythm was considered false positive (specificity 95.9%; 95% confidence interval 91.3-98.1%). During 4 h of influenza vaccination in 676 patients (age 74 ± 7.1 years), the MyDiagnostick correctly diagnosed AF in all 55 patients (prevalence 8.1%). In 11 patients (1.6%), AF was not diagnosed before, all with a CHA2DS2VASc score of >1.
The high AF detection performance of the MyDiagnostick, combined with the ease of use of the device, enables large screening programmes for detection of undiagnosed AF.
Background
Non-vitamin K antagonist oral anticoagulants (NOACs) are prescribed to patients with atrial fibrillation (AF) to reduce the risk of stroke. Prescribing the correct dose warrants careful ...consideration of the prevailing dose criteria that differ per NOAC. Electronic systems are useful to intercept prescriptions that are incorrect based on simple ‘primary’ criteria, for example dosing frequency and drug-drug interactions with concomitant medication. However, these systems do not take into account patient characteristics such as age, renal function or weight, which are crucial elements to determine the NOAC dose.
Methods
Our goal was to determine the appropriateness of all prescriptions, as compared with the product labelling approved by the European Medicines Agency, to address common pitfalls in prescribing NOACs. AF patients with a first NOAC prescription between January 2012 and December 2016 were identified from our electronic hospital information system (Martini Hospital, Groningen, the Netherlands).
Results
The study included 3,231 AF patients who had started on an NOAC; 10.7% received an inappropriate dose and the appropriateness of the prescription could not be determined in 14.1%. Underdosing and overdosing occurred in 5.4% and 4.5% of all prescriptions, respectively. A reduced-dose NOAC was a predictor for incorrect prescribing (odds ratio: 2.70, 95% confidence interval: 2.13–3.41). Patient factors were identified that predicted incorrect prescriptions for dabigatran and apixaban.
Conclusion
An incorrect prescription occurred more often in the reduced-dose NOAC group. Clinical parameters such as renal function are often unknown whilst these are essential to determine the right NOAC and dose.
Currently available antiarrhythmic drugs are only moderately effective against atrial fibrillation (AF) and may cause ventricular proarrhythmia. AVE0118 is a blocker of atrium-specific early K+ ...currents (I(Kur)/I(to)).
Effects of intravenous AVE0118 and dofetilide on atrial effective refractory period (AERP) and inducibility of AF were measured before and after 48-hours of AF-induced electrical remodeling in the goat. During persistent AF (53+/-19 days), the cardioversion efficacy and effects on atrial wavelength of AVE0118, dofetilide, and ibutilide were evaluated. QT durations were measured during atrial pacing and persistent AF. After 48 hours of AF, the effect of dofetilide on AERP was reduced, and induction of AF was not prevented. In contrast, the class III action of AVE0118 was enhanced, and AF inducibility decreased from 100% to 32% (P<0.001). At 1, 3, and 10 mg x kg(-1) x h(-1), AVE0118 terminated persistent AF in 1 of 8, 3 of 8, and 5 of 8 goats, respectively. Dofetilide and ibutilide terminated AF in 1 of 5 and 2 of 7 goats. AVE0118 0.5, 1.5, and 5 mg/kg prolonged the AERP during AF and increased the fibrillation wavelength from 6.7+/-0.6 to 8.5+/-0.5, 9.7+/-0.5, and 11.2+/-0.9 cm (P<0.01). Whereas dofetilide and ibutilide prolonged QT duration, AVE0118 had no appreciable effect.
AVE0118 markedly prolongs the AERP during AF without affecting QT duration. Cardioversion of AF was due to an approximately 2-fold increase in fibrillation wavelength. Atrium-selective class III drugs like AVE0118 may be a promising new option for safe and effective cardioversion of AF.
The management of patients with atrial fibrillation (AF) is often inadequate due to deficient adherence to the guidelines. A nurse-led AF clinic providing integrated chronic care to improve guideline ...adherence and activate patients in their role, may effectively reduce morbidity and mortality but such care has not been tested in a large randomized trial. Therefore, we performed a randomized clinical trial to compare the AF clinic with routine clinical care in patients with AF.
We randomly assigned 712 patients with AF to nurse-led care and usual care. Nurse-led care consisted of guidelines based, software supported integrated chronic care supervised by a cardiologist. The primary endpoint was a composite of cardiovascular hospitalization and cardiovascular death. Duration of follow-up was at least 12 months. Adherence to guideline recommendations was significantly better in the nurse-led care group. After a mean of 22 months, the primary endpoint occurred in 14.3% of 356 patients of the nurse-led care group compared with 20.8% of 356 patients receiving usual care hazard ratio: 0.65; 95% confidence interval (CI) 0.45-0.93; P= 0.017. Cardiovascular death occurred in 1.1% in the nurse-led care vs. 3.9% in the usual care group (hazard ratio: 0.28; 95% CI: 0.09-0.85; P= 0.025). Cardiovascular hospitalization amounted (13.5 vs. 19.1%, respectively, hazard ratio: 0.66; 95% CI: 0.46-0.96, P= 0.029).
Nurse-led care of patients with AF is superior to usual care provided by a cardiologist in terms of cardiovascular hospitalizations and cardiovascular mortality. Trial registration information: Clinicaltrials.gov identifier number: NCT00391872.
Aims To assess the relation between the atrial fibrillation (AF) subtype and thrombo-embolic events. Methods and results The observational Euro Heart Survey on AF (2003–04) enrolled 1509 paroxysmal, ...1109 persistent, and 1515 permanent AF patients, according to the 2001 American College of Cardiology, American Heart Association, and the European Society of Cardiology guidelines definitions. A 1 year follow-up was performed. Permanent AF patients had at baseline a worse stroke risk profile than paroxysmal and persistent AF patients. In paroxysmal AF, the risk for stroke, any thrombo-embolism, major bleeding and the combined endpoint of cardiovascular mortality, any thrombo-embolism, and major bleeding was comparable with persistent and permanent AF, in both univariable and multivariable analyses. Compared with AF patients without stroke, patients suffering from a stroke had a comparable frequency and duration of AF attacks, but tended to have a worse stroke risk profile at baseline. During 1 year following cardioversion, paroxysmal AF patients had a higher risk for stroke (P = 0.029) and any thrombo-embolism (P = 0.001) than persistent AF patients. Conclusion In the Euro Heart Survey, paroxysmal AF had a comparable risk for thrombo-embolic events as persistent and permanent AF. This observation strengthens the guideline recommendation not to consider the clinical AF subtype when deciding on anticoagulation.
Patients with atrial fibrillation who undergo a coronary intervention are eligible for both anticoagulation and (dual) antiplatelet therapy ((D)APT). An optimal balance has to be found to reduce the ...thromboembolic risk (i.e. stroke, systemic embolism and myocardial infarction) and to minimise the increased risk of bleeding with concomitant use of an anticoagulant and (D)APT. Owing to a lack of evidence, the guideline recommendations are predominantly based on expert opinion. Current evidence indicates that the combination of a non-vitamin K oral anticoagulant (NOAC) and clopidogrel is safer than vitamin-K oral antagonists plus DAPT, which increases the risk of bleeding, without clear advantages in regard to efficacy. Concerning whether (
N
)OACs should be combined with single APT rather than DAPT, the findings of the WOEST, PIONEER AF-PCI and RE-DUAL PCI trials seem to favour a combination with clopidogrel only, thus omitting aspirin. Choosing the optimal treatment strategies for individual patients on NOACs and (D)APT will remain a challenge for clinicians, though triple therapy seems to be the less favourable option owing to the increased risk of bleeding.
Aims To investigate the clinical characteristics, management, and outcome of patients with paroxysmal atrial fibrillation (AF) associated with autonomic triggers. Methods and results One thousand ...five hundred and seventeen patients with paroxysmal AF participated in the Euro Heart Survey on AF. We categorized patients according to trigger pattern as reported by the physician: adrenergic (AF associated with exercise, emotion or during daytime only and absence of vagal triggers), vagal (postprandial or night time only, without presence of adrenergic triggers) and mixed (combination of vagal and adrenergic triggers). Vagal AF was found in 91 patients (6%), adrenergic in 229 patients (15%) and mixed in 175 (12%) patients. Underlying heart disease was equally prevalent in the three groups. Among patients with vagal AF, 73% were treated with non-recommended drugs according to the guidelines. In vagal AF, non-recommended treatment was associated with a shift to persistent or permanent AF in 19% of the patients, compared with none in the group receiving recommended treatment (P = 0.06). Conclusion This study is the first to address the issue of autonomic trigger patterns and AF in a large population. Autonomic trigger patterns were seen frequently in paroxysmal AF patients. Autonomic influences should be taken into consideration since non-recommended treatment may result in aggravation of vagal AF.
Background
Cryoballoon pulmonary vein isolation (PVI) is a common therapy for atrial fibrillation (AF). While moderately increased sinus rhythm heart rate (HR) after PVI has been observed, ...inappropriate sinus tachycardia (IST) is a rare phenomenon. We aimed to investigate the prevalence and natural history of an abnormal sinus HR response after cryoballoon PVI.
Methods
We included 169/646 (26.2%) patients with AF undergoing PVI with available Holter recordings before and 3, 6 and 12 months after the procedure. Patients with AF on Holter monitoring were excluded. Mean HR increase ≥ 20 bpm or an IST-like pattern (mean HR > 90 bpm or > 80 bpm when beta-blocking agents were used) following PVI was categorised as abnormal sinus HR response.
Results
Following PVI, mean HR ± standard deviation increased in the entire group from 63.5 ± 8.4 to 69.1 ± 9.9 bpm at 3 months (
p
< 0.001), and to 71.9 ± 9.4 bpm at 6 months (
p
< 0.001). At 12 months, mean HR was 71.2 ± 10.1 bpm (
p
< 0.001). Only 7/169 patients (4.1%) met criteria for abnormal sinus HR response: mean HR was 61.9 ± 10.6 bpm (pre-ablation), 84.6 ± 9.8 bpm (3 months), 80.1 ± 6.5 bpm (6 months) and 76.3 ± 10.1 bpm (12 months). Even at 12 months, mean HR was significantly different from that pre-ablation in this group (
p
= 0.033). However, in patients meeting IST-like pattern criteria, mean HR at 12 months was no longer significantly different from that pre-ablation.
Conclusion
Few patients had an abnormal sinus HR response after PVI. Peak HR was observed 3 months after PVI, but HR was still significantly increased 12 months post-ablation compared with pre-ablation. An IST-like pattern was rarely observed. In these patients, HR decreased to pre-ablation values within a year.
Background
In patients hospitalised with COVID-19, an increased incidence of thromboembolic events, such as pulmonary embolism, deep vein thrombosis and stroke, has been reported
.
It is unknown ...whether anticoagulation can prevent these complications and improve outcome.
Methods
A systematic literature search was performed to answer the question: What is the effect of (prophylactic and therapeutic dose) anticoagulation therapy in COVID-19 patients on cardiovascular and thromboembolic complications and clinical outcome? Relevant outcome measures were mortality (crucial), hospital admission, length of stay, thromboembolic complications (pulmonary embolism, stroke, transient ischaemic attack), need for mechanical ventilation, acute kidney injury and use of renal replacement therapy. Medline and Embase databases were searched with relevant search terms until 17 July 2020. After systematic analysis, eight studies were included. Analysis was stratified for the start of anticoagulation before or during hospital admission.
Results
There was insufficient evidence that therapeutic anticoagulation could improve the outcome in patients hospitalised with COVID-19. None of the studies demonstrated improved mortality, except for one very small Italian study. Furthermore, none of the studies showed a positive effect of anticoagulation on other outcome measures in COVID-19, such as ICU admission, length of hospital stay, thromboembolic complications, need for mechanical ventilation, acute kidney failure or need for renal replacement therapy, except for two studies demonstrating an association between anticoagulation and a lower incidence of pulmonary embolism. However, the level of evidence of all studies varied from ‘low’ to ‘very low’, according to the GRADE methodology.
Conclusion
Analysis of the literature showed that there was insufficient evidence to answer our objective on the effect of anticoagulation on outcome in COVID-19 patients, especially due to the low scientific quality of the described studies. Randomised controlled studies are needed to answer this question.
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