Atrial Fibrillation Or Atrial Flutter Research Articles

Anticoagulation Patterns Among Community-Dwelling Older Adults With Atrial Fibrillation.

To assess clinicians' prescribing practices for anticoagulation in older adults with atrial fibrillation or atrial flutter (AF/F) and determine factors common among those without anticoagulation. We performed a community-based retrospective cohort study of adults aged 65 years and older with a history of nonvalvular AF/F to determine the rate of oral anticoagulation utilization. We also assessed for associations between anticoagulation use and comorbid conditions and common geriatric syndromes. A total of 3832 patients with a diagnosis of nonvalvular AF/F were included (mean [SD] age, 79.9 [8.4] years), 2693 (70.3%) of whom were receiving anticoagulation (51.7%, a vitamin K antagonist; 48.1%, a direct-acting oral anticoagulant). Patients with higher Elderly Risk Assessment index (ERA) scores, a surrogate for health vulnerability, received anticoagulation less often than patients with lower scores. The percentage of patients with a history of falling was higher among those who did not receive anticoagulation than among those who did (44.4% vs 32.8%; P < .001). Similarly, a diagnosis of dementia was more common in the no-anticoagulation group than the anticoagulation group (18.5% vs 12.7%; P < .001). A substantial proportion of older adults with AF/F do not receive anticoagulation. Those without anticoagulation had higher risk of health deterioration based on higher ERA scores and had a higher incidence of dementia and fall history. This suggests that the presence of geriatric syndromes may influence the decision to withhold anticoagulation.

Heart failure and the risk of left atrial thrombus formation in patients with atrial fibrillation or atrial flutter.

The aim of the study was to evaluate the prevalence of left atrial thrombus (LAT) on transoesophageal echocardiography (TOE) in patients with atrial fibrillation or atrial flutter (AF/AFl) with reference to the presence of heart failure (HF) and its subtypes. The research is a sub-study of the multicentre, prospective, observational Left Atrial Thrombus on Transoesophageal Echocardiography (LATTEE) registry, which comprised 3109 consecutive patients with AF/AFl undergoing TOE prior to direct current cardioversion or catheter ablation. TOE parameters, including presence of LAT, were compared between patients with and without HF and across different subtypes of HF, including HF with preserved (HFpEF), mid-range (HFmrEF), and reduced ejection fraction (HFrEF). HF was diagnosed in 1336 patients (43%). HF patients had higher prevalence of LAT than non-HF patients (12.8% vs. 4.4%; P<0.001). LAT presence increased with more advanced type of systolic dysfunction (HFpEF vs. HFmrEF vs. HFrEF: 7.4% vs. 10.5% vs. 20.3%; P<0.001). Univariate analysis revealed that HFrEF (odds ratio [OR] 4.13; 95% confidence interval [95% CI]: 3.13-5.46), but not HFmrEF or HFpEF, was associated with the presence of LAT. Multivariable logistic regression indicated that lower left ventricular ejection fraction (OR per 1%: 0.94; 95% CI 0.93-0.95) was an independent predictor of LAT formation. Receiver operator characteristic analysis showed LVEF ≤48% adequately predicted increased risk of LAT presence (area under the curve [AUC] 0.74; P<0.0001). The diagnosis of HFrEF, but neither HFmrEF nor HFpEF, confers a considerable risk of LAT presence despite widespread utilization of adequate anticoagulation.

Diagnostic Yield, Outcomes, and Resource Utilization With Different Ambulatory Electrocardiographic Monitoring Strategies

Accurate diagnosis of arrhythmias is improved with longer monitoring duration but can risk delayed diagnosis. We compared diagnostic yield, outcomes, and resource utilization by arrhythmia monitoring strategy in 330 matched adults (mean age 64 years, 40% women, and 30% non-White) without previously documented atrial fibrillation or atrial flutter (AF/AFL) who received ambulatory electrocardiographic monitoring by 14-day Zio XT (patch-based continuous monitor), 24-hour Holter, or 30-day event monitor (external loop recorder) between October 2011 and May 2014. Patients were matched by age, gender, site, likelihood of receiving Zio XT patch, and indication for monitoring, and subsequently followed for monitoring results, management changes, clinical outcomes, and resource utilization. AF/AFL ≥30 seconds was noted in 6% receiving Zio XT versus 0% by Holter (p=0.04) and 3% by event monitor (p=0.07). Nonsustained ventricular tachycardia was noted in 24% for Zio XT patch versus 8% (p <0.001) for Holter and 4% (p <0.001) for event monitor. No significant differences between monitoring strategies in outcomes or resource utilization were observed. Prolonged monitoring with 14-day Zio XT patch or 30-day event monitor was superior to 24-hour Holter in detecting new AF/AFL but not different from each other. Documented nonsustained ventricular tachycardia was more frequent with Zio XT than 24-hour Holter and 30-day event monitor without apparent increased risk of adverse outcomes or excess utilization. In conclusion, additional efforts are needed to further personalize electrocardiographic monitoring strategies that optimize clinical management and outcomes.

Admission Cardiac Diagnostic Testing with Electrocardiography and Troponin Measurement Prognosticates Increased 30‐Day Mortality in COVID‐19

BackgroundCardiovascular involvement in coronavirus disease 2019 (COVID‐19) is common and leads to worsened mortality. Diagnostic cardiovascular studies may be helpful for resource appropriation and identifying patients at increased risk for death.Methods and ResultsWe analyzed 887 patients (aged 64±17 years) admitted with COVID‐19 from March 1 to April 3, 2020 in New York City with 12 lead electrocardiography within 2 days of diagnosis. Demographics, comorbidities, and laboratory testing, including high sensitivity cardiac troponin T (hs‐cTnT), were abstracted. At 30 days follow‐up, 556 patients (63%) were living without requiring mechanical ventilation, 123 (14%) were living and required mechanical ventilation, and 203 (23%) had expired. Electrocardiography findings included atrial fibrillation or atrial flutter (AF/AFL) in 46 (5%) and ST‐T wave changes in 306 (38%). 27 (59%) patients with AF/AFL expired as compared to 181 (21%) of 841 with other non‐life‐threatening rhythms (P<0.001). Multivariable analysis incorporating age, comorbidities, AF/AFL, QRS abnormalities, and ST‐T wave changes, and initial hs‐cTnT ≥20 ng/L showed that increased age (HR 1.04/year), elevated hs‐cTnT (HR 4.57), AF/AFL (HR 2.07), and a history of coronary artery disease (HR 1.56) and active cancer (HR 1.87) were associated with increased mortality.ConclusionsMyocardial injury with hs‐cTnT ≥20 ng/L, in addition to cardiac conduction perturbations, especially AF/AFL, upon hospital admission for COVID‐19 infection is associated with markedly increased risk for mortality than either diagnostic abnormality alone.

P5016Usefulness of different electrocardiographic patterns as predictors of in-hospital mortality in acute pulmonary embolism

Abstract Background Many electrocardiographic (ECG) patterns may be present in acute pulmonary embolism (PE), but their prevalence and association with in hospital mortality (IHM) are less well established. Objective Assess the correlation between different ECG patterns and IHM in patients (Pts) with PE using a whole country dataset. Methods Prospective multicenter registry which included Pts with acute PE hospitalized in 75 academic centers from October 2016 to November 2017. We considered the following ECG patterns: sinus tachycardia, pulmonary P waves, Q waves in DII-aVF leads, negative T waves in V1-V4, ST segment elevation in aVR and V1, atrial fibrillation or atrial flutter (AF/AF), right bundle branch block (RBBB), ST segment depression, S1Q3T3 pattern or Qr in V1. Statistical analysis was carried out using de STATA version 13.1. A value of p&lt;0.0.5 was considered statistically significant. Results We included 684 Pts; mean age 63.8±16.7 years (43% male). Global IHM was 12%. The most prevalent ECG patterns were sinus tachycardia (51.7%), S1Q3T3 (24.5%), negative T waves in V1- V4 (16%), RBBB (9.9%), AF/AF (8.6%). Four ECG patterns remained statistically significant predictors of IHM on multivariate analysis: AF/AF (OR: 3.81; CI 95% 1.82–7.95, p&lt;0.01), pulmonary P waves (OR: 3.81; CI 95% 1.2–12, p&lt;0.04), RBBB (OR: 2.71; CI 95% 1.39–5.30, p&lt;0.01) and sinus tachycardia (OR: 2.05; CI 95% 1.18–3.54, p&lt;0.04). ECG pattern and in-hospital mortality.Multivariate analysis Electrocardiographic pattern OR CI 95% p value AF/AF 3.81 1.82–7.95 &lt;0.01 Pulmonary P waves 3.81 1.20–12.00 &lt;0.04 RBBB 2.71 1.39–5.30 &lt;0.01 Sinus tachycardia 2.05 1.18–3.54 &lt;0.04 Q waves in DII-aVF 0.93 0.32–2.64 0.89 ST segment depression 1.07 0.39–2.96 0.80 Negative T waves in V1-V4 0.93 0.47–1.81 0.83 S1Q3T3 pattern 0.75 0.39–1.41 0.37 Qr in V1 2.07 0.63–6.73 0.22 ST segment elevation in aVR 2.38 0.79–7.15 0.12 Conclusions We corroborate the usefulness of the ECG as a prognostic tool in acute PE. Four simple ECG patterns (AF/AF, Pulmonary P waves, RBBB and sinus tachycardia) were associated with a higher IHM and therefore should be considered for PE risk stratification.

Thromboprophylaxis for Patients with High-risk Atrial Fibrillation and Flutter Discharged from the Emergency Department

IntroductionMany patients with atrial fibrillation or atrial flutter (AF/FL) who are high risk for ischemic stroke are not receiving evidence-based thromboprophylaxis. We examined anticoagulant prescribing within 30 days of receiving dysrhythmia care for non-valvular AF/FL in the emergency department (ED).MethodsThis prospective study included non-anticoagulated adults at high risk for ischemic stroke (ATRIA score ≥7) who received emergency AF/FL care and were discharged home from seven community EDs between May 2011 and August 2012. We characterized oral anticoagulant prescribing patterns and identified predictors of receiving anticoagulants within 30 days of the index ED visit. We also describe documented reasons for withholding anticoagulation.ResultsOf 312 eligible patients, 128 (41.0%) were prescribed anticoagulation at ED discharge or within 30 days. Independent predictors of anticoagulation included age (adjusted odds ratio [aOR] 0.89 per year, 95% confidence interval [CI] 0.82–0.96); ED cardiology consultation (aOR 1.89, 95% CI [1.10–3.23]); and failure of sinus restoration by time of ED discharge (aOR 2.65, 95% CI [1.35–5.21]). Reasons for withholding anticoagulation at ED discharge were documented in 139 of 227 cases (61.2%), the most common of which were deferring the shared decision-making process to the patient’s outpatient provider, perceived bleeding risk, patient refusal, and restoration of sinus rhythm.ConclusionApproximately 40% of non-anticoagulated AF/FL patients at high risk for stroke who presented for emergency dysrhythmia care were prescribed anticoagulation within 30 days. Physicians were less likely to anticoagulate older patients and those with ED sinus restoration. Opportunities exist to improve rates of thromboprophylaxis in this high-risk population.

Trial design: Computer guided normal-low versus normal-high potassium control in critically ill patients: Rationale of the GRIP-COMPASS study

BackgroundPotassium depletion is common in hospitalized patients and can cause serious complications such as cardiac arrhythmias. In the intensive care unit (ICU) the majority of patients require potassium suppletion. However, there are no data regarding the optimal control target in critically ill patients. After open-heart surgery, patients have a strongly increased risk of atrial fibrillation or atrial flutter (AFF). In a novel trial design, we examined if in these patients different potassium control-targets within the normal range may have different effects on the incidence of AFF.Methods/DesignThe "computer-driven Glucose and potassium Regulation program in Intensive care Patients with COMparison of PotASSium targets within normokalemic range (GRIP-COMPASS) trial" is a single-center prospective trial in which a total of 1200 patients are assigned to either a potassium control-target of 4.0 mmol/L or 4.5 mmol/L in consecutive alternating blocks of 50 patients each. Potassium levels are regulated by the computer-assisted potassium suppletion algorithm called GRIP-II (Glucose and potassium regulation for Intensive care Patients). Primary endpoint is the in-hospital incidence of AFF after cardiac surgery. Secondary endpoints are: in-hospital AFF in medical patients or patients after non-cardiac surgery, actually achieved potassium levels and their variation, electrolyte and glucose levels, potassium and insulin requirements, cumulative fluid balance, (ICU) length of stay, ICU mortality, hospital mortality and 90-day mortality.DiscussionThe GRIP-COMPASS trial is the first controlled clinical trial to date that compares potassium targets. Other novel methodological elements of the study are that it is performed in ICU patients where both targets are within the normal range and that a computer-assisted potassium suppletion algorithm is used.Trial registrationNCT 01085071 at ClinicalTrials.gov

Recurrence Rates of Arrhythmias During Pregnancy in Women With Previous Tachyarrhythmia and Impact on Fetal and Neonatal Outcomes

In women with heart disease, sustained arrhythmias can result in an increased risk to the mother and fetus. The purpose of this study was to determine the recurrence rates of arrhythmias during pregnancy in women with cardiac rhythm disorders and examine the impact on fetal and neonatal outcomes. Women with tachyarrhythmias before pregnancy who underwent obstetric care at the Toronto General and Mount Sinai Hospitals from 1990 to 2002 were included. The recurrence rates of arrhythmias were calculated. A multivariate logistic model was used to identify predictors of fetal complications. Seventy-three women had 87 pregnancies; 36 pregnancies were in women with a history of paroxysmal supraventricular tachycardia, 23 with paroxysmal atrial fibrillation or atrial flutter (AF/Afl), 6 with persistent AF/Afl, and 22 with ventricular tachycardia. In the women in sinus rhythm at baseline, 44% (36 of 81 pregnancies) developed recurrences of tachyarrhythmias during pregnancy or in the early postpartum period. The specific recurrence rates during pregnancy in women with a history of supraventricular tachycardia, paroxysmal AF/Afl, and ventricular tachycardia were 50%, 52%, and 27%, respectively. The 6 women in AF/Afl at baseline remained in this rhythm throughout their pregnancy. Adverse fetal events occurred in 17 of the 87 pregnancies (20%). Adverse fetal events occurred more commonly in women who developed antepartum arrhythmias (RR 3.4, 95% confidence interval 1.0 to 11.0, p = 0.045) compared with those who did not. In conclusion, in women with preexisting cardiac rhythm disorders, exacerbation of arrhythmia during pregnancy is common. Recurrence of arrhythmia during the antepartum period increases the risk of adverse fetal complications, independent of other maternal and fetal risk factors.

Esmolol versus diltiazem in the treatment of postoperative atrial fibrillation/atrial flutter after open heart surgery

Background Supraventricular tachyarrhythmias are common after open heart surgery. Possible causative factors for these arrhythmias include operative trauma, atrial ischemia, electrolyte imbalances, pericardial irritation, and excess catecholamines. Two agents commonly used to control ventricular rate in atrial fibrillation or atrial flutter (AF/AFL) are β-blockers and calcium channel blockers. Methods and Results This randomized study was designed to compare the safety and efficacy of intravenous diltiazem versus intravenous esmolol in patients with postoperative AF/AFL after coronary bypass surgery and/or valve replacement surgery. A comparative cost analysis was also performed. Thirty patients received either esmolol (n = 15) or diltiazem (n = 15) for AF/AFL. During the first 6 hours of treatment, 66.6% of esmolol-treated patients converted to sinus rhythm compared with 13.3% of the diltiazem-treated patients (P <.05). At 24 hours, 66.6% of the diltiazem group converted to SR compared with 80% of the esmolol group (not significant). Drug-induced side effects, time to rate control (<90 beats/min), number of patients requiring cardioversion, and length of hospitalization were similar for the two groups. The drug cost/successfully treated patient for esmolol versus diltiazem was $254 versus $437 at 6 hours and $529 versus $262 at 24 hours. Conclusions Although this is a small study, it suggests that esmolol is more effective in converting patients to normal sinus rhythm than diltiazem during the initial dosing period. No differences in conversion rates were observed between the two groups after 24 hours. Additional studies are needed to confirm whether esmolol is the initial drug of choice in patients with postoperative AF/AFL after coronary bypass surgery. (Am Heart J 2000;140:176-80.)