Cardioversion In Patients Research Articles

Abstract 14763: Discontinuation of Dofetilide or Qt Prolongation is Much More Common in Real-world Setting Than Reported in Clinical Trials

Introduction: Dofetilide is a class III anti-arrhythmic agent approved for achieving and maintaining sinus rhythm in patients with symptomatic atrial fibrillation or flutter (AF). Due to a risk of QT prolongation and ventricular tachycardia (VT) patients initiated on Dofetilide need to be hospitalized for at least 3 days to closely monitor ECG. In large clinical trials 1.8-2.5% of the patients had to discontinue Dofetilide due to QT prolongation. We aimed to evaluate the frequency and correlates of discontinuation of Dofetilide due to QT prolongation (QTc >500 msec) or VT in a real-world, inpatient setting. Methods: We included 100 consecutive patients, hospitalized for Dofetilide initiation at the Minneapolis VA Medical Center from 2011 to 2014. Data was collected retrospectively from electronic medical records. Results: The mean age was 63.8 ± 9.1 years. The indication for Dofetilide was AF (88%) and VT (12%). Dofetilide had to be discontinued in 21% of the patients due to QTc prolongation (17%) or VT (2%) or lack of efficacy (2%). One patient died in the hospital. The mean QTc in patients in whom Dofetilide had to be discontinued was 512±53 msec. In 29% of the cases Dofetilide cardioverted patients to sinus rhythm. Patients who had to discontinue Dofetilide were less likely to have coronary heart disease (CHD) than those who were discharged on Dofetilide (14% vs. 44%, respectively; p= 0.012) (Table). The average number of doses received by patients before discharge was 5.5±0.9 in patients who were discharged on Dofetilde vs. 3.2±1.5 in whom Dofetilide was discontinued because of QTc prolongation (55% discontinued after 2 nd dose). Concomitant QTc prolonging drugs were used in 29% of patients who had to discontinue Dofetilide vs. 24% of those who were discharged on Dofetilide (p=0.78) (Table). Conclusion: The incidence of Dofetilide discontinuation due to high-risk ECG features in the real world setting is remarkably higher than that reported in prior clinical trials.

Efficacy and Transesophageal Echocardiographic Findings of Short-term Dabigatran or Rivaroxaban Therapy for Electrical Cardioversion in Patients with Atrial Fibrillation

Efficacy and Transesophageal Echocardiographic Findings of Short-term Dabigatran or Rivaroxaban Therapy for Electrical Cardioversion in Patients with Atrial Fibrillation

Rivaroxaban in non valvular atrial fibrillation: subgroups analysis

After the ROCKET AF study main paper several subgroups analysis were recently published. These studies are useful to better evaluate the rivaroxaban efficacy and safety in different clinical conditions. Here the subgroup analysis of patients with moderate renal failure, heart failure and diabetes are presented. Post hoc data on patients who underwent an electrical or pharmacological cardioversion during ROKET AF follow up were available and here we analyze also the results of the first randomized study on electrical cardioversion in patients treated with new oral anticolagulants: the X-VeRT trial. A metanalysis of all the studies with rivaroxaban (one on stroke prevention in atrial fibrillation, two on acute coronary syndromes, four on deep venous thrombosis prophylaxis and two on pulmonary embolism treatment) with respect to the risk of myocardial infarction is examined.

Исследование X–VeRT: современная антикоагулянтная терапия при проведении кардиоверсии у больных с фибрилляцией предсердий

Исследование X–VeRT: современная антикоагулянтная терапия при проведении кардиоверсии у больных с фибрилляцией предсердий

Evaluating the Efficacy and Safety of Internal Cardioversion with Implantable Cardioverter Defibrillator Device for Atrial Fibrillation in Systolic Heart Failure Patients

Atrial fibrillation (AF) commonly observed in patients with heart failure and cardioversion was often needed to restore the sinus rhythm. Previously, there is no study evaluating usefulness of internal cardioversion with implantable cardioverter defibrillator (ICD) device. In this study, we aimed to compare the efficacy and long-term effects of internal cardioversion with ICD devices compared to conventional external cardioversion in patients with AF and heart failure. Seventy patients with AF and heart failure who underwent electrical cardioversion were enrolled in the study. Forty patients (mean age 65.36 ± 10.37, 35 male) were assigned to undergo internal cardioversion with approximately 35 J shocks delivered through the ICD electrode. Standard external cardioversion was performed for the remaining patients (30 patients; mean age 66.20 ± 11.89; 24 male) that were similar with regard to baseline, and electrocardiographic characteristics. Sinus rhythm was restored in 32 of 40 patients (80.0%) assigned to internal cardioversion compared with 25 of 30 patients (83.3%) assigned to external cardioversion (P = 0.725). We did not witness any serious complication during the procedure and hospitalization. On the follow-up, there was no statistically significant difference in recurrence of AF and incidence of major cardiovascular events between the internal and external cardioversion groups. Internal cardioversion with ICD device is an effective and safe method to restore sinus rhythm in heart failure patients with AF.

Is one month treatment with dabigatran before cardioversion of atrial fibrillation sufficient to prevent thromboembolism?: Table 1

The use of direct oral anticoagulants (DOACs) in patients undergoing elective direct current (DC) cardioversion of non-acute atrial fibrillation (AF) can potentially shorten the time from initiation of anticoagulation treatment to cardioversion, compared with warfarin. The safety of this strategy needs to be investigated. Data from subgroup analysis from clinical trials with DOAC do not clarify whether 4-week treatment with DOAC is sufficient to prevent thromboembolism (TE) after cardioversion. The aim of this retrospective study was to assess the incidence of TE in anticoagulant naive patients converted after one month's pre-treatment with dabigatran. We scrutinized the medical records of 631 patients where dabigatran had been used prior to elective DC cardioversion. Transoesophageal echocardiography was rarely performed. Thromboembolism within 30 days of cardioversion was the primary endpoint. A total of 570 patients were naive to OAC when dabigatran was initiated. The mean age in this group was 64.2 ± 11 years and 31.7% were women. The mean CHA2DS2-VASc score was 2.0 ± 1.5. The dose of dabigatran was 150 mg b.i.d. in 94% of the patients. The median time from initiation of dabigatran to cardioversion was 32.0 ± 15 days. In 91% cardioversion resulted in sinus rhythm. During the 30-day follow-up, three TE occurred for an incidence of 0.53% (0.18-1.54). In this retrospective study from clinical material, we found a low incidence of TE when dabigatran was used as TE prophylaxis in association with elective cardioversion. These results indicate that dabigatran is a safe alternative strategy to warfarin during cardioversion in patients with AF.

Non-vitamin K antagonist oral anticoagulants in the cardioversion of patients with atrial fibrillation: systematic review and meta-analysis.

Non-vitamin K antagonist oral anticoagulants (NOACs) are at least non-inferior to Vitamin K Antagonists (VKAs) for stroke prevention on patients with non-valvular atrial fibrillation (AF). We aimed to evaluate the efficacy and safety of NOACs in patients undergoing cardioversion through a systematic review and meta-analysis. MEDLINE, Cochrane Library, and Web of Science(®) databases (until September 2014) were searched for studies fulfilling inclusion criteria. Two reviewers independently selected randomized controlled trials (RCTs) evaluating NOACs and VKA in patients with AF undergoing cardioversion. The primary outcome was ischemic stroke or systemic embolism (IS/SE). Secondary outcomes were major bleeding, myocardial infarction, and mortality. Risk ratio (RR) and 95 % confidence intervals were derived through random-effects meta-analysis. Heterogeneity was evaluated through I (2) test. Four RCTs (3 post-hoc analysis) evaluating apixaban, dabigatran, and rivaroxaban in 3,512 patients with AF were included. The risk of IS/SE with NOACs was similar to VKA (RR 0.60, 95 % CI 0.20-1.80; I (2) = 17 %). There was no significant increase in major bleeding (RR 1.27, 95 % CI 0.58-2.81; I (2) = 0 %), myocardial infarction (RR 0.71, 95 % CI 0.10-5.04; I (2) = 0 %), or mortality (RR 0.87, 95 % CI 0.24-3.08; I (2) = 0 %) with NOACs. This systematic review and meta-analysis suggests that NOACs may be as safe as VKAs in the setting of AF cardioversion.

Impact of hybrid procedure on P wave duration for atrial fibrillation ablation.

Hybrid procedure (HP) involves epicardial isolation of pulmonary vein and posterior wall of left atrium, and endocardial checking of lesions and touchups (if needed). We aimed at observing the effect of hybrid procedure on P wave duration (PWD), calculated automatically from surface ECG leads at start and end of HP, and also for relationship to atrial fibrillation (AF) recurrence at 9 months. Forty-one patients (32 male; mean age, 58.4 ± 9.5 years) underwent HP, as first ever ablation. A new automated method was used for P wave segmentation and PWD estimation from recognizable P waves in ECG lead I or II before and after HP, based on fitting of each P wave by means of two Gaussian functions. Overall, PWD was significantly decreased after procedure (104.4 ± 25.1 ms vs. 84.7 ± 23.8 ms, p = 0.0151), especially in persistent AF patients (122.4 ± 32.2 ms vs. 85.6 ± 24.5 ms, p = 0.02). PWD preprocedure was significantly higher in persistent than in paroxysmal patients (122.4 ± 32.2 ms vs. 92.5 ± 17.9 ms, p = 0.0383). PWD was significantly decreased after procedure in prior electrical cardioverted patients (106.7 ± 30.5 ms vs. 84.7 ± 23.1 ms, p = 0.0353). After 9-month follow-up of 40 patients, HP-induced PWD decrease was significant for the 12 persistent patients without recurrence (122.4.1 ± 35.3 ms vs. 85.6 ± 22.0 ms, p = 0.0210). Preprocedure PWD was higher for persistent than paroxysmal patients. HP reduced PWD significantly. Nine-month follow-up suggests that HP is successful in restoring and maintaining sinus rhythm. To individualize AF therapy, AF type-based selection of patients may be possible before procedure. Automated analysis of PWD from surface ECG is possible.

Проґнозування тривалого утримання синусового ритму після кардіоверсії у пацієнтів з неклапанною персистентною фібриляцією передсердь

Проґнозування тривалого утримання синусового ритму після кардіоверсії у пацієнтів з неклапанною персистентною фібриляцією передсердь

Safety and efficacy of external electrical cardioversion in patients with left ventricular leads.

Atrial arrhythmias lower the biventricular pacing percentage in cardiac resynchronization therapy (CRT) treated patients (pts) and have a high prevalence in this population. External electrical cardioversion (ECV) is commonly performed to restore sinus rhythm. There is a paucity of data on the safety and efficacy of ECV in pts with CRT devices. Forty-three pts with CRT devices undergoing ECV at two centers were included prospectively. Devices were interrogated immediately prior to and after ECV, as well as after 4 weeks. Devices (CRT-D in 38 and CRT-P in 5) were all implanted in left pectoral position, with predominantly bipolar left ventricular (LV) leads. Sixty-one shocks were delivered, all biphasic. Arrhythmia had recurred in 36 % of pts at follow-up (FU). There was a significant increase in LV lead threshold voltage and drop in bipolar LV lead impedance after ECV, which returned to normal at FU. An at least twofold increase in pacing threshold voltage at FU was seen in 2 LV leads and a 0.5 V increase in threshold in 3 LV leads. Overall, biventricular pacing significantly increased during FU. ECV in CRT pts was safe and effective in this two-center study. A transient increase in LV lead pacing threshold was observed. Relevant changes in pacing threshold at FU occurred in five LV leads-identification and regular FU of these pts are necessary. Restoring SR through ECV significantly increased the biventricular pacing percentage but arrhythmia recurrence was frequent. CRT pts with atrial arrhythmias require close FU after ECV.

Prediction of atrial fibrillation recurrence after cardioversion in patients with left-atrial dilation.

Little is known about the impact of left-ventricular (LV) diastolic dysfunction on risk of atrial fibrillation (AF) recurrence in patients with left-atrial (LA) dilation. To evaluate, in patients with symptomatic persistent AF and LA dilation, the incremental role of LV diastolic dysfunction in predicting early AF recurrence after cardioversion (CV). From July 2011 to July 2013, 175 patients with persistent AF referred to our centre for CV were screened. Inclusion criteria were: European Heart Rhythm Association (EHRA) class ≥2 despite optimal medical treatment and heart rate at rest ≤80 bpm, LA volume ≥34 mL/m(2), EF > 35%, absence of untreated ischaemic disease and significant valvular disease, successful CV. Finally, 127 patients (age 64 ± 10 years, 60% EHRA ≥3, LA volume 42 ± 15 mL/m(2)) were enrolled. At 3 months, 37 (29%) patients presented AF recurrence. At univariate analysis, AF duration >90 days before CV (P < 0.01), septal e' <8 cm/s (P 0.03), and septal E/e' ratio ≥11 (P < 0.001) but no LA dimensions significantly correlated with AF recurrence. Logistic regression analysis confirmed septal E/e' ratio ≥11 as the best predictor of recurrence (OR 3.25 95% CI 1.19-8.86 P 0.001) together with an AF duration >90 days before the CV (OR 2.69 95% CI 1.01-7.53 P 0.04). At ROC curve analysis, the septal E/e' ratio ≥11 showed the best diagnostic accuracy (AUC 0.66, 95% CI 0.55-0.76, P 0.007). In this population with symptomatic persistent AF and LA enlargement, septal E/e' ratio ≥11 and AF duration >90 days predicted AF recurrence at 3 months.

Anterior-posterior versus anterior-lateral electrode position for external electrical cardioversion of atrial fibrillation: A meta-analysis of randomized controlled trials

Several clinical trials have shown inconsistent results regarding the effect of electrode positions on the success of electrical cardioversion. The aim of this meta-analysis was to investigate the effect of the anterior-posterior electrode position on the success of electrical cardioversion in patients undergoing external electrical cardioversion for atrial fibrillation. Pubmed, EMBASE, the Cochrane Library and the Chinese National Knowledge Infrastructure were searched for randomized controlled trials. The effect of the anterior-posterior electrode position on cardioversion success is presented as a risk ratio with 95% confidence interval. Ten trials with 1281 patients were included in the analysis. The anterior-posterior electrode position had no advantages in terms of success of electrical cardioversion for atrial fibrillation compared with the anterior-lateral electrode position (risk ratio 1.02, 95% confidence interval 0.96-1.09; P=0.50). Subgroup analysis showed that patients with a left atrium diameter≤45 mm and lone atrial fibrillation might derive benefits from the anterior-posterior electrode position in terms of success of cardioversion. No evidence of publication bias was detected. The present analysis suggests that only patients with a left atrium diameter≤45 mm and lone atrial fibrillation might derive benefits from the anterior-posterior electrode position compared with the anterior-lateral electrode position during external electrical cardioversion for atrial fibrillation. However, there was insufficient evidence to support any advantages for the anterior-posterior electrode position in other situations.

The mechanical fibrillation pattern of the atrial myocardium is associated with acute and long-term success of electrical cardioversion in patients with persistent atrial fibrillation.

Electrophysiological studies demonstrate that a short atrial fibrillation cycle length (AFCL) is related with poor outcome of electrical cardioversion (ECV) of atrial fibrillation (AF). We found previously that the mechanical AFCL (AFCL-tvi) and atrial fibrillatory velocity (AFV-tvi) may be determined noninvasively using color tissue velocity imaging (TVI) and closely relates to the electrophysiological AFCL. To evaluate the relation between AFCL-tvi, AFV-tvi, and success of ECV in patients with AF. We prospectively studied 133 patients with persistent AF by performing echocardiography before ECV and measured the AFCL-tvi and AFV-tvi in the right atrium and left atrium. Recurrent AF was monitored. Nineteen (14%) patients had failure of ECV, 42 (32%) remained in sinus rhythm after 1-year follow-up, and 72 (54%) had a recurrence of persistent AF. Patients with immediate ECV failure had a lower median AFV-tvi measured in the right atrium than did patients with a successful ECV: 0.7 cm/s (0.2-1.0 cm/s) vs. 1.7 cm/s (0.9-2.8 cm/s) (P = .008). Patients with maintenance of sinus rhythm after 1 year had a longer AFCL-tvi measured in the left atrium than did patients with recurrence of AF (150 ms vs 137 ms; P = .017) and had a higher AFV-tvi in both atria (1.4 vs. 0.9 cm/s in the left atrium; P = .013 and 2.2 vs 1.4 cm/s in the right atrium; P = .011). Multivariate analyses showed that all atrial TVI parameters were independently associated with the maintenance of sinus rhythm after 1 year. Higher atrial fibrillatory wall velocities and longer AFCLs determined by echocardiography are associated with acute and long-term success of ECV.

0422: Atrial fibrillation (AF): the cardioversion in the era of ablation

If the management of atrial fibrillation in its thromboembolic component knows more adherences to recommendations, it should be noted that the rhythmic component is experiencing a trend towards acceptance of the AF at the expense of a restoration strategy sinus rhythm. To evaluate the effectiveness of the drug cardioversion or electrical cardioversion in patients hospitalized in the cardiology department of HMIMV Rabat. This is a prospective study conducted over a period of one year, including 45 patients with non-valvular AF, candidates for chemical or electrical cardioversion. All our patients have undergone transthoracic echocardiography, sometimes supplemented with a transesophageal echocardiography and an assessment of thyroid The average age of our patients was 52.7 years with a sex ratio 2/1. 25% of our patients had hypertensive heart disease, 8% ischemic heart disease, 4% dilated cardiomyopathy and the rest had a healthy heart. The average diameter of the left atrium was 41 cm with an average surface to 19 cm 2 . 60% of our patients have undergone cardioversion by external shock, and 40% of theme by injection of amiodarone or flecainide. The rate of restoration of sinus rhythm was 78%, with a recurrence rate at one month 19%. The predictive factors of recurrence were an ancient atrial fibrillation, a large left atrium and a score CHA2DS2-VASC ≥ 1. This study, showing an acceptable level of restoration and maintenance of sinus rhythm, confirms the interest of promoting a strategy of rhythm control, subject to patient selection on predictors of success.

Abstract T P335: Eligibility and Preference of New Oral Anticoagulants in Patients With Atrial Fibrillation: Comparison Between Patients With Versus Without Stroke or TIA

BACKGROUNDS: Recent randomized clinical trials of new oral anticoagulants (NOACs) forms the basis for international guidelines for the management of patients with atrial fibrillation. However, strict enrollment criteria may limit the applicability of results of trials to clinical practice. We estimated the eligibility for participation in landmark trials of NOACs of an unselected group of atrial fibrillation patients with or without stroke/TIA. In addition, we compared the preference for NOACs use between patients with versus without stroke/TIA. METHODS: Four hundred patients were prospectively and consecutively enrolled in a database from a university medical center. We applied three large NOAC trials' enrollment criteria (RE-LY, ROCKET-AF, and ARISTOTLE). In addition, INR lability (time in therapeutic window for patients taking warfarin) and bleeding risk schemes (ATRIA) were measured. RESULTS: The proportions of patients fulfilling the trial enrollment criteria ranged from 20% to 75%, depending on the differences in the indications/contraindications of studies (lower in ROCKET-AF than others) and presence or absence of stroke/TIA (20-60% vs. 75%). The main reasons for ineligible for NOACs are lower CHADS2 score and planned cardioversion for patients without stroke/TIA, whereas low creatinine clearance and bleeding-related complications for those with stroke/TIA. TTR is lower in the former, especially in patients with severe disability. In addition, bleeding tendency as measured by ATRIA is much higher in patients with stroke/TIA, mainly due to concomitant use of antithrombotics. CONCLUSIONS: Our data confirm that patients enrolled in randomized clinical trials are representative of most stroke patients with atrial fibrillation, but partly of nonstroke patients, in clinical practice. When INR lability and bleeding tendency with warfarin use were considered, the use of NOACs was preferred in patients with stroke/TIA than in patients without

Safety of Short-Term Use of Dabigatran or Rivaroxaban for Direct-Current Cardioversion in Patients With Atrial Fibrillation and Atrial Flutter

Direct-current cardioversion (DCCV) for persistent atrial fibrillation or atrial flutter (AF) carries a risk of thromboembolic events (TEs). Therapeutic anticoagulation with warfarin is recommended for 3 to 4 weeks before and 4 weeks after DCCV to reduce TE; however, the safety of short-term anticoagulation with the novel oral anticoagulants (dabigatran and rivaroxaban) before DCCV has not been assessed. A retrospective cohort study was performed on all patients undergoing elective DCCV for AF at Northwestern Memorial Hospital from June 1, 2012 to September 30, 2013. Inclusion criteria included patients taking any of the novel oral anticoagulants for 21 to 60 days before DCCV and successful DCCV to sinus rhythm. Patients were monitored for a minimum of 60 days after DCCV to evaluate for TEs including stroke, transient ischemic attack, systemic emboli, and death. In total, 53 patients (47 men, 89%; age 65±10 years, median 66) were evaluated. Agents used were dabigatran (30 patients, 57%) and rivaroxaban (23 patients, 43%) for an average of 38±9 days. The mean CHADS2 score was 1.2±1.1 (score=0, 26%; 1, 43%; 2, 17%; and >3, 13%). Eleven patients (21%) underwent a transesophageal echocardiography before their DCCV; all showed no thrombus. No patients were found to have episodes of TE within 60 days of DCCV. No patients were found to have major bleeding events. In conclusion, the use of short-term dabigatran or rivaroxaban therapy for DCCV of AF appears safe.

Фармакоэкономические аспекты проведения медикаментозной кардиоверсии у пациентов с фибрилляцией предсердий в условиях стационара

Фармакоэкономические аспекты проведения медикаментозной кардиоверсии у пациентов с фибрилляцией предсердий в условиях стационара

Efficacy and Safety of Apixaban in Patients After Cardioversion for Atrial Fibrillation: Insights From the ARISTOTLE Trial (Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation)

The aim of this study was to determine the risk of major clinical and thromboembolic events after cardioversion for atrial fibrillation in subjects treated with apixaban, an oral factor Xa inhibitor, compared with warfarin. In patients with atrial fibrillation, thromboembolic events may occur after cardioversion. This risk is lowered with vitamin K antagonists and dabigatran. Using data from the ARISTOTLE (Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation) trial, we conducted a post-hoc analysis of patients undergoing cardioversion. A total of 743 cardioversions were performed in 540 patients: 265 first cardioversions in patients assigned to apixaban and 275 in those assigned to warfarin. The mean time to the first cardioversion for patients assigned to warfarin and apixaban was 243 ± 231 days and 251 ± 248 days, respectively; 75% of the cardioversions occurred by 1 year. Baseline characteristics were similar between groups. In patients undergoing cardioversion, no stroke or systemic emboli occurred in the 30-day follow-up period. Myocardial infarction occurred in 1 patient (0.2%) receiving warfarin and 1 patient receiving apixaban (0.3%). Major bleeding occurred in 1 patient (0.2%) receiving warfarin and 1 patient receiving apixaban (0.3%). Death occurred in 2 patients (0.5%) receiving warfarin and 2 patients receiving apixaban (0.6%). Major cardiovascular events after cardioversion of atrial fibrillation are rare and comparable between warfarin and apixaban. (Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation [ARISTOTLE]; NCT00412984)

Internal cardioversion of persistent atrial fibrillation in implantable cardioverter defibrillator patients: the juice is not worth the squeeze

Internal cardioversion of persistent atrial fibrillation in implantable cardioverter defibrillator patients: the juice is not worth the squeeze

Oxidative Stress and Atrial Fibrillation

Atrial fibrillation (AF), one of the most prevalent cardiac arrhythmias, afflicts >3 million people in the United States.1 Because the risk of developing AF increases with age, the prevalence of AF is projected to be 7.6 million in 2050,1 when 1 in 5 Americans will be over the age of 65.2 AF not only causes debilitating symptoms and functional impairments owing to worsened hemodynamics and embolic stroke, it also increases the risk of mortality up to 1.5- to 1.9-fold.3 Despite the significant morbidity and mortality burden incurred with AF, there are limited therapeutic options that may improve the outcomes of AF patients, and these options are associated with significant AF recurrence rates.4 Article see p 1748 One possible explanation for the limitations of current therapies is that they do not address effectively or completely the underlying causes of AF. Evidence has been mounting that AF is associated with systemic and cardiac oxidation.4,5 Risk factors for AF are similar to those of atherosclerosis, a disease known to be perpetuated by oxidative stress. These risk factors, such as hypertension, aging, diabetes mellitus, and coronary artery bypass surgery, have each been associated with increases in the systemic markers of oxidation.4 In addition, there is also evidence of increased cardiac oxidation of myofibrillar protein5 and membrane lipids6 with AF or with risk factors linked to AF. Although it is not clear whether cardiac oxidation leads to systemic markers of oxidation or whether systemic oxidation leads to cardiac oxidation, the association of oxidative stress and AF is robust and suggests that AF is possibly a manifestation of a systemic disease. Despite the link between oxidative stress and AF, systemic antioxidant therapy for arrhythmias has not met with much success in clinical trials.7, …