Ventricular Rate Control Research Articles

Reducing diltiazem-related hypotension in atrial fibrillation: Role of pretreatment intravenous calcium.

This study evaluated the efficacy of intravenous (IV) calcium pretreatment for preventing diltiazem-induced hypotension and assessed its safety in adult patients with atrial fibrillation (AF)/atrial flutter (AFL) with rapid ventricular response (RVR). This randomized, double-blind, placebo-controlled trial included 217 adults with AF/AFL and a ventricular rate>120 beats per minute, who were randomized into three groups: those who received an IV NaCl 0.9% placebo pretreatment prior to IV diltiazem (PD; 73 patients) and those who received 90mg (C90D; 71 patients) and 180mg (C180D; 73 patients) IV calcium chloride pretreatment before IV diltiazem. We compared participants' systolic blood pressure (SBP) and heart rate (HR) at baseline and at 5, 10, and 15min post-treatment, as well as the incidence of adverse events (e.g., hypotension, urticaria, nausea) among the groups. The PD and C90D pretreatment groups had significantly lower HR measurements at 10 and 15min compared to the C180D group. In addition, at 5min, the mean SBP in the PD group was significantly lower compared to the C90D and C180D groups. At 10min, the mean SBP was significantly higher in the C180D group than in the other groups. Furthermore, at 15min, the mean SBP was significantly higher in both the C90D and C180D groups than in the PD group. There were no significant differences between the calcium pretreatment and placebo groups in terms of the need for additional diltiazem doses or the incidence of adverse events. IV calcium pretreatment effectively prevents diltiazem-induced hypotension in patients with AF/AFL with RVR without compromising the efficacy of diltiazem in achieving and maintaining ventricular rate control. National Library of Medicine Clinical Trial Registry; No.: NCT06494007; URL: https://clinicaltrials.gov/study/NCT06494007.

A decade of follow-up: atrial fibrillation, pulmonary pressure, and the progression of tricuspid regurgitation

Abstract Background While Atrial fibrillation is considered a risk factor for tricuspid regurgitation (TR), prospective long term data in the field is lacking. This analysis aimed to identify risk factors of TR progression during a decade of follow up among patients with and without AF. Methods Patients with full echocardiographic and clinical follow of at least 5 years were included. Individuals presenting with significant TR at baseline were excluded. Patients were divided into two groups based on baseline diagnosis of AF, followed by stratification according to systolic pulmonary artery pressure (sPAP). The primary outcome was the occurrence of new significant TR (≥ Moderate). Results Study population included 15,957 patients with a median age of 63 (IQR: 54-72) of whom 6,068 (38%) were women and 1,837 (11.5%) had baseline AF. During a median follow-up period of 11 years (8.5 – 13.5), 1,191 (7.5%) patients developed significant TR. Compared with sinus rhythm, patients with AF were 4 and 2 times more likely to develop significant TR during follow up in a univariate and multivariate models, respectively (95% CI 3.66 - 4.68 and 1.98 – 2.56, p < 0.001 for both). Older age, female sex, chronic kidney disease (CKD), left heart disease (LHD) and impaired right ventricular (RV) function, rate control and permanent AF were all risk factors for TR progression. The association of baseline AF with TR during follow up was sPAP – dependent, such that among patients with normal sPAP AF associated risk was high while among patients with high baseline sPAP AF-associated risk was significantly lower (HR 2.87 vs. 1.77; p for interaction < 0.001). Competing risk analysis with death as competing event yielded consisted results. Conclusions Baseline AF is a strong and independent risk factor for TR development. This association is more pronounced among patients with normal pulmonary arterial pressures, emphasizing the need for focused research on preventing TR development in this population.

Use of ivabradine in children with junctional ectopic tachycardia after pediatric cardiac surgery; two-centre experience.

Although amiodarone is traditionally used in the treatment of postoperative junctional ectopic tachycardia (JET), the search for new treatments is ongoing. We present our experience with ivabradine at two medical centers. Between January 2022 and January 2023, patients who developed JET after pediatric cardiac surgery were prospectively followed up and documented. The diagnosis of JET was made with the support of the electrophysiology team and treatment was based primarily on whether JET disrupted hemodynamics. This study was conducted at two high-volume centers, which record a total of 1130 pediatric cardiac surgeries within a year. The study recruited 26 patients with median heart rate 180 beats per minute, and 10 (38%) patients had impaired hemodynamics. Out of the 26 study participants, 14 (54%) cases were treated with ivabradine alone, 10 (38%) cases were treated with amiodarone + ivabradine, and 2 patients (8%) with high heart rates and prolonged junctional arrhythmia were treated with ivabradine and flecainide. The median time to ventricular rate control was 12 h, and the median time to sinus rhythm conversion was 55.5 h. No ivabradine-related side effects were observed in any of the patients, and no patient experienced JET recurrence after discontinuing treatment. Ivabradine seems to be a safe and effective medical treatment that can be used as the primary treatment in patients with stable hemodynamics, as an adjunctive therapy to amiodarone in patients with impaired hemodynamics.

MULTIFOCAL ATRIAL TACHYCARDIA AND HYPERTROPHIC CARDIOMYOPATHY IN THREE PATIENTS WITH COSTELLO SYNDROME

Abstract Introduction Costello syndrome is a rare disease, caused by mutation of the HRAS gene, associated with intellectual disability, growth retardation, facial dimorphisms. Cardiac abnormalities, mainly cardiac hypertrophy and multifocal atrial tachycardia, are present in 1/3 of patients. Clinical Cases From 2019 to 2023, 3 newborns with Costello syndrome came under our observation. M.M. showed respiratory distress, hypotonia and dysmorphic notes; genetic analysis highlighted the pathogenic variant c.64C>A (p.Gln22Lys). On the echocardiogram, septal hypertrophic cardiomyopathy was found with left outflow obstruction and mitral insufficiency. Therapy with propranolol was undertaken. Holter ECG never revealed arrhythmias. At the last check–up, SIV hypertrophy, continent mitral valve, free left ventricular outflow. The second patient, O.L., arrived at 10 days of age following a run of supraventricular tachycardia. He had bilateral clubfoot and facial dimorphisms. The echocardiogram was normal. On Holter ECG atrial tachycardia interrupted by rare sinus beats. Therapy with flecainide was undertaken, without benefit. Subsequently, was undertaken amiodarone, then associated with digitalis. She was discharged with satisfactory control of the average ventricular rate, but later due to the appearance of chaotic atrial arrhythmia, propranolol was added; on the Holter ECG in triple therapy, periods of sinus rhythm alternating with short episodes of atrial tachycardia were observed. Genetic analysis revealed the pathogenic variant c.34G>A, p.(Gly12Ser) of the HRAS gene. The third patient, F.A., presented atrial tachycardia. Flecainide therapy had transient benefit. Subsequently propranolol was added, without benefit. Therapy with amiodarone was initiated. Transesophageal electrophysiological study demonstrated multifocal atrial tachycardia, unresponsive to overdrive pacing. Partial control of the average ventricular rate was achieved in triple therapy. On the echocardiogram, mild concentric hypertrophy and dysplastic pulmonary valve. Genetic testing detected the c.35G>C, p(Gly12Ala) variant of the HRAS gene. Conclusions Costello syndrome requires cardiac monitoring for the possible presence of multifocal atrial tachycardia and hypertrophic cardiomyopathy. Arrhythmia, which can also occur independently of hypertrophy, can be self–limited in the first months of life with aggressive pharmacological treatment but can persist or worsen in ¼ of patients.

Nonpharmacologic rate control of postoperative atrial fibrillation in the canine sterile pericarditis model.

Postoperative atrial fibrillation (POAF) is common following open heart surgery, and is associated with significant morbidity. Medications used for ventricular rate control of POAF may not be effective in controlling rapid ventricular rates during the postoperative period because of increased sympathetic tone. The purpose of this study was to develop nonpharmacologic rate control of POAF by atrioventricular node (AVN) fat pad stimulation using clinically available temporary pacing wires in the canine sterile pericarditis model. We studied 10 sterile pericarditis dogs in the closed-chest state on postoperative days 1-3. The AVN fat pad stimulation (amplitude 2-15 mA; frequency 20 Hz; pulse width 0.03-0.2 ms) was performed during sustained POAF (>5 min). We measured ventricular rate and inefficient ventricular contractions during sustained POAF and compared it with and without AVN fat pad stimulation. Also, the parameters of AVN fat pad stimulation to achieve a rate control of POAF were measured over the postoperative days. Eleven episodes of sustained POAF were induced in 5/10 sterile pericarditis dogs in the closed-chest state on postoperative days 1-2. During POAF, the AVN fat pad stimulation decreased the ventricular rate from 178 ± 52 bpm to 100 ± 8 bpm in nine episodes. Nonpharmacologic rate control therapy successfully controlled the ventricular rate and eliminated inefficient ventricular contractions during POAF for the duration of the AVN fat pad stimulation. The AVN fat pad stimulation output remained relatively stable over the postoperative days. During sustained POAF, nonpharmacologic rate control by AVN fat pad stimulation effectively and safely controlled rapid ventricular rates throughout the postoperative period.

Comparison of the Effectiveness and Safety of Metoprolol and Diltiazem in Atrial Fibrillation With Rapid Ventricular Rate Patients: A Systematic Review and Meta-Analysis.

This study aims to assess the association between intravenous diltiazem and metoprolol in rate control for atrial fibrillation (AF) patients with rapid ventricular rate, focusing on rate control efficacy and hemodynamic adverse events. Following thePreferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, electronic searches were conducted in Embase, PubMed, and Cochrane CentralRegister of Controlled Trials (CENTRAL) until February 20, 2024. The primary outcome was achieving ventricular rate control < 110/min. Secondary outcomes included new hypotension (systolic blood pressure < 90 mm Hg) and bradycardia (heart rate < 60/min). Nineteen studies (three randomized controlled trials and 16 observational studies) were included in this meta-analysis. Pooled analysis showed intravenous metoprolol resulted in a 39% lower rate control attainment compared to diltiazem (OR: 0.61; 95% CI: 0.44 to 0.84; p = 0.002). There were no significant differences in bradycardia (OR: 0.51; 95% CI: 0.22 to 1.22; p = 0.13) or hypotension risk (OR: 1.08; 95% CI: 0.72 to 1.61; p = 0.72) between the two groups. Intravenous diltiazem demonstrated superior rate control efficacy compared to metoprolol in AF patients with rapid ventricular rate. However, no significant differences were observed in safety outcomes, namely, bradycardia and hypotension.

The relationship between different ventricular rate control levels and cardiac remodeling in early persistent atrial fibrillation: a prospective cohort study.

Atrial fibrillation (AF) is a prevalent cardiac arrhythmia, with ventricular rate control being a critical therapeutic target. However, the optimal range for ventricular rate control remains unclear. Additionally, the relationship between different levels of ventricular rate control and cardiac remodeling in patients with atrial fibrillation remains unclear. This study aims to explore the relationship between different levels of heart rate control and cardiac remodeling in patients with early persistent atrial fibrillation. A bi-center prospective cohort study was conducted, enrolling patients with newly diagnosed persistent AF and rapid ventricular rates, yet with a normal cardiac size, from March 2019-May 2020 at the people's hospital of Chongqing Hechuan and the First Affiliated Hospital of Zhengzhou University. Patients were divided into four groups based on their average ventricular rate levels from 24 h Holter monitoring: Group I (40 ≤ average rate < 60 bpm), Group II (60 ≤ average rate <80 bpm), Group III (80 ≤ average rate < 100 bpm), and Group IV (average rate ≥ 100 bpm).The study tracked changes in left atrial diameter (LAD), left ventricular end-diastolic diameter(LVEDD),left ventricular ejection fraction(LVEF), and the severity of mitral regurgitation over one year. A total of 764 patients were enrolled. We found that there were no significant differences in cardiac remodeling among the groups of patients before the observation. However, after one-year follow-up observation, there were significant differences in the degree of cardiac remodeling among the groups (p < 0.001). Specifically, the severity of cardiac remodeling, including LVEDD, LAD, LVEF, and mitral regurgitation, showed the following trend: Group II < Group I < Group III < Group IV. Further regression analysis indicated that body mass index (BMI) might be related to changes in LAD. Additionally, the use of digoxin could affect changes in left ventricular ejection fraction. At the same time, the use of diltiazem, bisoprolol, as well as factors like hypertension, coronary artery disease, smoking, diabetes, and chronic obstructive pulmonary disease, might be closely associated with the worsening of mitral regurgitation. This study shows that in early persistent AF patients, different levels of heart rate control are related to varying degrees of cardiac remodeling. These results suggest that maintaining an average ventricular rate within the range of 60-80 beats per minute may be associated with milder cardiac remodeling. On the other hand, an average heart rate greater than 100 bpm appears to be associated with the most severe cardiac remodeling. ChiCTR2400079978; Registered 17 January 2024-Retrospectively registered: https://www.chictr.org.cn/showproj.html?proj=198684.

Choice of sinus rhythm control strategy in patients with atrial fibrillation: why, when and how? A review

After 20 years of dubious notions of parity between sinus rhythm control and ventricular rate control strategies in patients with atrial fibrillation, there is evidence of the prognostic superiority of the former. The review article presents the results of randomized trials that support early rhythm control in patients with atrial fibrillation, possible pharmacological and non-pharmacological methods of such treatment in real clinical practice.

An innovative impurity profiling of esmolol hydrochloride injection using UPLC-MS based multiple mass defect filter, chemometrics and in-silico toxicity prediction

Esmolol hydrochloride injection is indicated for the rapid control of ventricular rate in patients with atrial fibrillation or atrial flutter in perioperative, postoperative, or other emergent circumstances where short term control of ventricular rate with a short-acting agent is desirable. The potential toxic impurities in pharmaceuticals at micro levels or trace levels are of increasing concern to both pharmaceutical industries and regulatory agencies, due to their potential risk to human health. The impurity investigation of esmolol remains incomplete. Thereby, efficient impurities monitoring and potential toxicity assessment should be emphasized to assure drug safety. Impurity profiling methods of esmolol were developed using ultraperformance liquid chromatography plus Q-Exactive Orbitrap tandem mass spectrometry (UPLC-QE-MS) based multiple mass defect filter and chemometrics. Impurities were characterized by both UPLC-QE-MS and reference substance comparison. The toxicities of esmolol impurities were predicted by employing quantitative structure–activity relationship. The results showed that a total of 20 impurities were detected and identified using the above integrated strategy, 14 impurities (EP2-3, EP5-6, EP8-9, EP12-13, EP15-20) have firstly found. EP20 was predicted as hepatotoxic and mutagenic using QSAR model, and its hepatotoxicity were verified in vivo. The EP1 contents showed maximum volatility in all batches, and varied by sample. EP1 and its accompanying product of methanol were measured. This UPLC-MS/MS based chemometrics strategy is useful for monitoring the manufacturing process and quality control of esmolol hydrochloride injection.

Prognostic Impact of Landiolol in Patients with Acute Heart Failure and Atrial Fibrillation with Rapid Ventricular Rates: A Pilot Observational Study

Introduction: Guidelines recommend ventricular rate control to <130 bpm during atrial fibrillation (AF) in patients with acute decompensated heart failure (ADHF) to avoid aggravating deteriorations in cardiac outputs. We aimed to evaluate the prognostic impact of landiolol in patients with ADHF and AF. Methods: This observational study included 60 patients who were urgently hospitalized with ADHF and presented with AF and a heart rate (HR) ≥130 bpm at admission. The patients were assigned to the landiolol group (n = 37) or the reference group (n = 23) based on their intravenous landiolol use within 24 h after admission. The primary endpoint was death from any cause. Results: The groups’ baseline characteristics were similar. A significant HR reduction occurred in the landiolol group at 2 h after admission. Compared with the reference group, the HR was significantly lower (111.6 vs. 97.9 bpm, p = 0.02) and the absolute HR reduction was greater (−32.2 vs. −50.0 bpm, p = 0.006) in the landiolol group at 48 h after admission. The landiolol group’s mortality rate was significantly lower than that in the reference group (log-rank test, p = 0.032). landiolol use within 24 h after admission was independently associated with lower all-cause mortality (adjusted hazard ratio: 0.15, 95% confidence interval: 0.02–0.92). Conclusion: Patients with ADHF and AF who received landiolol for rate control during the acute phase had better prognoses than those who did not receive landiolol.

Esterases Involved in the Rapid Bioconversion of Esmolol after Intravenous Injection in Humans.

Esmolol is indicated for the acute and temporary control of ventricular rate due to its rapid onset of action and elimination at a rate greater than cardiac output. This rapid elimination is achieved by the hydrolysis of esmolol to esmolol acid. It has previously been reported that esmolol is hydrolyzed in the cytosol of red blood cells (RBCs). In order to elucidate the metabolic tissues and enzymes involved in the rapid elimination of esmolol, a hydrolysis study was performed using different fractions of human blood and liver. Esmolol was slightly hydrolyzed by washed RBCs and plasma proteins while it was extensively hydrolyzed in plasma containing white blood cells and platelets. The negligible hydrolysis of esmolol in RBCs is supported by its poor hydrolysis by esterase D, the sole cytosolic esterase in RBCs. In human liver microsomes, esmolol was rapidly hydrolyzed according to Michaelis-Menten kinetics, and its hepatic clearance, calculated by the well-stirred model, was limited by hepatic blood flow. An inhibition study and a hydrolysis study using individual recombinant esterases showed that human carboxylesterase 1 isozyme (hCE1) is the main metabolic enzyme of esmolol in both white blood cells and human liver. These studies also showed that acyl protein thioesterase 1 (APT1) is involved in the cytosolic hydrolysis of esmolol in the liver. The hydrolysis of esmolol by hCE1 and APT1 also results in its pulmonary metabolism, which might be a reason for its high total clearance (170-285 mL/min/kg bodyweight), 3.5-fold greater than cardiac output (80.0 mL/min/kg bodyweight).

Anaesthetic management in a dog with constrictive pericarditis complicated with bi‐atrial enlargement and atrial fibrillation undergoing subtotal pericardiectomy

AbstractA 2‐year 8‐month‐old female dobermann presented for a recheck after previous crown reduction and vital pulp therapy. On cardiac auscultation, rapid and irregularly irregular heart rhythm and irregular and asynchronous pulses were detected. On electrocardiogram and transthoracic echocardiogram, findings were suggestive of constrictive pericarditis complicated with bi‐atrial enlargement and atrial fibrillation. Subtotal pericardiectomy was performed. The patient was premedicated with methadone (0.2 mg/kg intravenously), and anaesthesia was induced with midazolam (0.2 mg/kg intravenously) and propofol (60 mg), and maintained with isoflurane in oxygen. Constant‐rate infusions of fentanyl (0.1–0.2 µg/kg/min) and lidocaine (50 µg/kg/min) were administered. Dobutamine (1–5 µg/kg/min) helped to maintain mean arterial blood pressure above 65 mmHg. Fluid resuscitation and noradrenaline infusion (0.1 µg/kg/min) started after constriction was released to optimise preload. Haemodynamic support and ventricular rate control continued during the immediate postoperative period. Recovery from general anaesthesia was uneventful.

Atrial fibrillation-induced tachycardiomyopathy and heart failure: an underappreciated and elusive condition.

Many patients with persistent, chronic, or frequently recurring paroxysmal atrial fibrillation (AF) may develop a tachycardiomyopathy (TCM) with left ventricular (LV) dysfunction and heart failure (HF), which is reversible upon restoration and maintenance of sinus rhythm, when feasible, or via better and tighter ventricular rate (VR) control. Mechanisms involved in producing this leading cause of TCM (AF-TCM) include loss of atrial contraction, irregular heart rate, fast VR, neurohumoral activation, and structural myocardial changes. The most important of all mechanisms relates to optimal VR control, which seems to be an elusive target. Uncontrolled AF may also worsen preexisting LV dysfunction and exacerbate HF symptoms. Data, albeit less robust, also point to deleterious effects of slow VRs on LV function. Thus, a J-shaped relationship between VR and clinical outcome has been suggested, with the optimal VR control hovering at ~ 65bpm, ranging between 60 and 80bpm; VRs above and below this range may confer higher morbidity and mortality rates. A convergence of recent guidelines is noted towards a stricter rather than a more lenient VR control with target heart rate &lt; 80bpm at rest and &lt; 110bpm during moderate exercise which seems to prevent TCM or improve LV function and exercise capacity and relieve TCM-related symptoms and signs. Of course, restoring and maintaining sinus rhythm is always a most desirable target, when feasible, either with drugs or more likely with ablation. All these issues are herein reviewed, current guidelines are discussed and relevant data are tabulated and pictorially illustrated.

Abstract 11706: His Bundle Pacing and Atrioventricular Nodal Ablation in the Management of Refractory Atrial Fibrillation, a Systematic Review and Meta-Analysis

Introduction: Ventricular rate control is critical in management of atrial fibrillation (AF). When pharmacologic therapy fails in controlling the ventricular rate, atrioventricular nodal ablation (AVNA) and pacing is considered an effective therapy for symptomatic management. His bundle pacing (HBP) is considered a physiologic mode of pacing with AVNA ensuring synchronized activation of right and left ventricles preserving ventricular functioning. Hypothesis: HBP and AVNA are feasible, safe, and effective for management of refractory AF. Methods: We identified 218 studies after literature review of EMBASE, Medline, and Cochrane databases. Our analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. Results: Six studies (two randomized controlled trials, four observational cohorts) were included in the final meta-analyses. A total of 275 patients underwent attempted permanent HBP and AVNA. The mean age of patients was 70.74 (SD 4.38; 95% CI 62.15-79.32). Mean implant success rate for acute HBP was 94.5% (SD 10.12; 95% CI 74.70, 100.00). Selective HBP was noted in 44.7% (95% CI 12.5-76.9), while Non-selective-HBP was noted at rate of 42.2% (95% CI 10.2-74.2). The mean follow-up duration was 21.71 months (SD 3.77; 95% CI 14.32-29.11). All-cause mortality had a pooled proportion of 0.107 (SD 0.110, 95% CI -0.109-0.323); hospitalization proportion was 0.078 (SD 0.072; 95% CI -0.063-0.219). We noted a significant improvement in left ventricular ejection fraction (LVEF) (Baseline [BL] 41.84%, Follow-up [FU] 53.63%, Standardized mean difference [SMD] 0.646, p 0.028), NYHA class (BL 2.77, FU 1.55, SMD -2.542, p &lt;0.001) and LV end diastolic volume (SMD -0.495, 95% CI -0.721, -0.269, p &lt;0.001). We found a significant rise of threshold potential (BL 1.12 V, FU 1.49 V, SMD 0.393, p &lt;0.001 and an increase between baseline and follow up QRS duration (BL 102.21 ms, FU 106.90 ms, SMD 0.646, p 0.028). Conclusion: HBP and AVNA are feasible, safe, effective and has high success rate for management of refractory AF. Further studies are needed to evaluate its role in comparison to left bundle branch area pacing and cardiac resynchronization therapy to evaluate comparative efficacy in refractory AF.

Efficacy of propafenone vs. amiodarone in pharmacological cardioversion of recent-onset atrial fibrillation to sinus rhythm: a pooled meta-analysis of 9 randomized controlled trials

Abstract Background Atrial fibrillation (AF) is the most common sustained cardiac dysrhythmia and is associated with substantial morbidity and mortality. It can be managed either through ventricular rate control or conversion to sinus rhythm while for the patients with recent onset of AF, the latter is the recommended choice of treatment. Purpose To determine crude rates and the likelihood of conversion to sinus rhythm from recent-onset AF and mean difference in time to do so with respect if pharmacological cardioversion with propafenone or amiodarone is utilized. Methods MEDLINE and EMBASE electronic databases were searched and after exclusion criteria were applied, a total of 94 potential studies were identified, while 9 randomized controlled trials (RCTs) were included in the meta-analysis. These RCTs were conducted from 1994 until 2019 and investigated the use of oral/intravenous propafenone vs. amiodarone to convert recent-onset AF to sinus rhythm. The main outcome measures were a) likelihood of sinus rhythm restoration and for this analysis, an odds ratio (OR) with 95% confidence interval (95% CI) was reported, and b) mean time to sinus rhythm conversion between two treatment groups and the outcome measure for this endpoint was a mean difference (MD, in minutes). In both instances, OpenMeta[Analyst] software was used to perform meta-analysis while random-effects model was used with a restricted maximum likelihood-REML correction factor. Heterogeneity between RCTs was examined by the I2 test. Results A total of 9 RCTs pooled 822 patients, 410 randomized to propafenone and 412 to amiodarone treatment. All trials reported conversion rates while 7 trials reported on the time needed to reach sinus rhythm. Of these, only trials measuring conversion time during 12 to 24 hours were considered. Seven trials monitored patients for conversion during the 24 hours, one trial up until 12 hours, and 1 trial up to 8 hours. In most trials, recent-onset AF was defined as lasting ≤48 hours, and most were designed to perform intravenous drug comparisons. On average, conversion to sinus rhythm was achieved in 76.1% cases treated with propafenone and 71.8% cases treated with amiodarone. Propafenone use was non-significantly associated with a higher likelihood of conversion to sinus rhythm compared to amiodarone (OR 1.26, 95% CI 0.825–1.912) and there was a low degree of heterogeneity observed between trials (I2=34.9%, P=0.139; Figure 1). On the other hand, treatment with propafenone was associated with a significantly shorter mean time to sinus rhythm conversion compared to amiodarone (MD −304 minutes, 95% CI −342 to −266) and there was no heterogeneity observed between included trials (I2=2.78%, P=0.440; Figure 2). Conclusion Propafenone and amiodarone are similarly efficacious in converting patients from recent-onset atrial fibrillation to sinus rhythm, however, propafenone acts significantly faster and cuts mean time to sinus rhythm for about 5 hours. Funding Acknowledgement Type of funding sources: None. Figure 1. Odds ratio for conversion to SRFigure 2. Mean difference in minutes to reach SR

Management strategies for atrial fibrillation and flutter in patients with transthyretin cardiac amyloidosis

Abstract Background Atrial fibrillation (AF) and flutter (AFL) are common in transthyretin cardiac amyloidosis (ATTR-CM). Ventricular rate control drugs in ATTR-CM are poorly tolerated but data addressing tolerability and efficacy of rhythm control strategies is limited. Purpose We report characteristics and outcomes of AF/AFL in a cohort with ATTR-CM. Methods A single center observational study of patients seen at our Amyloidosis Center with wild-type or hereditary ATTR-CM diagnosed between 2005–2019. Treatment was prescribed as per treating cardiologists. Results Eighty-four patients with ATTR-CM (average age 74±10 years, 94% male) had mean follow-up of 27.6±22.8 months. AF/AFL occurred in 61 patients (73%). Clinically significant rapid ventricular response (RVR) was common as well attempted rate control with AV node blockers (Table 1). However, discontinuation was frequent (80%), often for adverse effects of hypotension (33%), bradycardia (15%), or presyncope/syncope (10%). Rhythm control was initiated in 64%, most often with cardioversion (DCCV) or ablation (Table 2). Post-DCCV recurrence was common (91%) and time to recurrence did not differ with use of anti-arrhythmic drugs (AAD; 5.8 months (IQR 1.9–12.5) vs without AAD 6.2 months (IQR 1.9–12.5) p=0.83). TEE was performed for 33% of DCCV with thrombus seen in 11% of cases – all patients who were not anticoagulated at the time. TEE was otherwise deferred due to known AF/AFL duration &amp;lt;48 hours (13%) or adequate anticoagulation (54%). Ablation was performed in 23% of patients with AFL (all for typical AFL) with 2 patients (14%) having recurrence after mean of 60.9 months. Pulmonary vein isolation for AF was performed in 12% (86% for persistent AF) with 86% recurrence after median of 6.2 months (IQR 5.6–12.3). Most patients (62%) with rhythm control had subjective improvement (≥1 NYHA class or resolved palpitations). Among AAD, amiodarone was most well tolerated with only 8% of patient discontinuing due to side effects. DCCV and ablation resulted in no direct complications although one patient had a perforation of a previously unknown Zenker diverticulum during TEE pre-DCCV. Conclusions In our ATTR-CM cohort, AF/AFL was common. Rate control was poorly tolerated and often abandoned. While rhythm control of AF/AFL had a favorable safety profile and successful conversion to sinus rhythm led to symptomatic improvement in a majority of cases, durable success with rhythm control was limited, often requiring multiple therapies. DCCV is only modestly successful and not significant improved with AAD. Ablation was successful in cases of cavo-tricuspid isthmus dependent AFL but had limited success in AF. Funding Acknowledgement Type of funding sources: None.

Antiarrhythmic therapy for atrial fibrillation: current guidelines of the European Society of Cardiology and the European Association for Cardio-Thoracic Surgery (ESC/EACTS)

The treatment of atrial fibrillation (AF) remains one of the most difficult tasks in modern cardiology. In 2020, the European Society of Cardiology (ESC), together with the European Association for Cardio-Thoracic Surgery (EACTS), published guidelines for the diagnosis and management of AF, which include several new directives.ESC experts have formulated a novel concept for treatment of AF patients. The first component of treatment ‘A' (Anticoagulation/ Avoid stroke) is anticoagulant therapy in patients with increased risk of thromboembolic events. The second line of treatment ‘B' (Better symptom control) is the control of arrhythmia symptoms, selection of a rhythm control strategy or ventricular rate control. The third direction ‘C' includes cardiovascular risk factors and comorbid conditions management.The most challenging tasks in AF treatment are the control of arrhythmia symptoms. As in the previous version of 2016 guidelines, the latest ones identify 2 following strategies in treatment of AF: rhythm control and ventricular rate control.According to the current ESC/EACTS guidelines (2020), antiarrhythmic therapy continues to be one of the important directions in AF management. Early prescription f antiarrhythmic and anticoagulant agents with an increased risk of thromboembolic events, catheter ablation can not only improve the quality of life, but also the prognosis of patients with AF.

Transcriptomic Profiling of Canine Atrial Fibrillation Models After One Week of Sustained Arrhythmia.

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Nuances of Cardiac Resynchronization Therapy in Patients with Dilated Cardiomyopathy and Atrial Fibrillation (a Clinical Case)

Dilated cardiomyopathy (DCM) is a steadily developing disease characterized by progressive chronic heart failure (CHF) resistant to drug therapy. Cardiac resynchronization therapy (CRT) significantly improves the prognosis in these patients if they have indications for implantation of resynchronization devices. The article presents a clinical case of successful implantation of a cardioversion-defibrillation cardiac resynchronization device in a patient suffering from DCM in combination with permanent atrial fibrillation (AF). The nuances of ventricular rate control and the role of the catheter procedure for modifying the atrioventricular junction are discussed.

Occipitoatlantal decompression and noninvasive vagus nerve stimulation slow conduction velocity through the atrioventricular node in healthy participants.

Management of atrial fibrillation includes either rhythm control that aims at establishing a sinus rhythm or rate control that aims at lowering the ventricular rate, usually with atrioventricular nodal blocking agents. Another potential strategy for ventricular rate control is to induce a negative dromotropic effect by augmenting cardiac vagal activity, which might be possible through noninvasive and nonpharmacologic techniques. Thus, the hypothesis of this study was that occipitoatlantal decompression (OA-D) and transcutaneous auricular vagus nerve stimulation (taVNS) not only increase cardiac parasympathetic tone as assessed by heart rate variability (HRV), but also slow atrioventricular conduction, assessed by the PQ-interval of the electrocardiogram (EKG) in generally healthy study participants without atrial fibrillation. To test whether OA-D and/or transcutaneous taVNS, which have been demonstrated to increase cardiac parasympathetic nervous system activity, would also elicit a negative dromotropic effect and prolong atrioventricular conduction. EKGs were recorded in 28 healthy volunteers on three consecutive days during a 30min baseline recording, a 15min intervention, and a 30min recovery period. Participants were randomly assigned to one of three experimental groups that differed in the 15min intervention. The first group received OA-D for 5min, followed by 10min of rest. The second group received 15min of taVNS. The intervention in the third group that served as a time control group (CTR) consisted of 15min of rest. The RR- and PQ-intervals were extracted from the EKGs and then used to assess HRV and AV-conduction, respectively. The OA-D group had nine participants (32.1%), the taVNS group had 10 participants (35.7%), and the CTR group had nine participants (32.1%). The root mean square of successive differences between normal heartbeats (RMSSD), an HRV measure of cardiac parasympathetic modulation, tended to be higher during the recovery period than during the baseline recording in the OA-D group (mean±standard error of the mean [SEM], 54.6±15.5 vs. 49.8±15.8ms; p<0.10) and increased significantly in the taVNS group (mean±SEM, 28.8±5.7 vs. 24.7±4.8ms; p<0.05), but not in the control group (mean±SEM, 31.4±4.2 vs. 28.5±3.8ms; p=0.31). This increase in RMSSD was accompanied by a lengthening of the PQ-interval in the OA-D (mean±SEM, 170.5±9.6 vs. 166.8±9.7ms; p<0.05) and taVNS (mean±SEM, 166.6±6.0 vs. 162.1±5.6ms; p<0.05) groups, but not in the control group (mean±SEM, 164.3±9.2 vs. 163.1±9.1ms; p=0.31). The PQ-intervals during the baseline recordings did not differ on the three study days in any of the three groups, suggesting that the negative dromotropic effect of OA-D and taVNS did not last into the following day. The lengthening of the PQ-interval in the OA-D and taVNS groups was accompanied by an increase in RMSSD. This implies that the negative dromotropic effects of OA-D and taVNS are mediated through an increase in cardiac parasympathetic tone. Whether these findings suggest their utility in controlling ventricular rates during persistent atrial fibrillation remains to be determined.