Direct Current Cardioversion Research Articles

Comparison of Bolus Dosing of Methohexital and Propofol in Elective DirectCurrent Cardioversion.

Background Methohexital and propofol can both be used as sedation for direct current cardioversion (DCCV). However, there are limited data comparing these medications in this setting. We hypothesized that patients receiving methohexital for elective DCCV would be sedated more quickly, recover from sedation faster, and experience less adverse effects. Methods and Results This was a prospective, blinded randomized controlled trial conducted at a single academic medical center. Eligible participants were randomly assigned to receive either methohexital (0.5 mg/kg) or propofol (0.8 mg/kg) as a bolus for elective DCCV. The times from bolus of the medication to achieving a Ramsay Sedation Scale score of 5 to 6, first shock, eyes opening on command, and when the patient could state their age and name were obtained. The need for additional medication dosing, airway intervention, vital signs, and medication side effects were also recorded. Seventy patients who were randomized to receive methohexital (n=37) or propofol (n=33) were included for analysis. The average doses of methohexital and propofol were 0.51 mg/kg and 0.84 mg/kg, respectively. There were no significant differences between methohexital and propofol in the time from end of injection to loss of conscious (1.4±1.8 versus 1.1±0.5 minutes; P=0.33) or the time to first shock (1.7±1.9 versus 1.4±0.5 minutes; P=0.31). Time intervals were significantly lower for methohexital compared with propofol in the time to eyes opening on command (5.1±2.5 versus 7.8±3.7 minutes; P=0.0005) as well as at the time to the ability to answer simple questions of age and name (6.0±2.6 versus 8.6±4.0 minutes; P=0.001). The methohexital group experienced less hypotension (8.1% versus 42.4%; P<0.001) and less hypoxemia (0.0% versus 15.2%; P=0.005), had lower need for jaw thrust/chin lift (16.2% versus 42.4%; P=0.015), and had less pain on injection compared with propofol using the visual analog scale (7.2±9.7 versus 22.4±28.1; P=0.003). Conclusions In this model of fixed bolus dosing, methohexital was associated with faster recovery, more stable hemodynamics, and less hypoxemia after elective DCCV compared with propofol. It can be considered as a preferred agent for sedation for DCCV. Registration URL: https://www.clinicaltrials.gov/ct; Unique identifier: NCT04187196.

Atrial flutter and fibrillation in patients with pulmonary arterial hypertension or chronic thromboembolic pulmonary hypertension in the ASPIRE registry: Comparison of rate versus rhythm control approaches

BackgroundThe development of atrial flutter and fibrillation (AFL/AF) in patients with pre-capillary pulmonary hypertension has been associated with an increased risk of morbidity and mortality. Rate and rhythm control strategies have not been directly compared. MethodsEighty-four patients with pulmonary arterial hypertension (PAH) or chronic thromboembolic pulmonary hypertension (CTEPH) with new-onset AFL/AF were identified in the ASPIRE registry. First, baseline characteristics and rates of sinus rhythm (SR) restoration of 3 arrhythmia management strategies (rate control, medical rhythm control and DC cardioversion, DCCV) in an early (2009–13) and later (2014–19) cohort were compared. Longer-term outcomes in patients who achieved SR versus those who did not were then explored. ResultsSixty (71%) patients had AFL and 24 (29%) AF. Eighteen (22%) patients underwent rate control, 22 (26%) medical rhythm control and 44 (52%) DCCV. SR was restored in 33% treated by rate control, 59% medical rhythm control and 95% DCCV (p < 0.001). Restoration of SR was associated with greater improvement in functional class (FC) and Incremental Shuttle Walk Distance (p both <0.05). It also independently predicted superior survival (3-year survival 62% vs 23% in those remaining in AFL/AF, p < 0.0001). In addition, FC III/IV independently predicted higher mortality (HR 2.86, p = 0.007). Right atrial area independently predicted AFL/AF recurrence (OR 1.08, p = 0.01). DCCV was generally well tolerated with no immediate major complications. ConclusionsRestoration of SR is associated with superior functional improvement and survival in PAH/CTEPH compared with rate control. DCCV is generally safe and is more effective than medical therapy at achieving SR.

The Predictive Value of the Left Atrial Kinetic Energy for Atrial Fibrillation Recurrence.

Background and aimDetermining which patients will experience recurrence of atrial fibrillation (AF) is crucial for treatment modification. This study aimed to investigate the predictive value of left atrial kinetic energy (LAKE) in AF recurrence.Materials and methodsA total of 120 consecutive patients who achieved sinus rhythm (SR) with electrical direct current cardioversion and met the inclusion criteria were included in the study. Transthoracic echocardiography (TTE) and LAKE values were calculated on the first day after cardioversion. Rhythm control was performed with 12-lead electrocardiography in the first-month follow-up.ResultsWhile 81 (67.5%) patients were in SR at one month, AF recurrence was detected in 39 (32.5%) patients. In the AF group, AF duration, cardioversion energy, number of diabetic patients, left atrium (LA) diameter, LA pre-mitral A wave volume, LA minimum volume, and pulmonary artery pressure values were significantly higher than in the SR group, while mitral A wave velocity and LAKE values were significantly lower. In multivariate regression analysis, AF duration (OR: 1.54; 95% CI: 1.22 - 1.93; p < 0.001), LA diameter (OR: 1.33; 95% CI: 1.10 - 1.61; p = 0.002), and LAKE (OR: 0.96; 95% CI: 0.94 - 0.99; p = 0.007) were determined to be independent predictors of AF recurrence at one month.ConclusionsLA diameter, AF duration, and LAKE were found to be significant predictors of AF recurrence after cardioversion.

Unstable Atrial Fibrillation RVR and DNR: A Challenging Ethical Dilemma

An 82-year-old man with history of dementia and atrial fibrillation (AF) was admitted for sepsis and subsequently developed AF with rapid ventricular response (RVR). Given a recent do not resuscitate (DNR) order, there was disagreement among providers regarding the use of direct current cardioversion (DCCV). This patient case reveals the ethical challenges faced by providers when patients with a DNR order develop unstable AF with RVR and discusses an ethical framework for decision-making regarding DCCV in patients with a DNR order. This case also promotes changes to clinical practice, such as discussing DCCV when discussing code status and replacing DNR with “no cardiopulmonary resuscitation.”

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.

Predictors of recurrence after catheter ablation and electrical cardioversion of atrial fibrillation: an umbrella review of meta-analyses.

The recurrence rates after catheter ablation (CA) and direct current (DC) cardioversion remain high, although they have been established treatments of rhythm control of atrial fibrillation (AF). This umbrella review systematically appraises published meta-analyses of both observational and randomized controlled trials (RCTs) for the association of risk and protective factors for arrhythmia recurrence after CA and DC cardioversion of AF. Three bibliographic databases were searched up to June 2021. Evidence of association was rated as convincing, highly suggestive, suggestive, weak, or not significant with respect to observational studies and as high, moderate, low, or very low with respect to RCTs, according to established criteria. Thirty-one meta-analyses were included. Of the 28 associations between CA and the risk of arrhythmia recurrence, none presented convincing evidence, and only the time from diagnosis to ablation over 1 year provided highly suggestive evidence. The association between hypertension and metabolic profile provided suggestive evidence. The associations of Class IC and III antiarrhythmic drugs use with the recurrence after DC cardioversion were supported by an intermediate level of evidence. Although AF is a major health issue, few risk- and protective factors for AF recurrence have been identified. None of these factors examined were supported by convincing evidence, whereas established factors such as female gender and left atrial volume showed only weak association. An early CA strategy combined with treatment of metabolic syndrome and hypertension prior to CA may reduce the risk of arrhythmia recurrence. The use of antiarrhythmics can increase the success rate of DC cardioversion. PROSPERO registry number: CRD42021270613.

Usefulness of the systemic immune-inflammation index in predicting atrial fibrillationrecurrence after direct current cardioversion.

Background: We aimed to determine whether there is a relationship between thesystemic immune-inflammation (SII) index and the recurrence of atrial fibrillation (AF) after successful direct current cardioversion (DCCV). Methods: The study included 99 patients with persistent AFwho underwent successful cardioversion between 2015 and 2020. Results: In multiple regression analyses, the SII index was found to be a better independent predictor of AF recurrence after successful DCCV (p<0.001). The cut-off value of SII (563) was associated with 96.9% sensitivity and 55.2% specificity to predict AF recurrence after DCCV. Conclusion: As a simple biomarker, SII index is an independent parameter for predicting AF recurrence after successful DCCV in patients with persistent AF. Also, SII levels can predict AF recurrence better than neutrophil-to-lymphocyte ratio.

Incidence of left atrial appendage thrombus despite 3 weeks of anticoagulation and the need for precardioversion echocardiography.

BackgroundOne of the most catastrophic complications of Atrial fibrillation (AF) is thromboembolic stroke. Current guidelines recommend that 3 weeks of anticoagulation is adequate prior to direct current cardioversion (DCCV) to prevent thromboembolism. Here we present data regarding, which anticoagulant is most likely to show a presence of an Left atrial appendage thrombus (LAAT) on trans esophageal echocardiogram (TEE) for DCCV despite 3 weeks of anticoagulation.ObjectiveTo investigate the effectiveness of both vitamin k antagonist (VKA) and direct oral anticoagulants (DOAC) in patients with AF as an anticoagulant for LAAT after 3 weeks of medication.MethodsThis is a single‐high volume tertiary center, where TEE precardioversion is the standard practice. We reviewed data over 10 months where DCCV was intended on individuals with AF who were fully anticoagulated for at least 3 weeks with either a VKA or taking a DOAC.ResultsThe data showed a statistical difference between patients who were fully anticoagulated for at least 3 weeks with VKA in comparison to DOACs. Patients on DOACs are significantly less likely to have an LAAT after at least 3 weeks of anticoagulation. OR = 0.04 (CI 95% 0.005–0.42; p‐value < .05). Despite anticoagulation for at least 3 weeks, 40% of our patients still had a LAAT.ConclusionOur data indicates that all patients should be required to undergo a TEE prior to DCCV. This data also adds to the current evidence and supports the use of DOAC in AF to prevent LAAT.

Left Ventricular Ejection Fraction Can Predict Atrial Thrombosis Even in Non-High-Risk Individuals with Atrial Fibrillation.

Background—Current guidelines do not recommend routine use of transesophageal echocardiography (TOE) in anticoagulated patients with atrial fibrillation (AF). The aim of our study was to identify predictors for left atrial thrombosis (LAT) in patients with AF that would require TOE despite anticoagulation therapy, using clinical, laboratory and echocardiographic data which are usually obtained in those patients in a real-world setting. Methods—We analyzed data from electronic medical records (EMR) of consecutive AF patients referred to two university hospitals between January 2014 and December 2017 for pulmonary vein isolation (PVI) or direct current cardioversion. The primary endpoint was the presence of left atrial thrombus on TOE. Multivariable and univariable logistic regression models were computed using variables that were significantly different between the LAT and the control groups. Results—A total of 838 patients were included, of whom 132 (15.8%) had LAT. After controlling for other variables, only the left ventricle ejection fraction (LVEF) remained statistically significant with an OR of 0.956 (95% CI 0.934–0.979), p < 0.01. Regression models including LVEF had significantly higher areas under the receiver operating characteristic (ROC) curves, including in subgroups with non-high thromboembolic risk (CHA2DS2-Vasc = 0 or 1), with an area under the curve (AUC) of 0.76 (95% CI 0.71–0.81), p < 0.0001. Conclusions—The LVEF is an independent predictor of LAT, and it might improve thromboembolic risk stratification in future models. LVEF significantly increased the predictive value of the CHA2DS2-Vasc model and was able to identify LAT in non-high-risk patients.

Novel use of intraprocedural ibutilide during atrioventricular nodal reentrant tachycardia ablation

Abstract Atrial fibrillation (AF) is known to occur during electrophysiology studies during the induction of supraventricular tachycardia, especially with isoprenaline. If AF is sustained ablation becomes challenging. DC cardioversion (DCCV) is preferred as medications like amiodarone alters subsequent analysis. We report a 45-year-old female with atrioventricular nodal reentrant tachycardia (AVNRT) (induced with isoprenaline), who developed spontaneous AF, which recurred several times (despite successful DCCV). It was finally controlled with ibutilide. She was taken up after 1 h when AVNRT could be reinduced without any occurrence of AF. The AV nodal property was altered minimally. Radiofrequency ablation could be successfully performed. This is the first report of ibutilide-aided AVNRT ablation, which appears feasible and does not affect inducibility.

Wolff–Parkinson–White syndrome with supraventricular tachycardia

Abstract Wolff–Parkinson–White (WPW) syndrome is a congenital abnormality of the cardiac conducting system. In the general population, its prevalence is 0.15%–0.3%, with supraventricular tachycardia (SVT) being the most common rhythm disorder associated with it. SVT is the most common cardiac arrhythmia in children that requires therapy. It occurs because an accessory conduction pathway allows atrioventricular impulses to reenter the normal conduction pathway, thus completing a circuit that stimulates the atrium and ventricle at a rapid rate. Symptoms are nonspecific but could be life-threatening in infants, necessitating prompt intervention and prophylaxis. Cardioversion by pharmacologic or synchronized direct current (DC) is indicated in life-threatening or refractory arrhythmias. We report a 16-month-old Nigerian girl who had WPW syndrome and developed SVT that required synchronized DC cardioversion.

Length of stay and cost of care associated with admissions for atrial fibrillation among patients with cancer

BackgroundThe aim of this study is to assess the burden of AF-related hospitalizations inclusive of inflation-adjusted cost-of-care and length-of-stay (LOS) among cancer patients and the impact of direct current cardioversion (DCCV) on these outcomes.MethodsUsing the National Inpatient Sample (NIS), patients hospitalized with either a primary or secondary diagnosis of AF and comorbid cancer were identified and both cost of hospitalization and LOS were evaluated for each group. Subgroup analyses were performed for specific cancer types (breast, lung, colon, prostate and lymphoma), and those receiving DCCV.ResultsThe prevalence of co-morbid AF was 8.2 million (16%) and 35.5 million (10%) among those with vs. those without cancer, respectively (odds ratio = 1.6, 95% confidence interval = 1.5–1.7; P < 0.001). Over time, both primary and prevalent AF admissions among those with comorbid cancer increased from 1.1% and 12.3% in 2003 to 1.5% and 21% in 2015, respectively. The total cost of hospitalization increased 94.4% among those with AF and comorbid cancer compared to 23.9% among those without cancer. Among the subgroup of patients with comorbid cancer and primary admission for AF undergoing DCCV, length of stay (2.7 vs. 2.2 days; P < 0.001, model 1) and cost of care ($7,093 vs. 6,152; P < 0.001) were both significantly higher.ConclusionsAF related admissions are increasing for all populations especially amongst those patients with a comorbid diagnosis of cancer, including all cancer subtypes evaluated. Among those patients who underwent DCCV, cancer patients had longer length of stay and increased health care costs.

ELECTRICAL STORM FOLLOWING CORONARY ARTERY BYPASS GRAFTING IN A PATIENT WITH HYPERTHYROIDISM: A CASE REPORT

An electrical storm, dened as repeated ventricular arrhythmia has been reported as a relatively rare but challenging event. We report a case of an electrical storm following coronary artery bypass grafting (CABG) surgery in a 49-year-old man with untreated hyperthyroidism. The patient underwent successful CABG surgery after being diagnosed with ST elevation myocardial infarction and three vessel disease of coronary artery. Six days after the operation, ventricular tachy-arrhythmias were continuously observed, and direct current cardioversions were performed more than 30 times over 24 hours. Based on laboratory test results, the patient had persistent hyperthyroidism, and we continued anti- thyroid therapy and anti-arrhythmic medication. Eventually, the patient was successfully treated with a second trial of catheter ablation. In conclusion, physicians must carefully manage thyroid function in patients undergoing cardiac surgery. We also recommend that cardiac surgery teams take a multidisciplinary perioperative approach to critical care for cardiac surgery.

Left atrial thrombus in atrial fibrillation/flutter patients in relation to anticoagulation strategy: LATTEE registry

Abstract Funding Acknowledgements Type of funding sources: None. Background Atrial fibrillation (AF) and flutter (AFl) increase the risk of thromboembolism by promoting clot formation in the left atrium. Current guidelines recommend initiation of oral anticoagulation (OAC) with vitamin K antagonists (VKAs) or, preferably, non-VKA-OACs (NOACs) in men and women with a CHA2DS2VASc score of ≥2 and ≥3, respectively. Effective OAC is also recommended 3 weeks before elective AF cardioversion or catheter ablation with pre-procedural ttransesophageal echocardiography (TEE) as an alternative. However, TEE before AF/AFl cardioversion or ablation is often performed even in anticoagulated patients, given that, in clinical practice, "effective" OAC may be difficult to achieve and/or verify. Purpose The aim of the study was to assess the prevalence of left atrial thrombus (LAT) in AF/AFl in relation to OAC strategy. Methods The Left Atrial Thrombus on Transesophageal Echocardiography (LATTEE) registry was a prospective, observational study enrolling consecutive patients with AF or AFl in whom TEE was performed before direct current cardioversion or catheter ablation, hospitalized in 13 cardiology departments in Poland. Patients’ recruitment process started from November 2018 in the coordinating centre and lasted 12 months since the beginning of the study in each participating centre or longer, i.e., until the inclusion of at least 200 patients at each participating centre (with the last patient enrolled in May 2020). Results Of 3109 patients enrolled, 88% were on chronic, 1.5% on transient OAC and 10% without OAC. Of patients on chronic OAC, 39% received rivaroxaban, 30% dabigatran, 14% apixaban and 18% vitamin K antagonists (VKA). Patients on apixaban were oldest, had worst renal function and highest both bleeding and thromboembolic risk, and more often received reduced doses. Overall, prevalence of LAT was 8.0% (7.3% on chronic OAC vs. 15% without OAC; p&amp;lt;0.01). In patients on VKA, prevalence of LAT was doubled compared to patients on non-VKA-OACs (NOACs) (13% vs. 6.0%; p&amp;lt;0.01), even after propensity score matching (13% vs. 7.5%; p&amp;lt;0.01) and in multivariable logistic regression (OR 1.9, 95% confidence interval 1.4-2.8). Prevalence of LAT in patients on apixaban was higher (9.8%) than in those on rivaroxaban (5.7%) and dabigatran (4.7%; p&amp;lt;0.01 for both comparisons). However, in propensity score matching and multivariable logistic regression, there was no difference in the risk of LAT between apixaban and other NOACs. Conclusions Prevalence of LAT in AF is non-negligible even on chronic OAC. In the real-world AF/AFl population, the risk of LAT seems higher on VKA compared to NOAC, and similar between different NOACs.

Validation of a novel smartphone-based photoplethysmographic method for ambulatory heart rhythm diagnostics

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Vinnova - The Swedish Agency for Innovation Systems. Region Stockholm Innovation Fund. Introduction Devices for long-term and ambulatory recording of heart rhythm have limited availability within health care systems worldwide, potentially leading to missed diagnoses and limitations in peri-procedural heart rhythm management. As smartphones are becoming ubiquitous the availability of heart rhythm diagnostics and management of atrial fibrillation (AF) using smartphone photoplethysmography (PPG) compared to electrocardiography (ECG) is increasing. Previous validation studies of smartphone-PPG applications have all been performed under supervision in healthcare settings. In addition, no previous study has validated smartphone-PPG compared to simultaneous ECG recordings, with manual heart rhythm interpretation of the PPG recordings nor have they included patients with atrial flutter (AFL). Purpose The aim of this study was to validate a novel smartphone-PPG method for heart rhythm diagnostics in patients with AF and/or AFL when in use unsupervised in an ambulatory setting. Methods Unselected patients undergoing direct current cardioversion at a University Hospital for treatment of AF or AFL were asked to perform one-minute heart rhythm recordings post-treatment at least twice daily for 30 days in their home environment. All included were provided with an unmodified iPhone 7 smartphone running the CORAI Heart Monitor PPG application simultaneously with a single-lead ECG recording (KardiaMobile). PPG and ECG recordings were interpreted independently by two readers. Results In total 280 patients, with median age of 69.0 years (31% women) were included from November 2018 to July 2020 and registered 18 005 simultaneous PPG and ECG recordings. Of the PPG recordings 96.9% had sufficient quality for diagnosis compared to 95.1% of the ECG recordings (p &amp;lt; 0.001). Precardioversion ECG recordings were interpreted as AF in 82.1%, AFL in 14.3% and as having insufficient quality for diagnosis in 3.6% of the patients. After removal of recordings with insufficient quality 69.7% of ECG recordings were interpreted as sinus rhythm, 28.2% as AF and 2.1 % as AFL. Manual interpretation of the PPG recordings diagnosed AF/AFL (sensitivity) in 97.7% and sinus rhythm (specificity) in 99.4% of the recordings compared to manually interpreted ECG recordings, with an overall accuracy of 98.9%. Results excluding recordings interpreted as AFL on ECG or PPG diagnosed AF (sensitivity) in 99.0% and sinus rhythm (specificity) in 99.7% of the recordings, with an overall accuracy of 99.5%. Conclusion A novel smartphone-PPG method can be used by patients unsupervised in their home environment for accurate heart rhythm diagnostics of AF and AFL with high sensitivity and specificity.

Outcome Analysis in Elective Electrical Cardioversion of Atrial Fibrillation Patients: Development and Validation of a Machine Learning Prognostic Model.

Background: The integrated approach to electrical cardioversion (EC) in atrial fibrillation (AF) is complex; candidates can resolve spontaneously while waiting for EC, and post-cardioversion recurrence is high. Thus, it is especially interesting to avoid the programming of EC in patients who would restore sinus rhythm (SR) spontaneously or present early recurrence. We have analyzed the whole elective EC of the AF process using machine-learning (ML) in order to enable a more realistic and detailed simulation of the patient flow for decision making purposes. Methods: The dataset consisted of electronic health records (EHRs) from 429 consecutive AF patients referred for EC. For analysis of the patient outcome, we considered five pathways according to restoring and maintaining SR: (i) spontaneous SR restoration, (ii) pharmacologic-cardioversion, (iii) direct-current cardioversion, (iv) 6-month AF recurrence, and (v) 6-month rhythm control. We applied ML classifiers for predicting outcomes at each pathway and compared them with the CHA2DS2-VASc and HATCH scores. Results: With the exception of pathway (iii), all ML models achieved improvements in comparison with CHA2DS2-VASc or HATCH scores (p < 0.01). Compared to the most competitive score, the area under the ROC curve (AUC-ROC) was: 0.80 vs. 0.66 for predicting (i); 0.71 vs. 0.55 for (ii); 0.64 vs. 0.52 for (iv); and 0.66 vs. 0.51 for (v). For a threshold considered optimal, the empirical net reclassification index was: +7.8%, +47.2%, +28.2%, and +34.3% in favor of our ML models for predicting outcomes for pathways (i), (ii), (iv), and (v), respectively. As an example tool of generalizability of ML models, we deployed our algorithms in an open-source calculator, where the model would personalize predictions. Conclusions: An ML model improves the accuracy of restoring and maintaining SR predictions over current discriminators. The proposed approach enables a detailed simulation of the patient flow through personalized predictions.

CE-543-03 EARLY RHYTHM CONTROL IN PATIENTS WITH INCIDENT ATRIAL FIBRILLATION WHO HAD A PRIOR HISTORY OF STROKE: A NATIONWIDE POPULATION-BASED COHORT STUDY

Early rhythm control therapy has been demonstrated to be associated with a lower risk of stroke compared to usual care in patients with atrial fibrillation (AF). However, there are limited data regarding the benefit of early rhythm control therapy for secondary prevention for stroke in patients with AF. To compare the risk of recurrent stroke between early rhythm control therapy and usual care in patients with new-onset AF and a history of prior stroke. Using the Korean nationwide claims database, we identified patients who were newly diagnosed as AF and had a history of prior stroke. Patients who received rhythm control therapy, including antiarrhythmic drug (AAD), direct current cardioversion (DCC), or AF catheter ablation, within 1 year after incident AF were defined as the early rhythm control group, otherwise as the usual care group. The propensity score weighting method was used to balance baseline characteristics between the two groups. Incident stroke was evaluated as a primary outcome. A total of 53,509 patients were included (mean age 72±11 years, 53% men; mean CHA2DS2-VASc score 5.5±1.6). All patients were prescribed oral anticoagulants. Among the total study population, 12,455 patients were assigned to the early rhythm control group (AAD, DCC, and AF catheter ablation in 99.4%, 8.6%, and 3.9%, respectively), and 41,054 patients were in the usual care group. During a median 2.6 years (IQR 1.5 to 4.5 years) of follow-up, 4382 patients had an incident stroke (IR, 2.6 per 100 person-years). Early rhythm control was associated with a lower risk of recurrent stroke compared to usual care (hazard ratio, 0.720, 95% confidence interval, 0.666-0.779, p<0.001) (Figure). Early rhythm control consistently showed a lower risk of stroke than usual care regardless of the characteristics of prior stroke, whether recent, severe, and disabling stroke or not. In this large-scale observational cohort study, early rhythm control within 1 year after AF diagnosis might be beneficial to prevent recurrent stroke in patients with incident AF and a history of prior stroke. Integrated care, including optimal rhythm control with appropriate anticoagulation, should be considered for patients who had incident AF and a history of stroke to reduce the risk of recurrent stroke.

PO-674-03 INTRAVENOUS SOTALOL FOR ACUTE CONVERSION OF INTRA-ATRIAL-REENTRANT-TACHYCARDIA IN ADULTS WITH CONGENITAL HEART DISEASE

Intra-atrial-reentrant-tachycardia (IART) is a common source of morbidity in adults with congenital heart disease (ACHD). Most patients (pts) that present with IART are treated with direct current cardioversion (DCCV). There is limited data on the efficacy of intravenous (IV) anti-arrhythmics for acute conversion of IART in the ACHD population.

PO-654-08 EFFICACY AND SAFETY OF SINGLE DAY LOADING OF INTRAVENOUS SOTALOL PRIOR TO DIRECT CURRENT CARDIOVERSION FOR THE TERMINATION OF CARDIAC ATRIAL ARRHYTHMIAS: AN OBSERVATIONAL STUDY

Sotalol is an antiarrhythmic used to prevent atrial fibrillation (AF) and atrial flutter (AFl). Under its FDA indication, intravenous (IV) sotalol is administered as a single infusion reducing hospitalization from 3 days to 1 day compared to traditional oral loading. Sotalol may have a role as adjunct therapy prior to direct current cardioversion (DCCV).

Narrow vs Wide QRS Complex Tachycardia in a Patient With Wolf-Parkinson-White Syndrome.

Narrow vs Wide QRS Complex Tachycardia in a Patient With Wolf-Parkinson-White Syndrome.