Rhythm Control Medications Research Articles

Left Atrial Reservoir Strain and Recurrence of Atrial Fibrillation Following De-Novo Pulmonary Vein Isolation - Results of the ASTRA-AF Pilot Study.

Achieving early rhythm control and maintaining sinus rhythm are associated with improved outcomes in patients with atrial fibrillation (AF). Pulmonary vein isolation (PVI) is a validated alternative to medical rhythm control. This study determined associations between left atrial strain reservoir (LASR) and AF recurrence after PVI.Methods and Results: In all, 132 patients (88 with paroxysmal AF [PAF], 44 with persisting AF [PersAF]) who presented in sinus rhythm for de novo PVI of AF between December 2017 and January 2019 were included in the study. All patients underwent preprocedural echocardiography. After 12 months, all patients underwent 24-h Holter electrocardiogram monitoring to screen for AF recurrence. Kaplan-Meier curve analysis revealed an association between decreasing LASRand increased AF recurrence, with a cut-off at 31.4%. In univariable Cox regression analysis, LASRdemonstrated an association with AF recurrence, with hazard ratios (HR) of 0.83 (95% confidence interval [CI] 073-0.93; P=0.001) per 5% increase in univariable models and 0.83 (95% CI 073-0.95; P=0.005) in multivariable analysis. When clinical variables with age, sex and type of AF (PAF/PersAF) were included in the multivariable analysis, LASRremained relevant in a model with age (HR 0.86; 95% CI 073-1.00; P=0.046). In patients undergoing de novo PVI for AF, LASRcould be of use in risk stratification regarding AF recurrence.

COVID-19 pandemic and initiation of treatment for atrial fibrillation: a nationwide analysis of claims data

BackgroundThe COVID-19 pandemic profoundly disrupted the delivery of medical care. It remains unclear whether individuals diagnosed with new onset disease during the pandemic were less likely to initiate treatments after diagnosis. We sought to evaluate changes in the treatment initiation of patients newly diagnosed with atrial fibrillation (AF) after the onset of the COVID-19 pandemic.MethodsIn this retrospective cohort study, we identified individuals with incident AF from 01/01/2016–09/30/2021 using Optum’s de-identified Clinformatics® Data Mart Database. The primary outcome was initiation of oral anticoagulation (OAC) within 30 days of AF diagnosis. Secondary outcomes included initiation of OAC within 180 days of diagnosis, initiation of warfarin, direct oral anticoagulants (DOACs), rhythm control medications and electrical cardioversion within 30 days of diagnosis. We constructed interrupted time series analyses to examine changes in the outcomes following the onset of the pandemic.ResultsA total of 573,524 patients (age 73.0 ± 10.9 years) were included in the study. There were no significant changes in the initiation of OAC, DOAC, and rhythm control medications associated with the onset of the pandemic. There was a significant decrease in initiation of electrical cardioversion associated with the onset of the pandemic. The rate of electronic cardioversion within 30 days of diagnosis decreased by 4.9% per 1,000 patients after the onset of the pandemic and decreased by about 35% in April 2020, compared to April 2019, from 5.53% to 3.58%.ConclusionThe COVID-19 pandemic did not affect the OAC initiation within 30 days of AF diagnosis but was associated with a decline in the provision of procedures for patients newly diagnosed with AF.

Comparison of early rhythm control strategies in patients with atrial fibrillation: a nationwide population-based cohort study

Abstract Background Early rhythm control within 1-year after atrial fibrillation (AF) diagnosis is associated with a lower risk of major adverse cardiovascular event (MACE). Recently, AF catheter ablation (AFCA) using cryoballoon ablation as initial therapy has been demonstrated to be superior to drug therapy for the prevention of AF recurrence in patients with paroxysmal AF. However, there is still lack of evidence whether AFCA for the method of early rhythm control is superior to medical rhythm control therapy for the reduction of MACE risk. Purpose To evaluate the association between rhythm control treatment and the risk of MACE for early rhythm control in AF patients Methods Using a Korean nationwide claims database, patients with AF who received rhythm control therapy including antiarrhythmic agents (AAD), direct current cardioversion (DCC), and AF catheter ablation (AFCA, radiofrequency ablation or cryoballoon ablation) within 1-year after AF onset between 2011 and 2020 were included. According to rhythm control treatment, patients were categorized two groups as follow: (1) medical rhythm control group who prescribed AAD or underwent DCC, and (2) AFCA group who underwent radiofrequency or cryoballoon ablation. The primary outcome was MACE, the composite of ischemic stroke, admission for heart failure (HF), and myocardial infarction (MI). For the safety outcome, the composite of cardiac tamponade, syncope, sick sinus syndrome, atrioventricular block, pacemaker implantation, and sudden cardiac arrest was evaluated. Multivariable Cox regression analysis were performed. Results A total of 229,056 pateints were included (mean age 67.3±13.6 and 59.4% of men). Mean duration from new AF diagnosis to rhythm control treatment was 29.1±69.2 days. Among total, 221,952 patients received medical rhythm control and 7104 patients received AFCA. Compared to medical rhythm control group, AFCA group was associated with lower risks of ischemic stroke, admission for HF, and MI (adjusted hazard ratio [95% confidence interval]: 0.342 [0.287-0.408], p<0.001 for ischemic stroke, 0.356 [0.282-0.451], p<0.001 for admission for HF, and 0.640 [0.452-0.906], p=0.011 for MI) (Figure A). AFCA for early rhythm control showed a significantly lower risk of MACE than medical early rhythm control (0.328 [0.283-0.380], p<0.001, Figure A). Compared to medical rhythm control, AFCA showed a similar risk for safety outcome (1.197 [0.920-1.556], p=0.180). Among AFCA group, cryoballoon ablation showed comparable risks of ischemic stroke (0.465 [0.113-1.922], p=0.290), admission for HF (0.262 [0.035-1.936], p=0.189), MI (0.823 [0.100-6.767], p=0.856), and MACE (0.449 [0.164-1.228], p=0.118) with radiofrequency ablation (Figure B). Conclusion Regarding on the method of early rhythm control for AF, catheter ablation of AF might reduce the risk of MACE without a significant increase of safety outcome to medical rhythm control. Further results from randomized clinical trials are needed.

In patients with atrial fibrillation, are rhythm control medications superior to rate control medications in decreasing mortality?

In patients with atrial fibrillation, are rhythm control medications superior to rate control medications in decreasing mortality?

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.

Atrial fibrillation in patients with an atrial septal defect in a single centre cohort during a long clinical follow-up: its association with closure and outcome of therapy

ObjectiveCurrently, consensus is lacking on the relation between closure of atrial septal defect (ASD) and the incidence of atrial fibrillation (AF), which is a known complication in ASD patients. More...

BMI differences among in-hospital management and outcomes in patients with atrial fibrillation: findings from the Care for Cardiovascular Disease project in China

BackgroundUnderweight or obese status influences the prognosis of atrial fibrillation (AF). However, the association between stratification of body mass index (BMI) and in-hospital outcomes in patients with AF, remains lacking in China.MethodsUsing data from the Improving Care for Cardiovascular Disease in China-AF project, which was launched in February 2015 and recruited 150 hospitals in China, we compared characteristics, in-hospital treatments and clinical outcomes among the stratifications of BMI for Asians.ResultsA total of 15,867 AF patients with AF were enrolled, including 830 (5.23%) underweight, 4965 (31.29%) with normal weight, 3716 (23.42%) overweight, 5263 (33.17%) obese class I and 1093 (6.89%) obese class II participants. Compared with normal weight patients, underweight, overweight, and obese patients showed increased percentages of CHADS2 scores (3–6) and CHA2DS2-VASc scores (5–9). During hospitalization, overweight or obese patients showed greater use of rhythm control medications, anticoagulant drugs, and intervention therapies than underweight–normal weight patients. In adjusted logistic models, BMI was a strong predictor of in-hospital mortality. Especially, underweight BMI was associated with higher incidence of in-hospital mortality, with an adjusted odds ratio of 2.08 (95% confidence interval, 1.56–4.46; p = 0.04) than overweight and obese BMI.ConclusionsAsian patients with AF and high BMI received more medical treatments and presented less adverse in-hospital outcomes compared with those with underweight–normal weight. Although low BMI may be associated with other comorbidities and advanced age, underweight BMI retained a negative correlation with all-cause mortality in the patients with AF during hospitalization.

Impact of atrial fibrillation catheter ablation on mortality, stroke, and heart failure hospitalizations: A meta-analysis.

The impact of atrial fibrillation catheter ablation (AFCA) on hard clinical endpoints remains controversial. Our aim was to conduct a random-effect model meta-analysis on efficacy data from high-quality large matched database/registry studies and randomized clinical trials. We compared long-term all-cause mortality, stroke, and hospitalization for heart failure in patients undergoing AFCA vs patients treated with medical therapy alone (rhythm and/or rate control medications) in a general AF population. PubMed/MEDLINE and Embase databases were screened and a total of nine studies were selected (one randomized clinical trial-CABANA-and eight large matched population studies). A total of 241 372 patients (27 711 in the ablation group, 213 661 in the nonablation group) were included. After a median follow-up of 3.5 years, AFCA decreased the risk of mortality (hazard ratio [HR], 0.62; 95% confidence interval [CI], 0.54-0.72; I2 = 54%; number needed to treat [NNT] = 28), stroke (HR, 0.63; 95% CI, 0.56-0.70; I2 = 23%; NNT = 59) and hospitalization for heart failure (HR, 0.64; 95% CI, 0.51-0.80; I2 = 28%; NNT = 33) compared with AF patients treated with medical therapy alone. Based on the currently available efficacy and effectiveness evidence, AFCA significantly reduces the risk of death, stroke, and hospitalization compared with medical therapy alone.

Anaphylaxis-induced atrial fibrillation and anesthesia: Pathophysiologic and therapeutic considerations.

Atrial fibrillation is the most common cardiac arrhythmia in western society affecting more than 35 million individuals worldwide annually. It is a common postoperative complication and may also occur spontaneously during general and local anesthesia administration. Aging, diabetes mellitus, hypertension, and cardiovascular diseases including cardiomyopathies, congenital cardiac anomalies, heart failure, myocardial ischemia, pericarditis, previous cardiac surgery, vascular disease, and valvular heart disease are some correlated factors. Beyond age, increased incidence of atrial fibrillation has been correlated to autoimmune system activation as it is the underlying mechanism of persistent atrial fibrillation development. Current research supports an association between the complement system activation and lymphocyte-pro-inflammatory cytokines release with the cardiac conduction system and atrial fibrosis. The loss of CD28 antigen from CD4+ CD28+ T lymphocytes seems to play a major role in atrial fibrillation development and prognosis. Except atrial fibrillation, a variety of additional electrocardiographic changes, resembling those with digitalis intoxication may accompany anaphylaxis and particularly Kounis syndrome. Histamine is one well-known mediator in allergic and inflammatory conditions as physiologically regulates several cardiovascular and endothelial functions with arrhythmogenic potential. The increased oxidative stress, measured by the redox potentials of glutathione, has been correlated with atrial fibrillation incidence and prevalence. The use of antazoline, a first-generation antihistamine agent used for rapid conversion of recent-onset atrial fibrillation in patients with preserved left ventricular function and for rapid atrial fibrillation termination during accessory pathway ablation denotes that anaphylaxis-induced histamine production could be the cause of atrial fibrillation at least in some instances. The anaphylaxis diagnosis in anesthesia can be challenging owing to the absence of cutaneous manifestetions such as flushing, urticaria, or angioedema. Anticoagulation for stroke prevention, rate and rhythm control medications, invasive methods such as radiofrequency ablation or cryoablation of pulmonary veins as well surgical ablation constitute the treatment basis of atrial fibrillation. Understanding the underlying mechanisms of atrial fibrillation by cardiologists, anesthesiologists and surgeons, as well as potential treatments, to optimize care is of paramount importance.

Cost-Effectiveness of Rate- and Rhythm-Control Drugs for Treating Atrial Fibrillation in Korea.

PurposeAlthough the economic and mortality burden of atrial fibrillation (AF) is substantial, it remains unclear which treatment strategies for rate and rhythm control are most cost-effective. Consequently, economic factors can play an adjunctive role in guiding treatment selection.Materials and MethodsWe built a Markov chain Monte Carlo model using the Korean Health Insurance Review & Assessment Service database. Drugs for rate control and rhythm control in AF were analyzed. Cost-effective therapies were selected using a cost-effectiveness ratio, calculated by net cost and quality-adjusted life years (QALY).ResultsIn the National Health Insurance Service data, 268149 patients with prevalent AF (age ≥18 years) were identified between January 1, 2013 and December 31, 2015. Among them, 212459 and 55690 patients were taking drugs for rate and rhythm control, respectively. Atenolol cost $714/QALY. Among the rate-control medications, the cost of propranolol was lowest at $487/QALY, while that of carvedilol was highest at $1363/QALY. Among the rhythm-control medications, the cost of pilsicainide was lowest at $638/QALY, while that of amiodarone was highest at $986/QALY. Flecainide and propafenone cost $834 and $830/QALY, respectively. The cost-effectiveness threshold of all drugs was lower than $30000/QALY. Compared with atenolol, the rate-control drugs propranolol, betaxolol, bevantolol, bisoprolol, diltiazem, and verapamil, as well as the rhythm-control drugs sotalol, pilsicainide, flecainide, propafenone, and dronedarone, showed better incremental cost-effectiveness ratios.ConclusionPropranolol and pilsicainide appear to be cost-effective in patients with AF in Korea assuming that drug usage or compliance is the same.

CATHETER ABLATION OF ATRIAL FIBRILLATION IN HEART FAILURE WITH REDUCED EJECTION FRACTION: A SYSTEMATIC REVIEW AND META-ANALYSIS

There is growing evidence that Atrial Fibrillation (AF) ablation may result in improved outcomes in select patients with AF and heart failure with reduced ejection fraction (HFrEF). The objective of this study was to examine the impact of AF ablation on mortality, hospitalization rate, left ventricular ejection fraction (LVEF), and quality of life in patients with HFrEF, compared to contemporary alternative treatment modalities. We conducted a systematic review and meta-analysis of trials that randomized patients with HFrEF (LVEF ≤40%) to an AF ablation arm or an alternative treatment modality (medical rate control, medical rhythm control, AV node ablation with biventricular pacing). Two independent reviewers extracted study data and performed quality assessments using Grading of Recommendations and the Cochrane Risk Bias Tool. We reported changes on the following outcomes: mortality, heart failure (HF) hospitalization rate, LVEF improvement, quality of life as measured by the Minnesota living with heart failure questionnaire (MLHFQ), six-minute walk test (6MWT), procedural efficacy, and complication rate per procedure. 2009 unique records were identified and screened, and 12 were selected for full text review. Ultimately, seven moderate to high quality randomized controlled trials with 856 patients met inclusion criteria. Four studies used medical rate control as a comparator group, while the three remaining studies used medical rhythm control, either medical rate or rhythm control, and AV node ablation with biventricular pacing, respectively. There were significantly reduced rates of HF-related hospitalization (RR 0.58; CI 0.46,0.74; p<0.001) and all-cause mortality (RR 0.51; CI 0.35,0.75; p<0.001) with AF ablation. Additionally, there was improvement in LVEF (mean difference 7.6%; CI 3.9,11.3; p<0.001) with AF ablation compared to alternative therapies. AF ablation was superior in enhancing quality of life based on MLHFQ scores (mean difference -9.8 points; CI -15, -4.5; p<0.001), and there was a greater reduction in BNP levels post-AF ablation compared to other modalities (mean difference -138.1pg/ml; CI -223, -53; p=0.001). There were 50 procedural complications in a total of 555 ablation procedures performed, culminating in a complication rate of 9.0%. The pooled mean procedural efficacy for the first and final ablations were 61.2% and 74.4%, respectively. In selected patients with AF and HFrEF, AF ablation is associated with a substantial improvement in mortality, HF-hospitalization rate, left ventricular function, and quality of life. Consideration should be given for referral of these patients for assessment of AF ablation candidacy.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Association of Healthcare Plan with atrial fibrillation prescription patterns.

Atrial fibrillation (AF) is treated by many types of physician specialists, including primary care physicians (PCPs). Health plans have different policies for how patients encounter these providers, and these may affect selection of AF treatment strategy. We hypothesized that healthcare plans with PCP-gatekeeping to specialist access may be associated with different pharmacologic treatments for AF. We performed a retrospective cohort study using a commercial pharmaceutical claims database. We utilized logistic regression models to compare odds of prescription of oral anticoagulant (OAC), non-vitamin K-dependent oral anticoagulant (NOAC), rate control, and rhythm control medications used to treat AF between patients with PCP-gated healthcare plans (eg, HMO, EPO, POS) and patients with non-PCP-gated healthcare plans (eg, PPO, CHDP, HDHP, comprehensive) between 2007 and 2012. We also calculated median time to receipt of therapy within 90 days of index AF diagnosis. We found similar odds of OAC prescription at 90 days following new AF diagnosis in patients with PCP-gated plans compared to those with non-PCP-gated plans (OR: OAC 1.01, P = 0.84; warfarin 1.05, P = 0.08). Relative odds were similar for rate control (1.17, P < 0.01) and rhythm control agents (0.93, P = 0.03). However, PCP-gated plan patients had slightly lower likelihood of being prescribed NOACs (0.82, P = 0.001) than non-gated plan patients. Elapsed time until receipt of medication was similar between PCP-gated and non-gated groups across drug classes. Pharmaceutical claims data do not suggest that PCP-gatekeeping by healthcare plans is a structural barrier to AF therapy, although it was associated with lower use of NOACs.

Catheter ablation for treatment of patients with atrial fibrillation and heart failure: a meta-analysis of randomized controlled trials

BackgroundThere is a little evidence for the effects of catheter ablation (CA) on hard endpoints in patients with atrial fibrillation (AF) and heart failure (HF).MethodsPubMed, Embase and Cochrane Library were searched for randomized controlled trials (RCTs) enrolling patients with AF and HF who were assigned to CA, rate control or medical rhythm control groups. This meta-analysis was performed by using random-effect models.ResultsSeven RCTs enrolling 856 participants were included in this meta-analysis. CA reduced the risks of all-cause mortality (risk ratio [RR] 0.52, 95% CI 0.35 to 0.76), HF readmission (RR 0.58, 95% CI 0.46 to 0.66) and the composite of all-cause mortality and HF readmission (RR 0.55, 95% CI 0.47 to 0.66) when compared with control. But there was no significant difference in cerebrovascular accident (RR 0.56, 95% CI 0.23 to 1.36) between two groups. Compared with control, CA was associated with improvement in left ventricular ejection fraction (mean difference [MD] 7.57, 95% CI 3.72 to 11.41), left ventricular end systolic volume (MD -14.51, 95% CI -26.84 to − 2.07), and left ventricular end diastolic volume (MD -3.78, 95% CI -18.51 to 10.96). Patients undergoing CA exhibited increased peak oxygen consumption (MD 3.16, 95% CI 1.09 to 5.23), longer 6-min walk test distance (MD 26.67, 95% CI 12.07 to 41.27), and reduced Minnesota Living with Heart Failure Questionnaire scores (MD -9.49, 95% CI -14.64 to − 4.34) than those in control group. Compared with control, CA was associated with improved New York Heart Association class (MD -0.74, 95% CI -0.83 to − 0.64) and lower B-type natriuretic peptide levels (MD -105.96, 95% CI -230.56 to 19.64).ConclusionsCA was associated with improved survival, morphologic changes, functional capacity and quality of life relative to control. CA should be considered in patients with AF and HF.

2135 Impact of primary care physician gatekeeping on medication prescriptions for atrial fibrillation

OBJECTIVES/SPECIFIC AIMS: Atrial fibrillation (AF) is the most commonly encountered arrhythmia in clinical practice, and has widely varying treatments for stroke prevention and rhythm management. Some of these therapies are increasingly being prescribed by primary care physicians (PCPs). We therefore sought to investigate if healthcare plans with PCP gatekeeping for access to specialists are associated with different pharmacologic treatment strategies for the disease. In particular, we focused on oral anticoagulants (OACs), non-vitamin K-dependent oral anticoagulants (NOACs), rate control, and rhythm control medications. METHODS/STUDY POPULATION: We examined a commercial pharmaceutical claims database (Truven Marketscan™) to compare the prescription frequency of OAC, rate control, and rhythm control medications used to treat AF between patients with PCP-gated health plans (where the PCP is the gatekeeper to specialist referral—i.e., HMO, EPO, POS) and patients with non-PCP-gatekeeper health plans (i.e., comprehensive, PPO, CHDP, HDHP). To control for potential confounders, we also used multivariable logistic regression models to calculate adjusted odds ratios which accounted for age, sex, region, Charlson comorbidity index, CHADS2Vasc score, hypertension, diabetes, stroke/transient ischemic attack, prior myocardial infarction, peripheral artery disease, and antiplatelet medication use. We also calculated median time to therapy to determine if there was a difference in time to new prescription of these medications. RESULTS/ANTICIPATED RESULTS: We found only small differences between patients in PCP-gated and non-PCP-gated plans regarding prescription proportion of anticoagulants at 90 days following new AF diagnosis (OAC 44.2% vs. 42%, p&lt;0.01; warfarin 39.1% vs. 37.1%, p&lt;0.01; NOAC 5.9% vs. 6.0%, p=0.64). We observed similar trends for rate control agents (76.4% vs. 73.4%, p&lt;0.01) and rhythm control agents (24.4% vs. 24.6%, p=0.83). We found similar odds of OAC prescription at 90 days following new AF diagnosis between patients in PCP-gated and non-PCP-gated plans (adjusted OR for PCP-gated plans relative to non-gated plans: OAC 1.006, p=0.84; warfarin 1.054, p=0.08; NOAC 0.815, p=0.001; dabigatran 0.833, p=0.004; and rivaroxaban 0.181, p=0.02). We observed similar trends for rate control agents (1.166, p&lt;0.0001) and rhythm control agents (0.927, p=0.03). Elapsed time until receipt of medication was similar between PCP-gated and non-gated groups [OAC 4±14 days (interquartile range) vs. 5±16 days, p&lt;0.0001; warfarin 4±14 vs. 5±14, p&lt;0.0001; NOAC 7±26 vs. 6±23, p=0.2937; rhythm control 13±35 vs. 13±34, p=0.8661; rate control 10±25 vs. 11±30, p&lt;0.0001]. DISCUSSION/SIGNIFICANCE OF IMPACT: We found that plans with PCP gatekeeping to specialist referrals were not associated with clinically meaningful differences in prescription rates or delays in time to prescription of oral anticoagulation, rate control, and rhythm control drug therapy. In some cases, PCP gatekeeping plans had very small but statistically significant lower odds of being prescribed NOACs. These findings suggest that PCP gatekeeping does not appear to be a major structural barrier in receipt of medications for AF, although non-PCP-gated plans may vary slightly favor facilitating the prescription of NOACs. Our findings that overall OAC prescriptions did not differ by PCP gating status may suggest completion of the rapid dissemination and uptake phase for most AF treatments. The small but statistically significant odds ratios favoring the non-PCP-gated populations in NOACs further suggests that in this newer drug group, the process is ongoing, with more specialists representing early adopters. Interestingly, the low primary care odds ratio of rivaroxaban use, relative to dabigatran, may be indicative of a gradient of uptake of later-generation NOACs, although interpretability is limited by the small number of patients in the rivaroxaban group.

Smartphone electrocardiogram monitoring: current perspectives

Smartphone electrocardiogram monitoring: current perspectives Andrew L Walker,1 Joseph B Muhlestein2 1University of Utah School of Medicine, Department of Internal Medicine, Salt Lake City, UT, USA; 2Intermountain Medical Center Heart Institute, Salt Lake City, UT, USA Abstract: Three-fourths of Americans now own smartphones. Mobile health applications are becoming increasingly common for the management of various chronic diseases, and have the potential to improve health outcomes. One of these is the sector of smartphone electrocardiogram (ECG) technology. Previously, obtaining an ECG has involved a bulky machine requiring medical training to operate. Most of the smartphone ECG technologies involve a single-lead ECG obtained on a small device that communicates with a smartphone. Many companies offer smartphone ECG technology. The most prevalent and studied of these is the Kardia Mobile device by AliveCor&reg;, which has a Food and Drug Administration-approved algorithm for detecting atrial fibrillation (AF). Here, we specifically review smartphone ECG technology including model specifications, cost, and ongoing clinical trials. We also review clinical uses of the technology including screening and monitoring of AF, QT monitoring during initiation of rhythm control medications, and the ability to accurately detect ST-elevation myocardial infarction. Keywords: smartphone, ECG, AliveCor, Kardia Mobile, Cardiac Designs, ECG Check, D-Heart, QardiaCore, EPI Mini, iHealth Rhythm, atrial fibrillation

Addressing Multimorbidity and Polypharmacy in Individuals With Atrial Fibrillation.

The objectives of this review were to (1) discuss how multimorbidity and polypharmacy contributes to the complexity of management among individuals with AF and (2) identify any interventions to manage polypharmacy in relation to AF. Based on the four landmark clinical trials of novel anticoagulants, the most common comorbidities with AF are hypertension, heart failure, diabetes, stroke and myocardial infarction. Polypharmacy was also found prevalent in 76.5% of patients with AF, with a median of six drugs per patient. Despite the consequences of polypharmacy in AF, there is very little evidence-based intervention designed to manage it. Hence, there is a need for further research to examine interventions to manage polypharmacy in relation to AF. Atrial fibrillation (AF) is the most common type of cardiac arrhythmia requiring treatment in adults. Due to the structural and/or electrophysiological abnormalities that occur in AF, patients are managed through the use of prophylactic anticoagulant and rate and/or rhythm control medications. However, these medications are considered high risk and can increase the chances of medication misadventure. Additionally, AF rarely occurs in isolation and is known to coexist with multiple other medical comorbidities, i.e. multimorbidity. This also increases the number of medications, i.e. polypharmacy and pill burden which results in treatment non-compliance to prescribed therapy.

Delayed Onset of Atrial Fibrillation and Ventricular Tachycardia after an Automobile Lightning Strike

BackgroundLightning strike is a rare medical emergency. The primary cause of death in lightning strike victims is immediate cardiac arrest. The mortality rate from lightning exposure can be as high as 30%, with up to 70% of patients left with significant morbidity. Case ReportAn 86-year-old male was struck by lightning while driving his vehicle and crashed. On initial emergency medical services evaluation, he was asymptomatic with normal vital signs. During his transport, he lost consciousness several times and was found to be in atrial fibrillation with intermittent runs of ventricular tachycardia during the unconscious periods. In the emergency department, atrial fibrillation persisted and he experienced additional episodes of ventricular tachycardia. He was treated with i.v. amiodarone and admitted to cardiovascular intensive care unit, where he converted to a normal sinus rhythm on the amiodarone drip. He was discharged home without rhythm-control medications and did not have further episodes of dysrhythmias on follow-up visits. Why Should an Emergency Physician Be Aware of This?Lightning strikes are one of the most common injuries suffered from natural phenomenon, and short-term mortality ordinarily depends on the cardiac effects. This case demonstrates that the cardiac effects can be multiple, delayed, and recurrent, which compels the emergency physician to be vigilant in the initial evaluation and ongoing observation of patients with lightning injuries.

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OBJECTIVES/SPECIFIC AIMS: (1) Determine person (sex, age, education level), environment (marital status, living alone, insurance), and health and illness (BMI, type of AF, comorbidities) characteristics that are associated with outcomes (QOL, symptom severity, and emotional and functional status). (2) Determine the association of symptom management strategies (ablation, cardioversion, and rate and rhythm control medications) and outcomes (QOL, symptom severity, and emotional and functional status). (3) Test person (sex, age, and education level) and environment (marital status, living alone, insurance) characteristics as moderators of the effect of symptom management strategies (ablation, cardioversion, and rate and rhythm control medications) on outcomes (QOL, symptom severity, and emotional and functional status). METHODS/STUDY POPULATION: AF patients (≥18 years of age) already enrolled in the PaTH study will be included. To date, 1026 total participants have been enrolled. Based on the enrolled participants, 92% (945) of our study population are Caucasian and 36% (362) are female. The age range of the enrolled participants is: 2% (16) 18−39, 4% (42) 40−49, 11% (108) 50−59, 33% (343) 60−69, 34% (353) 70−79, and 16% (162) 80+. Participants are recruited through in-person, email, phone, patient portal messaging and post mail techniques to ensure a representative sample. The PaTH study integrates electronic health record and insurance claims data with patient-reported outcome measures collected through online surveys. RESULTS/ANTICIPATED RESULTS: We hypothesize that sex, older age, low education level, living alone, absence of partner, absence of insurance coverage, high BMI, and a high number of comorbidities will be associated with lower QOL, high symptom severity, and low emotional and functional status. We further hypothesize that symptom management strategies will be associated with higher QOL, low symptom severity, and high emotional and functional status, and that these associations will be moderated by person and environment characteristics. DISCUSSION/SIGNIFICANCE OF IMPACT: The proposed research is an important first step in determining potential causes of person and environment differences in symptom severity. It will lead to tailored symptom management interventions for individuals most at risk for experiencing high symptom severity.

Real-life practice in the management of new-onset postoperative atrial fibrillation early after cardiac surgery

Objectives: To investigate the real-world pharmacological management of postoperative atrial fibrillation (POAF) in patients undergoing cardiac surgery. Methods: A retrospective cohort analysis consisting of adult patients who underwent coronary artery bypass grafting, valve or combined surgery from January to December 2011 was performed using a clinical registry. The peri- and postoperative pharmacological management (rate control, rhythm control, anticoagulant therapy) of POAF was evaluated. Stepwise multivariate regression analyses were used to identify determinants for medication use at discharge. Results: The cohort consisted of 1145 patients, of whom 377 (32.9%) developed POAF and 271 (23.7%) were included. At discharge, 251 patients (92.6%) received β-blocker therapy and 122 (45.0%) received antiarrhythmic therapy. Two hundred sixty-one (96.3%) received rateand/ or rhythm-control therapy. Forty-eight (17.7%) patients received warfarin on discharge, although 38 had an additional indication. Men and urgent inpatients were less likely to be discharged on warfarin. Among 145 patients discharged on antiarrhythmic and/or anticoagulant therapy, 121 (83.4%) attended follow-up. Only 28.1% (34 of 121) had an electrocardiogram or Holter monitoring performed; despite this, antiarrhythmic medications were either continued or not addressed in 47.7% (51 of 107) of patients discharged on therapy. Conclusions: Treatment of POAF with rate- and/or rhythm-control medications was consistent with current national guideline recommendations. However, anticoagulant therapy use was low and appeared to be limited to patients with another indication. Assessment of POAF medications and rhythm status at postoperative follow-up visit was inconsistent. Thus, efforts to improve the management of POAF should focus on appropriately discontinuing unnecessary medications at postoperative follow-up to minimize the risk of adverse effects.

Health-related quality of life in patients with atrial fibrillation treated with rhythm control versus rate control: insights from a prospective international registry (Registry on Cardiac Rhythm Disorders Assessing the Control of Atrial Fibrillation: RECORD-AF).

Improving health-related quality of life (HRQoL) is an important treatment goal in the management of patients with atrial fibrillation (AF). Uncertainty exists as to whether patients' HRQoL differ when treated with medical rhythm control or rate control. We compared HRQoL between patients treated with rhythm control or rate control in a large observational registry of patients with recent-onset AF. In the Registry on Cardiac Rhythm Disorders Assessing the Control of Atrial Fibrillation (RECORD-AF), 2439 patients with recent onset (<1 year) AF completed an AF-specific HRQoL questionnaire, the University of Toronto Atrial Fibrillation Severity Scale. HRQoL was assessed by the AF symptom severity score (0-35, with higher scores reflecting more severe AF-related symptoms) at baseline and 1 year. The minimal clinically important difference was defined as a change of ≥3 points. The primary analysis was based on a propensity score-adjusted longitudinal regression analysis which compared the change in AF symptom severity scores between the 2 groups. Over an average follow-up of 1 year, the AF symptom severity scores improved in both groups (rhythm control: -2.82 point [95% confidence interval, -3.22 to -2.41]; rate control: -2.11 point [95% confidence interval, -2.54 to -1.67]; P<0.01 for both groups). The magnitude of improvement was higher in the rhythm control group than the rate control group (unadjusted difference: -0.75 point; 95% confidence interval, -1.31 to -0.19; P=0.01; propensity score-adjusted difference: -0.71 point; 95% confidence interval, -1.31 to -0.11; P=0.02). In this observational cohort of recent-onset AF patients, treatment with medical rhythm- or rate control over 1 year was associated with an improvement in HRQoL. The magnitude of HRQoL improvement was minimally higher in patients treated with rhythm control than rate control. However, the overall degree of improvement was not large, and its clinical significance was uncertain.