Pharmacological Cardioversion Research Articles

Clinical experience of new antiarrhythmic drug refralon for pharmacological cardioversion in patients with atrial fibrillation after pulmonary vein cryoablation

We present two cases of successful pharmacological cardioversion using antiarrhythmic drug refralon in patients with persistent atrial fibrillation after pulmonary vein cryoablation and ineffective electrical cardioversion. These clinical cases represent the first experience of successful use of refralon in patients who underwent cryoablation.

Experience of pharmacological cardioversion with refralon in persistent atrial fibrillation and flutter according to the data of the cardiology department of Orenburg regional clinical hospital

Aim. To assess the effectiveness and safety of refralon based cardioversion on the experience of the cardiology department of Orenburg Regional Clinical Hospital.Methods. The archival medical histories of 14 patients with persistent atrial fibrillation (AF) and 2 patients with persistent atrial flutter (AFL) (overall 16 patients), who underwent an attempt to restore sinus rhythm with refralon, were analyzed. The mean age of the patients was 51.7±10.4 years. The mean duration of AF/AFL since its last detection was 8.0±6.5 weeks (from 8 days to 8 months). Fifteen patients had hypertension, 3 of them had coronary artery disease (CAD), and 1 patient had CAD with type 2 diabetes mellitus. One of the patients had lone AF. Before cardioversion, all patients underwent the following examination: clinical and biochemical blood tests, clinical urine tests, electrocardiography (ECG), echocardiography (Echo), transesophageal Echo, Holter ECG, the determination of the level of thyroid-stimulating hormone, thyroxine, electrolytes, including potassium and magnesium.Results. According to Echo, initially, the transverse size of the left atrium in patients was 4.3±0.3 cm. Its increase was noted in 68.7% of patients (from 4.3 to 5.0 cm). Restoration of sinus rhythm after the first step of refralon administration at a dose of 10 μg/kg was achieved in 8 patients, after the second step of administration (total dose 20 μg/kg) - in 5 patients and after the third step (total dose 30 μg/kg) - in 2 patients. In 1 patient, restoration of sinus rhythm was not achieved after the administration of the third bolus. Out of 15 patients with restored sinus rhythm, AF recurrence occurred in three. In one of the patients with successful cardioversion, the sinus rhythm was restored the next day. The duration of the last episode of AF and the size of the left atrium did not significantly affect the effectiveness of cardioversion and amounted to 62±54 days and 4.3±0.35 cm, respectively, in patients with successful cardioversion, and with a recurrence of AF - 34.3±28 days and 4.2±0.35 cm (p=0.2; р=0.6). The efficacy of cardioversion with refralon was 71.4% in patients with AF, and 100% in patients with AFL. No adverse events of refralon were found in patients.Conclusion. At the time of discharge, sinus rhythm was recorded in 12 out of 16 patients (75%). The ineffectiveness of cardioversion with refralon was noted only in patients with AF; in all patients with AFL the sinus rhythm was restored.

Rhythm disturbances associated with lidocaine administration in four dogs with supraventricular tachyarrhythmias.

To describe arrhythmias associated with administration of lidocaine in dogs treated for supraventricular tachyarrhythmias. Four dogs with recent-onset supraventricular tachyarrhythmias: 3 dogs had atrial fibrillation (AF), and 1 had focal atrial tachycardia (FAT), which was thought to be AF at the time of assessment. The substrate of the supraventricular tachyarrhythmia was considered to be due to primary cardiomyopathy in 1 dog, high vagal tone in 2 dogs, and the change in hemodynamics from heavy sedation in 1 dog. Pharmacological cardioversion using lidocaine was only successful in the 2 dogs with vagally mediated AF. In these 2 cases, lidocaine administration resulted in a paroxysmal atrial flutter that was self-limiting and quickly led to sinus rhythm within 10 seconds in 1 dog but did not change over a 5-minute interval and required additional boluses in another dog. In the latter case, the dog showed severe bradycardia for 17.5 seconds prior to achieving sinus rhythm. The 2 unsuccessful cases both developed ventricular arrhythmias shortly after the lidocaine administration, with 1 case degenerating into ventricular fibrillation and cardiac arrest. Arrhythmias associated with lidocaine should be considered when treating dogs with supraventricular tachyarrhythmia.

Cardioversion of recent-onset atrial fibrillation using intravenous antiarrhythmics: A European perspective.

Pharmacological cardioversion using intravenous antiarrhythmic agents is commonly indicated in symptomatic patients with recent-onset atrial fibrillation (AF). Except in hemodynamically unstable patients who require emergency direct current electrical cardioversion, for the majority of hemodynamically stable patients, pharmacological cardioversion represents a valid option and requires the clinician to be familiar with the properties and use of antiarrhythmic agents. The main characteristics of selected intravenous antiarrhythmic agents for conversion of recent-onset AF, the reported success rates, and possible adverse events are discussed. Among intravenous antiarrhythmics, flecainide, propafenone, amiodarone, sotalol, dofetilide, ibutilide, and vernakalant are commonly used. Antazoline, an old antihistaminic agent with antiarrhythmic properties was also reported to give encouraging results in Poland. Intravenous flecainide and propafenone are the only Class I agents still recommended by recent guidelines. Intravenous new Class III agents as dofetilide and ibutilide have high and rapid efficacy in converting AF to sinus rhythm but require strict surveillance with electrocardiogram (ECG) monitoring during and after intravenous administration because of the potential risk of QT prolongation and Torsades de Pointes, which can be prevented and properly managed. Vernakalant, a partial atrial selective was shown to have a high success rate and to be safe in real-life use.

Rapid pharmacological cardioversion of recent-onset atrial fibrillation using antazoline in elderly patients.

There is insufficient evidence on the efficacy and safety of pharmacological cardioversion of recent‑onset atrial fibrillation (AF) in elderly patients. Antazoline has been shown to be effective and safe in various patient populations. We aimed to compare the clinical efficacy and safety of intravenous antazoline for pharmacological cardioversion of recent‑onset AF between patients aged 75 years or older and those younger than 75 years. This retrospective analysis was conducted using data derived from emergency room medical records of patients referred for pharmacological cardioversion due to symptomatic AF lasting less than 48 hours. The threshold for old age was set at 75 years. Conversion to sinus rhythm was considered the primary efficacy outcome. The primary safety outcome was defined as any adverse event requiring hospitalization. The study included 334 participants, of whom 110 patients were aged 75 years or older (study group) and 224 patients were younger than 75 years (controls). Successful cardioversion was achieved using lower mean (SD) antazoline doses in the study group than in controls: 151 (59) mg vs 168 (58) mg (P = 0.039). Study and control groups showed a similar efficacy and safety of antazoline (78.2% and 68.3%, respectively; odds ratio [OR], 1.66; 95% CI, 0.98-1.31; P = 0.06) as well as hospitalization rates (0.9% and 4.0%, respectively; OR, 0.22; 95% CI, 0.03-1.75; P = 0.17). Intravenous antazoline seems to be effective and safe for pharmacological cardioversion of recent‑onset AF in elderly patients in the emergency setting.

The reinvented old player – an antazoline is effective in pharmacological cardioversion of atrial fibrillation

Abstract Introduction Antazoline (ANT) is an old antihistaminic medication with antiarrhythmic properties. After intravenous administration ANT exerts rapid antiarrhythmic effect often resulting in conversion of atrial fibrillation (AF) to sinus rhythm (SR) and is widely used in Poland for this purpose in the last years. However, published data on its effectiveness, safety and clinical utility for rapid AF termination are limited and ANT is not recognized as a cardioversion drug. Aim To assess the real-world efficacy of ANT for pharmacological cardioversion of paroxysmal and persistent non-valvular AF. Methods Our single center, retrospective, observational study included patients (pts) with history paroxysmal or persistent AF episode lasting less than 6 months, in stable cardiopulmonary condition who were qualified for elective pharmacological cardioversion with intravenous ANT. The primary end-point was the conversion of AF to SR confirmed in electrocardiography (ECG) during the 6-hours observation. Results A total of 176 pts (mean age 68.4±12.0 years, 49% male) were enrolled into the study. In 93 patients (52%) AF duration was shorter than 48 hours and median AF duration time was 24 (7–432) hours. The overall success rate of pharmacological cardioversion of AF with intravenous ANT was 45.5% (80/176 pts). The mean used dose of ANT was 250.9±65.4mg. The subgroup analysis, regarding the AF duration, suggested the effectiveness of ANT mainly in in short-lasting AF (effectiveness of antazoline based cardioversion for AF lasting <48h vs others: 75.3% vs 12.0%, p<0.001). In multivariable logistic regression model AF duration (for every 24h in AF – OR=0.97; 95% CI 0.96–0.98), the left atrium antero-posterior diameter (OR=0.92; 95% CI 0.86–0.99) and the serum creatinine level (OR=0.15; 95% CI 0.03–0.73) were identified as independent predictors of antazoline based pharmacological cardioversion effectiveness, even after adjustment for comorbidities. The ROC curves revealed that the optimal cut-off value for AF duration time predicting ANT's effectiveness was 48h (AUC=0.876; 95% CI 0.815–0.922) – Figure 1. There were only one episode of bradycardia <45 bpm related to ANT administration. Conclusions Antazoline is effective and safe in rapid pharmacological cardioversion of paroxysmal AF, especially in the short-lasting AF (<48 hours) and in patients without the left atrium enlargement and significant renal disease. Funding Acknowledgement Type of funding sources: None. Figure 1. ROC curve analysis

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

Pharmacological cardioversion of recent-onset atrial fibrillation in patients with chronic kidney disease: sub-analysis of the CANT study

Abstract Purpose Pharmacological cardioversion (PCV) is commonly a primary option for termination of recent-onset atrial fibrillation (AF) at the emergency departments (ED), and there are reports proving that antazoline is a noteworthy agent to restore sinus rhythm. This is a sub-analysis of the CANT study evaluating the effectiveness and safety of antazoline in patients with AF at different stages of chronic kidney disease (CKD). Methods Total n=777 patients admitted to ED for the urgent termination of AF were included into this analysis. We analysed the results concerning effectiveness and safety of PCV with special consideration of antazoline, in patients at 3 stages of CKD defined on the basis of eGFR (CKD-EPI): Group I ≥60 mL/min (n=531), Group II 45–59 mL/min (n=149), and Group III <45 mL/min (n=97). Primary end-point was the termination of AF, a restoration of a sinus rhythm and its persistence until discharge. Results Patients of group III were older and with higher prevalence of comorbidities, however, we have not found statistically significant differences in overall effectiveness of PCV in comparison with the other groups. In patients receiving amiodarone, the PCV success rate was similar in all the studied groups, but along with a renal function decline, it decreased in patients receiving antazoline (79.1 vs 35%; p<0.001), and it increased close to a significant manner in patients receiving propafenone (69.9 vs 100%; p=0.067; Figure). In patients of Group I, antazoline restored a sinus rhythm as effectively as propafenone and amiodarone, however in patients of Group III, both antazoline and amiodarone became less effective in restoring a sinus rhythm than propafenone (p=0.002 and p=0.034, respectively). The rate of safety endpoint was highest in patients of Group III (eGFR<45 mL/min), and it was significantly higher than in patients of Group I and II (p=0.008 and p=0.036, respectively). We have not observed antazoline-related adverse events in any of studied groups of patients. Conclusion This real-world registry analysis revealed a different influence of CKD on individual drug effectiveness, and while propafenone and amiodarone maintained their AF termination efficacy, antazoline became significantly less effective in restoring sinus rhythm. Its favourable safety profile has not changed. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): The study received no external funding

AN ALREADY SICK HEART: A CASE OF FATAL SARS-COV-2 MYOCARDITIS

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) myocarditis has recently been described in case reports. A systematic review in early 2021 found fourteen case reports of myocarditis or myopericarditis secondary to this viral infection. We describe an interesting case of proven non-ischemic cardiac dysfunction in the setting of acute infection. Despite steroid treatment, which has been suggested to have favorable outcomes, our patient did not survive. CASE PRESENTATION: We present a case of a 77-year-old man with extensive electrophysiologic and ischemic cardiac disease who presented to the hospital for generalized weakness, malaise, and shortness of breath. The patient's cardiac history was significant for atrial flutter s/p ablation, coronary artery disease s/p coronary artery bypass graft in the distant past, peripheral artery disease s/p right lower extremity revascularization, and carotid stenosis s/p carotid endarterectomy. SARS-CoV-2 PCR test was positive. The patient had increasing hypoxia which required non-invasive ventilation and eventually, tracheal intubation and mechanical ventilation. The hospital course was complicated by the development of persistent chest pain associated with elevated cardiac enzymes. EKG showed diffuse ST-segment depressions. An echocardiogram revealed diffuse left ventricular hypokinesis and a reduced ejection fraction of 20% which was not present previously. In this setting, the patient was ruled in for acute coronary syndrome and underwent cardiac catheterization. Cardiac catheterization demonstrated patent grafts and no significant obstructive disease. A presumptive diagnosis of myocarditis was made. The patient's clinical status deteriorated despite optimal medical treatment, and he developed hemodynamically unstable atrial fibrillation that did not respond to pharmacologic treatment or cardioversion and resulted in cardiogenic shock and, ultimately, his death. DISCUSSION: SARS-CoV-2 myocarditis has been described in select case reports internationally. Many of these cases are described in patients with no previously identified comorbid conditions. This case suggests that in patients with underlying electrophysiologic dysfunction, SARS-CoV-2 myocarditis is associated with poor outcomes. CONCLUSIONS: The mechanism of the effect of SARS-CoV-2 on the heart is unclear and includes myocarditis or myopericarditis. In our patient, cardiac catheterization which was performed during his hospitalization confirmed no ischemic disease and suggested the presence of myocarditis which was ultimately fatal in the setting of refractory cardiogenic shock. Further research is needed into the optimal management of myocarditis associated with SARS-CoV-2. REFERENCE #1: Sawalha K, Abozenah M, Kadado AJ, et al. Systematic Review of COVID-19 Related Myocarditis- Insights on Management and Outcome. Cardiovasc Revasc Med. Feb 2021;23:107-113. REFERENCE #2: Purdy A, Ido F, Sterner S, et al. Myocarditis in COVID-19 presenting with cardiogenic shock: a case series. Eur Heart J Case Rep. Feb 2021;5(2):ytab028. REFERENCE #3: Fried JA, Ramasubbu K, Bhatt R, et al. The Variety of Cardiovascular Presentations of COVID-19. Circulation. 2020;141(23):1930-1936. DISCLOSURES: No relevant relationships by Sravani Gajjala, source=Web Response No relevant relationships by Stacey Jou, source=Web Response No relevant relationships by Zein Kattih, source=Web Response No relevant relationships by Rosaline Ma, source=Web Response No relevant relationships by Akhilesh Mahajan, source=Web Response No relevant relationships by Vinayak Shenoy, source=Web Response

Frontal plane QRS-T angle predicts early recurrence of acute atrial fibrillation after successful pharmacological cardioversion with intravenous amiodarone.

Although restoration of sinus rhythm is the integral part of the atrial fibrillation (Af) management, recurrence frequency of Af is high after cardioversion. However, little is known about the association of electrocardiography (ECG) parameters with Af recurrence after restoration of sinus rhythm. The present study aimed to investigate whether frontal plane QRS-T (fQRST) angle, as a marker of ventricular repolarization heterogeneity, predicts Af recurrence after successful pharmacological cardioversion. One hundred and sixty-five paroxysmal Af patients with an acute Af episode who underwent successful pharmacological cardioversion with intravenous amiodarone infusion were included into the study. Patients were divided into two groups according to presence or absence of in-hospital Af recurrence. The association between fQRST angle and Af recurrence was investigated. Af recurrence was observed in 42 (25.4%) patients. The mean fQRST angle was significantly higher in patients with Af recurrence compared to those without Af recurrence (90±45.8 vs. 51±38.2, p<0.001). Also, Af recurrence was more frequent in patients who had fQRST angle >90˚, compared to patients with fQRST angle ≤90˚ (54.1% vs. 13.7%, p<0.001). Moreover, ROC curve analysis demonstrated that an increased fQRST angle >92.5˚ predicted in-hospital Af recurrence with a sensitivity of 76.2% and a specificity of 81.4% (AUC:0.728, p<0.001). Furthermore, multivariate analysis demonstrated that fQRST angle was an independent predictor of in-hospital Af recurrence after successful pharmacological cardioversion (OR: 1.892, 95% CI: 1.361-2.917, p<0.001). As a parameter that can be easily calculated from automated ECG recordings, fQRST angle may be useful in the prediction of early Af recurrence after successful pharmacological cardioversion with amiodarone.

In acute atrial flutter, adding pharmacologic before electrical cardioversion did not increase conversion to normal sinus rhythm.

Stiell IG, Sivilotti MLA, Taljaard M, et al. A randomized, controlled comparison of electrical versus pharmacological cardioversion for emergency department patients with acute atrial flutter. CJEM. 2021;23:314-24. 33959925.

Anticoagulation in Atrial Fibrillation Cardioversion: What Is Crucial to Take into Account.

The therapeutic dilemma between rhythm and rate control in the management of atrial fibrillation (AF) is still unresolved and electrical or pharmacological cardioversion (CV) frequently represents a useful strategy. The most recent guidelines recommend anticoagulation according to individual thromboembolic risk. Vitamin K antagonists (VKAs) have been routinely used to prevent thromboembolic events. Non-vitamin K antagonist oral anticoagulants (NOACs) represent a significant advance due to their more predictable therapeutic effect and more favorable hemorrhagic risk profile. In hemodynamically unstable patients, an emergency electrical cardioversion (ECV) must be performed. In this situation, intravenous heparin or low molecular weight heparin (LMWH) should be administered before CV. In patients with AF occurring within less than 48 h, synchronized direct ECV should be the elective procedure, as it restores sinus rhythm quicker and more successfully than pharmacological cardioversion (PCV) and is associated with shorter length of hospitalization. Patients with acute onset AF were traditionally considered at lower risk of thromboembolic events due to the shorter time for atrial thrombus formation. In patients with hemodynamic stability and AF for more than 48 h, an ECV should be planned after at least 3 weeks of anticoagulation therapy. Alternatively, transesophageal echocardiography (TEE) to rule out left atrial appendage thrombus (LAAT) should be performed, followed by ECV and anticoagulation for at least 4 weeks. Theoretically, the standardized use of TEE before CV allows a better stratification of thromboembolic risk, although data available to date are not univocal.

Safety and Efficacy of Ibutilide for Acute Pharmacological Cardioversion of Rheumatic Atrial Fibrillation

Introduction: Ibutilide is indicated for acute cardioversion of nonvalvular atrial fibrillation (AF). However, its efficacy and safety in the pharmacological cardioversion of rheumatic AF are unknown. Methods: Patients with mild-to-moderate rheumatic mitral valve (MV) disease with symptomatic, paroxysmal, or persistent AF were included in the analysis. Intravenous ibutilide was administered at doses tailored to body weight (0.5–2.0 mg) for over 10 min. The primary end point was efficacy, assessed as the rate of conversion of AF to sinus rhythm. The secondary end point was safety, including arrhythmic events and death within 24 h of drug initiation. Results: From June 2016 to October 2018, 165 patients (94 with mitral stenosis, 23 with mitral regurgitation, 11 with mixed MV disease, and 37 with MV replacement) received ibutilide (mean dose 0.90 ± 0.54 mg). Ibutilide successfully converted AF to sinus rhythm in 127/165 (76.9%) patients, with a conversion time of 7.9 ± 4.1 min. The QTc increased from 419.9 ± 15.8 to 487.5 ± 34 ms after ibutilide administration (p < 0.001). The mean change in QTc after ibutilide administration (∆QTc) was 72.01 ± 36.03. There were no deaths, but 3 patients (1.8%) developed torsades de pointes (TdP) requiring defibrillation 55 ± 37 min after infusion. Conclusion: Ibutilide cardioverted 77% of rheumatic AF to sinus rhythm, indicating its potential as a clinically useful option for pharmacological cardioversion of rheumatic AF. TdP is a potentially serious adverse event that requires careful monitoring.

Implementation of a Procainamide-Based Cardioversion Strategy for the Management of Recent-Onset Atrial Fibrillation.

Atrial fibrillation/flutter (AF) remains the most common rhythm disturbance in adult patients presenting to emergency departments (EDs). Although pharmacologic cardioversion has been established as safe and effective in recent-onset AF, its use in U.S. EDs is uncommon. The purpose of this study was to assess the safety and efficacy of intravenous (IV) procainamide for pharmacologic cardioversion in patients presenting to the ED with AF of <48-hr duration. Patients presenting to the ED with recent-onset AF (<48 hr) undergoing a cardioversion strategy with IV procainamide from 2017 to 2019 were reviewed. Clinical outcomes assessed included rates of cardioversion, hospital admission, stroke, and return ED visits for arrhythmia or serious adverse events. A total of 64 patients received procainamide therapy-60.9% achieved cardioversion and 35.9% were admitted to the hospital. The mean dose was 1062.4 mg (12.1 mg/kg). No patients returned to the ED secondary to stroke and 9.4% experienced complications attributed to procainamide, the most common being hypotension. Within 30 days of therapy, 20.3% of patients returned to the ED secondary to arrhythmia recurrence. Patients experiencing cardioversion with procainamide were less likely to be admitted to the hospital (25.6% vs. 52.0%; p = 0.04) or receive a rate control agent (17.9% vs. 64.0%; p = 0.001). There was no significant difference in the rate of 30-day return between those who experienced pharmacologic cardioversion and those who did not (p = 0.220). The implementation of a procainamide-based acute cardioversion strategy for patients presenting to the ED with recent-onset AF resulted in a 60% cardioversion rate, which was associated with a significantly higher rate of discharge from the ED. Transient hypotension was the most common adverse event. Further investigation into ED-based protocols for management of recent-onset AF is necessary to better understand their safety and efficacy.

Early pharmacologic conversion of atrial fibrillation after off-pump coronary artery bypass grafting.

BackgroundThe aim of this study was to evaluate the efficacy of early amiodarone-based pharmacological cardioversion for postoperative atrial fibrillation (POAF) following off-pump coronary bypass grafting (OPCAB).MethodsA total of 507 patients who underwent OPCAB between 2015 and 2017 were categorized into POAF (n=94) and no-POAF (n=413) groups. Patients in the POAF group were treated according to the following institutional protocol: 150 mg loading dose of intravenous amiodarone, followed by oral administration with sequential maintenance doses at 600, 400, and 200 mg per day. If sinus rhythm was restored before discharge, patients were discharged without amiodarone or anticoagulants, except for dual antiplatelets.ResultsBefore discharge at index hospitalization, 97.8% of POAF patients had restored sinus rhythm. Independent risk factors for POAF were age, unstable angina, prior percutaneous transluminal coronary angioplasty, and left atrial diameter. The mean follow-up duration was 41.1±12.8 months. Freedom from overall mortality and composite events, including mortality, major bleeding requiring admission and cerebrovascular events, were similar between the 2 groups. Results were consistent after propensity-score matching.ConclusionsAmiodarone-based rapid pharmacological cardioversion of POAF resulted in a high sinus rhythm conversion rate (97.9%). Rate of late adverse cardiovascular events including stroke, were low even without anticoagulation. As optimal treatment and anticoagulation guidelines for POAF after OPCAB have not yet been established, amiodarone-based treatment protocols may be considered as a useful option.

Older female relatives of Covid-19 patients have an unsatisfactory perception of emergency room performance by clinical staf

Flecainide is a class I antiarrhythmic used for supraventricular tachyarrhythmias with mild adverse reactions. We present a case report in a 78-year-old male that came to the emergency department with atrial fibrillation and was subsequently treated with flecainide. During the infusion, the patient went into cardiac arrest. Cardiopulmonary resuscitation was performed until the return of spontaneous circulation was achieved after 1min and 40 seconds. Conclusion. Some trials, like The Cardiac Arrhythmia Suppression Trial (CAST), consider flecainide to be safe, but our case report, together with several other published reports brings attention to the use of flecainide in pharmacologic cardioversion of atrial fibrillation as a cause of cardiac arrest. Keywords: Older man, atrial fibrillation, emergency department, cardiac arrest, flecainide

Cardiac arrest in an older male patient treated with flecainide for atrial fibrillation

Flecainide is a class I antiarrhythmic used for supraventricular tachyarrhythmias with mild adverse reactions.We present a case report in a 78-year-old male that came to the emergency department with atrial fibrillation and was subsequently treated with flecainide. During the infusion, the patient went into cardiac arrest. Cardiopulmonary resuscitation was performed until the return of spontaneous circulation was achieved after 1 min and 40 seconds. Conclusion. Some trials, like The Cardiac Arrhythmia Suppression Trial (CAST), consider flecainide to be safe, but our case report, together with several other published reports brings attention to the use of flecainide in pharmacologic cardioversion of atrial fibrillation as a cause of cardiac arrest. Keywords: Older man, atrial fibrillation, emergency department, cardiac arrest, flecainide

Increased inpatient mortality in patients hospitalized for atrial fibrillation and atrial flutter with concomitant amyloidosis: Insight from National Inpatient Sample (NIS) 2016-2017

PurposeUsing National Inpatient Database (NIS), comparison of clinical outcomes for patients primarily admitted for atrial fibrillation/flutter with and without a secondary diagnosis of amyloidosis was done. Inpatient mortality was the primary outcome and hospital length of stay (LOS), mean total hospital charges, odds of undergoing cardiac ablation, pharmacologic cardioversion, having a secondary discharge diagnosis of heart block, cardiogenic shock and cardiac arrest were secondary outcomes. MethodsNIS database of 2016, 2017 was used for only adult hospitalizations with atrial fibrillation/flutter as principal diagnosis with and without amyloidosis as secondary diagnosis using ICD-10 codes. Multivariate logistic with linear regression analysis was used to adjust for confounders. Results932,054 hospitalizations were for adult patients with a principal discharge diagnosis of atrial fibrillation/flutter. 830 (0.09%) of these hospitalizations had amyloidosis.Atrial fibrillation/flutter hospitalizations with co-existing amyloidosis have higher inpatient mortality (4.22% vs 0.88%, AOR: 3.92, 95% CI 1.81–8.51, p = 0.001) and likelihood of having a secondary discharge diagnosis of cardiac arrest (2.40% vs 0.51%, AOR: 4.80, 95% CI 1.89–12.20, p = 0.001) compared to those without amyloidosis. ConclusionsHospitalizations of atrial fibrillation/flutter with co-existing amyloidosis have higher inpatient mortality and odds of having a secondary discharge diagnosis of cardiac arrest compared to those without amyloidosis. However, LOS, total hospital charges, likelihood of undergoing cardiac ablation, pharmacologic cardioversion, having a secondary discharge diagnosis of heart block and cardiogenic shock were similar between both groups.

Non-valvular atrial fibrillation recurrence after sinus rhythm restoring at different follow-up periods: phenotype-genotype high-risk groups, considering rs10465885 polymorphism in connexin-40 gene

Abstract Funding Acknowledgements Type of funding sources: None. Purpose to provide risk stratification of non-valvular atrial fibrillation (AF) recurrence after sinus rhythm restoring (SRR) in patients (pts) with AF at different follow-up periods (3 months (AFr3m), 12 months (AFr12m) and 18 months [AFr18m]), based on phenotype-genotype high-risk groups, considering rs10465885 polymorphism in connexin-40 gene (SNP-Cx40). Methods. We enrolled 186 pts (mean age (55 ± 10) years; males 123 [66,1%]) with AF (paroxysmal – 86, persistent – 72, stable – 28 pts; first onset (FO) AF – 48 pts). Clinical, laboratory and echocardiographic data were analyzed. SNP-Cx40 was genotyped by real time PCR (T – reference, C – minor allele) in 112 pts. The genotypes were distributed as follows: TT – 25,9% (n = 29); CT – 49,1% (n = 55); CC – 25,0% (n = 28). SRR was performed in 112 cases (102 pts) with non-permanent AF: 30 – pharmacological cardioversion (PCV), 62 – direct-current cardioversion (DCV), 20 cases – radiofrequency ablation (RFA). AFr3m occurred in 53 (43,4%) of 122 available cases; AFr12m – 65,5% (76/116); AFr18m – 75,2% (79/105). The Artificial Neural networks (ANNs) analysis was performed to select the AF recurrence predictors. We considered the ANN activation function value (Y) and its relation to Y cut-off value (Ycrit). In case of Y &amp;gt; Ycrit, the AF recurrence risk was considered as «high». Results. We built three nonlinear ANN models (multilayer perceptrons) for AFr3m (Ycrit = 0,496), AFr12m (Ycrit = 0,503) and AFr18m (Ycrit = 0,720) risk prediction. In case of SNP-Cx40 CC genotype carriage, we determined the additional increase of AFr3m risk after PCV in pts with CHA2DS2-VASc score «0» and normal (Y = 0,629) or mildly decreased (Y = 0,616) left ventricular mid-wall fractional shortening, and in the case of its moderate decrease – both after PCV (Y = 0,585) and DCV (Y = 0,627). The CC genotype was associated with AFr12m high risk in pts without heart failure (HF) and mildly increased left atrial dimension (LAD) – both after PCV (FO AF with known precise event duration (PED); Y = 0,906) or DCV (FO AF with unknown PED; Y = 0,911). Additionally, CC genotype was associated with AFr12m high risk after RFA in pts without HF and normal or mildly increased LAD (Y = 0,912), and in pts with HF B or C1 stage (according to modified AHA/ACC classification) with moderately increased LAD (Y = 0,912). The high-risk groups of AFr18m in pts with CC genotype were as follows (Y = 0,913): after RFA in pts with recurrent AF and presence of episodes lasting ≥7 days; after PCA in case of FO AF with unknown PED and index episode lasting ≥1 month; after DCV in case of FO AF with unknown PED and index episode lasting ≥12 months. Conclusion. AFr3m, AFr12m and AFr18m, besides SNP-Cx40, were non-linearly associated with SRR type, and certain clinical and echocardiographic phenotypic parameters, which could be used for AF recurrence risk stratification, with the selection of phenotype-genotype high-risk groups, considering SNP-Cx40.

Cinderella drug: an antazoline is effective in pharmacological cardioversion of atrial fibrillation - Single center experience

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Antazoline (ANT) is an old antihistaminic medication with antiarrhythmic properties. After intravenous administration ANT exerts rapid antiarrhythmic effect often resulting in conversion of persistent atrial fibrillation (AF) to sinus rhythm (SR). However, published data on its effectiveness, safety and clinical utility for rapid AF termination are limited and ANT is not recognized as a cardioversion drug. Aim To assess the real-world efficacy of ANT for pharmacological cardioversion of paroxysmal and persistent non-valvular AF. Methods We conducted a single center, retrospective, observational study including patients (pts) with history paroxysmal or persistent AF episode lasting less than 6 months, in stable cardiopulmonary condition who were qualified for elective pharmacological cardioversion with intravenous ANT. The primary end-point was the conversion of AF to SR confirmed in electrocardiography (ECG) during the 6-hours observation. Results A total of 176 pts (mean age 68.4 ± 12.0 years, 49% male) were enrolled into the study. In 93 patients (52%) AF duration was shorter than 48 hours and median AF duration time was 24 (7 – 432) hours. The overall success rate of pharmacological cardioversion of AF with intravenous ANT was 45.5% (80/176 pts). The mean used dose of ANT was 250.9 ± 65.4mg. The subgroup analysis, regarding the AF duration, suggested the effectiveness of ANT mainly in in short-lasting AF (effectiveness of antazoline based cardioversion for AF lasting &amp;lt;48h vs others: 75.3% vs 12.0%, p &amp;lt; 0.001). In multivariable logistic regression model AF duration (for every 24h in AF - OR = 0.97; 95% CI 0.96 – 0.98), the left atrium antero-posterior diameter (OR = 0.92; 95% CI 0.86 – 0.99) and the serum creatinine level (OR = 0.15; 95% CI 0.03 – 0.73) were identified as independent predictors of antazoline based pharmacological cardioversion effectiveness, even after adjustment for comorbidities. The ROC curves revealed that the optimal cut-off value for AF duration time predicting ANT’s effectiveness was 48h (AUC = 0.876; 95% CI 0.815 – 0.922). There were only one episode of bradycardia &amp;lt;45 bpm related to ANT administration. Conclusions Intravenous antazoline administration is effective and safe in rapid pharmacological cardioversion of paroxysmal AF, especially in the short-lasting AF (&amp;lt;48 hours) and in patients without the left atrium enlargement and significant renal disease. Abstract Figure.