Previous Episodes Of Atrial Fibrillation Research Articles

Association of intravenous digoxin use in acute heart failure with rapid atrial fibrillation and short-term mortality according to patient age, renal function, and serum potassium.

Intravenous digoxin is still used in emergency departments (EDs) to treat patients with acute heart failure (AHF), especially in those with rapid atrial fibrillation. Nonetheless, many emergency physicians are reluctant to use intravenous digoxin in patients with advanced age, impaired renal function, and potassium disturbances due to its potential capacity to increase adverse outcomes. We investigated whether intravenous digoxin used to treat rapid atrial fibrillation in patients with AHF may influence mortality in patients with specific age, estimated glomerular filtration rate (eGFR), and serum potassium classes. A secondary analysis of patients included in in the Spanish EAHFE cohort, which includes patients diagnosed with AHF in the ED. 45 Spanish EDs. Two thousand one hundred ninety-four patients with AHF and rapid atrial fibrillation (heart rate ≥100 bpm) not receiving digoxin at home, divided according to whether they were or were not treated with intravenous digoxin in the ED. The relationships between age, eGFR, and potassium with 30-day mortality were investigated using restricted cubic spline (RCS) models adjusted for relevant patient and episode variables. The impact of digoxin use on such relationships was assessed by checking interaction. The median age of the patients was 82 years [interquartile range (IQR) = 76-87], 61.4% were women, 65.2% had previous episodes of atrial fibrillation, and the median heart rate at ED arrival was 120 bpm (IQR = 109-135). Digoxin and no digoxin groups were formed by 864 (39.4%) and 1330 (60.6%) patients, respectively. There were 191 deaths within the 30-day follow-up period (8.9%), with no differences between patients receiving or not receiving digoxin (8.5 vs. 9.1%, P = 0.636). Although analysis of RCS curves showed that death was associated with advanced age, worse renal function, and hypo- and hyperkalemia, use of intravenous digoxin did not interact with any of these relationships ( P = 0.156 for age, P = 0.156 for eGFR; P = 0.429 for potassium). The use of intravenous digoxin in the ED was not associated with significant changes in 30-day mortality, which was confirmed irrespective of patient age or the existence of renal dysfunction or serum potassium disturbances.

P485 CONSERVATIVE MANAGEMENT OF A BIOLOGICAL MITRAL VALVE THROMBOSIS IN A PATIENT WITH RECENT COVID19 INFECTION

Abstract Prosthetic valve thrombosis is defined as the presence of non–infectious material, within the valve apparatus, that interferes with the normal function of the prosthesis itself. The rate of thrombosis is normally higher in patients with mechanical valves respect to those with a biological valve. It is a potentially fatal complication of valve replacement surgery. Treatment options include: surgery, fibrinolysis, and anticoagulant therapy; those depending on multiple factors: position of the valve, thrombotic burden, surgical risk, clinical presentation and patient‘s wishes. Complications of SARS–CoV2 infections can also extend beyond the respiratory system, triggering sometimes a systemic pro–inflammatory and pro–thrombotic state with potential cardiovascular complications. We present the case of a 74–year–old man with a mitral bioprosthetic valve (Carpentier–Edwards n29) and an aortic bioprosthesis valve (Carpentier–Edwards pericardial n27) taking anticoagulant therapy (Apixaban) for previous episodes of atrial fibrillation. One year after the surgery, the patient was affected by COVID19 infection characterized by fever and asthenia lasting for about 14 days. Subsequently, he experienced exertional dyspnea with a mitral valve thrombosis (25 mm) as echocardiographic finding and with pulmonary hypertension (PAPs 50 mmHg). After a multidisciplinary team discussion, once signs of peripheral embolization had been ruled out and considering NOAC therapy, it was decided to modify the therapy with low–molecular heparin and subsequently with Warfarin (INR 2.5–3.5). Four days later during a follow–up examination, was observed the improvement of dyspnoea and flow parameters and the reduction of thrombus size (21 mm) without any sign of embolic complications. Considering clinical stability in the following period, it was decided to continue with the same therapy. Subsequent checks showed an unchanged echocardiographic examination with same thrombus dimensions. In order to verify echocardiographic findings, a cardiac CT was performed which confirmed the presence of hypodense material compatible with thrombus formation (11 mm by 15 mm) on the mitral prosthesis.

Atrial Fibrillation in a Patient with Interatrial Block after Successful Atrial Flutter Ablation: May Interatrial Block Be a Link for a Continuum of Atrial Arrhythmias?

Background: Electrocardiographic interatrial block (IAB) typically exists when a conduction delay over the Bachmann’s bundle is present. By analogy to other types of block, there is a continuum of IAB severity; partial IAB is defined as a P-wave duration 120 ms and advanced interatrial block (aIAB) is defined as a P-wave duration 120 ms in conjunction with biphasic P-wave morphology in inferior leads II, III, and aVF. Moreover, IAB seems to be a key factor in the genesis of atrial fibrillation (AF). On the contrary, it is not clear if the presence of advanced IAB may be associated with an occurrence of AF after cavotricuspid atrial flutter ablation in patients without previous episodes of atrial fibrillation. So, may be useful to evaluate on surface electrocardiogram the P-wave morphology and duration in sinus rhythm after the ablation procedure just to identify patients at high risk for atrial fibrillation development. Advanced IAB is frequently associated with atrial tachyarrhythmias, and it was found to predict AF and may be helpful for clinical decisions. Case presentation: In this case involving a man who underwent a typical atrial flutter ablation, we documented that aIAB during the post-ablation period which seems to induce atial fibrillation episodes. To our knowledge, it is unusual to detect an aIAB after cavotricuspid atrial flutter ablation and subsequently associate it with a new onset of AF. Conclusions: Our observation supports a possible aIAB induction of AF after cavotricuspid atrial flutter ablation and potentially may representing a link in the continuum of atrial arrhythmias. P-wave morphology and duration should be better evaluated soon after AFlu ablation to better stratify patients who are at high risk for atrial fibrillation development and eventually prolonged anti-coagulation therapy.

510 Giant left atrial appendage aneurysm in a 47 years old male: a case report

Abstract Aims Left atrial appendage aneurysm (LAAA) is a rare condition mostly due to congenital malformations or secondary causes. Methods and results Since very few cases are described in the literature, there is uncertainty in treatment and prognosis. Diagnosis is achieved by advanced imaging as transesophageal echocardiography (TEE), which also allows the detection of thrombus, moreover cardiac magnetic resonance (CMR) could be more specific in describing sizes and relationships with surrounding anatomical structures. Surgical aneurysmectomy could be indicated in the majority of cases, especially if compression of other cardiac chambers or mediastinal structures are present. Medical therapy can include tromboprophylaxys and arrhythmias management. Since high quality evidence is scarce, a shared decision making by Heart Team approach should be considered. We present the case of a 47 years old male who came to our attention for palpitations and epigastric pain. The ECG showed high ventricular rate atrial fibrillation (AF) with wide QRS (left bundle branch block morphology). Due to haemodynamic instability the patient underwent urgent electrical cardioversion and coronary angiography showed patent coronary arteries. He had a giant left auricle appendage diagnosed twelve years before and was on antiarrhythmic prophylaxis for previous AF episodes. A TEE was performed and confirmed the diagnosis of LAAA also showing hypokinetic anterior-apical wall due to the interplay with the giant aneurysm. Subsequent CMR showed no LGE and confirmed the absence of thrombus in the LAAA. After Heart Team consultation surgical treatment was proposed to the patient who refused any invasive procedure. Therefore medical treatment was achieved by direct oral anticoagulation and antiarrhythmic therapy with betablockers and flecainide per os. Moreover, a loop recorder for longitudinal monitoring was implanted. At 6 months of follow-up the patient was asymptomatic except for a brief paroxysm of self-limited AF. 510 Figure 1CMR scan showing giant left atrial appendage aneurysm. (A) Transversal view. (B) Frontal view. (C) Sagittal view.510 Figure 2TOE mid oesophageal 57° showing giant left atrial appendage.

Atrial fibrillation in patients with SARS-CoV-2 infection

Introduction and objectivethe SARS-CoV-2 infection ranges from asymptomatic to critical forms and several prognostic factors have been described. Atrial fibrillation (AF) is common in acute situations where it is linked with more complications and mortality. We aimed to evaluate the prognostic information of AF in this population. Methodsretrospective analysis of a cohort of 517 patients consecutively admitted in a tertiary hospital due to SARS-CoV-2 infection. We divided the patients in two groups according the development of AF and compared the main features of both groups. An univariable and multivariable analysis of mortality were also performed. Resultsamong 517 patients with SARS-CoV-2 infection admitted in a tertiary center, 54 (10.4%) developed AF. These patients are older (81.6 vs 66.5 years old, p<0.001) and present more hypertension (74% vs 47%, p<0.001), cardiomyopathy (9% vs 1%, p=0.002), previous heart failure admission (9% vs 0.4%, p<0.001), previous episodes of AF (83% vs 1%, p<0.001) and bigger left atrium (47.8 vs 39.9mm, p<0.001). AF COVID-19 patients present more acute respiratory failure (72% vs 40%, p<0.001) and higher in-hospital mortality (50% vs 22%, p<0.001). Predictors of AF development are age and previous AF. AF is not an independent predictor of in-hospital mortality. Predictors are age, creatinine>1.5mg/dL at admission, LDH>250UI/L at admission and acute respiratory failure. ConclusionAtrial fibrillation appears in 10% of hospitalized patients with SARS-CoV-2 infection. These patients present more comorbidities and two-fold increase in hospital mortality. Atrial fibrillation is not an independent prognostic factor.

Subacute postoperative atrial fibrillation after heart surgery: incidence and predictive factors in cardiac rehabilitation

Abstract Funding Acknowledgements Type of funding sources: None. Background. Postoperative atrial fibrillation (POAF) is the most common arrhythmic complication following cardiac surgery. It may occur between the second and fourth postoperative days as acute POAF, or within 30 days as subacute POAF (sPOAF). The incidence varies from 15% to 60%, with the highest rates observed in patients undergoing valvular surgery. POAF is associated with longer hospital stay and higher thromboembolic risk, which consistently increase patients’ morbidity and mortality. Identification of high-risk categories may allow optimization of in-hospital prevention and treatment, possibly improving clinical outcomes. Aim of the study. The aim of this study was to assess the incidence of sPOAF and to identify possible predictors in patients performing Cardiovascular Rehabilitation (CR) after Cardiac Surgery (CS). Methods. A single-centre retrospective study was performed on 383 post-cardiac surgery patients hospitalised in our CR Unit for inpatient rehabilitation. The entire population was on sinus rhythm at the admission in CR and continuous monitoring with 12-lead ECG telemetry was performed during the hospital stay. We calculated the incidence of sPOAF and then evaluated the predictive value of the following variables: anamnestic data, type of cardiac intervention, clinical course in both CS and CR Unit, laboratory parameters including baseline neutrophil-to-lymphocyte ratio (NLR). Results. Median age was 65 years (63% male). sPOAF was documented in 122 cases (31.9%). Patients developing sPOAF were older [median age 69 (63-76) vs. 61 (51-70); p &amp;lt; 0.001)], more frequently underwent complex surgical procedures (50% vs. 36%; p = 0.009) and were known for previous episodes of atrial fibrillation (27.9% vs. 11.2%; p &amp;lt; 0.001). On the first day after surgery (T1), sPOAF group showed higher values of glycemia [median 155 (126.5–186.8) vs. 129 (106.5–164); p &amp;lt; 0.001] and troponin T [median 721.5 (470.1–1084.3) vs. 488 (301.6-776.2); p &amp;lt; 0.001]. The multivariate analysis identified advanced age (OR 1.04, 95% CI 1.01-1.08; p = 0.023), acute POAF in the Cardiac Surgery Unit (OR 3.51, 95% CI 1.62-7.59; p = 0.001), baseline NLR (OR 1.46, 95% CI 1.10-1.93; p = 0.008) and T1-troponin &amp;gt; 552 ng/L (OR 4.16 95% CI 1.50-11.53; p = 0.006) as independent risk predictors of sPOAF during the CR period. Conclusions. sPOAF is common after cardiac surgery occurring in 31.9% of patients during CR. Age, acute POAF, baseline NLR and elevated troponin T on the first postoperative day were shown predictors of increased sPOAF risk. Recognition of new predictors of POAF could be helpful to better stratify patients, improving management strategies and outcomes.

Atrial fibrillation in patients with SARS-CoV-2 infection

Introduction and objectivethe SARS-CoV-2 infection ranges from asymptomatic to critical forms and several prognostic factors have been described. Atrial fibrillation (AF) is common in acute situations where it is linked with more complications and mortality. We aimed to evaluate the prognostic information of AF in this population. Methodsretrospective analysis of a cohort of 517 patients consecutively admitted in a tertiary hospital due to SARS-CoV-2 infection. We divided the patients in two groups according the development of AF and compared the main features of both groups. An univariable and multivariable analysis of mortality were also performed. Resultsamong 517 patients with SARS-CoV-2 infection admitted in a tertiary center, 54 (10.4%) developed AF. These patients are older (81.6 vs 66.5 years old, p<0.001) and present more hypertension (74% vs 47%, p<0.001), cardiomyopathy (9% vs 1%, p=0.002), previous heart failure admission (9% vs 0.4%, p<0.001), previous episodes of AF (83% vs 1%, p<0.001) and bigger left atrium (47.8 vs 39.9mm, p<0.001). AF COVID-19 patients present more acute respiratory failure (72% vs 40%, p<0.001) and higher in-hospital mortality (50% vs 22%, p<0.001). Predictors of AF development are age and previous AF. AF is not an independent predictor of in-hospital mortality. Predictors are age, creatinine>1.5mg/dL at admission, LDH>250UI/L at admission and acute respiratory failure. ConclusionAtrial fibrillation appears in 10% of hospitalized patients with SARS-CoV-2 infection. These patients present more comorbidities and two-fold increase in hospital mortality. Atrial fibrillation is not an independent prognostic factor.

Atrial fibrillation burden and risk of new development through artificial intelligence analysis of an electrocardiogram in hospitalized patients with heart failure and preserved ejection fraction

Abstract Background Analysis of a 12-lead electrocardiogram (ECG) in sinus rhythm by artificial intelligence (AI) has demonstrated to identify the risk of underlying paroxysmal atrial fibrillation (AF) with reasonable accuracy in the overall population. Purpose This study investigates whether AI based ECG analysis can predict new AF development in patients with heart failure and preserved ejection fraction (HFpEF) without previous AF history, as well as predict AF burden in patients with AF history. Methods This retrospective cohort study includes 424 patients with HFpEF, consecutively admitted to receive treatment with intravenous diuretics for congestion. A previously validated AI algorithm that provides an AF risk score based on ECG analysis was applied in all subjects. Patients were stratified according to AF history: (1) no history; (2) paroxysmal AF; (3) persistent AF; or (4) permanent AF. In patients without AF history, the impact of AI-predicted AF risk on new AF development was assessed. In patients with previous AF episodes, the relationship between AI-predicted AF risk and AF burden as well as underlying echocardiography substrate was evaluated. Results Eighty-three patients had paroxysmal AF (19.5%), 48 persistent AF (11%), and 121 permanent AF (28.5%). AF patients were older, with lower body mass index and higher heart rate. Lower systolic blood pressure, larger left atrial volume index (LAVI), worse diastolic function, more tricuspid valve regurgitation, and more need for pacing were observed with increasing AF severity. In 172 patients without AF history followed for 979±875 days, 61 developed AF (35%) after a median time of 2,118 days. AI-predicted AF risk was associated with new-onset AF after adjustments for age, gender, systolic blood pressure, body mass index and LAVI [HR (95% CI) = 1.15 (1.04–1.28); P-value=0.007; figure]. Only 5/61 patients who developed AF during follow-up (8.2%) were anticoagulated at baseline. In patients with previous AF, the AI-predicted risk score increased significantly with AF burden (46±25% in paroxysmal AF, 59±22% in persistent AF, and 69±17% in permanent AF; P-value&amp;lt;0.001). The score was weakly but significantly correlated with LAVI (Pearson's r=0.27; P-value&amp;lt;0.001) and right ventricular systolic pressure (Pearson's r=0.30; P-value&amp;lt;0.001). When stratifying patients according to AI-predicted AF risk (0–25% versus 26–50% versus 51–75% versus 76–100%), there was a progressively longer time since onset of the first AF episode [29 months (4–77 months) versus 9 months (0–62 months) versus 38 months (2–88 months) versus 54 months (3–112 months), respectively; P-value=0.046]. Conclusions An AI-predicted AF risk score based on ECG analysis was associated with AF burden in HFpEF patients and did independently predict new-onset AF in those without previous history. Time to new onset of atrial fibrillation Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): Belgian American Educational Foundation (B.A.E.F.); Special Research Fund (BOF) of Hasselt University (Hasselt, Belgium)

P6544A real world study of high frequency atrial anti-tachycardia pacing in new algorithm for atrial arrhythmia

Abstract Background Advanced pacemakers feature atrial antitachycardia pacing (aATP) therapies for terminating atrial arrhythmia. Previous studies showed the efficacy of combined atrial preventive pacing and aATP in patients with pacemakers. The independent effect of aATP and the impact for patients outside the clinical trials has not been well elucidated. Methods In a single center, prospective, all-comers trial, we enrolled 567 patients implanted cardiac devices with Reactive ATP function. History of permanent atrial fibrillation (AF) was not included. After device interrogation of the AF burden and the longest AF duration in the last 6 months, aATP was programmed as a bit more aggressive setting than MINERVA trial (time interval was set as every 2 hours). As for newly implanted devices, aATP was activated after at least 3 months run-in period. Primary and secondary outcomes were the longest AF duration and cumulative percentage of progression into permanent AF, respectively. Results Of 541 eligible patients, aged 75.3±10.7 years, 356 pacemaker, 82 ICD and 103 CRT patients, the longest single episode of AF lasted ≤6 min in 439 patients (81.1%), &gt;6 min to 6 h in 43 (8.0%), &gt;6–24 h in 33 (6.1%), and &gt;24 h in 26 (4.8%) at the enrollment. During mean follow-up of 1.9 years, the longest AF episode lasted &gt;24 h in 49 patients (9.1%) and 14 patients (2.6%) progressed into permanent AF. According with baseline longest single episode of AF, patients with AF ≤6 min developed an episode &gt;24 h in 0.8% at 1 year and 3.2% at 2 years follow up; patients with AF &gt;6 min to 6 h developed an episode &gt;24 h in none at 1 year and 7% at 2 years follow up; and patients with AF &gt;6–24 h developed an episode &gt;24 h in 19% at 1 year and 42% at 2 years follow up, respectively. In a subgroup analysis of in 192 patients with at least 1 aATP, 46 patients with high efficacy (&gt;44%) did not developed an episode &gt;24 h. Only one patient developed into permanent AF without aATP therapy. On multivariate analysis, neither ICD nor CRT was independent risk factor for developing the longest AF episode &gt;24 h. Conclusions The independent use of aATP without atrial preventive pacing was effective for preventing AF progression in a real world cohort. Even without the previous AF episodes, aATP could prevent AF development, especially in patients showing high aATP efficacy. Future research is required to enhance the aATP success rate.

The influence of atrial fibrillation on the levels of NT-proBNP versus GDF-15 in patients with heart failure

BackgroundIn heart failure (HF), levels of NT-proBNP are influenced by the presence of concomitant atrial fibrillation (AF), making it difficult to distinguish between HF versus AF in patients with raised NT-proBNP. It is unknown whether levels of GDF-15 are also influenced by AF in patients with HF. In this study we compared the plasma levels of NT-proBNP versus GDF-15 in patients with HF in AF versus sinus rhythm (SR).MethodsIn a post hoc analysis of the index cohort of BIOSTAT-CHF (n = 2516), we studied patients with HF categorized into three groups: (1) AF at baseline (n = 733), (2) SR at baseline with a history of AF (n = 183), and (3) SR at baseline and no history of AF (n = 1025). The findings were validated in the validation cohort of BIOSTAT-CHF (n = 1738).ResultsPlasma NT-proBNP levels of patients who had AF at baseline were higher than those of patients in SR (both with and without a history of AF), even after multivariable adjustment (3417 [25th–75th percentile 1897–6486] versus 1788 [682–3870], adjusted p < 0.001, versus 2231 pg/mL [902–5270], adjusted p < 0.001). In contrast, after adjusting for clinical confounders, the levels of GDF-15 were comparable between the three groups (3179 [2062–5253] versus 2545 [1686–4337], adjusted p = 0.36, versus 2294 [1471–3855] pg/mL, adjusted p = 0.08). Similar patterns of both NT-proBNP and GDF-15 were found in the validation cohort.ConclusionThese data show that in patients with HF, NT-proBNP is significantly influenced by underlying AF at time of measurement and not by previous episodes of AF, whereas the levels of GDF-15 are not influenced by the presence of AF. Therefore, GDF-15 might have additive value combined with NT-proBNP in the assessment of patients with HF and concomitant AF.Graphic abstract

Trends and Predictors of Oral Anticoagulation in Patients with Atrial Fibrillation: A Serial Cross-Sectional Study from 2011 to 2016

Abstract Background: Despite the efficacy of vitamin K antagonists against stroke in patients with atrial fibrillation (AF), the underuse of this therapy is well documented. Objectives: To evaluate trends and predictors of oral anticoagulants utilization in patients with AF. Methods: Observational, retrospective, serial cross-sectional study between 2011-2016. Comparisons between groups were performed using the Student t, Mann-Whitney and Chi-square tests. Logistic regression was used to identify independent predictors of anticoagulation. A p value < 0.05 was considered significant. Results: A total of 377 patients were analyzed. The mean age was 70 ± 15 years; 52% were male and 75% were anticoagulated (20% with VKA and 55% with DOAC). Over 5 years, the overall frequency of anticoagulation increased by 22.4%. The use of DOACs increased from 29% to 70%, whereas the use of VKA decreased from 36% to 17%. The use of antiplatelet agents alone also fell from 21% to 6%. The predictors of anticoagulation were previous episodes of AF (OR 3.1, p < 0.001), hypertension (OR 3.0, p < 0.001) and HASBLED score (OR 0.5, p < 0.001). The predictors of DOAC use were serum creatinine (OR 0.2, p = 0.002), left atrial size (OR 0.9, p = 0.003) and biological valve prosthesis (OR 0.1, p = 0.007). Of the 208 patients using DOACs, 63 (30%) received inadequate prescriptions: 5 with severe drug interactions and 58 with incorrect dosing. Conclusions: Between 2011 and 2016, DOACs were rapidly incorporated into clinical practice, replacing AVKs and antiplatelets, and contributing to greater use of anticoagulation in patients with AF.

Use of short-term steroids in the prophylaxis of atrial fibrillation after cardiac surgery

ObjectivesTo assess the effectiveness of corticosteroids in the prophylaxis of postoperative atrial fibrillation (AF) in patients undergoing elective coronary artery bypass grafting or valvular heart surgery in terms of reducing its incidence and decreasing the length of hospital stay. MethodsThis prospective double blinded randomized study was conducted at Queen Alia Heart Institute (Amman, Jordan) from June 2014 to June 2015 on 340 patients who underwent their first on-pump elective coronary artery bypass grafting (CABG) alone or combined with valvular surgery. Inclusion criteria consisted of elective first time CABG or combined with valvular surgery, use of β-adrenergic blockade, and normal sinus rhythm. Exclusion criteria included a history of heart block, previous episodes of AF or flutter, uncontrolled diabetes mellitus, history of peptic ulcer disease, systemic bacterial or mycotic infection, permanent pacemaker, and any documented or suspected supraventricular or ventricular arrhythmias. Patients were randomized into two equal groups (n=170 each), then each group was subdivided into patients who underwent CABG alone (n=120), and patients underwent valvular heart surgery with or without CABG (n=50). In the treatment group, patients were given 1g of methylprednisolone before cardiopulmonary bypass then 100mg of hydrocortisone every 8 hours for the first 3days postoperatively. The primary endpoint was the overall occurrence of postoperative AF. ResultsAF developed in 21.1% (36 patients) in the treatment group in contrast to 38.2% (65 patients) in the control group (p<0.05). In the subdivided groups (CABG only), approximately 20% (24 patients) developed AF in the treatment group in contrast to 35% (42 patients) in the control group (p<0.05). In the other group, (CABG+VALVE) 24% (12 patients) developed AF compared with 46% (23 patients) in the control group (p<0.05). The length of hospital stay was 6.02±11.23days in the treatment group while it was 5.98±1.86days in the control group, which was found to be statistically nonsignificant. No statistical significant difference in the rate of postoperative complications including mediastinitis as well superficial wound infections was observed between the two groups. ConclusionProphylactic short-term use of steroids both intraoperatively and postoperatively proved to be safe and effective in reducing the incidence of postoperative AF in patients undergoing CABG alone or combined with valve surgery.

Epidemiology of new-onset paroxysmal atrial fibrillation in the General Intensive Care Unit population and after discharge from ICU. A retrospective epidemiological study.

Evidence of various cardiac arrhythmias in septic patients has been demonstrated by multiple clinical reports and observations. Most cardiac arrhythmias in sepsis are new-onset and may be related to sepsis-induced myocardial dysfunction. We propose to investigate and analyze data of new-onset paroxysmal atrial fibrillation (AF) in a critically ill septic population. This is a retrospective epidemiologic study. We collected clinical data from two hundred septic patients who developed a new episode of atrial fibrillation during their hospitalization in General Intensive Care Unit (GICU) between January 2007 and June 2013. Of these 200 septic patients, 81 septic patients developed a new episode of AF and included in the present study. Thirty-seven patients had no past medical history of atrial fibrillation (AF) or antiarrhythmic therapy (new episode of atrial fibrillation, Group 1) and 44 had previously known episodes of atrial fibrillation and were prescribed antiarrhythmic therapy at home (Group 2). Group 2 patients had longer duration of recurrent episodes of atrial fibrillation compared to patients in Group 1 (11.07 ± 8.7 vs. 7.4 ± 6.1 days; P = 0.013). The overall ICU and in-hospital mortality rate was similar in both study groups. There was no significant difference in new stroke and pulmonary embolism (PE) between both study groups (P > 0.05). In the present study we demonstrated no difference in morbidity and mortality rate in-ICU and after discharge between septic patients who had previous AF episodes and patients who had no previous past medical history of any cardiac arrhythmias.

Demographic and clinical characteristics of patients with atrial fibrillation and cardioversion as planned therapeutic options in the International Registry on Cardioversion of Atrial Fibrillation RHYTHM-AF Polish substudy

Cardioversion of atrial fibrillation (AF) and maintenance of sinus rhythm are the basic strategies of treating AF patients. Precise data regarding the current practice of AF cardioversion in Europe in clinical practice is lacking. The primary objective of this prospective observational study was to characterise patients and treatment patterns in whom cardioversion was the planned therapeutic option. Patients with recent onset of AF were included, regardless of when the timing of the cardioversion was planned. Ten countries participated in the study, with Poland contributing 501 patients. The global enrollment period lasted from May 2010 to June 2011. Follow-up data was collected 60 days after enrollment via a medical chart abstraction or a telephone interview. The average age of the Polish patient population was 64.2 years, and 38.5% of patients were female. Mean duration of arrhythmia was 3.3 years. Paroxysmal AF was diagnosed in 38.3% and persistent AF in 43.6% of patients. The most prevalent AF risk factors were hypertension (75.0%), diabetes mellitus (20.5%), and family history of AF (12.1%). Mean body mass index of study patients was 29.5 kg/m². The most pertinent factors triggering AF were emotion (12.4%), exercise (6.5%), electrolyte disturbances (5.5%), and acute myocardial infarction (3.7%). Only 14.2% of patients were asymptomatic. Previous episodes of AF were present in 83.1% of patients and 58.5% of them had previous cardioversion: 49.8% pharmacological and 50.2% electrical. The most often used anti-arrhythmic drugs were amiodarone (53.4%) and propafenone (32.2%). The rate of antithrombotic treatment was low: 59.6%. Finally electrical cardioversion had been undergone by 165 (53%) patients and pharmacological by 146 (47%) patients. The population of patients with AF and planned cardioversion represented typical patients with non-valvular AF and standard symptoms, the vast majority of whom were symptomatic. The study group in terms of comprehensive characteristics is representative of the general population of AF patients.

Abstract 18292: Incidence and Recurrence of Atrial Fibrillation in Patients Undergoing Cavotricuspid Isthmus Ablation for Typical Atrial Flutter

Background: A proportion of patients with cavotricuspid dependent right atrial flutter (AFL) have previous episodes of atrial fibrillation (AF). Many patients with isolated AFL (no previous AF) develop AF after AFL ablation. There is limited data evaluating the impact of AFL ablation on the a) development of AF in those without AF and b) recurrence of AF in patients with previous AF. Methods: We performed a retrospective study including all consecutive patients (with or without previous AF) undergoing cavotricuspid isthmus ablation for AFL in a large academic center. Results: A total of 589 patients underwent AFL ablation between 2007 and 2012. Mean age was 64 ±13 years with 74% males. Mean left ventricular ejection fraction was 50 ±14%. Median duration since diagnosis of AFL was 2 months (IQ range 1-10) months. 289 (49%) patients had a history of AF (paroxysmal in 95%) and the remaining 300 (51%) patients did not have AF. Patients “with AF” were on more antiarrhythmics (AADs) prior to ablation when compared to those “without AF”. 67 (23%) patients “with AF” had AF in the lab spontaneously, by programmed stimulation or with isoproterenol infusion when compared to 27 (9%) patients “without AF”; p&lt;0.001. After a mean follow-up time of 31 months, 200 (34%) patients were on AADs (47% vs 12% in patients with and without AF respectively). During follow up, 166 (57%) of the patients “with AF”, had a recurrence of AF and 87 (29%) patients “without AF” developed AF; p&lt;0.001. The independent predictors of AF during follow up in patients with prior AF were CHADS2 score, number of AADs used and AF induction during the procedure. In patients without prior AF, LVEF was the only independent predictor of incident AF Conclusions: At 2.5 years after AFL ablation a) 29% of the patients with isolated AFL develop incident AF and b) 43% of the patients with prior AF do not have AF recurrence. LVEF is the only independent predictor for new onset AF in patients without prior AF.

Abstract 18939: Trends in Antithrombotic Therapy for Atrial Fibrillation in the Veterans Affairs

INTRODUCTION: The CHADS2 is a stroke risk score developed in 2001 to guide the selection of antithrombotic therapy for patients with atrial fibrillation (AF). Since 2001 the CHADS2 has been adopted into multiple practice guidelines. Anticoagulation by warfarin or newer anticoagulants is recommended for patients with CHADS2 of 2 or higher, with aspirin or clopidogrel recommended for lower CHADS2 scores. We evaluated trends during 2002-2011 in antithrombotic therapy by CHADS2 score for patients with new AF episodes in the Veterans Affairs (VA). METHODS: New AF episodes were defined by at least two encounters for AF (ICD-9-CM 427.31) and no previous AF episodes based on national VA data (n=297,611). Patient age and diagnoses for hypertension, diabetes, heart failure, and stroke during the 12 months preceding AF were used to calculate CHADS2 scores. Receipt of warfarin, dabigatran, or clopidogrel within 90 days of the AF episode was identified in VA national pharmacy data. Trends in antithrombotic therapy by CHADS2 score were examined in unadjusted analyses and in analyses that controlled for bleeding risk. RESULTS: Overall, 54% of patients received antithrombotics within 90 days of AF. Among those, 88% received warfarin and 18% received clopidogrel. Dabigatran (available in the VA in 2011) accounted for 0.4% of patients in 2010-2011. From 2002 through 2011, the proportion of patients prescribed warfarin within 90 days of AF decreased by 26%, 23%, 15%, 13%, 8%, and 10%, for patients with CHADS2 score of 0, 1, 2, 3, 4, and 5-6, respectively (p&lt;.0010). Clopidogrel use decreased by 17% and 20% over the 10-year period for patients with CHADS2 of 1 or 5 or more, respectively, but increased for patients with CHADS2 of 1, 2, or 3. Results were similar controlling for bleeding risk factors. LIMITATIONS: We were unable to assess the use of aspirin due to its availability without a prescription. CONCLUSIONS: Widespread adoption of the CHADS2 stroke risk score in practice guidelines appears to have impacted anticoagulation prescribing patterns for warfarin. Results for clopidogrel were mixed, likely due to the use of clopidogrel for other cardiac conditions. The overall decline in antithrombotic agents in our study, even among patients with high CHADS, warrants investigation.

Clinical characteristics of patients with asymptomatic recurrences of atrial fibrillation in the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico–Atrial Fibrillation (GISSI-AF) trial

Atrial fibrillation (AF) is a common arrhythmia that frequently recurs after restoration of sinus rhythm. In a consistent percentage of cases, AF recurrences are asymptomatic, thus making its clinical management difficult in relation to both therapeutic efficacy and thromboembolic risk. The GISSI-AF trial enrolled 1,442 patients in sinus rhythm with previous AF episodes. Patients were randomized to valsartan or placebo and followed for 12 months. To improve the likelihood of detecting arrhythmic recurrences, arrhythmic follow-up was based on both programmed or symptom-related control visits and transtelephonic electrocardiographic transmissions. The present post hoc analysis was performed on 1,638 arrhythmic episodes that occurred in 623 patients. Asymptomatic AF recurrences were present in 49.5% of patients. In multivariable analysis, asymptomatic AF recurrences were significantly associated with a longer duration of qualifying arrhythmias (odds ratio [95% CI] 1.57 (1.26-1.97), P < .0001). A lower ventricular response (P < .001) and a longer duration of the arrhythmic recurrence (P < .001) characterized asymptomatic episodes. Patients with asymptomatic events were more likely to be in AF at the time of electrocardiographic control at the end of the 12-month follow-up (adjusted odds ratio [95% CI] 4.9 (2.8-8.4), P < .001). Moreover, a higher CHADS(2) (Congestive heart failure, history of Hypertension, Age≥75 years, Diabetes mellitus, and past history of Stroke or TIA doubled) score and a more frequent use of amiodarone, calcium-channel blockers, and digitalis characterized patients with asymptomatic, whereas 1C drugs were more often used in subjects with symptomatic recurrences. Asymptomatic AF recurrences were frequent in the GISSI-AF study population in patients who were more likely to develop persistent-permanent AF and were characterized by an increased thromboembolic risk.

Predictors of arrhythmia recurrence in patients with lone atrial fibrillation

The need for antiarrhythmic drugs (AAD) after a first episode of atrial fibrillation (AF) is determined by the probability of recurrence. The aim of this study was to asses the probability of relapse and the predictors of recurrence in patients with idiopathic AF. A cohort of 98 consecutive patients younger than 65 years admitted at the emergency room because of an episode of symptomatic idiopathic (lone) AF was included in this study. On admission, a complete medical history was taken, and an echocardiogram and 24-h Holter monitoring were performed. Patients were seen at 3 and 6 months after the index episode. There were 35 (35.7%) patients with a new-onset AF episode and 63 (64.3%) with a recurrent AF episode. A majority of them were male (71%), with a mean age of 48+/-11 years. Patients with new-onset AF episodes did not receive AAD. At 6 month follow-up, 57% of all patients suffered at least one symptomatic AF relapse. Patients with AF relapses belong more often to the recurrent group vs. new-onset group of AF (65.1 vs. 34.9%, respectively, P = 0.03); they had larger LA diameter indexed for body surface area (BSA) (22.6+/-3.7 vs. 19.8+/-3.2 mm/m(2), P = 0.001), larger left ventricular end-systolic diameter (18.4+/-3.1 vs. 17.2+/-2.5 mm/m(2), P = 0.05) and a tendency towards a higher proportion of atrial tachycardia runs on Holter (66.7 vs. 50%, P = 0.09). Logistic regression analysis showed that the presence of previous episodes of AF (OR: 3.2; 95% CI; 1.0-8.0, P = 0.04) and a larger anteroposterior LA diameter (OR: 1.3; 95% CI; 1.1-1.6, P = 0.001) were independent predictors of AF recurrences at 6 months. The recurrence rate in lone AF patients is high. The presence of previous episodes and a mildly enlarged anteroposterior LA diameter increase the probability of relapse of lone AF.

TEE screening in Atrial flutter: A single-centre experience with retrospective validation of a new risk score for the presence of atrial thrombi

Transesophageal echocardiography (TEE) has been proposed as a screening tool to exclude the presence of atrial thrombi and left atrial spontaneous echocontrast before cardioverting persistent atrial flutter (AFl) and atrial fibrillation (AF). However in pure AFl a very low prevalence of atrial thrombi has been observed by many investigators: a confirmation of this finding would make TEE screening redundant. We review our database of patients with AFl who underwent TEE screening before cardioversion in the last 5 years. A new risk score for the presence of left atrial thrombus (AFLAT score) is here proposed, as a potential tool to avoid unnecessary TEE exams. Out of the 106 patients examined, in fourteen left atrial thrombi were diagnosed (13%). Only two cases belonged to the pure AFl subgroup (prevalence = 3%), while twelve cases were detected in the subgroup of AFl patients with previous AF episodes (prevalence = 32%, p < 0.001). All of the fourteen patients with a positive TEE for thrombus were identified by a AFLAT score > 2. The validation of this index in a larger and prospective setting would lead to a 85% reduction in unnecessary TEE exams in patients with pure AFl undergoing cardioversion.

Influence of pacing modalities on the incidence of atrial fibrillation in patients without prior atrial fibrillation. A prospective study.

Many studies suggest that patients who receive a physiological pacemaker have a reduced incidence of atrial fibrillation compared to patients receiving a ventricular pacemaker. In order to evaluate the impact of different pacing modalities on the incidence of atrial fibrillation, we prospectively analysed 210 patients. Patients with previous episodes of atrial fibrillation were excluded from the study. The patient population included 110 patients paced for sick sinus syndrome and 100 patients paced for total atrioventricular block or second degree type atrioventricular block. Patients were followed for 5 years; the incidence of atrial fibrillation was 10% at 1 year, 23% at 3 years and 31% at 5 years. There was an increase in the incidence of atrial fibrillation in patients receiving a ventricular pacemaker compared to patients receiving a physiological pacemaker. The pacing modality appeared to influence the incidence of atrial fibrillation in paced patients; patients with ventricular pacing had a significantly higher incidence of arrhythmias than did patients with physiological pacing.