Rapid Ventricular Rate Research Articles

Distinguishing between overdrive excited and suppressed ventricular beats in guinea pig ventricular myocardium.

Rapid ventricular pacing rates induces two types of beats following pacing cessation: recovery cycle length (RCL) prolongation (overdrive suppression) and RCL shortening (overdrive excitation). The goals of this study were to compare common experimental protocols for studying triggered activity in whole-heart preparations and differentiate between recovery beats using a new methodology. Post-pacing recovery beat cycle length (RCL) and QRS were normalized to pre-paced R-R and QRS intervals and analyzed using a K-means clustering algorithm. Control hearts only produced suppressed beats: RCL ratio increased with rapid pacing (25 ± 4.0%, n = 10) without changing QRS duration. Rapid pacing during hypercalcemia + hypothermia (5.5 mM and 34°C) produced significantly earlier excited beats (53 ± 14%, n = 5) with wider QRS durations (58 ± 6.3%, n = 5) than suppressed beats. Digoxin + hypothermia (0.75 μM) produced the most excited beats with significantly earlier RCL (44 ± 3.2%, n = 6) and wider QRS (60 ± 3.1%, n = 6) ratios relative to suppressed beats. Increasing pacing further shortened RCL (30 ± 7.8%, n = 6). In a prospective study, TTX (100 nM) increased RCL ratio (15 ± 6.0%, n = 10) without changing the QRS duration of excited beats. The algorithm was compared to a cross-correlation analysis with 93% sensitivity and 94% specificity. This ECG based algorithm distinguishes between triggered and automatic activity.

Fibromuscular Dysplasia Leading to Spontaneous Coronary Artery Dissection with Sudden Cardiac Arrest.

A 30-year-old previously healthy female, who was six-week postpartum, experienced sudden collapse and tonic-clonic seizure. Emergency medicine services arrived at the scene and the patient was found to be in ventricular fibrillation. Advanced cardiovascular life support (ACLS) was initiated with return of spontaneous circulation. Afterwards, her initial EKG showed atrial fibrillation with rapid ventricular rate, ST elevation in leads II, III, and aVF, and ST depression in V2–V4. She was transferred to a tertiary care hospital where emergent angiogram was performed revealing obstruction of blood flow in the proximal and mid right coronary artery (RCA). A hazy and irregularly contoured appearance of the RCA was consistent with diagnosis of fibromuscular dysplasia. Subsequently, intravascular ultrasonogram (IVUS) was performed which confirmed the diagnosis of RCA dissection. Successful revascularization of the RCA was performed using two bare mental stents. After a complicated course in hospital, she was discharged in stable condition and did very well overall.

Management of Dysrhythmia in Emergency Department.

To the Editor: In volume 2, No. 3 (2014) of this journal an interesting case report, describing a patient with atrial filbrillation (AF) and Wolff-Parkinson-White syndrome (WPW), was published (1). As the respective authors described, the patient was a 23-year-old man who had palpitation, on the Electrocardiograph (ECG), which was provided, we saw irregular monomorphic wide complex tachycardia with a heart rate of about 150 per minute. The patient was treated with digoxin and consequently developed severe lethargy, weakness, sweating and bradycardia. Post treatment ECG showed normal sinus rhythm (heart rate about 60) and obvious signs of WPW syndrome (short PR interval, initial delta waves and wide QRS). Based on post treatment ECG and response to procainamide, the authors concluded that administering digoxin in this patient was wrong and had resulted in the patient's symptoms. I would like to share my points of view on this case with your respective readers: 1. Signs suggesting concurrence of AF and WPW on ECG are rapid ventricular rate (too rapid for conduction through atrioventricular (AV) node; more than 180-200 in most literature) and wide bizarre polymorphic QRS complexes (resulting from either varying fusions of impulses conducted through accessory pathway and AV node or existence of multiple APs) (2-5). Based on his pretreatment ECG, the patient did not have any of the two mentioned criteria (he had monomorphic wide complex irregular tachycardia with a heart rate of about 150). To this date, no guideline has recommended assuming any case of AF with widened QRS as WPW concurrency. As the patient did not show any signs suggesting WPW, using digoxin was not wrong based on ECG findings (despite the fact that if the physician knew about his WPW digoxin administration was surely wrong). Therefore, it seems that symptoms that developed post digoxin administration were not related to the patient’s rhythm or baseline WPW syndrome. 2. Based on 2014 AHA/ACC guideline for the management of patients with AF, intravenous procainamide or ibutilide are drugs of choice in patients with AF and WPW. Intravenous amiodarone is contraindicated in AF and WPW concurrency, just like adenosine, digoxin, or nondihydropyridine calcium channel antagonists (6).

Long-term follow-up in AV junction ablation via the SVC in patients undergoing concurrent device implantation: a single center experience.

Ablation of the atrioventricular junction (AVJ) combined with pacemaker implantation (the "ablate and pace" approach) has been an effective treatment strategy for patients with atrial fibrillation (AF) when rate control is the goal of therapy and when rapid ventricular rates during AF is refractory to pharmacologic therapy. This report describes the feasibility and safety of catheter ablation of AVJ via a superior vena cava (SVC) approach performed during concurrent pacemaker or defibrillator implantation. A total of 170 consecutive patients with drug-refractory AF underwent combined AVJ ablation and pacemaker or defibrillator implantation using the axillary or subclavian venous approach. The acute and long-term success of achieving complete atrioventricular (AV) block, the impact of the ablation procedure on the total procedure time and fluoroscopy duration, and procedural complications were evaluated. A dual-chamber device in 61% of patients and biventricular device in 39% patients. Catheter ablation of the AVJ was acutely successful in 166 patients (97.6%). The mean procedure time of the AVJ ablation was 7.0 ± 3.3 minutes and the mean fluoroscopy time during the ablation procedure was 3.1 ± 3.2 minutes. The average duration of RF energy application required to achieve complete AV block was 129 ± 65 seconds. Procedural complications were observed in seven patients. Complete AV block persisted in 96% of patients during a mean follow-up of 26 ± 16 months. Catheter ablation of the AVJ can be performed successfully and safely using the SVC approach in patients undergoing concurrent device implantation, and it may offer several advantages over the conventional femoral approach.

Elevated brain natriuretic peptide level in patients undergoing atrial fibrillation ablation: is it a predictor of failed ablation or a mere function of atrial rhythm and rate at a point in time?

Pre- and postablation atrial fibrillation (AF) brain natriuretic peptide (BNP) levels were shown to predict increased recurrence of AF following ablation. Our objective was to assess whether elevated BNP levels merely represent the presence of AF at the time of measurement or indeed the true recurrence of AF. In a prospective study of 88 patients undergoing AF ablation, BNP levels were measured immediately before, after, 24 h, and 4-6 months postablation. BNP levels were stratified by presenting rhythm and ventricular rate at the time of measurement. Median BNP level preablation was higher in patients presenting in AF compared to sinus rhythm (SR) (54(44-79) pg/ml vs. 30(18-47) pg/ml, p < 0.001). Postablation restoration of SR in patients presenting in AF reduced median BNP levels from 54(44-79) pg/ml to 40(37-51) pg/ml, (p < 0.001). However, no change was noted in patients who presented in and maintained SR throughout the procedure (30(18-47) pg/ml to 27(16-40) pg/ml, p = 0.270). At 4-6 months, BNP measured in patients in SR was not significantly different from postablation BNP (35(22-53) pg/ml vs. 38(20-52) pg/ml, p = 0.656), although 35% of them had AF recurrence in 1-year follow-up. Median BNP level measured in five patients while in atrial arrhythmia was elevated compared to postablation BNP (464(421-464) pg/ml to 37(36-37) pg/ml, p = 0.043). BNP levels and ventricular rates are positively correlated at all times pre- and postablation. BNP level rises acutely during AF and with rapid ventricular rates. BNP level seems to be a function of atrial rhythm and ventricular rate rather than short- or long-term predictor of AF ablation success.

Clinical Reasoning: A 68-year-old man with a first presentation of status epilepticus

A 64-year-old man with transfusion-dependent myelodysplastic syndrome (MDS), hypertension, chronic obstructive pulmonary disease, hypothyroidism, blindness from treated syphilitic chorioretinitis, and no prior seizure history presented in generalized status epilepticus. His daily home medication regimen included prednisone 20 mg (chronic therapy for MDS), diltiazem 120 mg, digoxin 250 μg, tiotropium 80 μg, and levothyroxine 112 μg. On admission he was febrile to 39.9 °C and in atrial fibrillation with rapid ventricular rate. Initial hematologic profile showed 11,910 leukocytes/mm(3) (12% immature forms, 46% neutrophils, 32% lymphocytes), hematocrit of 30.8%, and platelet count of 215,000/mm(3), with an otherwise normal serum chemistry.

A shocking complication of a pneumothorax: chest tube-induced arrhythmias and review of the literature.

We describe a patient with a recent chest tube insertion leading to atrial fibrillation with rapid ventricular rate that led to multiple inappropriate internal cardiac defibrillator (ICD) shocks. This is the first reported case of this occurring in a patient with an ICD leading to inappropriate shocks. Our elderly patient with emphysema presented with a spontaneous pneumothorax and developed rapid atrial fibrillation following emergency tube thoracostomy. The patient had a single lead ICD and received multiple inappropriate shocks for the rapid ventricular rate in the therapy zone. Although medical treatment helped stabilize the patient, resolution of the atrial fibrillation occurred only after the chest tube was removed. In a patient with a chest tube or other intrathoracic catheters, maintaining a high index of suspicion that chest tube insertions can cause secondary life threatening cardiovascular complications needs to be considered. In such patients, removal of the device proves to be the most prudent treatment action.

A case of paroxysmal atrial fibrillation following low voltage electrocution

BackgroundElectrical injury may result in arrhythmias, however atrial fibrillation following low voltage electrocution is not a common occurrence.Case presentationA 70-year-old South-Asian woman with no prior history of cardiovascular disease presented following an accidental low voltage electrocution with loss of consciousness. On initial assessment she was found to be in atrial fibrillation with a moderate to rapid ventricular rate. Troponin I and 2D echo were normal. Transient rise in markers of muscle damage were noted. The arrhythmia resolved spontaneously without active intervention.ConclusionLoss of consciousness and the path of electrical conduction involving the heart may herald cardiac involvement following electrocution. Low voltage electrocution may cause cardiac insult. Conservative management may suffice in management of atrial fibrillation without cardiovascular compromise.

Left Atrial Thrombus After Appendage Closure Using LARIAT

HomeCirculation: Arrhythmia and ElectrophysiologyVol. 6, No. 4Left Atrial Thrombus After Appendage Closure Using LARIAT Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBLeft Atrial Thrombus After Appendage Closure Using LARIAT Evaldas Giedrimas, MD, Albert C. Lin, MD and Bradley P. Knight, MD Evaldas GiedrimasEvaldas Giedrimas From the Division of Cardiology, Department of Internal Medicine, Northwestern University, Chicago, IL. Search for more papers by this author , Albert C. LinAlbert C. Lin From the Division of Cardiology, Department of Internal Medicine, Northwestern University, Chicago, IL. Search for more papers by this author and Bradley P. KnightBradley P. Knight From the Division of Cardiology, Department of Internal Medicine, Northwestern University, Chicago, IL. Search for more papers by this author Originally published1 Aug 2013https://doi.org/10.1161/CIRCEP.113.000532Circulation: Arrhythmia and Electrophysiology. 2013;6:e52–e53IntroductionThe left atrial appendage (LAA) is the source of thromboembolism in the vast majority of patients with atrial fibrillation and stroke.1 As a consequence, a newer paradigm of targeting the LAA has evolved, including the use of several percutaneous techniques, including the LARIAT snare device (SentreHEART).2 This minimally invasive strategy involves pericardial suture ligation of the LAA base using a combined percutaneous endocardial and epicardial approach.Case ReportA 75-year-old male with atrial fibrillation, hypertension, and end-stage liver disease complicated by esophageal varices was referred for LAA closure using the LARIAT device. The procedure was uneventful, and complete closure of the LAA was confirmed using intraoperative transesophageal echocardiography (Figures 1 and 2). The patient was discharged without oral anticoagulation. His postoperative course was complicated by an increase in the frequency of atrial fibrillation with rapid ventricular rates despite several antiarrhythmic drugs. Three weeks after the LAA closure procedure, the patient underwent atrioventricular nodal ablation and dual chamber permanent pacemaker implantation.Download figureDownload PowerPointFigure 1. A baseline transesophageal image of the left atrial appendage before closure. LA indicates left atrium; and LAA, left atrial appendage.Download figureDownload PowerPointFigure 2. A transesophageal image of the left atrial appendage after closure using a suture snare LARIAT device. LA indicates left atrium; LAA, left atrial appendage; and LV, left ventricle.A follow-up transesophageal echocardiography, 3 months later, showed complete closure of LAA with no evidence of residual flow. However, there was a 0.8×0.8 cm oval, pedunculated, mobile left atrial thrombus attached to the endocardial site of LAA closure (Figure 3). He was also found to have 2 thrombi in the right atrium (1.1×1.0 cm; 0.9×1.0 cm). The patient was subsequently started on warfarin. A repeat transesophageal echocardiography 3 months later showed resolution of all thrombi and no clinical sequelae.Download figureDownload PowerPointFigure 3. A transesophageal image of an endocardial left atrial pedunculated thrombus (arrow) seen 3 months after left atrial appendage closure. LA indicates left atrium; LAA, left atrial appendage; and LV, left ventricle.DiscussionThis case raises the concern that LAA occlusion using an epicardial suture snare acutely increases local inflammation and, subsequently, left atrial thrombogenicity at the endocardial site of LAA closure. Further investigation about the need for anticoagulation after LAA closure is warranted.DisclosuresNone.FootnotesThe online-only Data Supplement is available at http://circep.ahajournals.org/lookup/suppl/doi:10.1161/CIRCEP.113.000532/-/DC1.Correspondence to Bradley P. Knight, MD, Bluhm Cardiovascular Institute of Northwestern, 251 E Huron St, Feinberg 8-503E, Chicago, IL. E-mail [email protected]

GW24-e0442 Inhibition of biventricular pacing due to oversensing of atrial fibrillation by a left ventricular lead: Interest of remote monitoring

ObjectivesAtrial oversensing by a ventricular lead may cause asystole in a pacemaker dependent patient or inappropriate shocks in an implanted cardioverter defibrillator recipient patient. In cardiac resynchronization therapy (CRT) devices...

Rate Control in Atrial Fibrillation: Methods for Assessment, Targets for Ventricular Rate during AF, and Clinical Relevance for Device Therapy.

Rate control is a widely used treatment strategy for management of patients with atrial fibrillation (AF). Multiple studies have shown that pharmacologic rate control is as effective as pharmacologic rhythm control for management of AF. A snapshot ECG or intermittent monitoring using Holters is the most widely used technique for assessing ventricular rate during AF. Patients with implantable devices, such as pacemakers, implantable cardioverter defibrillators, cardiac resynchronization therapy devices, and implantable loop recorders provide the ability for continuous long term monitoring of AF and ventricular rate during AF. It has been shown that continuous monitoring of AF and ventricular rate during AF by implantable devices is the most comprehensive method for assessment of AF occurrence and poor rate control, particularly in patients with paroxysmal and asymptomatic AF. Rapid ventricular rate during AF, as assessed by implantable devices, has been shown to cause reduction in cardiac resynchronization therapy, predict inappropriate defibrillation therapy, and identify increased risk for cardiovascular hospitalizations. The ventricular rate targets for achieving good rate control during AF depend on the patient characteristics with stricter targets recommended for patient with compromised functional capacity, such as patients with HF. Thus it can be hypothesized that timely intervention based on continuous assessment of AF and poor rate control, with ventricular rate targets defined based on cardiovascular disease state, may improve clinical outcomes in patients with AF.

症例 WPW症候群 心房細動によるまれな高度頻拍の1例

症例 WPW症候群 心房細動によるまれな高度頻拍の1例

Reversing Dabigatran in Life-Threatening Bleeding Occurring During Cardiac Ablation With Factor Eight Inhibitor Bypassing Activity

We report a case of a patient receiving dabigatran who developed a life-threatening bleeding complication during cardiac ablation that rapidly resolved after administration of Factor Eight Inhibitor Bypassing Activity (FEIBA). Therapeutic anticoagulation with warfarin during cardiac ablation has been shown to reduce the risk of stroke and systemic embolism. Cardiac tamponade is a potentially life-threatening procedural complication requiring emergent reversal of anticoagulation and pericardiocentesis. Dabigatran is superior to warfarin in preventing stroke and systemic embolism in nonvalvular atrial fibrillation, but has not been evaluated for use during cardiac ablation. Dabigatran is without a known reversal agent and, should tamponade occur during ablation, it is unclear what reversal strategy could be used to establish hemostasis. A 67-year-old man with history of atrial fibrillation with rapid ventricular rate, two previous atrial fibrillation ablations, and prescribed dabigatran 150 mg bid was admitted for an atrial fibrillation ablation procedure. The last dabigatran dose was 7 hours prior to procedure. During the procedure, a transseptal perforation occurred, requiring an emergent pericardiocentesis. Within 60 minutes, approximately 4.5 L of blood was removed via the pericardiocentesis. Low-dose FEIBA (3159 units, 26 U/kg actual body weight) over 15 minutes was administered. Hemostasis was noted within minutes of initiating the infusion with cessation of bleeding after administration was complete. This case report describes the potential ability of a low dose of the activated prothrombin complex concentrate, FEIBA, to reestablish hemostasis independent of the pharmacologic effects of dabigatran. Additional studies are warranted to confirm the findings of our observation.

Corrigendum to: ‘ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012’ [Eur J Heart Fail 2012;14: 803–869

In the table on page 827, the text ‘should not be used’ should read ‘are not recommended’ in two instances. These occur in rows 1 and 2. In row 3, the text ‘should be avoided if possible’ should be changed to ‘are not recommended’. Row 3 should read ‘NSAIDs and COX-2 inhibitors are not recommended as they may cause sodium and water retention … ’ The table on page 832 should read as follows: The bullet point ‘The patient requires pacing because of an intrinsically slow ventricular rate’ should be placed above the text beginning ‘CRT-P/CRT-D may be considered … ’ In the table on page 845, the text ‘should be considered’ should read ‘is recommended’ in two instances. These occur in the table section ‘Patients with AF and a rapid ventricular rate’, rows 3 and 4. Row 3 should read ‘Electrical cardioversion or pharmacological cardioversion with amiodarone is recommended in patients … ’. Row 4 should read ‘Intravenous administration of a cardiac glycoside should be considered for rapid control of the ventricular rate. In addition, in row 1 of this section the authors would like to add ‘It is recommended that’ to the beginning of the sentence, so it reads: ‘It is recommended that patients should be fully anticoagulated … ’

Atrial Fibrillation Through the Years

Information about a real patient is presented in stages (boldface type) to an expert clinician (Dr Valentin Fuster), who responds to the information, sharing his reasoning with the reader (regular type). A discussion by the authors follows. A 61-year-old man presents with 2 weeks of exertional dyspnea. Pertinent medical history includes hypertension, nephrolithiasis, and internal hemorrhoids. He takes no medications and has no known drug allergies. His father died after a myocardial infarction at 57 years of age. He formerly smoked 1 pack of cigarettes daily for 15 years but ceased tobacco use 10 years before presentation. He ingests 2 glasses of alcohol weekly and denies illicit drug use. His caffeine intake is limited. He is an architect and is married, with healthy children. On physical examination, his temperature is 98.0°F, blood pressure is 130/85 mm Hg bilaterally, pulse is irregular at 130 beats per minute, and respiratory rate is 18 breaths per minute with an oxygen saturation of 97% while breathing room air. He is a slender white man in no distress. His jugular venous pressure is elevated at 14 cm H 2 O. There is no thyromegaly, and the carotid upstrokes are brisk, without bruits. Cardiovascular examination reveals a rapid and irregular heart rhythm with variation in the intensity of the first heart sound. The point of maximal impulse is not displaced. The remainder of the chest and abdominal examination is within normal limits. The extremities are warm and show mild pitting edema. Laboratory testing is significant for normal renal function and electrolytes, but a hemogram reveals a mild thrombocytopenia of 90 000 platelets/μL. ECG demonstrates atrial fibrillation (AF) with an average ventricular rate of 123 bpm ( Figure 1 ). Figure 1. The 12-lead ECG showing atrial fibrillation with a rapid ventricular rate. Dr Valentin Fuster : This is a …

Iceberg in Small Pulmonary Embolism

An 82-year-old man presented to our emergency department complaining of shortness of breath over recent days. He had a medical history of hypertension, dilated cardiomyopathy, and chronic atrial fibrillation. Electrocardiography showed atrial fibrillation with rapid ventricular rate. We carried out contrast-enhanced computed tomography due to his high Modified Well's scores and elevated D-dimer. This revealed a small filling defect over the left lateral basal segmental artery and posterior branch of the basal trunk of the right pulmonary artery with patent bilateral main pulmonary trunks. This was compatible with pulmonary embolism (Fig. 1A and B, arrow). The Pulmonary Embolism Severity Index was 112.1) No vasopressor was needed after admission except oxygen supplement. Intravenous unfractionated heparin was given according to Raschke Nomogram.2) Doppler was used for evaluation of the limbs, which showed no evidence of deep venous thrombosis. Standard transthoracic echocardiography (TTE) was used the next day, which disclosed one huge floating thrombus located over the right atrium (Fig. 1C). This moved into the right ventricle during diastolic phase (Fig. 1D). The patient succumbed suddenly with pulseless electrical activity before the emergent operation. Emergent TTE showed disappearance of the floating thrombus and severe right ventricle dysfunction. Even though echocardiography is not recommended as a routine diagnostic test for PE, especially in hemodynamically stable subjects, this case serves as a reminder of the importance of TTE in PE patients. This is true not only in terms of right ventricle function evaluation, but also because it may facilitate the earlier identification and aggressive management of possible existing intra-cardiac thrombus. Fig. 1

In vivo validation of an ultra-high field, high temporal resolution myocardial tagging technique for assessment of diastolic function in mice

Background Heart failure with preserved ejection fraction accounts for approximately half of all heart failure cases and is associated with similar morbidity and mortality. Although abnormalities of diastolic function are felt to play an important role, no specific treatments have been identified for this common condition, primarily because of poor understanding of its pathophysiology. Despite development of several murine models of this disease, accurate non-invasive assessment of diastolic function has been challenging. Echocardiographic measurements have been limited by small heart sizes, rapid ventricular rates and high inter-observer variability. The aim of this study was to assess the ability of ultra-high field, high temporal resolution CMR tagging to assess diastolic function in mice, compared to the gold-standard technique of invasive pressure-volume loop analysis.

Current Role of Atrioventricular Junction (AVJ) Ablation

Atrioventricular junction ablation with permanent pacemaker insertion is a highly effective treatment approach in patients with atrial fibrillation that is resistant to other treatment modalities, especially in the elderly or those with severe comorbidities. This effect likely reflects reversal of rapid ventricular rates and regularizing ventricular rates. There is increasing evidence that cardiac resynchronization therapy devices may be beneficial in selected populations after atrioventricular node ablation. The limitations of this approach include continued need for anticoagulation and lifelong pacemaker therapy.

Atrial Fibrillation Ablation and Heart Failure

Atrial fibrillation (AF) worsens outcome in patients with systolic heart failure and the presence of heart failure (HF) predicts a 5- to 6-fold increase in risk of AF. In addition to loss of atrial systole, AF may contribute to left ventricular (LV) systolic dysfunction due a rapid ventricular rate, irregularity of rhythm and exacerbation of mitral regurgitation due to atrial dilatation. Elimination of atrial fibrillation with catheter ablation can improve ejection fraction and reduce heart failure symptoms and appears superior to AV node ablation and bi-ventricular pacing. AF ablation can restore sinus rhythm in most patients with heart failure. Additional study is warranted to identify which patients will receive maximum benefit from aggressive rhythm control and to determine efficacy in patients with diastolic heart failure.

Atrial Fibrillation Management in Elderly

Atrial fibrillation (AF) in older adults is inherently more clinically challenging than sinus rhythm because it is associated with diminished functional capacity and quality of life, as well as higher incidence of mortality, stroke, and coronary events. AF with a rapid ventricular rate is particularly likely to cause demand ischemia, heart failure with preserved ejection fraction (HFPEF), as well as tachycardia-related cardiomyopathy. Indications for direct-current cardioversion, pharmacological cardioversion, rate control, and nondrug therapies are discussed. Differences in clinical outcome based on ventricular rate control versus drug treatment to maintain sinus rhythm are also reviewed. Indications for anticoagulation for chronic or paroxysmal AF are included, including long-term warfarin and direct thrombin inhibitors (dabigatran, rivaroxaban, or apixaban) and/or aspirin.