Rate Control Medications Research Articles

Rates of therapeutic interventions in a large real-world cohort with insertable cardiac monitors

Abstract Background Insertable cardiac monitors (ICMs) provide up to several years of continuous monitoring and have demonstrated high diagnostic yields for arrhythmia detection. However, the rates of arrhythmia-related therapeutic interventions following ICM implant have not been comprehensively characterized across indicated patient populations. Purpose To quantify rates of arrhythmia therapies in a large, real-world U.S. cohort of ICM patients. Methods De-identified patients receiving a Reveal LINQ ICM between Oct 1, 2016 – Sept 30, 2020 with no prior cardiac implantable electronic devices (CIEDs) and ≥1 year of follow-up in the Optum Clinformatics® Data Mart claims database were identified (N=17,037). Patients were stratified by indication for ICM placement: N=431 (2.5%) of patients were indicated for AF ablation monitoring, 2,193 (12.9%) for AF management, N=4,852 (28.5%) Cryptogenic stroke, N=1,252 (7.3%) Palpitations, 1,346 (7.9%) Suspected AF, 6,716 (39.4%) Unexplained syncope, and 247 (1.4%) Ventricular tachycardia (VT). Each patient was followed in the claims database after ICM insertion until end of continuous claims enrollment, end of database, or death. Therapeutic interventions for arrhythmias were characterized during follow-up, including procedures (CIED implants, cardioversion, and ablation) and arrhythmia medication initiation (antiarrhythmics, rate-control medications, and oral anticoagulants). Results Mean(SD) follow-up in the claims database post ICM placement was 3.4(1.3) years; 52.4% of patients were female, and mean age was 70.8(11.9) years. Overall, 54.5% of patients received a therapeutic intervention during follow-up, with 25.0% of patients receiving a therapeutic procedure and 44.0% initiating an arrhythmia-related medication (table). The highest procedure rates included implantable pulse generator (IPG) implants in the Unexplained syncope population (21.4% of patients) and cardiac ablations in the populations receiving ICM for known AF (27.8% of AF ablation monitoring patients and 23.5% of AF management patients). Medication initiation rates were highest for oral anticoagulants in the Cryptogenic stroke population (31.0% of patients). The mean time from ICM insertion to therapeutic action was 13(13) months for procedures and 7(11) months for medication initiation. Conclusions In a large sample of real-world ICM patients, more than half received a therapeutic intervention after ICM placement. Time to intervention was lengthy and showed substantial variability amongst patients, underscoring the importance of long-term continuous monitoring to uncover clinically-relevant arrhythmia findings.

Atrial fibrillation fact sheet in Korea 2024 (part 3): treatment for atrial fibrillation in Korea: medicines and ablation

BackgroundAtrial fibrillation (AF) is a prevalent cardiac arrhythmia associated with significant morbidity and mortality, posing a considerable burden on healthcare systems. In Republic of Korea, the prevalence and incidence of AF have increased in recent years. There have also been significant changes in the trends of antiarrhythmic drug (AAD) use and procedural treatments for AF.ObjectivesThis study aims to review the trends in AF treatment strategies in Republic of Korea, particularly focusing on the utilization of antiarrhythmic drugs and catheter ablation.MethodsThe Korean National Health Insurance Service (K-NHIS) data were used to identify AF patients from 2013 to 2022. AAD usage and catheter ablation procedures were analyzed annually. AADs were classified into Class IC and III drugs. Trends in beta-blockers, calcium channel blockers, and digoxin prescriptions were also examined. The primary endpoint was the trend of AAD use and AF catheter ablation (AFCA) over 10 years.ResultsIn 2022, 940,063 patients had a prior diagnosis of AF. From 2013 to 2022, the use of AADs increased from 12.1 to 16.4% among prevalent AF patients. Beta-blockers were the most commonly prescribed rate control medication, while the use of calcium channel blockers and digoxin declined. The frequency of AFCA procedures also increased, from 0.5% of prevalent AF patients in 2013 to 0.7% in 2022. Younger patients, males, and those with lower CHA2DS2-VASc scores were more likely to receive AFCA. Regional variations in treatment patterns were observed, with Seoul exhibiting higher rates of procedural treatments and AAD prescriptions.ConclusionsOver the past decade, there has been a significant increase in the use of AADs and AFCA procedures in Republic of Korea. These trends reflect recent advancements in AF management advocating a refined rhythm control strategy.

Serious Bleeding in Patients With Atrial Fibrillation Using Diltiazem With Apixaban or Rivaroxaban

Diltiazem, a commonly prescribed ventricular rate-control medication for patients with atrial fibrillation, inhibits apixaban and rivaroxaban elimination, possibly causing overanticoagulation. To compare serious bleeding risk for new users of apixaban or rivaroxaban with atrial fibrillation treated with diltiazem or metoprolol. This retrospective cohort study included Medicare beneficiaries aged 65 years or older with atrial fibrillation who initiated apixaban or rivaroxaban use and also began treatment with diltiazem or metoprolol between January 1, 2012, and November 29, 2020. Patients were followed up to 365 days through November 30, 2020. Data were analyzed from August 2023 to February 2024. Diltiazem and metoprolol. The primary outcome was a composite of bleeding-related hospitalization and death with recent evidence of bleeding. Secondary outcomes were ischemic stroke or systemic embolism, major ischemic or hemorrhagic events (ischemic stroke, systemic embolism, intracranial or fatal extracranial bleeding, or death with recent evidence of bleeding), and death without recent evidence of bleeding. Hazard ratios (HRs) and rate differences (RDs) were adjusted for covariate differences with overlap weighting. The study included 204 155 US Medicare beneficiaries, of whom 53 275 received diltiazem and 150 880 received metoprolol. Study patients (mean [SD] age, 76.9 [7.0] years; 52.7% female) had 90 927 person-years (PY) of follow-up (median, 120 [IQR, 59-281] days). Patients receiving diltiazem treatment had increased risk for the primary outcome (RD, 10.6 [95% CI, 7.0-14.2] per 1000 PY; HR, 1.21 [95% CI, 1.13-1.29]) and its components of bleeding-related hospitalization (RD, 8.2 [95% CI, 5.1-11.4] per 1000 PY; HR, 1.22 [95% CI, 1.13-1.31]) and death with recent evidence of bleeding (RD, 2.4 [95% CI, 0.6-4.2] per 1000 PY; HR, 1.19 [95% CI, 1.05-1.34]) compared with patients receiving metoprolol. Risk for the primary outcome with initial diltiazem doses exceeding 120 mg/d (RD, 15.1 [95% CI, 10.2-20.1] per 1000 PY; HR, 1.29 [95% CI, 1.19-1.39]) was greater than that for lower doses (RD, 6.7 [95% CI, 2.0-11.4] per 1000 PY; HR, 1.13 [95% CI, 1.04-1.24]). For doses exceeding 120 mg/d, the risk of major ischemic or hemorrhagic events was increased (HR, 1.14 [95% CI, 1.02-1.27]). Neither dose group had significant changes in the risk for ischemic stroke or systemic embolism or death without recent evidence of bleeding. When patients receiving high- and low-dose diltiazem treatment were directly compared, the HR for the primary outcome was 1.14 (95% CI, 1.02-1.26). In Medicare patients with atrial fibrillation receiving apixaban or rivaroxaban, diltiazem was associated with greater risk of serious bleeding than metoprolol, particularly for diltiazem doses exceeding 120 mg/d.

How well do ED physician practices align with the CAEP acute atrial fibrillation checklist for stroke prevention and disposition?

Acute atrial fibrillation (AF)/flutter (AFL) is a common emergency department (ED) presentation. In 2021, an updated version of CAEP's Acute AF/AFL Best Practices Checklist was published, seeking to guide management. We assessed the alignment with and safety of application of the Checklist, regarding stroke prevention and disposition. This health records review included adults presenting to two tertiary care academic EDs between January and August 2022 with a diagnosis of acute AF/AFL. Patients were excluded if their initial heart rate was < 100 or if they were hospitalized. Data extracted included: demographics, CHADS-65 score, clinical characteristics, ED treatment and disposition, and outpatient prescriptions and referrals. Our primary outcome was the proportion of patient encounters with one or more identified safety issues. Each case was assessed according to seven predetermined criteria from elements of the CAEP Checklist and either deemed "safe" or to contain one or more safety issues. We used descriptive statistics with 95% confidence intervals. 358 patients met inclusion criteria. The mean age was 66.9years, 59.2% were male and 77.4% patients had at least one of the CHADS-65 criteria. 169 (47.2%) were not already on anticoagulation and 99 (27.6%) were discharged home with a new prescription for anticoagulation. The primary outcome was identified in 6.4% (95% CI 4.3-9.5) of encounters, representing 28 safety issues in 23 individuals. The safety concerns included: failure to prescribe anticoagulation when indicated (n = 6), inappropriate dosing of a direct oral anticoagulant (DOAC) (n = 2), inappropriate prescription of rate or rhythm control medication (n = 9), and failure to recommend appropriately timed follow-up for new rate control medication (n = 11). There was a very high level of ED physician alignment with CAEP's Best Practices Checklist regarding disposition and stroke prevention. There are opportunities to further improve care with respect to recommendation of anticoagulation and reducing inappropriate prescriptions of rate or rhythm medications.

Clinical efficacy of catheter ablation versus medical rate control among patients with atrial fibrillation across heart failure phenotypes: a meta-analysis of randomized controlled trials

Abstract Background Atrial fibrillation (AF) is the most common arrhythmia encountered in clinical practice. It frequently co-exists with heart failure (HF) with complex dynamic interactions. Trials comparing rate and rhythm control strategies with the latter based on anti-arrhythmic drugs (AADs) failed to show benefit of one strategy over the other. Therefore, it is still unclear what constitutes an ideal AF management, especially in the context of HF. Objective To compare the clinical efficacy between catheter ablation and medical rate control among patients with atrial fibrillation and heart failure Study Selection Only randomized controlled trials (RCT) comparing catheter ablation and medical rate control in patients with atrial fibrillation and heart failure were selected for review. Methods Pubmed, Embase, and Cochrane databases were searched for randomized controlled trials (RCTs) reporting clinical outcomes of catheter ablation versus medical rate control for AF in HF patients with &amp;gt; 6 months follow-up. Primary endpoint was change in left ventricular ejection fraction (LVEF). Secondary endpoints were 6-minute walk test (6MWT) distance, quality of life (QoL), BNP levels, and number of adverse events. Results Five RCTs with 615 patients were included in the analysis. Patients in the catheter ablation had greater improvement in LVEF (WMD 7.38, 95%CI: p &amp;lt; 0.001), longer 6-min walk distance (WMD 17.41, CI 95%: p &amp;lt; 0.0001), lower Minnesota Living with Heart Failure Questionnaire (MLHFQ) scores (WMD -6.21, CI 95%: p &amp;lt; 0.00001), and lower BNP levels (WMD -113.1 ng/L, CI 95%: p &amp;lt; 0.00001), compared with medical rate control. However, catheter ablation group had higher rates of adverse events mostly from procedural complications (RR 2.2, CI 95%: p = 0.005). Conclusion Catheter ablation is superior to medical rate control in terms of LVEF improvement, increase in functional status, reduction in biomarker, and better quality of life among patients with AF and HF.

Use and Association of Rate Control and Anti-Arrhythmic Medications with Risk of Subsequent Stroke and Mortality Among Hemodialysis Patients with Atrial Fibrillation

Use and Association of Rate Control and Anti-Arrhythmic Medications with Risk of Subsequent Stroke and Mortality Among Hemodialysis Patients with Atrial Fibrillation

Diagnosing Atypical Flutter in the Post-atrial Fibrillation Ablation Patient: A Case Report.

Late atrial arrhythmias after catheter ablation for atrial fibrillation occur in up to 30% of post-ablation patients and are increasingly encountered by emergency physicians. However, diagnosing the exact mechanism of the arrhythmia on the surface electrocardiogram (ECG) remains challenging due to atrial scarring leading to heterogeneous P-wave morphology. A 74-year-old male with a history of prior catheter ablation for atrial fibrillation presented with palpitations and subacute symptoms of heart failure. The patient's ECG revealed narrow complex tachycardia with more P waves than QRS complexes. The differential diagnosis included typical flutter, atypical flutter, and focal atrial tachycardias with 2:1 conduction block. P waves were positive in V1 and across all precordial leads (absent precordial transition). This favors atypical flutter originating from the left atrium over typical cavotricuspid isthmus-dependent right atrial flutter. Transthoracic echocardiogram showed a reduced ejection fraction due to tachycardia-mediated cardiomyopathy. The patient underwent a repeat electrophysiology study and ablation, which confirmed the presence of an atypical flutter circuit using the mitral annulus, known as perimitral flutter. Repeat catheter ablation resulted in maintenance of sinus rhythm. At follow-up, his ejection fraction recovered. Recognizing ECG findings suggestive of atypical flutter impacts initial emergency department decisions and triage as atypical flutter post-atrial fibrillation ablation is frequently resistant to rate-controlling medications and often requires cardiology and/or electrophysiology consultation if available.

MP-453086-7 ATRIOVENTRICULAR JUNCTION ABLATION AND CARDIAC RESYNCHRONIZATION THERAPY IN PATIENTS WITH NONOBSTRUCTIVE HYPERTROPHIC CARDIOMYOPATHY AND PERMANENT ATRIAL FIBRILLATION

Atrial fibrillation (AF) is the most common arrhythmia encountered with hypertrophic cardiomyopathy (HCM) and is associated with adverse cardiovascular outcomes. The outcomes of ablate-and-pace strategy for the management of refractory AF in HCM patients are unclear. The objective of this retrospective study was to investigate the incremental benefit and safety of atrioventricular junction (AVJ) ablation and biventricular pacing (CRT) in patients with nonobstructive (NO) HCM and symptomatic permanent AF. Between January 2016 and December 2021, 20 patients with NO-HCM underwent AVJ ablation + CRT for uncontrolled permanent AF. The control group included 86 NO-HCM patients with permanent AF treated by the best medical rate-control therapy. A 1:1 propensity score (PS) matching analysis weighted on clinical (age, gender, hypertension, diabetes, recent hospitalization for heart failure [HF], cerebrovascular accident, chronic kidney disease, NYHA class) and imaging characteristics (left ventricle [LV] ejection fraction [EF], left atrial dimension, estimated pulmonary hypertension, maximal wall thickness, late gadolinium enhancement extension) was performed to compare outcomes between groups. The primary endpoint was a composite of all-cause mortality and hospitalization due to HF during follow-up. PS matching yielded 40 patients, 20 patients with AVN ablation + CRT (Group 1), and 20 patients in best medical rate-control therapy (Group 2). CRT was achieved in all patients (100% CRT-D). No acute procedure-related complications were noted. The mean paced QRS duration was 119±12 ms. Within the matched cohort, mean age was 64±7 years, the median time since AF diagnosis was 2 years (IQR 0.8-2.3 years), the mean LV EF was 53%±5%. During a median follow-up period of 23 months (IQR 19-27 months), patients in Group 1 had a lower risk of primary outcomes (HR 0.7; 95% CI 0.47-0.92; p=0.04), mainly driven by a significantly lower risk of HF hospitalization (HR 0.4; 95% CI 0.23–0.75; p=0.02). Compared to Group 2, Group 1 experienced a significant improvement in LV EF (55%±5% [Group 1] vs 48%±6% [Group 2], p=0.03) and improvement in NYHA class. No long-term device-related complications were noted. Ablation of AVJ + CRT was safe and superior to medical therapy in reducing HF hospitalization in patients with NO-HCM and permanent AF.

A value-based budget impact model for dronedarone compared with other rhythm control strategies.

Aim: The budgetary consequences of increasing dronedarone utilization for treatment of atrial fibrillation were evaluated from a US payer perspective. Materials & methods: A budget impact model over a 5-year time horizon was developed, including drug-related costs and risks for long-term clinical outcomes (LTCOs). Treatments included antiarrhythmic drugs (AADs; dronedarone, amiodarone, sotalol, propafenone, dofetilide, flecainide), rate control medications, and ablation. Direct comparisons and temporal and non-temporal combination scenarios investigating treatment order were analyzed as costs per patient per month (PPPM). Results: By projected year 5, costs PPPM for dronedarone versus other AADs decreased by $37.69 due to fewer LTCOs, treatment with dronedarone versus ablation or rate control medications+ablation resulted in cost savings ($359.94 and $370.54, respectively), and AADs placed before ablation decreased PPPM costs by $242 compared with ablation before AADs. Conclusion Increased dronedarone utilization demonstrated incremental cost reductions over time.

Association of Kidney Function With Risk of Adverse Effects of Therapies for Atrial Fibrillation

Atrial fibrillation (AF) is common in chronic kidney disease (CKD) and is treated with rate control medications, antiarrhythmic medications, as well as anticoagulation and procedures, each of which have associated risks. We aimed to evaluate the association of CKD status with the risks of adverse effects after initiation of AF therapies. This was a cohort study of community-based adults who newly initiated rate control medications, antiarrhythmic medications, warfarin, direct oral anticoagulants (DOACs) or received AF procedures in the 1 year after diagnosis of AF. Baseline estimated glomerular filtration rate (eGFR) was calculated using outpatient serum creatinine measures. Adverse effects within 1 year related to each AF therapy or within 1 month of an AF procedure were ascertained from vital sign databases, electrocardiograms (ECGs), and administrative codes. Fine-Gray hazard models were used to study the association of eGFR categories with risk of adverse effects for each AF therapy. Among 115,564 patients with incident AF, lower eGFR (vs. eGFR≥60 ml/min per 1.73 m2) was significantly associated with higher adjusted risk of adverse effects after initiation of rate control therapies (most commonly hypotension and bradycardia) as follows: eGFR 45-59 (hazard ratio [HR] 1.14, 95% confidence interval [CI] 1.07-1.22), 30-44 (HR 1.15, 95% CI 1.06-1.25), and 15-29 (HR 1.29, 95% CI: 1.12-1.47) ml/min per 1.73 m2. Lower eGFR was associated with higher adjusted risk of adverse effects (most commonly prolonged QRS and QTc intervals) after initiation of an antiarrhythmic medication (vs. eGFR >60 ml/min per 1.73 m2) as follows: eGFR 45-59 (HR 1.12, 95% CI 1.01-1.23) and eGFR<15 (HR 1.43, 95% CI 1.01-2.01) ml/min per 1.73 m2. There was a graded association between lower eGFR and risk of major bleeding with warfarin use, with the greatest risk among those with eGFR<15 ml/min per 1.73 m2 (HR of 2.93, 95% CI 1.99-4.30). There was no association of eGFR with major bleeding in patients receiving DOACs. Rates of adverse effects within 1 month of an AF procedure were low among patients with (n= 18) and without (n= 41) CKD and was underpowered for further analyses. In conclusion, lower eGFR was associated with significantly higher risks of adverse effects after initiation of commonly used therapies to treat AF. These data may help inform the complex therapeutic decisions in patients with CKD and AF.

Abstract 9460: Comparing Mortality Outcomes With Different Rate Controlling Agents in Patients With Atrial Fibrillation

Introduction: There is lack of information regarding the mortality benefits between different medications in patients with permanent atrial fibrillation (AF). Purpose: We aimed to identify if there is any difference in mortality between the use of different rate controlling medications in patients with permanent AF. Methods: We identified patients with permanent AF without history of heart failure (HF) by using the TriNetX research database which provides information from electronic medical records from several health care institutions primarily based in the United States. Patients were divided in 4 cohorts, those taking metoprolol, diltiazem, carvedilol, or atenolol. Propensity score matching (PSM) was used to equilibrate the cohorts based on past medical history and medications. The cohorts were compared amongst each other after PSM. Results: There was no difference in mortality, emergency room visits, or hospitalizations with the use of different rate-controlling medications. Conclusion: This study suggests that there is no difference in mortality with the use of metoprolol, carvedilol, atenolol, or diltiazem in patients with permanent AF without history of HF.

Comparison of diltiazem and metoprolol for atrial fibrillation with rapid ventricular rate: Systematic review and meta-analysis

BackgroundIntravenous calcium channel blockers or beta-blockers are the preferred rate control medications for hemodynamically stable patients with atrial fibrillation with rapid ventricular rate (AF-RVR) in the emergency department. ObjectivesTo compare the efficacy of intravenous diltiazem and metoprolol for rate control and safety with respect to development of hypotension and bradycardia in patients with AF-RVR. MethodsFor this systematic review and meta-analysis, we searched PubMed, Embase, Cochrane databases, and the clinicaltrials.gov registry between database inception and 30th May 2021. Articles were included if they compared efficacy and safety of diltiazem versus metoprolol in critically ill adult patients hospitalized with AF-RVR. Outcome measures were achievement of rate control, development of new hypotension, and bradycardia after drug administration. ResultsOf 86 records identified, 14 were eligible, all of which had a low to moderate risk of overall bias. The meta-analysis (Mantel-Haenszel, random-effects model) showed that diltiazem use was associated with increased achievement of rate control target compared to metoprolol [14 studies, n = 1732, Odds Ratio (OR): 1.92; 95% Confidence Intervals (CI):1.26 to 2.90; I2 = 61%]. In the pooled analysis, no differences were seen in hypotension using diltiazem vs metoprolol [12 studies, n = 1477, OR: 0.96; 95% CI:0.61 to 1.52; I2 = 35%] or bradycardia [9 studies, n = 1203, OR: 2.44; 95% CI: 0.82 to 7.31; I2 = 48%]. ConclusionsIntravenous diltiazem is associated with increased achievement of rate control target in patients with AF-RVR compared to metoprolol, while both medications are associated with similar incidence of hypotension and bradycardia.

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

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

18b Comparative Safety and Efficacy of a Hybrid Intravenous and Oral Diltiazem Protocol for Acute Rate Control in the Emergency Department

18b Comparative Safety and Efficacy of a Hybrid Intravenous and Oral Diltiazem Protocol for Acute Rate Control in the Emergency Department

Effect of specialist consultation on emergency department revisits among patients with uncomplicated recent-onset atrial fibrillation or flutter.

To examine the association between specialist consultation and risk of 30-day ED revisit in emergency department (ED) patients with recent-onset uncomplicated atrial fibrillation or flutter (AF/AFL). As a secondary analysis of a previously published trial, clinical experts identified predictors of consultation including age and sex, ED sinus conversion, thromboembolic risk, heart rate, rate control medication use, coronary artery disease and anti-platelet use, and chronic obstructive pulmonary disease. These were included in a propensity-matched hierarchical Bayesian model accounting for hospital site as a random effect, with 30-day ED revisit as the primary outcome. We also measured ED length of stay for consulted and non-consulted patients. We analyzed data from 11 sites for 829 ED patients with AF/AFL, of whom 364 (44%) had specialist consultation. A total of 128 patients (15.4%) had an ED revisit, 78 (16.8%) from the no consult group and 50 (13.7%) from the consult group. Consultation rates ranged from 8.8 to 71% between sites. Median length of stay was 591min (interquartile range [IQR] 359-1024) for consulted patients and 300min (IQR 212-409) for patients without consultation. After propensity-matching, consulted patients had a 0.6% (IQR -4 to 3%) lower risk of 30-day revisits than non-consulted patients (probability of lower risk 55%). In ED patients with uncomplicated AF/AFL, there was substantial between-site variation in specialist consultations; such consultation was unlikely to influence revisits within 30days while ED length of stay was nearly double. ED specialist consultations may not be necessary for uncomplicated patients.

Sex-Differences in Atrial Fibrillation Patients: Bias or Proper Management?

BackgroundStudies analyze the degree to which gender-based differences are affected by age and comorbidities show mixed results.MethodsUsing a retrospective cohort study, we analyzed 327 consecutive patients who presented to the emergency department (ED) due to Atrial Fibrillation (AF) from 2014 to 2017 with follow-up at one year.ResultsFemales with AF were older (p < 0.001), with higher Body Mass Indexes (BMI) (p < 0.001), and a higher rate of hypertension (p < 0.001), hyperlipidemia (p = 0.01), diabetes mellitus (p = 0.05), valvular heart disease (p = 0.05), and thyroid dysfunction (18.3% vs 1.8%, p < 0.001). AF males had higher rate of coronary artery disease (p < 0.001) and heart failure with reduced ejection fraction (p < 0.001). Females were managed with rate control medications more frequently than with antiarrhythmic (p < 0.001). After adjusting gender to age and comorbidities, females continued to have higher rates of heart failure hospitalization (Odds Ratio (OR) 2.73 95% Confidence Interval (CI) 1.04–5.89, P-value <0.001) and recurrent AF (OR 3.86, P-value=0.02). Thyroid dysfunction and the lack of antiarrhythmic treatments significantly increased the risk of AF (OR 5.95 95% CI 3.15–9.73, OR 3.42, respectively, P-value <0.001 for both) regardless of gender. The mortality rate differs only in a sub-group of females ≥75 years of age (OR 1.60, P < 0.001).ConclusionAF males and females differ significantly in baseline characteristics and tend to be treated unnecessarily differently for AF. Heart failure hospitalizations and recurrent AF continued to be associated with female AF patients, even after adjusting gender to age and comorbidities. Thyroid dysfunction and AF treatment may explain the higher rates of recurrent AF in female patients.

Rhythm Control Better Prevents Dementia than Rate Control Strategies in Patients with Atrial Fibrillation-A Nationwide Cohort Study.

Background: Atrial fibrillation (AF) increases the risk of dementia. Whether the pharmacological rhythm control of AF can reduce the risk of dementia compared to the rate control strategy remains unclear. We hypothesize that the rhythm control strategy is better than the rate control strategy in preventing dementia. Methods: AF patients aged ≥65 years were identified from the Taiwan National Health Insurance Database. Patients receiving anti-arrhythmic drugs at a cumulative defined daily dose (cDDD) of >30 within the first year of enrollment constituted the rhythm control group. Patients who used rate control medications for a cDDD of >30 constituted the rate control group. A multivariate Cox hazards regression model was used to determine the hazard ratio (HR) for dementia. Results: A total of 3382 AF patients (698 in the rhythm control group; 2684 in the rate control group) were analyzed. During a 4.86 ± 3.38 year follow-up period, 414 dementia events occurred. The rhythm control group had a lower rate of dementia than the rate control group (adjust HR: 0.75, p = 0.031). The rhythm control strategy reduced the risk of dementia particularly in those receiving aspirin (p = 0.03). Conclusions: In patients with AF, pharmacological rhythm control was associated with a lower risk of dementia than rate control over a long-term follow-up period, particularly in patients receiving aspirin treatment.

Anaesthetic and Perioperative Management of Elderly Female with Post Covid ARDS with Comorbities Undergoing Emergency Laparotomy for Obstructed Umbilical Hernia

Elderly female with chronic hypertension, known case of atrial flutter on rate control medication who recently treated for COVID-19 pneumonia on oxygen support(PFR=190) came to emergency room with complaints of abdominal mass and pain associated with vomiting, not passing stools. Diagnosed to have obstructed umbilical hernia with extensive secondary bacterial pneumonia with ARDS (ASA-4E). COVID-19 RTPCR test negative. Taken up for emergency laparotomy under combined spinal and epidural anaesthesia (CSEA). Post operatively patient was managed in intensive care unit for 5days with oxygen, invasive lines, vasopressor support and epidural infusion. Post covid patients presenting for emergency surgery requires evaluation of surgical illness and post covid sequels like oxygen dependency, cytokine storm, secondary bacterial infection, ARDS, lung fibrosis renal and liver dysfunction. Atrial flutter in perioperative period may lead to haemodynamic instability and thromboembolic events resulting in significant morbidity and mortality. Laparotomy in these patient is challenge. Needs better analgesia perioperative period to prevent further respiratory deterioration.

FAILURE TO CONSIDER FUTURE ATRIAL FIBRILLATION RATE CONTROL NEEDS AFTER PRESENTATION TO THE EMERGENCY DEPARTMENT WITH RAPID RATE

Atrial fibrillation (AF) usually presents to the emergency room (ED) with a rapid ventricular rate, which commonly, but not always, is symptomatic. Rate control is usually easily managed with diltiazem (DTZ) and beta blockers (BBs), typically metoprolol (MTP). Sinus rhythm is frequently restored within 48 hours by means of spontaneous conversion, electrical cardioversion, or medications. However, AF recurs within one year in 60-80% of these subjects. There are little data describing doses of DTZ and MTP used for AF rate control at discharge. A retrospective study of 576 patients presenting with acute AF were evaluated for admission and discharge rate control medications (RCMs). For the 319 (68%) patients with a ventricular rate ≥110bpm the admission and discharge dose of MTP was 61mg and 63mg and DTZ was 195mg and 204mg, respectively. Those who remained in AF had a modest increase in the two medications compared to the patients who converted to sinus rhythm. Current guidelines recommend DTZ up to 300 to 400mg and MTP up to 300mg for rate control for select patients. Concerns about high doses of MTP are mitigated by the MERIT-HF Trial demonstrating improved mortality and symptoms with doses of MTP up to 200mg demonstrating the safety and efficacy of MTP in high risk patients. Lack of follow-up of future AF recurrences is a limitation of the study. For those patients with acute AF and a heart rate (HR) &gt;110bpm, a minimal increase in RCMs for those in AF at discharge was noted.

741 A complex clinical mosaic of severe autoimmune calcific constrictive pericarditis with striking haemodynamic response to immunosuppressive therapy

Abstract Autoimmune constrictive pericarditis constitutes a conundrum to modern cardiology with much uncertainty surrounding both pathophysiology and optimal treatment strategies. We hereby describe the case of a 35-year-old woman of Nigerian origin with severe right heart failure secondary to calcific constrictive pericarditis. Her past medical history included coagulation factor XI deficiency, leukopenia, 2nd trimester miscarriage and premature labour due to placenta previa with fibrin deposition. Further investigations revealed atrial fibrillation, severe biatrial enlargement, moderate tricuspid and mitral regurgitation, pericardial thickening, post-capillary pulmonary hypertension and right ventricular dip-and-plateau pattern, compatible with severe constrictive pericarditis. Extensive screening for infectious and autoimmune causes only revealed borderline positive ANA (1:80). Thereafter, the patient underwent complete surgical pericardiectomy with pericardial biopsies revealing fibrous thickening, diffuse calcification and lymphocyte/macrophage infiltrates, in the absence of giant multinucleated cells or granulomas. The patient was later discharged but soon experienced relapse of exertional dyspnoea presenting with right-sided haemo-pneumothorax (requiring pleural drainage), diffuse alveolar haemorrhage, large right-sided basal and infrascissural pleural effusion, and ascites. She was treated with high dose iv furosemide, oral ibuprofen and colchicine, suspension of rate control medications, achieving initial reduction in pulmonary oedema and ascites, relapsing however after attempts to switch to oral diuretic therapy. Due to the finding of persistent lymphopenia, further immunological tests were conducted, revealing raised IgG1 levels as well as altered peripheral lymphocyte populations (raised CD4+/CD8+ ratio and CD8+ central memory, reduced CD8 effector memory). This finding in conjunction with the history of factor XI deficiency, 2nd trimester miscarriage and placental fibrin deposition as well as the observation of painful cutaneous nodules at sites of venepuncture, suggestive of Koebner’s phenomenon, veered the diagnostic focus to a potential autoimmune aetiology and in particular to systemic lupus erythematosus (&amp;gt;10 ACR-EULAR score points with case reports describing all the above as potential disease manifestations). Furthermore, revision of thoracic CT scans, demonstrated bilateral migratory peribronchovascular nodules with ground-glass halo. CT- guided biopsies thereof were performed revealing focal alveolar damage with capillaritis and alveolar haemorrhage, further corroborating the clinical suspicion of autoimmune disease and justifying the introduction of high-dose oral corticosteroid therapy. In liaison with our tertiary rheumatology centre, the patient was later switched to mycophenolate with gradual weaning from corticosteroid. Concurrent cardiological follow-up revealed persistence of good haemodynamic status (NYHA class II, absence of pulmonary oedema and ascites) with oral diuretic therapy, regression of cutaneous symptoms and echocardiography demonstrating consistent reduction in both mitral and tricuspid regurgitation. This constitutes to our knowledge the first report of autoimmune calcific constrictive pericarditis with significant haemodynamic response to immunosuppressive therapy. Despite the relative rarity of this disease entity, early recognition and instatement of immunosuppressive treatment may prove fundamental to halt and potentially reverse the haemodynamic progression of this highly morbid condition.