Rate Control Strategy Research Articles

Abstract 4127664: Influences of Age on Improvement of Health-Related Quality of Life in Patients with Atrial Fibrillation following Initial Treatment

Background: The prevalence of Atrial Fibrillation (AF), the most cardiac common arrhythmia, increases with age. Various treatment strategies are available to improve health-related quality of life (HRQoL) in patients with AF; however, the impact of age on HRQoL treatment benefits is unknown. Aims: To investigate the association of age with HRQoL benefit across different treatment strategies. Methods: Using data from a multicenter registry for outpatients with early recognized AF, HRQoL at enrollment and 1 year later was measured with the Atrial Fibrillation Effect on Quality-of-life quesTionnaire (AFEQT). The association between age and the 1-year changes in AFEQT-overall summary (OS) and subdomain scores with either rate or rhythm control strategies were assessed using generalized additive models (GAM) to address non-linear relationships. To support clinical interpretation, multivariable linear regression models were performed with categories of age ranges. Results: Among 2786 patients (31.7% women, 54.7% rhythm control); 946 were <65 of age, 1019 were ≥65–75, and 821 were ≥75 years old. Rhythm (vs. rate) control was pursued in 76.6%, 58.0%, and 33.6% and mean AFEQT-OS changes were 11.1 (SD 16.6), 8.0 (17.0), and 4.7 (18.2) in those aged <65, 65–74, and ≥75, respectively. The GAM showed improvements in AFEQT-OS attenuated with advancing age with both treatment strategies ( Figure ). Linear regression analyses showed lesser improvements in AFEQT-OS as higher age categories (≥65–75 vs. <65, β -1.12 [95% CI, -2.33 – 0.09]; ≥75 vs. <65, β -3.86 [-5.29 – -2.42]), which were mainly driven by lesser improvement in AFEQT-daily activities scores, without differences in AFEQT scores for symptom or treatment concerns ( Table ). Conclusions: In AF patients, HRQoL benefits after treatment were attenuated by advancing age, primarily driven by less improvement in functional limitations, underscoring the need for further research to identify optimal treatment strategies for older adults.

Atrial fibrillation – a comparative review of one of the most common arrhythmias in dogs and humans

Atrial fibrillation is the most prevalent arrythmia in dogs and humans and is characterised by chaotic depolarisation of the atria, resulting in damage to the atrial myocardium. It can lead to heart failure or worsen an existing condition and cause sudden death. Electrocardiographically, atrial fibrillation is characterised by the absence of P waves and an irregularly irregular rhythm, with narrow QRS complexes. Treatment of atrial fibrillation requires knowledge of pathophysiology and the pharmacology of antiarrhythmic drugs. In contrast to human medicine, the treatment of dogs revolves mainly around rate control strategies, although new studies propose the consideration of several rhythm strategies. Considering the complexity of atrial fibrillation, there is strong need for a consensus on classification, diagnosis and treatment in dogs.

Precise regulating the specific oxygen consumption rate to strengthen the CoQ10 biosynthesis by Rhodobater sphaeroides

Coenzyme Q10 (CoQ10) is the most consumed dietary supplement and mainly biosynthesized by aerobic fermentation of Rhodobacter sphaeroides (R. sphaeroides). Oxygen supply was identified as a bottleneck for improving CoQ10 yield in R. sphaeroides. In this study, a precise regulation strategy based on dielectric spectroscopy (DS) was applied to further improve CoQ10 biosynthesis by R. sphaeroide. First, a quantitative response model among viable cells, cell morphology, and oxygen uptake rate (OUR) was established. DS could be used to detect viable R. sphaeroides cells, and the relationship among cell morphology, CoQ10 biosynthesis, and OUR was found to be significant. Based on this model, the online specific oxygen consumption rate (QO2) control strategy was successfully applied to the CoQ10 fermentation process. QO2 controlled at 0.07 ± 0.01 × 10− 7mmol/cell/h was most favorable for CoQ10 biosynthesis, resulting in a 28.3% increase in CoQ10 production. Based on the multi-parameters analysis and online QO2 control, a precise online nutrient feeding strategy was established using conductivity detected by DS. CoQ10 production was improved by 35%, reaching 3384 mg/L in 50 L bioreactors. This online control strategy would be effectively applied for improving industrial CoQ10 production, and the precise fermentation control strategy could also be applied to other fermentation process.

A fuzzy control based strategy for adjusting band blade feed rate in constant power sawing

Abstract The variable cross-sectional shape of the blank reduces the efficiency of the sawing machine. Additionally, the wear of the band saw blade causes a mismatch between the feed rate and the load, further exacerbating the wear. This study studied a feed rate control strategy considering sawtooth wear to balance the relationship between cutting efficiency and band life. Initially, speed parameters for the cut-in and cut-out areas, along with acceleration and deceleration control algorithms, were established to ensure the smooth transition of the saw blade during the machining process. Additionally, a constant power sawing feed rate model that considers the influence of wear was developed, enabling dynamic adjustments to the feed rate based on the saw blade's wear state. This study also proposes a fuzzy control-based target current correction method, which dynamically adjusts the target current according to the current wear state of the saw blade, ensuring that sawing requirements were met under varying levels of wear. The accuracy of the sawing model and control strategy was verified through experiments. The results demonstrated that this strategy improved efficiency by 44% compared to the traditional uniform feed rate method. This study introduces a novel feed rate control strategy for sawing and offers an effective solution to the problem of saw tooth wear.

Rhythm and rate control strategies in patients with long-standing persistent atrial fibrillation treated with cardiac resynchronization: the results of the randomized Pilot-CRAfT study.

Atrial fibrillation (AF) is common in cardiac resynchronization therapy (CRT) recipients. It is a marker of impaired CRT response mainly mediated by the reduction of effectively captured biventricular paced beats (BiVp). There are no randomized trials comparing strategies to maintain high BiVp percentage. To compare the efficacy of rhythm vs rate control strategies in CRT recipients with long-standing persistent AF. We performed a randomized trial including CRT recipients with persistent AF resulting in low BiVp%. All patients received amiodarone, the rhythm control group received external electrical cardioversion (EC), and the rate control group received atrioventricular node ablation, if needed. The primary end-point was 12-month BiVp% (NCT). 43 patients were included in the analysis. The mean age was 68.4 (SD: ± 8.3) years and the mean BiVp% 82.4% ± 9.7%. AF lasted 25 ± 19 months. The mean baseline left ventricular ejection fraction (LVEF), left atrium area, and the maximal oxygen uptake (VO2max) were: 30 ± 8%, 33 ± 7 cm2, and 14 ± 5 mL/(kg*min), respectively. The EC success rate was 58%. 38% patients remained in sinus rhythm (SR) after 12 months. BiVp% increased similarly in both arms reaching 99% [95% CI 97.3-99.8] and 98% [94.0-99.0], P = 0.14 in rhythm and rate control groups, respectively. LVEF raised significantly only in the rhythm control group (ΔLVEF 4.1 (± 7.3), P = 0,018) which was driven by the patients who maintained SR. No differences in VO2max, QoL, clinical and safety end-points were observed. Despite comparable BiVp% in both groups, only restoration of SR led to improved left ventricular ejection fraction in CRT patients with long-standing AF. NCT01850277 registered on 22/04/2013.

The management of new-onset atrial fibrillation in critical illness: an update on current therapeutic options.

New-onset atrial fibrillation (NOAF) is the most prevalent arrhythmia among critically ill patients, correlating with heightened morbidity and mortality rates. Current evidence for managing NOAF in this patient population is limited. Numerous meta-analyses have been conducted to assess the efficacy of atrial fibrillation treatments in acute settings, including rate or rhythm control strategies, anticoagulation, and intensive care interventions. The employment of β-blockers for rate control appears to confer greater benefits in critically ill patients. However, the advantage of anticoagulation remains ambiguous because of bleeding risks, which is partly attributed to the scarcity of evidence in the complex context of critical illness. Approximately one-third of patients with transient atrial fibrillation face recurrence within a year. Therefore, vigilant posthospitalization follow-up and monitoring should be considered for high-risk patients to detect atrial fibrillation recurrence. Long-term anticoagulation strategies should be tailored to individual patient profiles, weighing the risks of thromboembolism. Factors predicting atrial fibrillation recurrence include age, the burden of atrial fibrillation, and atrial size. There are significant knowledge gaps concerning NOAF in critically ill patients, highlighting the need for further research, particularly randomized clinical trials.

Study on the dynamic characteristics and control strategies of the coupled system of the FHR and SCO2 cycle

The supercritical carbon dioxide (SCO2) Brayton cycle has high efficiency, compactness, and rapid response. Furthermore, the fluoride-salt-cooled high-temperature reactor (FHR), as a Generation IV nuclear reactor, is characterized by compactness, high temperature, and inherent safety. Therefore, the SCO2 cycle as the energy conversion system of the FHR can meet the requirements of modularity and compactness. However, the interaction characteristics between the FHR and SCO2 cycle are unknown, and the system control strategies that can guarantee the safety and flexibility of the coupled system need to be explored. In this study, a dynamic simulation model of the coupled system of the FHR and SCO2 cycle is established. Considering the complexity of the system, the dynamic characteristics of the FHR and SCO2 cycle are investigated separately. Then, the FHR and SCO2 cycle is coupled, and the interaction characteristics between the FHR and SCO2 cycle are further analyzed. It is shown that the coupled system is more flexible under SCO2 mass flow rate disturbance than under FHR reactivity disturbance. Based on that, various SCO2 mass flow rate control strategies are designed and investigated. Among them, the turbine bypass control strategy is the fastest, and system parameters are the most stable.

A decade of follow-up: atrial fibrillation, pulmonary pressure, and the progression of tricuspid regurgitation.

Long-term data on atrial fibrillation (AF) impact on tricuspid regurgitation (TR) progression and its relation to pulmonary pressure are scant. We investigated this association in a study spanning over a decade. Adults with echocardiographic evaluation before 2014, free of significant TR, were included. Patients were dichotomized by baseline AF, followed by stratification according to systolic pulmonary artery pressure (sPAP). The development of new significant TR and its impact on mortality were studied. Study population included 21502 patients (median age 65, 40% female), 13% had baseline AF. During a median follow-up of 12 years, 11% developed significant TR. Compared with patients free of AF, patients with baseline AF were 3.5 and 1.3 times more likely to develop significant TR in a univariate and multivariate models, respectively (95% CI 3.27-3.91, 1.18-1.44, p<0.001 for both). The risk of TR progression was higher in patients with permanent AF and those treated with rate control strategy (HR 1.95 and 2.01, respectively; p<0.001 for both). The association of AF with TR progression was sPAP-related, being more pronounced among patients with normal sPAP than among those with elevated sPAP (HR 1.5vs. 1.18; p for interaction<0.001). TR progression was independently linked to a two-fold higher mortality risk, consistent regardless of baseline AF (p<0.001). AF is an independent predictor of TR progression, especially in patients with normal sPAP. Subsequent research on strategies to prevent TR progression in this patient population are warranted.This analysis investigated the association of AF with TR progression, and the interaction of pulmonary arterial pressure with this link. Among patients with AF (Left), progression to significant TR is highly prevalent, with higher risk among patients with permanent AF and lower risk in those treated with rhythm control strategy. Pulmonary arterial pressure interacts with this association (Right), such that among patients with normal sPAP, the link between AF and TR progression is stronger, suggesting that the importance of proactive AF management in this sugroup of patients. TR has important implications on mortality, regardless of AF status (Middle).AF=Atrial Fibrillation; A-STR=Atrial Secondary TR; CIED=cardiac implantable electronic device; TR=Tricuspid Regurgitation; V-STR=Ventricular Secondary TR.

Evaluation of the management of a first crisis of atrial fibrillation in a group of Cameroon’s urban setting subjects

BackgroundAtrial fibrillation (AF) is the most common arrhythmia encountered in clinical practice. When atrial fibrillation is first diagnosed, it tends to be permanent and associated with significant morbidity and mortality. We aimed to study the management of a first episode of atrial fibrillation in a group of patients in Yaounde, Cameroon.MethodsWe conducted a retrospective study with data collected from the Cardiology department of Yaounde Central Hospital and the internal medicine department of Yaounde General Hospital over five years (January 2017 to December 2021), for a duration of 4 months, from February 2022 to May 2022. All patients older than 15 years with a first episode of atrial fibrillation were included, and all patients with incomplete medical records were excluded. The association between different variables was assessed using a χ² test and logistic regression method with a significance threshold of p < 0.05.ResultsOf the 141 patients recruited, the mean age was 68.5 ± 10.6 years. The sex ratio (M/F) was 0.7. The main associated factors and co-morbidities were hypertension in 70.2% (99) patients, heart failure in 36.9% (52) patients and a sedentary lifestyle in 33.3% (47) patients. The most common anticoagulant treatment was AntiVitamin K, used in 64.5% (91) of patients. Heart rate control was the most commonly used symptom control strategy in 85.1% (120) patients, mainly with beta-blockers in 52.5% (74). We found 1.4% (2) participants who were not treated with antithrombotics as recommended. Treatment of arrhythmia due to co-morbidities was not always recommended. The complication rate was 94.3% (133) patients. Control of the bleeding risk due to antithrombotic therapy and monitoring of anticoagulant therapy were not optimal. The heart rate control strategy had a higher success rate, and the sinus rhythm maintenance rate at one year was 61.7% (37) participants.ConclusionThe management of a first episode of atrial fibrillation at Yaoundé’s Central and General Hospitals is not always performed according to current recommendations and is far from optimal. However, nearly two out of three patients maintained sinus rhythm for one year.

Acceleration Slip Regulation Control Method for Distributed Electric Drive Vehicles under Icy and Snowy Road Conditions

To achieve a rapid and stable dynamic response of the drive anti-slip system for distributed electric vehicles on low-friction surfaces, this paper proposes an adaptive acceleration slip regulation control strategy based on wheel slip rate. An attachment coefficient fusion estimation algorithm based on an improved singular value decomposition unscented Kalman filter is designed. This algorithm combines Sage–Husa with the unscented Kalman filter for adaptive improvement, allowing for the quick and accurate determination of the road friction coefficient and, subsequently, the optimal slip rate. Additionally, a slip rate control strategy based on dynamic adaptive compensation sliding mode control is designed, which introduces a dynamic weight integral function into the control rate to adaptively adjust the integral effect based on errors, with its stability proven. To verify the performance of the road estimator and slip rate controller, a model is built with vehicle simulation software, and simulations are conducted. The results show that under icy and snowy road conditions, the designed estimator can reduce estimation errors and respond rapidly to sudden changes. Compared to traditional equivalent controllers, the designed controller can effectively reduce chattering, decrease overshoot, and shorten response time. Especially during road transitions, the designed controller demonstrates better dynamic performance and stability.

Rate control or rhythm control in patients with atrial fibrillation and acute coronary syndrome or percutaneous coronary intervention

BackgroundRestoring and maintaining sinus rhythm in patients with atrial fibrillation (AF) and acute coronary syndrome (ACS) or undergoing percutaneous coronary intervention (PCI) has been studied in clinical trials to reduce symptoms and improve quality of life. Limited data exist on the effectiveness of rate or rhythm control therapy in these patients. MethodsConsecutive patients with AF and ACS or referred for PCI were prospectively recruited in Fuwai Hospital during 2017–2020. The primary endpoints were all-cause death and major adverse cardiovascular and cerebrovascular events (MACCEs), including cardiovascular mortality, myocardial infarction, ischemic stroke, non-central nervous system embolism and ischemia-driven revascularization. Kaplan–Meier curves and Cox regressions were performed to evaluate the association between rhythm/rate control and subsequent outcomes. For the primary endpoints, we used the Benjamini–Hochberg correction for multiple comparisons. ResultsA total of 1499 patients with AF and ACS or undergoing PCI were included, with a median follow-up of 34.7 months. Compared to non-rate control, rate control strategy reduced the risk of subsequent MACCEs (adjusted HR, 0.320; 95 % CI 0.220–0.466; p <0.001; *p <0.002) and all-cause death (adjusted HR, 0.148; 95 % CI 0.093–0.236; p <0.001; *p <0.002). Similar trends were observed across all predefined subgroups (p <0.001). In the final multivariate model, rhythm control was not associated with a lower subsequent MACCEs but significantly improved all-cause mortality compared to non-rhythm control (adjusted HR, 0.546; 95 % CI 0.313–0.951; p =0.033; *p =0.044). ConclusionsIn this real-world study, rate control strategy was associated with lower risk of MACCEs and all-cause death in AF and ACS or undergoing PCI. Besides, management with rhythm control strategy may improve all-cause mortality.

Clinical Outcomes of Early Rhythm or Rate Control for New Onset Atrial Fibrillation Following Transcatheter Aortic Valve Replacement.

New onset atrial fibrillation (NOAF) is a common occurrence after transcatheter aortic valve replacement (TAVR) and portends a poorer prognosis. The optimal strategy for managing NOAF in this population is uncertain. This retrospective cohort study utilized deidentified patient data from the TriNetX Research Network. Patients with TAVR and NOAF were stratified into a rhythm control cohort if they were treated with antiarrhythmics, received AF ablation, or underwent cardioversion within 1 year of AF diagnosis. A rate control cohort was similarly defined by the absence of rhythm control strategies and treatment with a beta blocker, calcium channel blocker, or digoxin. After 1:1 propensity score matching, the Kaplan-Meier survival analysis and Cox proportional hazard ratios (HRs) were used to compare outcomes at 7 years of follow-up. We identified 569 patients in each cohort following propensity matching. At 7 years, the primary composite outcome of all-cause death, myocardial infarction, cerebrovascular accident, and heart failure hospitalization was not significantly different between the rhythm and rate control cohorts (HR 0.99, 95% CI 0.83-1.18). The individual components of the primary outcome in addition to all-cause hospitalization were also similar between the groups. Similar outcomes were seen among patients receiving an early rhythm or rate control strategy to manage NOAF after TAVR. The attenuated benefits of an early rhythm control strategy observed in this setting may be due to the overall high burden of comorbidities and advanced age of these patients.

One-year outcomes of rate versus rhythm control of atrial fibrillation in the Kerala-AF Registry.

There is ongoing debate around rate versus rhythm control strategies for managing atrial fibrillation (AF), however, much of the data comes from Western cohorts. Kerala-AF represents the largest prospective AF cohort study from the Indian subcontinent. To compare 12-month outcomes between rate and rhythm control strategies. Patients aged ≥18 years with non-transient AF were recruited from 53 hospitals across Kerala. Patients were stratified by rate or rhythm control. The primary outcome was a composite of all-cause mortality, arterial thromboembolism, acute coronary syndrome or hospitalization due to heart failure or arrhythmia at 12 months. Secondary outcomes included bleeding events and individual components of the primary. Predictors of the composite outcome were analysed by logistic regression. A total of 2901 patients (mean age 64.6 years, 51% female) were included (2464 rate control, 437 rhythm control). Rates of the primary composite outcome did not differ between groups (29.7% vs 30.0%; p = .955), nor did any component of the primary. Bleeding outcomes were also similar (1.6% vs 1.9%; p = .848). Independent predictors of the primary composite outcome were older age (aOR 1.01; p = .013), BMI <18 (aOR 1.51; p = .025), permanent AF (aOR 0.78; p = .010), HFpEF (aOR 1.40; p = .023), HFrEF (aOR 1.39; p = .004), chronic kidney disease (aOR 1.36; p < .001), and prior thromboembolism (aOR 1.31; p = .014). In the Kerala-AF registry, 12-month outcomes did not differ between rate and rhythm control cohorts.

Rhythm vs Rate Control Strategy for Atrial Fibrillation: A Meta-Analysis of Randomized Controlled Trials

BackgroundRhythm control, either with antiarrhythmic drugs or catheter ablation, and rate control strategies are the cornerstones of atrial fibrillation (AF) management. Despite the increasing role of rhythm control over the past few years, it remains inconclusive which strategy is superior in improving clinical outcomes. ObjectivesThis study summarizes the total and time-varying evidence regarding the efficacy of rhythm- vs rate-control strategies in the management of AF. MethodsWe systematically perused the MEDLINE, CENTRAL (Cochrane Central Register of Controlled Trials), and Web of Science databases for randomized controlled trials from inception to November 2023. We included studies that compared the efficacy of rhythm control (ie, antiarrhythmic drugs classes Ia, Ic, or III, AF catheter ablation, and electrical cardioversion) and rate control (ie, beta-blocker, digitalis, or calcium antagonist) strategies among patients with nonvalvular AF. The primary outcome was cardiovascular (CV) death, whereas secondary outcomes included all-cause death, stroke, hospitalization for heart failure (HF), sinus rhythm at the end of the follow-up, and rhythm control–related adverse events. A cumulative meta-analysis to assess temporal trends and a meta-regression analysis using the percentage of ablation use was performed. ResultsWe identified 18 studies with a total of 17,536 patients (mean age: 68.6 ± 9.7 years, 37.9% females) and a mean follow-up of 28.5 months. Of those, 31.9% had paroxysmal AF. A rhythm control strategy reduced CV death (HR: 0.78; 95% CI: 0.62-0.96), stroke (HR: 0.801; 95% CI: 0.643-0.998), and hospitalization for HF (HR: 0.80; 95% CI: 0.69-0.94) but not all-cause death (HR: 0.86; 95% CI: 0.73-1.02) compared with a rate control strategy. This benefit was driven by contemporary studies, whereas more ablation use within the rhythm control arm was associated with improved outcomes, except stroke. ConclusionsIn patients with AF, a contemporary rhythm control strategy leads to reduced CV mortality, HF events, and stroke compared with a rate control strategy.

Comparison between beta-blockers and calcium channel blockers in patients with atrial fibrillation according to renal function.

Rate control is the most commonly employed first-line management strategy for atrial fibrillation (AF) in patients with chronic kidney disease (CKD). Principal agents used to control heart rate (HR) include beta-blockers (BB) and nondihydropyridine calcium channel blockers (ND-CCB). However, there is a paucity of published studies of the differences between those drugs in CKD patients. The present study aimed to investigate the differences, in terms of hospitalizations due to a poor HR control, in patients with AF under a rate-control strategy according to glomerular filtration rate (GFR). The study cohort included 2804 AF patients under rate-control regime (BB or ND-CCB) between January 2014 and April 2020. The end point, determined by competing risk regression, was hospitalizations for AF with rapid ventricular response (RVR), slow ventricular response (SVR), and need for pacemaker. On multivariate analysis, there were no statistical differences between ND-CCB and BB for subjects with GFR > 60 mL/min/1.73 m2 (subdistribution heart rate [sHR] 0.850, 95% confidence interval [CI]: 0.61-1.19; p = .442) and GFR 30-59 mL/min/1.73 m2 (sHR 1.242, 95% CI: 0.80-1.63; p = .333), while in patients with GFR < 30 mL/min/1.73 m2, ND-CCB therapy was associated with increased hospitalizations due to poor HR control (sHR 4.53, 95% CI: 1.19-17.18; p = .026). In patients with GFR ≥ 30 mL/min/1.73 m2, the choice of ND-CCB or BB had no impact on hospitalizations due to poor HR control, while in GFR < 30 mL/min/1.73 m2, a possible association was detected. The effects of these drugs on GFR < 30 mL/min/1.73 m2 would require further investigation.

Ventricular response as a predictor of the termination of sustained paroxysmal atrial fibrillation.

Atrial fibrillation (AF) is the most common sustained atrial arrhythmia. Accurate detection of the timing and possibility of AF termination is vital for optimizing rhythm and rate control strategies. The present study evaluated whether the ventricular response (VR) in AF offers a distinctive electrocardiographic indicator for predicting AF termination. Patients experiencing sustained paroxysmal AF for more than 3h were observed using 24-h ambulatory Holter monitoring. VR within 5min before AF termination (VR 0-5min, BAFT) was compared with VR observed during the 60th to 65th min (VR 60-65min, BAFT) and the 120th to 125th min (VR 120-125min, BAFT) before AF termination. Maximum and minimum VRs were calculated on the basis of the average of the highest and lowest VRs across 10 consecutive heartbeats. Data from 37 episodes of paroxysmal AF revealed that the minimum VR0-5min, BAFT (64±20bpm) was significantly faster than both the minimum VR120-125min, BAFT (56±15bpm) and the minimum VR60-65min, BAFT(57±16bpm, p<.05). Similarly, the maximum VR0-5min, BAFT (158±49bpm) was significantly faster than the maximum VR120-125min, BAFT (148±45bpm, p<.05). In the daytime, the minimum VR0-5min, BAFT (66±20bpm) was significantly faster than both the minimum VR60-65min, BAFT (58±17bpm) and minimum VR120-125min, BAFT(57±15bpm, p<.05). However, the mean and maximum VR0-5min, BAFT in the daytime were similar to the mean and maximum VR120-125min in the daytime, respectively. At night, the minimum, mean, and maximum VR0-5min, BAFT were similar to the minimum, mean, and maximum VR120-125min, respectively. Elevated VR rates during AF episodes may be predictors for the termination of AF, especially during the daytime and in patients with nondilated left atria. These findings may guide the development of clinical approaches to rhythm control in AF.

Impact of pulmonary vein isolation on the prognosis of patients with atrial fibrillation and heart failure with reduced ejection fraction: an updated systematic review and meta-analysis

Aim. The study aimed to conduct a systematic review and meta-analysis of randomized clinical trials (RCTs) to determine the effect of pulmonary vein isolation (PVI) on the prognosis of patients with atrial fibrillation (AF) and chronic heart failure with reduced ejection fraction (HFrEF).Material and methods. We searched PubMed (MEDLINE), Google Scholar, and the Cochrane Library databases for studies that compared PVI with a conservative rhythm/heart rate (HR) control strategy in patients with AF and HFrEF. The primary endpoint in the major RCTs examining the effect of PVI on the prognosis of patients with HFrEF was a composite endpoint of all-cause mortality or HF-related hospitalization. Hazard ratios (HRs) based on Cox regression analysis were used as the baseline survival rates for the meta-analysis. To determine the weighted mean differences in improvement in left ventricular ejection fraction (LVEF) in the PVI and non-PVI groups, a pooled analysis of the mean LVEF changes with standard deviations taking into account the number of subjects in the compared groups was performed.Results. For this systematic review, 11 studies were selected from 2216 publications, which included 2379 patients. Three RCTs (n=968) were subjected to meta-analysis on time-to-event outcomes. The average follow-up period was 34 months. According to the meta-analysis, PVI was associated with a significant reduction in the risk of composite endpoint (HR: 0,53; 95% confidence interval (CI): 0,33-0,85; p=0,009). In addition, PVI compared with drug rhythm/rate control was associated with a significant reduction in the all-cause mortality risk (HR: 0,55; 95% CI: 0,34-0,89; p=0,01). Finally, a meta-analysis of 10 RCTs (n=1516) found a significant improvement in LVEF compared with drug rhythm/HR control or atrioventricular node ablation with biventricular pacing. The weighted mean difference in the LVEF change over time after 6-12-month follow-up was 5,25% (95% CI: 4,03-6,47; p&lt;0,001).Conclusion. PVI in patients with AF and HFrEF compared with drug rhythm/HR control is associated with a significant reduction in the risk of all-cause mortality and HF-related hospitalization and a greater improvement in LVEF compared with baseline.

Clinical decisions for appropriate management of patients with atrial fibrillation.

The management of patients with atrial fibrillation (AF) requires intricate clinical decision-making to optimize outcomes. In everyday clinical practice, physicians undergo difficult choices to better manage patients with AF. They need to balance thromboembolic and bleeding risk to focus on patients' symptoms and to manage a variety of multiple comorbidities. In this review, we aimed to explore the multifaceted dimensions of clinical decision-making in AF patients, encompassing the definition and diagnosis of clinical AF, stroke risk stratification, oral anticoagulant therapy selection, consideration of bleeding risk, and the ongoing debate between rhythm and rate control strategies. We will also focus on possible grey zones for the management of AF patients. In navigating this intricate landscape, clinicians must reconcile the dynamic interplay of patient-specific factors, evolving guidelines, and emerging therapies. The review underscores the need for personalized, evidence-based clinical decision-making to tailor interventions for optimal outcomes according to specific AF patient profiles.

Flecainide sebagai Antiaritmia untuk Fibrilasi Atrium dan Aritmia Lainnya

Atrial fibrillation (AF) is one of the most common arrhythmias globally, and its prevalence is projected to increase, including in Indonesia. AF progression is related to lower quality of life and less responsive to therapy or even becomes irreversible. The progression of AF is significantly slower with the rhythm control strategy than with the rate control strategy alone. The options for therapy in Indonesia are limited to amiodarone and propafenone. Amiodarone is one of the most common drugs prescribed for AF rhythm control, but associated with multiple organ toxicities, thus increasing the risk of multiple side effects, especially on long-term usage, potentially leading to drug discontinuation. Flecainide is an antiarrhythmia with a favourable effectiveness and safety profile, especially for AF management, used for acute cardioversion, long-term rhythm control, and as a therapeutic modality for AF with preexcitation syndrome. Flecainide is a potential drug to address the unmet needs of amiodarone as a long-term management for AF.

Arrhythmias and Device Therapies in Cardiac Amyloidosis.

Cardiac amyloidosis is caused by amyloid fibrils that deposit in the myocardial interstitium, causing restrictive cardiomyopathy and eventually death. The electromechanical, inflammatory, and autonomic changes due to amyloid deposition result in arrhythmias. Atrial fibrillation is by far the most common arrhythmia. The rate control strategy is generally poorly tolerated due to restrictive filling physiology and heart rate dependance, favoring adoption of the rhythm control strategy. Anticoagulation for stroke prophylaxis is warranted, irrespective of CHA2DS2-VASc score in patients with a favorable bleeding profile; data on left appendage closure devices are still insufficient. Ventricular arrhythmias are also not uncommon, and the role of implantable cardioverter-defibrillator in cardiac amyloidosis is controversial. There is no evidence of improvement in outcomes when used for primary prevention in these patients. Bradyarrhythmia is most commonly associated with sudden cardiac death in cardiac amyloidosis. Pacemaker implantation can help provide symptomatic relief but does not confer mortality benefit.