Rhythm-control Patients Research Articles

Abstract 13597: Treatment Patterns and Outcomes for Young Adults With Atrial Fibrillation: The KP YOUNG-AF Study

Introduction: Young adults with atrial fibrillation (AF) may be most vulnerable to adverse outcomes such as cardiac remodeling and stroke, due to exposeure to AF for a longer time over their life course. Research Question What are contemporary treatment patterns and outcomes for young adults with AF treated with rate or rhythm control strategies? Methods: We identified patients aged 21-60 years with incident AF diagnosed from 2010-2018 within a large, integrated healthcare system caring for >4.5M, and categorized them by treatment strategy within their first year after AF diagnosis: no treatment, rate control (AV nodal blockers only), or rhythm control (cardioversion, anti-arrhythmic drugs, or ablation). We examined crude outcomes of new onset heart failure (HF), stroke or transient ischemic attack (TIA), and use of oral anticoagulants (OAC), and examined multivariable associations between treatment strategy and outcomes using Cox regression. Results: Among 11,824 young adults with incident AF (mean [SD] age 51 [8.5] years; 32% female), 31% were treated with rhythm control, 50% with rate control, and 19% with no treatment. Those with no treatment were younger with fewer comorbidities. Crude rates (per 100 person-years) of incident HF and OAC were higher among rhythm control patients (HF: 4.45 for rhythm control, 2.51 for rate control, 0.56 for no treatment; OAC: 41.8 for rhythm control, 15.2 for rate control, 3.8 for no treatment), but rates of stroke/TIA were lower (0.71 for rhythm control, 0.92 for rate control, 0.51 for no treatment) (Figure). In adjusted analyses, no significant association was found for rhythm control (vs no rhythm treatment) for HF or stroke/TIA, but OAC use was higher (HR 1.66, 95%CI:1.57-1.70). Conclusions: Less than one third of young adults with AF received initial rhythm control therapy. Adverse outcomes were not associated with treatment strategy, but future studies should further examine long-term outcomes from sustained AF in young patients.

Abstract 19180: Early Rhythm Control is Associated With Improved Outcomes in Hypertrophic Cardiomyopathy Patients With Atrial Fibrillation

Background: Atrial fibrillation in hypertrophic cardiomyopathy (HCM) patients is associated with worse outcomes with regards to stroke, heart failure hospitalization and death. Contemporary data on Rhythm control (RyC) strategies and outcomes in HCM patients is limited. Objectives: We aimed to assess the clinical characteristics of HCM patients with AF receiving RyC (antiarrhythmic drug and/or catheter ablation) vs no rhythm control (NRC) and compare clinical outcomes between the two groups. Methods: We analyzed the electronic health records of the University of Pittsburgh Medical Center, a large multi-hospital system, between 2010 and 2022. Differences between baseline demographics, cardiovascular risk factors, and comorbidity burden were evaluated with t tests. Adjusted Cox proportional hazards and Kaplan-Meier analyses were performed to evaluate associations between use of rhythm control and all-cause age-adjusted mortality. Results: A total of 552 patients with HCM and AF were analyzed, of which 118 received RyC and 434 NRC. The RyC group was relatively younger (age 64 vs 70), received initial evaluation by a cardiologist (70% vs 57%), had lower CHA2DS2VASC scores (mean 2.5 vs 3.1) and fewer comorbidities (mean Elixhauser scores 3.0 vs 4.7). There were no significant differences in either ejection fraction or left atrial diameter between the groups. Among RyC patients, 38 received catheter ablation and 80 received antiarrhythmic drug as the initial RyC strategy. Over a median follow up of 2.9 years (IQR 0.96-6.0), use of RyC was associated with decreased mortality after adjustment for age, Elixhauser score, and CHA2DS2VASC score (HR 0.54, 95% CI 0.30-0.95, p<0.05, figure 1). Conclusion: Rhythm control in HCM and AF patients is associated with better outcomes as suggested by decreased overall mortality. Prospective studies are needed to establish the best RyC strategy in this cohort.

Mortality and ventricular arrhythmias in patients on d,l-sotalol for rhythm control of atrial fibrillation: A nationwide cohort study

Use of d,l-sotalol for rhythm control in patients with atrial fibrillation (AF) has raised safety concerns. Previous randomized studies are few and not designed for mortality outcome. The purpose of this study was to compare the incidences of mortality and ventricular arrhythmias in AF patients treated with d,l-sotalol for rhythm control vs matched control patients treated with cardioselective beta-blockers. This population-based cohort study included AF patients from the Swedish National Patient Registry (2006-2017) who underwent rhythm control after a second cardioversion. Incidence rates (IRs) and adjusted hazard ratios (aHRs) for mortality and a composite endpoint of cardiac arrest/death and ventricular arrhythmias were calculated for the overall cohort and a 1:1 propensity score matched cohort of d,l-sotalol vs beta-blocker treatment. Among patient treated with d,l-sotalol (n = 4987) and beta-blocker (n = 27,078) (mean follow-up 458 days), all-cause mortality was lower in patients treated with d,l-sotalol: IR 1.21; 95% confidence interval 0.95-1.52 vs 2.42 (2.26-2.60) deaths per 100 patient-years; aHR 0.66 (0.52-0.83). The difference in mortality persisted in the propensity score matched comparison (n = 4953 in each group): aHR 0.63 (0.48-0.86). No differences were observed in the composite outcome: IR in propensity cohorts 2.13 (1.78-2.52) vs 2.07 (1.73-2.53) events per 100 years; aHR 1.01 (0.78-1.29). There was no excess mortality with d,l-sotalol compared with cardioselective beta-blockers in patients undergoing rhythm control treatment for AF after a second cardioversion. Our results indicate that the risk associated with d,l-sotalol treatment for AF can be mitigated by careful patient selection and strict adherence to follow-up protocols.

Enhanced Ca2+-Dependent SK-Channel Gating and Membrane Trafficking in Human Atrial Fibrillation.

Small-conductance Ca2+-activated K+ (SK)-channel inhibitors have antiarrhythmic effects in animal models of atrial fibrillation (AF), presenting a potential novel antiarrhythmic option. However, the regulation of SK-channels in human atrial cardiomyocytes and its modification in patients with AF are poorly understood and were the object of this study. Apamin-sensitive SK-channel current (ISK) and action potentials were recorded in human right-atrial cardiomyocytes from sinus rhythm control (Ctl) patients or patients with (long-standing persistent) chronic AF (cAF). ISK was significantly higher, and apamin caused larger action potential prolongation in cAF- versus Ctl-cardiomyocytes. Sensitivity analyses in an in silico human atrial cardiomyocyte model identified IK1 and ISK as major regulators of repolarization. Increased ISK in cAF was not associated with increases in mRNA/protein levels of SK-channel subunits in either right- or left-atrial tissue homogenates or right-atrial cardiomyocytes, but the abundance of SK2 at the sarcolemma was larger in cAF versus Ctl in both tissue-slices and cardiomyocytes. Latrunculin-A and primaquine (anterograde and retrograde protein-trafficking inhibitors) eliminated the differences in SK2 membrane levels and ISK between Ctl- and cAF-cardiomyocytes. In addition, the phosphatase-inhibitor okadaic acid reduced ISK amplitude and abolished the difference between Ctl- and cAF-cardiomyocytes, indicating that reduced calmodulin-Thr80 phosphorylation due to increased protein phosphatase-2A levels in the SK-channel complex likely contribute to the greater ISK in cAF-cardiomyocytes. Finally, rapid electrical activation (5 Hz, 10 minutes) of Ctl-cardiomyocytes promoted SK2 membrane-localization, increased ISK and reduced action potential duration, effects greatly attenuated by apamin. Latrunculin-A or primaquine prevented the 5-Hz-induced ISK-upregulation. ISK is upregulated in patients with cAF due to enhanced channel function, mediated by phosphatase-2A-dependent calmodulin-Thr80 dephosphorylation and tachycardia-dependent enhanced trafficking and targeting of SK-channel subunits to the sarcolemma. The observed AF-associated increases in ISK, which promote reentry-stabilizing action potential duration shortening, suggest an important role for SK-channels in AF auto-promotion and provide a rationale for pursuing the antiarrhythmic effects of SK-channel inhibition in humans.

Abstract 15919: Adverse Outcomes Related Amiodarone Toxicity in Early Rhythm Control of Patients With Atrial Fibrillation: A Nationwide Cohort Study

Background: Early rhythm control therapy was associated with a lower risk of adverse cardiovascular outcomes than usual care among patients who had recently (within 1 year) been diagnosed with atrial fibrillation (AF). In real-world data, the most commonly selected initial rhythm control strategy was the Class III anti-arrhythmic drug (AAD) amiodarone, but adverse outcomes related amiodarone toxicity was not well reported in this population. This study sought to investigate the fatal and non-fatal adverse outcomes related amiodarone toxicity in early rhythm control of patients with AF. Methods: Using the database of Korean National Health Insurance Service, we analyzed the adverse outcomes related amiodarone toxicity in 140,908 (rhythm control: 57,148, rate control: 83,760) patients with AF undergoing rhythm control or rate control therapy, initiated within 1 year of AF diagnosis, between 2005 and 2015. Results: The most commonly used rhythm control strategy was the class III drug amiodarone (22,877 (40.0%) of 57,148 patients in early rhythm control), followed by class Ic drugs. Patients with amiodarone for initial rhythm control strategy showed higher rate of interstitial lung disease (1.43% vs. 0.75%, p<0.001), sudden cardia arrest duet to Torsade de Pointes (0.31% vs. 0.17%, p=0.001), and hypothyroidism (16.5% vs. 8.12%, p<0.001). But incidence rate of bradycardia needing a temporary pacemaker, bradycardia needing a permanent pacemaker, and toxic hepatitis were higher in early rhythm control patients with other AADs compared to patients with amiodarone. Conclusions: The most commonly used rhythm control strategy was amiodarone in AF patients undergoing early rhythm control. Using amiodarone for the initial rhythm control strategy showed a higher rate of interstitial lung disease, sudden cardia arrest duet to Torsade de Pointes, and hypothyroidism. Attention should be paid to amiodarone toxicity in selecting rhythm control strategy for these patients.

Rhythm Control Vs Rate Control in a Contemporary Ambulatory Atrial Fibrillation Cohort: Post Hoc Analysis of the IMPACT-AF Trial

BackgroundWe examined the characteristics and outcomes in a contemporary ambulatory population of patients with atrial fibrillation (AF), comparing rate control with rhythm control. MethodsThis is a post hoc analysis of a cluster-randomized trial (Integrated Management Program Advancing Community Treatment of Atrial Fibrillation [IMPACT-AF]) in ambulatory AF patients from 2016 to 2018, which compared use of a clinical decision support tool for general practitioners to usual care. This analysis compared patients managed with rate vs rhythm control, at entry into the study. Outcomes included AF-related emergency department (ED) visits, unplanned cardiovascular hospitalizations, and bleeding events at 12 months. ResultsA total of 870 patients were included in this analysis, 99 (11.4%) in the rhythm-control group, and 40% women. In the rhythm-control group, the mean age was younger (70 ± 11.4 vs 72.7 ± 9.5 years, P = 0.03), a higher number were paroxysmal (80% vs 43%, P < 0.001), and CHADS2 scores were lower. The rate of AF-related ED visits was higher in the rhythm-control group (17.2 vs 7.3%, P = 0.003), and repeat visits (rate ratio 3.03, 95% confidence interval [1.99-4.52], P < 0.001). The number of repeat ED visits was independently associated with female sex and being in the rhythm-control group. ConclusionsBoth rate- and rhythm-control patients have recurrent ED visits, with a higher rate in patients treated with rhythm control. These findings are observational, but taken in the context of current guidelines could help develop further therapies aimed at improving symptom burden in both rhythm- and rate-control patients to broadly improve healthcare utilization in the AF population.

Real-world applicability and impact of early rhythm control for European patients with atrial fibrillation: a report from the ESC-EHRA EORP-AF Long-Term General Registry

BackgroundUse of rate/rhythm control is essential to control symptoms in patients with atrial fibrillation (AF). Recently, the EAST-AFNET 4 trial described how early rhythm control strategy was associated with a lower risk of adverse clinical outcomes.ObjectivesThe aim was to evaluate the real-world applicability and impact of an early rhythm control strategy in patients with AF.MethodsUse of an early rhythm control strategy was assessed in a European cohort of AF patients derived from the EHRA-ESC EORP-AF General Long-Term Registry. Early rhythm control was defined as use of antiarrhythmic drugs or cardioversion/catheter ablation. The primary outcome included cardiovascular death, stroke, acute coronary syndrome, and worsening of heart failure. Quality of life and health-care resource usage were also assessed as outcomes.ResultsAmong the 10,707 patients evaluated for eligibility to EAST-AFNET 4, a total of 3774 (34.0%) were included. Early rhythm control was associated with better quality of life, but with greater use of health-care resources. During follow-up, the primary outcome occurred less often in early rhythm control patients than in those with no rhythm control (13.6% vs. 18.5%, p < 0.001). In the multivariate adjusted Cox regression model, no significant difference was found between no rhythm control and early rhythm control, for the primary outcome. No difference in the primary outcome between early rhythm control and ‘no rhythm control patients’ adherent to Atrial fibrillation Better Care (ABC) pathway’ was evident (p = 0.753)ConclusionsUse of an early rhythm control strategy was associated with a lower rate of major adverse events, but this difference was non-significant on multivariate analysis, being mediated by differences in baseline characteristics and clinical risk profile. Early rhythm control was associated with a higher use of health-care resources and risk of hospital admission, despite showing better quality of life.Graphic abstract

CPAP is associated with decreased risk of AF recurrence in patients with OSA, especially those younger and slimmer: a meta-analysis.

Obstructive sleep apnea (OSA) is associated with the management of atrial fibrillation (AF). This manuscript aims to discuss the effects of continuous positive airway pressure (CPAP) in patients with rhythm control strategies and patients with different ages, weights and length of follow-up. We searched Embase, PubMed, Cochrane, Web of Science and Ovid for relevant studies (from inception to 7 July 2019; English). The primary outcome was documented AF recurrence in CPAP users and nonusers. We assessed pooled data by use of a random-effects model. Nine prospective cohort studies with a total of 2134 participants met the inclusion criteria. Results showed that complementary CPAP therapy reduced AF recurrence (RR = 0.63; 95% CI, 0.56-0.72). In subgroup analyses, the benefits of CPAP were stronger in patients younger than 60years old (< 60years old: RR, 0.59; 95% CI, 0.50-0.68 vs. ≥ 60years old: RR, 0.73; 95% CI, 0.59-0.91), with a body mass index (BMI) of less than 30 (< 30: RR, 0.53; 95% CI, 0.37-0.77 vs. ≥ 30: RR, 0.65; 95% CI, 0.55-0.77) or with less follow-up time (≤ 1year: RR, 0.57; 95% CI, 0.42-0.79 vs. > 1year: RR, 0.64; 95% CI, 0.53-0.78). Complementary CPAP therapy reduces the risk of AF recurrence in OSA patients with rhythm control strategies. In addition to weight control and early AF intervention, CPAP compliance should be recommended along with periodic adjustments as necessary.

Treatment strategies and subsequent changes in the patient-reported quality-of-life among elderly patients with atrial fibrillation

BackgroundRhythm-control strategy, including catheter ablation (CA) application, constitutes an integral part of atrial fibrillation (AF) management. However, elderly patients are underrepresented in clinical trials, and reports on patient-reported outcome of various rhythm-control treatments remain limited. Therefore, we aimed to investigate the application of a rhythm-control strategy for elderly patients with AF. MethodsUsing a prospective, multicenter Japanese registry, we analyzed 733 patients with AF aged ≥70 years who completed the Atrial Fibrillation Effect on Quality-of-Life (AFEQT) questionnaire at baseline and 1-year visit. Improvement in patient-reported quality-of-life (QOL) was assessed according to their initial treatment strategy. ResultsA total of 321 patients (43.8%) were managed with rhythm-control strategy, of which 125 (17.1%) received treatment with antiarrhythmic drugs (AADs) alone and 196 (26.7%) underwent CA. Compared with the rate-control group, the rhythm-control group was younger and less likely to have comorbid conditions but had lower baseline AFEQT-overall summary (OS) scores (71.8 [standard deviation 20.3] vs. 80.0 [standard deviation 16.1]; P < .001). After the first year, AFEQT-OS scores improved regardless of treatment strategies (ie, rate- or rhythm-control). After adjusting for confounders, CA implementation and a lower baseline AFEQT score were associated with meaningful improvement in QOL (changes in AFEQT-OS score ≥5). QOL improvement among subgroups of rhythm-control patients with AADs alone was not clinically meaningful. ConclusionsIn contemporary Japanese clinical practice, rhythm-control strategy is widely implemented in elderly patients with AF, and CA use is associated with improvement in QOL in carefully selected patients.

Differentially expressed genes for atrial fibrillation identified by RNA sequencing from paired human left and right atrial appendages.

Atrial fibrillation is a significant worldwide contributor to cardiovascular morbidity and mortality. Few studies have investigated the differences in gene expression between the left and right atrial appendages, leaving their characterization largely unexplored. In this study, differential gene expression was investigated in atrial fibrillation and sinus rhythm using left and right atrial appendages from the same patients. RNA sequencing was performed on the left and right atrial appendages from five sinus rhythm (SR) control patients and five permanent AF case patients. Differential gene expression in both the left and right atrial appendages was analyzed using the Bioconductor package edgeR. A selection of differentially expressed genes, with relevance to atrial fibrillation, were further validated using quantitative RT-PCR. The distribution of the samples assessed through principal component analysis showed distinct grouping between left and right atrial appendages and between SR controls and AF cases. Overall 157 differentially expressed genes were identified to be downregulated and 90 genes upregulated in AF. Pathway enrichment analysis indicated a greater involvement of left atrial genes in the Wnt signaling pathway whereas right atrial genes were involved in clathrin-coated vesicle and collagen formation. The differing expression of genes in both left and right atrial appendages indicate that there are different mechanisms for development, support and remodeling of AF within the left and right atria.

Rhythm control better prevents stroke and mortality than rate control strategies in patients with atrial fibrillation - A nationwide cohort study

BackgroundAtrial fibrillation (AF) increases the risk of stroke and mortality. However, rhythm control strategy did not reduce cardiovascular risks in short-term studies. We hypothesize that rhythm control better prevents stroke and mortality than rate control in AF patients over a long-term period. MethodsAF patients aged ≥18 years were identified from Taiwan National Insurance Database. Patients using anti-arrhythmia drugs to control rhythm at a >30 defined daily dose (DDD) were defined as the rhythm control group. Patients who used rate control medications for >30 DDDs constituted the rate control group. Multivariate Cox hazards regression model was used to evaluate the hazard ratio (HR) for major adverse cardiovascular events (MACE), including ischemic/hemorrhagic stroke and mortality. ResultsA total of 11,968 AF patients were enrolled, and 2850 of them (654 in rhythm control group; 2196 in rate control group) were analyzed. During a 6.3 ± 3.7 year's follow-up, a total of 1101 MACE occurred. Compared to rate control group, rhythm control group displayed a lower rate of ischemic stroke (adjusted HR: 0.65, p = 0.002) and mortality (adjusted HR: 0.81, p = 0.009). The rhythm control group showed a lower incidence of MACE than that of the rate control group (adjusted HR: 0.82, p = 0.009). The reduction of stroke (p = 0.004), mortality (p = 0.006), and MACE (p = 0.007) risk was observed particularly in rhythm control patients with a CHA2DS2-VASc score of ≥3. ConclusionsIn patients with AF, rhythm control better prevents MACE risk than rate control over a long-term period, particularly in those at high risk (CHA2DS2-VASc score ≥3) for stroke.

Rate-control versus Rhythm-control Strategies and Outcomes in Septuagenarians with Atrial Fibrillation

BackgroundThe prevalence of atrial fibrillation substantially increases after 70 years of age. However, the effect of rate-control versus rhythm-control strategies on outcomes in these patients remains unclear. MethodsIn the randomized Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) trial, 4060 patients (mean age 70 years, range 49-80 years) with paroxysmal and persistent atrial fibrillation were randomized to rate-control versus rhythm-control strategies. Of these, 2248 were 70-80 years, of whom 1118 were in the rate-control group. Propensity scores for rate-control strategy were estimated for each of the 2248 patients and were used to assemble a cohort of 937 pairs of patients receiving rate-control versus rhythm-control strategies, balanced on 45 baseline characteristics. ResultsMatched patients had a mean age of 75 years; 45% were women, 7% were nonwhite, and 47% had prior hospitalizations due to arrhythmias. During 3.4 years of mean follow-up, all-cause mortality occurred in 18% and 23% of matched patients in the rate-control and rhythm-control groups, respectively (hazard ratio [HR] associated with rate control, 0.77; 95% confidence interval [CI], 0.63-0.94; P = .010). HRs (95% CIs) for cardiovascular and noncardiovascular mortality associated with rate control were 0.88 (0.65-1.18) and 0.62 (0.46-0.84), respectively. All-cause hospitalization occurred in 61% and 68% of rate-control and rhythm-control patients, respectively (HR 0.76; 95% CI, 0.68-0.86). HRs (95% CIs) for cardiovascular and noncardiovascular hospitalization were 0.66 (0.56-0.77) and 1.07 (0.91-1.27), respectively. ConclusionIn septuagenarian patients with atrial fibrillation, compared with rhythm-control, a rate-control strategy was associated with significantly lower mortality and hospitalization.

One‑year follow‑up of the Polish subset of the RecordAF registry of patients with newly diagnosed atrial fibrillation

Data on real-life management of atrial fibrillation (AF) in Poland is limited. To present data on 1-year follow-up of patients from Poland included in a worldwide registry on patients with AF (RecordAF). Patients with recent onset AF were included (n=303). Treatment strategy (rhythm or rate control) was noted at baseline. Therapeutic success (control of AF, with no incidence of cardiovascular events and no switch between the strategies) was assessed after one year. Data from 289 patients were assessable. A rhythm control strategy was noted in 70% of patients. Rhythm control patients received anti-thrombotic therapy less frequently than rate control patients (90.4% vs. 97.6%) but more often received class I (19.8% vs. 4.8%) and class III (20.8% vs. 4.8%) antiarrhythmic drugs (p<0.05 for all comparisons). Therapeutic success was noted in 71.5% of rhythm control patients vs. 29.1% of rate control patients (p<0.0001), a result driven by control of AF (89.3% in the rhythm control group vs. 56.1% in the rate control group, p<0.0001). The rate of cardiovascular events was similar in both groups (20.6% of all patients). Progression to permanent AF occurred in 5.9% of rhythm control patients vs. 73.2% of rate control patients (p<0.001). Most of the patients received thromboembolic prevention and the majority was assigned to rhythm control. Despite infrequent use of anti-arrhythmic drugs, a rhythm control strategy was associated with better AF control and slower progression but not with lower rate of cardiovascular events in patients with recent-onset AF in Poland.

Rate versus rhythm control for management of atrial fibrillation in clinical practice: Results from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF) registry

All patients with atrial fibrillation (AF) require optimization of their ventricular rate. Factors leading to use of additional rhythm control in clinical practice have not been thoroughly defined. The ORBIT-AF registry enrolled patients with AF from a broad range of practice settings and collected data on rate versus rhythm control, as indicated by the treating physician. Multivariable logistic regression analysis was performed to identify factors associated with each strategy. Of 10,061 patients enrolled, 6,859 (68%) were managed with rate only control versus 3,202 (32%) with rhythm control. Patients managed with rate control were significantly older and more likely to have hypertension, heart failure, prior stroke, and gastrointestinal bleeds. They also had fewer AF-related symptoms (41% with no symptoms vs 31% for rhythm control). Systemic anticoagulation was prescribed for 5,448 (79%) rate-control patients versus 2,219 (69%) rhythm-control patients (P < .0001). After multivariable adjustment, patients with higher symptom scores (severe symptoms vs. none, OR 1.62, 95% CI 1.41-1.87) and those referred to electrophysiologists (OR 1.64, 95% CI 1.45-1.85) were more likely to be managed with a rhythm control strategy. In this outpatient registry of US clinical practice, the majority of patients with AF were managed with rate control alone. Patients with more symptoms and who were treated by an electrophysiologist were more likely to receive rhythm-control therapies. A significant proportion of AF patients, regardless of treatment strategy, were not treated with anticoagulation for thromboembolism prophylaxis.

The occurrence of cardiovascular disease during 5-year follow-up in patients with idiopathic atrial fibrillation

Idiopathic atrial fibrillation (AF) may be an expression of as yet undetected underlying heart disease. We found it useful for clinical practice to study the long-term development of cardiovascular disease (CVD) in patients diagnosed with idiopathic AF. Forty-one consecutive idiopathic AF patients (56 ± 10 years, 66% male) were compared with 45 healthy control patients in permanent sinus rhythm. Patients were free of hypertension, antihypertensive and antiarrhythmic drugs, diabetes, congestive heart failure, coronary artery or peripheral vascular disease, previous stroke, thyroid, pulmonary and renal disease, and structural abnormalities on echocardiography. Baseline characteristics and echocardiographic parameters were equal in AF cases and controls. During a mean follow-up of 66 ± 11 months, CVD occurred significantly more often in idiopathic AF patients compared with controls (49 vs. 20%, P= 0.006). Patients with idiopathic AF were significantly younger at the time of their first CV event compared with controls (59 ± 9 vs. 64 ± 5 years, P= 0.027), and had more severe disease. Multivariable Cox regression analysis revealed that age, a history of AF, and echocardiographic left ventricular wall width were significant predictors of CVD development. Patients originally diagnosed with idiopathic AF develop CVD more often, at younger age, and with a more severe disease profile compared with healthy sinus rhythm control patients. The detection and treatment of CVD in an early stage could improve the prognosis of these patients. At present it seems prudent to regularly check idiopathic AF patients for the insidious development of CVD.

Insights Into Management of Atrial Fibrillation in Asia Pacific Gained From Baseline Data from REgistry on Cardiac rhythm disORDers (RecordAF-Asia Pacific [AP]) Registry

The burden of atrial fibrillation (AF) and the lack of data on AF and its management in the Asia Pacific highlight the need for a comprehensive prospective study of AF management in this region. To address this need, the REgistry on Cardiac rhythm disORDers (RecordAF-Asia Pacific [AP]) has been initiated to assess the management of AF in 8 countries across the Asia Pacific. RecordAF-AP is a prospective, observational survey of the management of recently diagnosed AF with 1 year of follow-up. Eligible patients with AF, treated or not, were included in the registry; with data recorded prospectively during the follow-up visits at 6 and 12 months. A total of 2,721 patients with AF were recruited, of whom 2,629 were eligible for evaluation (intent-to-treat population). At study inclusion, rhythm- and rate-control strategies were applied to 37% (n = 959) and 62% (n = 1,610) of the patients, respectively. At baseline, the rhythm-control patients were mainly prescribed class III agents (49%), class Ic agents (39%), or β blockers (except for sotalol; 35%). The rate-control patients were mainly prescribed β blockers (except for sotalol; 57%) or cardiac glycosides (32%). Patients receiving rate-control strategies were more likely to have a history of heart failure or valvular heart disease and persistent AF. In contrast, those receiving rhythm-control strategies were more likely to have recently diagnosed or paroxysmal AF. In conclusion, RecordAF-AP will provide much needed insight into the real-life management of patients with AF in the Asia Pacific region.

EP News: Clinical

Camm et al (J Am Coll Cardiol 2011;58:493–501, PMID 21777747) reported on the first worldwide, prospective, observational survey of management of atrial fibrillation (AF) in unselected, community-based patients (RECORDAF). Primary outcomes were therapeutic success and clinical outcomes associated with rhythm-control and rate-control strategies. Therapeutic success required that strategy was unchanged without clinical events. Maintenance of sinus rhythm was required in the rhythm-control group and heart rate ≤80 bpm in the rate-control group. In 5171 patients, the success was 54% overall (rhythm control 60% vs rate control 47%). The rhythm-control strategy was significantly related to superior therapeutic success (hazard ratio [HR] 1.34, P = .0002). The type of AF, presence of AF at baseline visit, and duration (>3 months) of AF, together with age older than 75 years and the presence of heart failure, predicted progression to permanent AF. The choice of rhythm control reduced the likelihood of AF progression (HR 0.20, P <.0001). The authors conclude that clinical outcomes in AF patients were driven mainly by hospitalizations for arrhythmia and proarrhythmia and other cardiovascular causes, but not by the choice of rate or rhythm strategy. Rhythm-control patients progressed less rapidly to permanent AF.

Antiarrhythmic drugs for maintaining of sinus rhythm

Abstract The pharmacological strategy to treat atrial fibrillation (AF) has been studied in the last years by a number of randomized studies. The overall results showed that the rhythm control strategy is not superior to the rate control strategy in terms of mortality or stroke, mostly due to limited efficacy and toxicity of antiarrhyhtmic drugs in the rhythm control patients. Regarding to these data, current antiarrhythmic therapy for recurrent AF is recommended on the basis of choosing safer, although possibly less efficacious drug. Flecainide, propafenone, sotalol and dronedarone are the first-line drugs for patients with a minimal or no heart disease, or hypertension without left ventricular hypertrophy. Sotalol and dronedarone are recommended as first-line drugs for patients with a coronary artery disease. Dronedarone should be considered in order to reduce cardiovascular hospitalizations related to AF/flutter. It can also be used safely in patients with hypertensive heart disease and stable NYHA class I-II heart failure. Amiodarone is the most effective antiarrhythmic in all clinical settings, but because of its toxicity profile should generally be used when other agents have failed or are contraindicated. Amiodarone is recommended as drug of choice in patients with severe heart failure or recently unstable NYHA class II.

Real-Life Observations of Clinical Outcomes With Rhythm- and Rate-Control Therapies for Atrial Fibrillation: RECORDAF (Registry on Cardiac Rhythm Disorders Assessing the Control of Atrial Fibrillation)

RECORDAF is the first worldwide, prospective, observational survey of management of atrial fibrillation (AF) in unselected, community-based patients. Primary outcomes were therapeutic success and clinical outcomes associated with rhythm-control and rate-control strategies. Patients with recent-onset AF were included (n = 5,604). Treatment strategy (rhythm control or rate control) was noted at baseline. Follow-up was 12 months. Therapeutic success required that strategy was unchanged without clinical events. Further maintenance of sinus rhythm was required in the rhythm-control group, and heart rate ≤80 beats/min in the rate-control group. Data from 5,171 patients were assessable. Therapeutic success was 54% overall (rhythm control 60% vs. rate control 47%), a result driven by control of AF: rhythm control, 81% vs. rate control, 74%. After adjustment for propensity score quintiles, the rhythm-control strategy was significantly related to superior therapeutic success (odds ratio: 1.34, 95% confidence interval: 1.15 to 1.55; p = 0.0002). Clinical events occurred in 18% of patients. The arrhythmia management strategy was not predictive of clinical events. The type (persistent), presence at baseline visit, and duration (>3 months) of AF, together with age older than 75 years and the presence of heart failure, predicted progression to permanent AF. The choice of rhythm control reduced the likelihood of AF progression (odds ratio: 0.20, 95% confidence interval: 0.17 to 0.25; p < 0.0001). Clinical outcomes in AF patients were driven mainly by hospitalizations for arrhythmia/proarrhythmia and other cardiovascular causes, but not by the choice of rate or rhythm strategy. Rhythm-control patients progressed less rapidly to permanent AF.

Warfarin and Aspirin Use in Atrial Fibrillation Among Practicing Cardiologist (from the AFFECTS Registry)

Among patients with atrial fibrillation (AF), the risk of thromboembolism is a significant concern. However, the reported use of warfarin among patients with AF at elevated risk of stroke remains low. In the present study, we have provided information on anticoagulation use reported during the recent Atrial Fibrillation: Focus on Effective Clinical Treatment Strategies (AFFECTS) Registry. Among patients identified by their physician at baseline to be at an increased risk of stroke, as determined from an assessment of the medical history, 74% received warfarin and 29% received aspirin. Post hoc analysis of warfarin use stratified by Congestive heart failure, Hypertension, Age, Diabetes, Stroke, (CHADS(2)) doubled score revealed that at the end of the study, warfarin use was 73% (155 of 213) and 66% (185 of 280) in the rate- and rhythm-control patients with a score of > or = 2, respectively, compared to 60% (183 of 306) and 49% (322 of 662) in the rate- and rhythm-control patients with a score of <2, respectively. The practicing cardiologists who participated in this registry initiated anticoagulation therapy in most of their patients with AF. However, warfarin use is not yet in line with the guidelines and evidence-based recommendations. Patients considered at no risk of stroke appear to have been overprescribed anticoagulant agents, and a considerable portion of high-risk patients did not receive warfarin. In conclusion, these results suggest that continued physician education of appropriate anticoagulation use in patients with AF is needed.