Rhythm Control Strategy In Patients Research Articles

Стратегия контроля ритма у пациентов с фибрилляцией предсердий в реальной клинической практике

Стратегия контроля ритма у пациентов с фибрилляцией предсердий в реальной клинической практике

Temporal trends in the availability and efficacy of catheter ablation for atrial fibrillation and atrial flutter in a highly populated urban area.

Pulmonary vein isolation has become one of the core modalities of the rhythm control strategy in patients with atrial fibrillation (AF). The aim of the study was to analyze temporal trends in the availability and efficacy of AF and atrial flutter (AFL) catheter ablation in an urban area of Upper Silesia in Poland. The source data were obtained from the SILCARD (Silesian Cardiovascular Database) covering an adult population of 3.8 million. The final study population included patients with diagnosis code I48 referred for catheter ablation between 2006 and 2017. The data included total number of procedures, patient sex, age, comorbidities, number of hospital admissions, and mortality rate. A total of 2745 patients were enrolled. The number of ablated patients increased more than 10‑fold (43 in 2006 vs 507 in 2017; P = 0.008) in the follow‑up period. The analysis showed an upward trend in the proportion of women (P = 0.02), hypertension prevalence (P = 0.004), and percentage of patients implanted (P = 0.02). A decrease was observed in the percentage of patients with stable angina (P <0.005) and hospitalization length (P <0.005). The all‑cause hospital readmissions rate decreased from 55.8% to 25.4% (P <0.005). There were significant reductions in the 12‑month all‑cause mortality (2.3% in 2006 vs 0.2% in 2017; P <0.005), stroke (2.3% in 2006 vs 0.2% in 2017; P = 0.047), and myocardial infarction rates (2.3% in 2006 vs 0.4% in 2017; P = 0.03). A considerable increase in the availability and efficacy of AF / AFL ablations was documented over the 12‑year follow‑up period.

P1741 Echocardiographic assessment of rate versus rhythm control strategy in patients with persistent atrial fibrillation

Abstract BACKGROUND Patients with persistent atrial fibrillation (AF) can be managed with either rhythm or rate control strategy. The restoration and maintenance of the sinus rhythm (SR) is not superior to the rate control regarding the total mortality and the rate of thromboembolic complications. Data concerning the effect of these strategies on left ventricular morphology and function is missing. PURPOSE The objective of our prospective randomised multicenter study in patients with persistent AF was to evaluate the effect of these two approaches on left ventricular morphology and function. METHODS The study group consisted of 205 patients (F/M 71/134; mean age 60.8 ± 11.2 years), including 101 patients randomized to the rate control approach (Group I) and 104 patients randomized to SR restoration with cardioversion and subsequent antiarrhythmic drug treatment (Group II). Mean duration of AF was 231.8 ± 112.4 days. At the end of follow-up (12 months), SR was present in 64% of patients in Group II. Echocardiographic examination was performed at a baseline and at 2 and 12 months. In the rate-control group, both right (22.1 ± 4.1 vs. 23.2 ± 3.8 cm2; p &amp;lt; 0.05) and left atrial (25.9 ± 5.2 vs. 26.8 ± 4.6 cm2 p &amp;lt; 0.05) enlargement was observed during the 12 months follow-up. A significant decrease in right (21.8 ± 3.0 vs. 21.2 ± 3.5 cm2; p &amp;lt; 0.05) and left atrial (26.2 ± 4.6 vs. 25.5 ± 5.0 cm2; p &amp;lt; 0.05) size in the rhythm control arm was observed. Both strategies led to a significant increase in left ventricular fractional shortening (32.1 ± 7.3 vs. 34.2 ± 6.5% and 31.3 ± 6.7 vs. 35.5 ± 8.9%, respectively; p &amp;lt; 0.05). The comparison of the left ventricular end-diastolic diameter revealed no difference within and between groups (50.8 ± 5.6 mm vs. 52.2 mm ± 6.8 mm at a baseline and 50.0 ± 6.0 vs. 52.0 ± ± 7.4 mm at 12 months, respectively). In rhythm-control group such trend was observed only in pts. with successfully maintained SR. According to LV function improvement, rhythm-control strategy was preferred in pts. with hypertension (RR 2.63; 95% C.I.: 0.93-5.45; p &amp;lt; 0.05) or congestive heart failure in NYHA II or III class (RR 2.13; 95% C.I.: 0.98-4.42; p &amp;lt; 0.05). CONCLUSIONS Both strategies led to a significant increase in LV FS. Rate-control strategy led to right and left atrium enlargement, but rhythm control resulted in their decrease.

Direct Current Cardioversion of Atrial Fibrillation in Patients With Left Atrial Appendage Occlusion Devices

BackgroundDirect current cardioversion (DCCV) is a common rhythm control strategy in patients with symptomatic atrial fibrillation or flutter. There is no long-term data regarding the safety of DCCV in patients with endocardial left atrial appendage occlusion (LAAO) devices. ObjectivesThe purpose of this study was to assess the feasibility and safety of DCCV in patients with an LAAO device. MethodsThis multicenter retrospective study included 148 patients with an LAAO device who underwent DCCV for symptomatic atrial fibrillation or atrial flutter. ResultsThe average age of the included patients was 72 ± 7 years and 59% were men. All patients (100%) had a transesophageal echocardiogram prior to DCCV. Device-related thrombus was seen in 2.7%. They were all successfully treated with oral anticoagulation (OAC) and were able to undergo DCCV after 6 to 8 weeks. DCCV restored sinus rhythm in all patients. None of the patients had DCCV-related thromboembolic complications. A total of 22% of patients were newly started on OAC after DCCV. There was no difference in DCCV-related complications between patients treated with or without OAC post-DCCV. Patients receiving OAC post-DCCV were found to undergo cardioversion at an earlier time after implantation (3.6 months [interquartile range (IQR): 0.7 to 8.6 months] vs. 8.6 months [IQR: 2.5 to 13.3 months]; p = 0.003). Three transient ischemic attacks, unrelated to DCCV, were found during follow-up. During a median follow-up of 12.8 months (IQR: 11.8 to 14.2 months), no device or left atrial thrombosis, device dislodgement, or a new device leak were observed. One patient died during follow-up due to noncardiac cause. ConclusionsDCCV is feasible in high-risk AF patients with an LAAO device without the need for oral anticoagulation if pre-procedural transesophageal echocardiography shows good device position, absence of device-related thrombus, and peridevice leak of ≤5 mm. The preliminary results are encouraging, but further large studies are warranted to establish safety.

P4774Older patients with atrial fibrillation and comorbidities are less likely to be treated with oral anticoagulation: insights from a nationwide study

Abstract Background Older patients with atrial fibrillation (AF) often have multiple chronic conditions adding complexity to treatment decisions. However, regarding older AF patients, the association between multimorbidity and quality of care has not been explored previously in a non-selected nationwide cohort. Purpose To investigate the association between morbidity burden and the treatment with oral anticoagulation therapy (OAC) and rhythm-control strategies in patients &gt;65 years of age with incident AF in Denmark. Methods Using Danish nationwide registers, we identified all Danish AF patients &gt;65 years of age hospitalized for incident AF between 2010 and 2016. Using logistic regression models, we estimated the association between morbidity burden (&lt;2, 2–3, 4–5, and &gt;5 comorbidities) and the likelihood of receiving AF specific treatments. Estimates were reported as odds ratios with 95% confidence intervals (OR, 95% CI) with &lt;2 comorbidities as reference. The primary outcome of interest was OAC therapy initiation. Secondary outcomes were initiation of anti-arrhythmic drugs (Class IC and Class III) and AF related procedures (electrical cardioversion and radiofrequency ablation). All models were adjusted for age, sex and calendar year. Results A total of 49,802 AF patients were eligible for inclusion, with a median age of 77.5 years (Interquartile range [IQR] 71.8–83.8) and 24,983 (50.2%) were male. A total of 25,181 (50.6%) patients had &lt;2 comorbidities, 18,714 (37.6%) had 2–3 comorbidities, 4,891 (9.8%) had 4–5 comorbidities, and 1,016 (2.0%) patients had &gt;5 comorbidities. The median CHA2DS2-VASc score ranged from 3 (IQR 2–3) to 5 (IQR 4–5) in patients with &lt;2 comorbidities and &gt;5 comorbidities, respectively. Increasing morbidity burden was associated with decreasing odds of being treated with OAC therapy with the lowest odds in patients with &gt;5 comorbidities (OR 0.39, 95% CI 0.34–0.45) compared with AF patients with &lt;2 comorbidities. (Figure 1) Using morbidity burden as a continuous variable, an increment of one comorbidity was associated with decreasing odds of initiating OAC therapy (OR 0.85, 95% CI 0.84–0.86). Morbidity burden was associated with increased odds of being prescribed anti-arrhythmic medication with the highest odds in patients with &gt;5 comorbidities (OR 2.50 95% CI 2.08–2.99). In contrast, having &gt;5 comorbidities was associated with decreased odds of AF related procedures (OR 0.32, 95% CI 0.23–0.43) compared to patients with &lt;2 comorbidities. Forest plot of OAC initiation factors Conclusion Morbidity burden is strongly associated with OAC initiation and rhythm-control strategies in older patients with incident AF. Older AF patients with multimorbidity are less likely to be treated with OAC although these are the patients who benefit most from treatment. Therefore, initiatives and quality improvement programs should be done to close this important gap between clinical trials and clinical practice.

Rhythm control for patients with atrial fibrillation complicated with heart failure in the contemporary era of catheter ablation: a stratified pooled analysis of randomized data.

The optimal treatment for patients with atrial fibrillation (AF) and heart failure (HF) has been a subject of debate for years. We aimed to evaluate the efficacy and safety of rhythm control strategy in patients with AF complicated with HF regarding hard clinical endpoints. Up-to-date randomized data comparing rhythm control using antiarrhythmic drugs (AADs) vs. rate control (Subset A) or rhythm control using catheter ablation vs. medical therapy (Subset B) in AF and HF patients were pooled. The primary outcomes were all-cause mortality, re-hospitalization, stroke, and thromboembolic events. A total of 11 studies involving 3598 patients were enrolled (Subset A: 2486; Subset B: 1112). As compared with medical rate control, the AADs rhythm control was associated with similar all-cause mortality [odds ratio (OR): 0.96, P = 0.65], significantly higher rate of re-hospitalization (OR: 1.25, P = 0.01), and similar rate of stroke and thromboembolic events (OR: 0.91, P = 0.76,); however, as compared with medical therapy, catheter ablation rhythm control was associated with significantly lower all-cause mortality (OR: 0.51, P = 0.0003), reduced re-hospitalization rate (OR: 0.44, P = 0.003), similar rate of stroke events (OR: 0.59, P = 0.27), greater improvement in left ventricular ejection fraction [weighted mean difference (WMD): 6.8%, P = 0.0004], lower arrhythmia recurrence (29.6% vs. 80.1%, OR: 0.04, P < 0.00001), and greater improvement in quality of life (Minnesota Living with Heart Failure Questionnaire score) (WMD: -9.1, P = 0.007). Catheter ablation as rhythm control strategy substantially improves survival rate, reduces re-hospitalization, increases the maintenance rate of sinus rhythm, contributes to preserve cardiac function, and improves quality of life for AF patients complicated with HF.

Rate Control Yields Better Clinical Outcomes Over a Median Follow-Up of 20 Months Compared to Rhythm Control Strategy in Patients With a History of Atrial Fibrillation: A Retrospective Cohort Study.

BackgroundClinical management of patients with a history of atrial fibrillation (AF) focuses on the goal of preventing AF recurrences, or, if this is impossible due to the fact that the arrhythmia has by now become permanent, it is aimed at the control of the ventricular response. In patients with AF, an important topic is the comparative evaluation in the mid/long-term of clinical outcomes arising from the various therapeutic regimens, including pharmacological approaches as well as radiofrequency catheter ablation (abl).MethodsIn the present cohort retrospective study, 175 cases of paroxysmal, persistent or long-lasting persistent AF have been grouped depending on therapeutic approach: abl-isolated or followed by chronic use of antiarrhythmics (74 cases), drug treatment for rate control strategy (60 cases), drug treatment for rhythm control strategy (41 cases). The effects respectively exerted by the three treatment modalities on the primary endpoint, namely a composite of death, disabling stroke, severe bleeding and cardiac arrest , have been compared through a median follow-up of 20 months (interquartile range = 18 - 24 months) using the Cox proportional-hazards regression analysis.ResultsAs documented by the Cox model, an increased risk of the primary composite endpoint was associated with the rhythm control strategy, as well as with the AF recurrences during the follow-up (for the former, hazard ratio (HR): 3.3159, 95% CI: 1.5415 to 7.1329, P = 0.0023; for the latter, HR: 1.0448, 95% CI: 1.0020 to 1.0895, P = 0.0410). Even hypertension was associated with an increased risk (HR: 1.1040; 95% CI: 1.0112 to 1.9662; P = 0.0477). On the contrary, a rate control strategy predicted a decreased risk of experiencing the primary endpoint (HR: 0.0711; 95% CI: 0.0135 to 0.3738; P = 0.0019) while abl did not exert a statistically significant effect on the same outcome.ConclusionsAF abl decreases the arrhythmic episodes but does not provide a statistically significant protection against the composite of death, disabling stroke, major bleeding and cardiac arrest after a 20-month follow-up. Moreover, in patients with a history of AF, rate control compared to rhythm control strategy provides better clinical outcomes over a mid-term follow-up.

Rate Versus Rhythm Control in Patients with Normal to Mild Left Atrial Enlargement: Insights from the AFFIRM Trial.

Atrial fibrillation is the most commonly encountered sustained arrhythmia and is associated with significant morbidity and mortality. Several trials have demonstrated that no mortality benefit exists when choosing a rhythm-control strategy over a rate-control strategy, with some trials suggesting an increase in mortality. Using the AFFIRM trial database we sought to determine the effect of rhythm control strategy in patients with normal or mild atrial enlargement. AFFIRM Trial database was used to evaluate the effect of rhythm-control strategy compared to rate-control strategy in a subgroup of patients with normal to mild left atrial (LA) enlargement. The primary outcome measures of this study were all-cause mortality, cardiovascular mortality, non-cardiovascular mortality, and hospitalization/ED visit. We identified a subgroup of subjects from the AFFIRM trial with normal or mild LA enlargement (n=2022 of 4060 total subjects). Subjects in the rhythm-control group(n= 1022) had an increased risk of all-cause mortality by 34% (RR 1.34, 95% CI 1.08-1.67; P=0.007) and hospitalization/ED visits by 10% (RR 1.10, 95% CI 1.05-2.16; P=<0.001) compared to rate control group(n= 1000). This study demonstrated that rhythm-control strategy increases the risk of mortality and hospitalization in a subgroup of patients with normal to mild atrial enlargement compared to rate-control strategy. Amiodarone use in this subgroup of patients likely drove these findings.

Rhythm Versus Rate Control for Atrial Fibrillation: A Meta-analysis of Randomized Controlled Trials

Atrial fibrillation (AF) is a common, sustained tachyarrhythmia, associated with an increased risk of mortality and thromboembolic events. We performed this meta-analysis to compare the clinical efficacy of rate and rhythm control strategies in patients with AF in a meta-analysis framework. A comprehensive search of PubMed, OVID, Cochrane-CENTRAL, EMBASE, Scopus, and Web of Science was conducted, using relevant keywords. Dichotomous data on mortality and other clinical events were extracted and pooled as risk ratios (RRs), with their 95% confidence-interval (CI), using RevMan software (version 5.3). Twelve studies (8451 patients) were pooled in the final analysis. The overall effect-estimate did not favor rate or rhythm control strategies in terms of all-cause mortality (RR= 1.13, 95% CI [0.88, 1.45]), stroke (RR= 0.97, 95% CI [0.79, 1.20]), thromboembolism (RR= 1.06, 95% CI [0.64, 1.76]), and major bleeding (RR= 1.10, 95% CI [0.90, 1.35]) rates. These findings were consistent in AF patients with concomitant heart failure (HF). The rate of rehospitalization was significantly higher (RR= 0.72, 95% CI [0.57, 0.92]) in the rhythm control group, compared to the rate control group. In younger patients (&lt;65 years), rhythm control was superior to rate control in terms of lowering the risk of all-cause mortality (p=0.0003), HF (p=0.003) and major bleeding (p=0.02). In older AF patients and those with concomitant HF, both rate and rhythm control strategies have similar rates of mortality and major clinical outcomes; therefore, choosing an appropriate strategy should consider individual variations, such as patient preferences, comorbidities, and treatment cost.

Percutaneous Treatment of Non-paroxysmal Atrial Fibrillation: A Paradigm Shift from Pulmonary Vein to Non-pulmonary Vein Trigger Ablation?

Pulmonary vein antrum isolation is the most effective rhythm control strategy in patients with paroxysmal AF. However, catheter ablation of non-paroxysmal AF has a lower success rate, even when persistent isolation of pulmonary veins (PVs) is achieved. As a result of arrhythmia-related electophysiological and structural changes in the atria, sites other than the PVs can harbour triggers. These non-PV triggers contribute to AF relapse. In this article, we summarise the rationale and current evidence supporting the arrhythmogenic role of non-PV triggers and our ablation approach to patients with non-paroxysmal AF.

Biatrial Electrical and Structural AtrialChanges in Heart Failure: Electroanatomic Mapping in Persistent Atrial Fibrillation inHumans.

This study sought to characterize the biatrial substrate in heart failure (HF) and persistent atrial fibrillation(PeAF). Atrial fibrillation (AF) and HF frequently coexist; however, the contribution of HF to the biatrial substratein PeAF is unclear. Consecutive patients with PeAF and normal left ventricular (NLV) systolic function (left ventricular ejection fraction [LVEF] >55%) or idiopathic cardiomyopathy (LVEF≤45%) undergoing AF ablation were enrolled. In AF, pulmonaryvein (PV) cycle length (PVCL) was recorded via a multipolar catheter in each PV and in the left atrial appendage for 100 consecutive cycles. After electrical cardioversion, biatrial electroanatomic mapping was performed. Complex electrograms, voltage, scarring, and conduction velocity were assessed. Forty patients, 20 patients with HF (mean age: 62 ± 8.9 years; AF duration: 15 ± 11 months; LVEF: 33 ± 8.4%) and 20 with NLV (mean age: 59 ± 6.7 years; AF duration: 14 ± 9.1 months; p= 0.69; mean LVEF: 61 ± 3.6%; p<0.001), were enrolled. HF reduced biatrial tissue voltage (p< 0.001) with greater voltage heterogeneity (p< 0.001). HF was associated with significantly more biatrial fractionation (left atrium [LA]: 30% vs. 9%; p< 0.001; right atrium [RA]: 28% vs. 11%; p< 0.001), low voltage (<0.5 mV) (LA: 23% vs. 6%; p= 0.002; RA: 20% vs 11%; p= 0.006), and scarring (<0.05mV) in the LA (p= 0.005). HF was associated with a slower average PVCL (185 vs. 164 ms; p= 0.016), which correlated significantly with PV antral bipolar voltage (R=-0.62; p< 0.001) and fractionation (R= 0.46; p=0.001). HF is associated with significantly reduced biatrial tissue voltage, fractionation, and prolongation of PVCL. Advanced biatrial remodeling may have implications for invasive and noninvasive rhythm control strategies in patients with AF and HF.

Abstract 13023: Characteristics of Treatment Failure With Rate and Rhythm Control Strategies in Patients With Atrial Fibrillation: Insights From the AFFIRM (Atrial Fibrillation Follow-up Investigation of Rhythm Management) Trial

Introduction: In patients with atrial fibrillation (AF) both “rate control” and “rhythm control” therapies have distinct set of limitations. We sought to investigate the rates and reasons of crossover from an initially assigned rate control arm to rhythm control and from rhythm to rate control therapy in patients who were enrolled in the AFFIRM trial. Methods: We compared the characteristics of patients who continued in the initially assigned treatment arm versus those who crossed over to the alternative treatment strategy in both “rhythm” and “rate” control arms. Two-sample t-test and chi-squared tests were used to compare means and proportions respectively. Results: A total of 4,060 patients were enrolled in the AFFIRM trial and over a mean follow-up duration of 3.5 years, 842 of them underwent crossover from an initially assigned treatment arm. The rate of crossover from an initially assigned rhythm control arm (594/2033, 29.2%) was more frequent than the rate of crossover from rate control to rhythm control (248/2027, 12.2%, p &lt; 0.0001). In the rhythm control arm, the patients who crossed over to rate control had a significantly higher incidence of prior failure of an antiarrhythmic drug (139/594, 23.4%) than in those who continued as assigned (210/1439, 14.6%, p &lt; 0.0001). In the rate control arm, patients who crossed over to rhythm control were relatively younger (68.3 ± 8.2 vs. 69.7 ± 8.0 years in those who continued, p = 0.01). The leading reasons for crossover to rate control were failure to achieve or maintain sinus rhythm (272/594, 45.8%) and intolerable adverse effects (122/594, 20.5%). In comparison, the major reasons for crossover to rhythm control were failure to control AF symptoms (159/248, 64.1%) and intolerable adverse effects (9/248, 3.6%). The difference in crossover pattern was statistically significant (p &lt; 0.0001). Conclusions: Rhythm control was abandoned more commonly than rate control in patients who were enrolled in the AFFIRM trial. Failure of antiarrhythmic drug therapy prior to randomization was a significant factor for crossover from rhythm to rate control. Patients who crossed over from rate to rhythm control were younger than those who continued. The crossover from rhythm to rate control was driven by the occurrence of adverse effects.

Determinants of Left Atrial Volume in Patients with Atrial Fibrillation.

IntroductionLeft atrial (LA) enlargement is an important risk factor for incident stroke and a key determinant for the success of rhythm control strategies in patients with atrial fibrillation (AF). However, factors associated with LA volume in AF patients remain poorly understood.MethodsPatients with paroxysmal or persistent AF were enrolled in this study. Real time 3-D echocardiography was performed in all participants and analyzed offline in a standardized manner. We performed stepwise backward linear regression analyses using a broad set of clinical parameters to determine independent correlates for 3-D LA volume.ResultsWe included 210 patients (70.9% male, mean age 61±11years). Paroxysmal and persistent AF were present in 95 (45%) and 115 (55%) patients, respectively. Overall, 115 (55%) had hypertension, 11 (5%) had diabetes, and 18 (9%) had ischemic heart disease. Mean indexed LA volume was 36±12ml/m2. In multivariable models, significant associations were found for female sex (β coefficient -10.51 (95% confidence interval (CI) -17.85;-3.16), p = 0.0053), undergoing cardioversion (β 11.95 (CI 5.15; 18.74), p = 0.0006), diabetes (β 14.23 (CI 2.36; 26.10), p = 0.019), body surface area (BSA) (β 34.21 (CI 19.30; 49.12), p<0.0001), glomerular filtration rate (β -0.21 (CI -0.36; -0.06), p = 0.0064) and plasma levels of NT-pro brain natriuretic peptide (NT-proBNP) (β 6.79 (CI 4.05; 9.52), p<0.0001), but not age (p = 0.59) or hypertension (p = 0.42). Our final model explained 52% of the LA volume variability.ConclusionsIn patients with AF, the most important correlates with LA volume are sex, BSA, diabetes, renal function and NT-proBNP, but not age or hypertension. These results may help to refine rhythm control strategies in AF patients.

Systematic analysis of ECG predictors of sinus rhythm maintenance after electrical cardioversion for persistent atrial fibrillation

Electrical cardioversion (ECV) is one of the rhythm control strategies in patients with persistent atrial fibrillation (AF). Unfortunately, recurrences of AF are common after ECV, which significantly limits the practical benefit of this treatment in patients with AF. The objectives of this study were to identify noninvasive complexity or frequency parameters obtained from the surface electrocardiogram (ECG) to predict sinus rhythm (SR) maintenance after ECV and to compare these ECG parameters with clinical predictors. We studied a wide variety of ECG-derived time- and frequency-domain AF complexity parameters in a prospective cohort of 502 patients with persistent AF referred for ECV. During 1-year follow-up, 161 patients (32%) maintained SR. The best clinical predictor of SR maintenance was antiarrhythmic drug (AAD) treatment. A model including clinical parameters predicted SR maintenance with a mean cross-validated area under the receiver operating characteristic curve (AUC) of 0.62 ± 0.05. The best single ECG parameter was the dominant frequency (DF) on lead V6. Combining several ECG parameters predicted SR maintenance with a mean AUC of 0.64 ± 0.06. Combining clinical and ECG parameters improved prediction to a mean AUC of 0.67 ± 0.05. Although the DF was affected by AAD treatment, excluding patients taking AADs did not significantly lower the predictive performance captured by the ECG. ECG-derived parameters predict SR maintenance during 1-year follow-up after ECV at least as good as known clinical predictors of rhythm outcome. The DF proved to be the most powerful ECG-derived predictor.

Rate versus rhythm control and outcomes in patients with atrial fibrillation and chronic kidney disease: Data from the GUSTO-III Trial

Atrial fibrillation (AF) and chronic kidney disease (CKD) have both been shown to portend worse outcomes after acute myocardial infarction (MI); however, the benefit of a rhythm control strategy in patients with CKD post-MI is unclear. We prospectively studied 985 patients with new-onset AF post-MI in the GUSTO-III trial, of whom 413 (42%) had CKD (creatinine clearance < 60 mL/min). A rhythm control strategy, defined as the use of an antiarrhythmic medication and/or electrical cardioversion, was used in 346 (35%) of patients. A rhythm control strategy was used in 34% of patients with CKD and 36% of patients with no CKD. At hospital discharge, sinus rhythm was present in 487 (76%) of patients treated with a rate control strategy, vs. 276 (80%) in those treated with rhythm control (p = 0.20). CKD was associated with a lower odds of sinus rhythm at discharge (unadjusted OR 0.56, 95% CI 0.38-0.84, p < 0.001). However, in multivariable analyses, treatment with a rhythm control strategy was not associated with discharge rhythm (HR 1.068, 95% CI 0.69-1.66, p = 0.77), 30-day mortality (HR 0.78, 95% CI 0.54-1.12, p = 0.18) or mortality from day 30 to 1 year (HR 1.00, 95% CI 0.59-1.69, p = 0.99). CKD status did not significantly impact the relationship between rhythm control and outcomes. Treatment with a rhythm or rate control strategy does not signifi cantly impact short-term or long-term mortality in patients with post-MI AF, regardless of kidney disease status. Future studies to investigate the optimal management of AF in CKD patients are needed.

Letter by Gasparovic and Kopjar Regarding Article, “Rhythm Versus Rate Control Therapy and Subsequent Stroke or Transient Ischemic Attack in Patients With Atrial Fibrillation”

To the Editor: We read with interest the article by Tsadok et al1 on the reduction of neurological events by adhering to the rhythm-control strategy in patients with atrial fibrillation (AF). The critical piece of information that is not disclosed in the article, however, is the efficacy of sinus rhythm maintenance within the rhythm-control cohort. It is the presence of stable sinus rhythm coupled with adequate atrial …

Comparison of Rate Versus Rhythm Control in Patients With Atrial Fibrillation and a Pacemaker

The effect of rate versus rhythm control in patients with atrial fibrillation who have undergone previous pacemaker (PM) implantation is unknown. We evaluated the mortality in patients with atrial fibrillation and a PM randomized to rate or rhythm control treatment strategies. The Atrial Fibrillation Follow-up Investigation of Rhythm Management data set was stratified by the presence (n = 250) or absence (n = 3,810) of a PM at randomization into the rate or rhythm control arm. Kaplan-Meier curves were used for univariate analysis, and proportional hazards were used for multivariate analysis. The subjects with a PM (n = 250) were older (73 vs 69 years, p <0.01) and had a greater prevalence of coronary artery disease (53% vs 37%, p <0.01) and congestive heart failure (33% vs 23%, p <0.01). All-cause mortality was significantly greater in the PM patients who were randomized to the rhythm control arm (n = 128) than in the patients enrolled in the rate control arm with or without a PM (n = 2,027, p <0.01) and those in the rhythm control arm without a PM (n = 1,905, p <0.01). Multivariate analysis revealed that predictors of all-cause mortality included PM patients randomized to the rhythm control arm (hazard ratio 2.59, 95% confidence interval 1.46 to 4.58, p <0.01) and the presence of congestive heart failure (hazard ratio 2.42, 95% confidence interval 1.40 to 4.16, p <0.01). In conclusion, all-cause mortality was greater among patients with atrial fibrillation with a PM, who were randomized to the rhythm control arm of the Atrial Fibrillation Follow-up Investigation of Rhythm Management study compared with all other patients enrolled in the Atrial Fibrillation Follow-up Investigation of Rhythm Management study. The rhythm control strategy in patients with a PM was an independent predictor of mortality.

Should rhythm control be preferred in younger atrial fibrillation patients?

Rate- and rhythm control are two fundamental strategies to treat atrial fibrillation (AF). However, there are inconsistent results between clinical trials about which treatment should be preferred. The aims of this study were to systematically summarize the clinical trials and compare rate- and rhythm control strategies regarding composite outcome of all cause mortality, worsening heart failure, and thromboembolic and bleeding events. English and non-English studies that were published from 1966 onwards were included in this meta-analysis if they were prospective randomized controlled trials which compared rate- and rhythm control strategies in patients with AF. The individual and combined outcomes were analyzed quantitatively with odds ratio and 95 % confidence interval. Ten prospective randomized controlled trials with 7,876 patients were identified. There was no significant difference regarding primary composite outcome (11.47 vs. 11.03 % per year; odds ratio (OR), 1.03; 95 % confidence interval (CI), 0.90-1.20; P = 0.64) between rate- and rhythm control groups in overall age group. Meta-analysis for studies with mean age <65 years showed that rate control had significantly higher risk in primary composite outcome compared with rhythm control (8.74 vs. 4.80 % per year; OR, 1.89; 95 %CI, 1.26-2.86; P = 0.002). A significant trend towards that rhythm control may be a preferable strategy for younger AF patients was observed in this study.

The use of serum bepridil concentration as a safe rhythm control strategy in patients with atrial tachyarrhythmias

The aim of this study was to evaluate the clinical significance of serum bepridil (Bep) concentration (SBC) for safely managing patients with atrial tachyarrhythmias (AT). Methods and resultsSBC was measured in 37 patients with AT, including atrial fribrillation (AF) (31 cases), AF+atrial flutter (AFL) (4 cases), AFL (1 case), and atrial tachycardia (1 case). The patients were administrated Bep for more than 4 weeks at the same dose. SBC was positively correlated with Bep dose per kilogram of body weight (p=0.015), QT interval (p=0.019), and QTc (p=0.034). The patients were divided into 2 groups according to their SBC: the high-SBC (HSBC) group of 8 patients with an SBC≥500ng/ml and a low-SBC (LSBC) group of 29 patients with an SBC<500ng/ml. There was no difference in maintenance of sinus rhythm between the groups. For clinical variables, QT and QTc were significantly longer in the HSBC than in the LSBC group (p=0.004 and p=0.016, respectively). Patients with QT>0.5 were more prominent in the HSBC group (37.5% vs. 3.4%, p=0.026), and torsade de points (TdP) occurred in only one patient in the HSBC group. However, there were several patients with normal QT/QTc despite having high SBC. ConclusionsIn patients treated with Bep, measurement of SBC is useful for preventing proarrhythmias.

Safety of Flecainide

Flecainide is a class Ic antiarrhythmic agent that has an important role as part of rhythm control strategies in patients with atrial fibrillation (AF). Early clinical data on the use of flecainide showed an increase in arrhythmias and mortality compared with placebo in patients with a previous myocardial infarction and asymptomatic or mildly symptomatic ventricular arrhythmias. These findings only apply to a specific group of patients with left ventricular dysfunction and ischaemic heart disease, but had a negative impact on the use of class Ic antiarrhythmics across all indications and patient groups. The aim of this review was to evaluate the available safety data for flecainide in the literature and to assess its current use in patients with AF. Current European guidelines now recommend the use of flecainide in carefully selected groups of patients with AF who do not have structural heart disease. This includes for the cardioversion of recent-onset AF, pretreatment prior to direct current cardioversion, out-of-hospital acute oral therapy ('pill-in-the-pocket' approach) and for the ongoing maintenance of sinus rhythm. Potential cardiac adverse effects of flecainide include proarrhythmia, conduction abnormalities and negative inotropic effects. Dizziness is the most frequent non-cardiac side effect, followed by blurred vision and difficulty focusing; these are almost all mild, transient and tolerable. Data from recent clinical trials in patients with supraventricular arrhythmias suggest that flecainide has a good tolerability profile in groups of appropriately selected patients. Caution is required when using flecainide in patients with renal dysfunction, and there are a number of drug interactions, but these are well documented and manageable. Overall, flecainide is a good choice for the pharmacological management of AF. It has a good safety record and low incidence of adverse effects, rare end-organ toxicity and a low risk of ventricular proarrhythmia. To ensure that the benefits of treatment outweigh any potential risks, careful patient selection and monitoring is required.