Same rhythm, different song—approaches to atrial fibrillation management by cardiologists and nephrologists

Abstract Atrial fibrillation (AF) is common in patients with chronic kidney disease (CKD), affecting 10–25% of patients requiring dialysis. Compared with the general population, patients requiring dialysis are also at increased risk of stroke, the major thromboembolic complication of AF. The evidence base for management strategies of AF specific to patients with advanced CKD is limited and not informed by randomized controlled trials. These gaps in evidence encompass rate and rhythm control strategies as well as a paucity of data informing which patients should receive anticoagulation. The European Renal Association–European Dialysis and Transplant Association and European Heart Rhythm Association undertook a survey of nephrologists and cardiologists exploring management strategies in patients with AF and CKD. We review the results of this survey, highlighting the differences in clinical approaches from cardiologists and nephrologists to these conditions. Closer collaboration between these specialties should lead to improved outcomes for patients with advanced CKD and AF. Specific issues that will need to be addressed may include healthcare burden to patients, location of clinics compared with dialysis sites and awareness of complications of treatments specific to CKD, such as calciphylaxis associated with vitamin K antagonism.

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Women and Atrial Fibrillation

10.22541/au.160690688.82582251/v1 ◽

2020 ◽

Author(s):

ANNABELLE VOLGMAN ◽

Emelia Benjamin ◽

Anne Curtis ◽

Margaret Fang ◽

Kathryn Lindley ◽

...

Keyword(s):

Atrial Fibrillation ◽

Control Strategies ◽

Management Strategies ◽

Treatment Strategies ◽

The United States ◽

Evidence Base ◽

Rhythm Control ◽

Control Treatment ◽

Increased Risk ◽

Control Management

Atrial fibrillation (AF) remains a growing problem in the United States and worldwide, imposing a high individual and health system burden, including increased resource consumption due to repeated hospitalizations, stroke, dementia, heart failure, and death. This comprehensive review summarizes the most recent data on sex-related differences in risks associated with AF. Women with AF have increased risk of stroke and death compared to men, and possible reasons for this disparity are explored. Women also continue to have worse symptoms and quality of life, and poorer outcomes with stroke prevention, as well as with rate and rhythm control management strategies. Many current rhythm control treatment strategies for AF, including cardioversion and ablation, are used less frequently in women as compared to men, whereas women are more likely to be treated with rate control strategies or anti-arrhythmic drugs. Sex differences should be considered in treating women with AF to improve outcomes and women and men should be offered the same interventions for AF. We need to improve the evidence base to understand if variation in utilization of rate and rhythm control management between men and women represents health inequities or appropriate clinical judgement.

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Key Issues in the Management of Atrial Fibrillation - Protecting the Patient and Controlling the Arrhythmia

Scottish Medical Journal ◽

10.1258/rsmsmj.52.3.27 ◽

2007 ◽

Vol 52 (3) ◽

pp. 27-35 ◽

Cited By ~ 1

Author(s):

S M M Jenkins ◽

F G Dunn

Keyword(s):

Atrial Fibrillation ◽

Stroke Risk ◽

Control Strategies ◽

Management Strategies ◽

Heart Association ◽

Clinical Excellence ◽

Evidence Base ◽

Surgical Interventions ◽

Key Issues ◽

European Society Of Cardiology

Atrial fibrillation (AF) is the most common sustained tachyarrhythmia and its prevalence is increasing. It is an independent risk factor for stroke and is associated with significant morbidity and mortality. AF currently accounts for 1% of NHS expenditure. The management of AF has a broad evidence base and both the American College of Cardiology/American Heart Association/European Society of Cardiology (ACC/AHA/ESC) and the National Institute for Clinical Excellence (NICE) have recently published guidelines. Some controversy persists regarding stroke risk stratification and appropriate anticoagulation regimes although a general consensus is now emerging. Rate and rhythm control strategies have been shown to be comparable in terms of clinical outcomes. Current anti-arrhythmic drugs have limited efficacy and significant side-effect profiles. Electrophysiological and surgical interventions have a role in both strategies. This article broadly reviews the evidence for different management strategies in AF and presents a practical approach to treatment in light of the recently published national and international guidelines.

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Abstract 3047: What Are the Effects of Nonsteroidal Anti-Inflammatory Drugs on Post-Cardiothoracic Surgery Outcomes?

Circulation ◽

10.1161/circ.116.suppl_16.ii_682-d ◽

2007 ◽

Vol 116 (suppl_16) ◽

Author(s):

Richard T Ruffin ◽

Jeffrey Kluger ◽

Stephanie M Wills ◽

C M White ◽

Craig I Coleman

Keyword(s):

Atrial Fibrillation ◽

Cardiothoracic Surgery ◽

Red Blood Cell Transfusion ◽

Beta Blockade ◽

Randomized Controlled ◽

Conflicting Evidence ◽

Increased Risk ◽

Inflammatory Drugs ◽

Surgery Outcomes ◽

Anti Inflammatory

Background: Two previous studies evaluating nonsteroidal anti-inflammatory drug (NSAID) use following cardiothoracic surgery (CTS) demonstrated conflicting evidence regarding their ability to reduce the incidence of postoperative atrial fibrillation (POAF). Moreover, neither study examined negative cardiovascular outcomes such as stroke and myocardial infarction (MI). Since a recent study evaluating paracoxib/valdecoxib following CTS demonstrated an increased risk of cardiovascular events, we sought to evaluate whether NSAIDs could reduce the incidence of POAF without increasing patients’ risk of stroke or MI. Methods: Patients (n=555) undergoing CTS from the randomized, controlled Atrial Fibrillation Suppression Trials (AFISTs) I, II and III were evaluated in this nested study. Demographic, surgical and medication use characteristics were prospectively collected as part of the AFIST trials. Endpoints included POAF, stroke, MI and the need for red blood cell transfusion. Multivariable logistic regression was used to calculate odds ratios with 95% confidence intervals. Results: The population was 67.8 ± 8.6 years old, 77.1% male, 14.6% underwent valve surgery, 6.1% had prior AF, 12.6% had heart failure and 84.0% and 44.1% received postoperative beta-blockade and prophylactic amiodarone. In total, 127 (22.9%) patients received a NSAID postoperatively. NSAID use was associated with reductions in the odds of POAF and the need for RBC transfusions. (Table ) No elevation in the odds of developing stroke or MI was observed. Conclusions: NSAIDs decreased the odds of developing POAF and the need for RBC transfusions without significantly increasing MI or stroke. Table. Effect of Nonsteroidal Anti-Inflammatory Drugs on Postoperative Outcomes

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Genetics of Atrial Fibrillation in 2020

Circulation Research ◽

10.1161/circresaha.120.316575 ◽

2020 ◽

Vol 127 (1) ◽

pp. 21-33 ◽

Cited By ~ 4

Author(s):

Carolina Roselli ◽

Michiel Rienstra ◽

Patrick T. Ellinor

Keyword(s):

Atrial Fibrillation ◽

Complex Disease ◽

Association Studies ◽

Heart Rhythm ◽

Genome Wide Association Studies ◽

Future Directions ◽

Genetics Research ◽

Genome Wide ◽

Increased Risk ◽

Rhythm Disorder

Atrial fibrillation is a common heart rhythm disorder that leads to an increased risk for stroke and heart failure. Atrial fibrillation is a complex disease with both environmental and genetic risk factors that contribute to the arrhythmia. Over the last decade, rapid progress has been made in identifying the genetic basis for this common condition. In this review, we provide an overview of the primary types of genetic analyses performed for atrial fibrillation, including linkage studies, genome-wide association studies, and studies of rare coding variation. With these results in mind, we aim to highlighting the existing knowledge gaps and future directions for atrial fibrillation genetics research.

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Systematic Review of Early Intensive Behavioral Interventions for Children With Autism

American Journal on Intellectual and Developmental Disabilities ◽

10.1352/2009.114:23-41 ◽

2009 ◽

Vol 114 (1) ◽

pp. 23-41 ◽

Cited By ~ 303

Author(s):

Patricia Howlin ◽

Iliana Magiati ◽

Tony Charman

Keyword(s):

Systematic Review ◽

Behavioral Interventions ◽

Children With Autism ◽

Evidence Base ◽

Group Level ◽

Inclusion Criteria ◽

Individual Level ◽

Randomized Controlled ◽

Improved Outcomes ◽

Comparison Groups

Abstract Recent reviews highlight limitations in the evidence base for early interventions for children with autism. We conducted a systematic review of controlled studies of early intensive behavioral interventions (EIBI) for young children with autism. Eleven studies met inclusion criteria (including two randomized controlled trials). At group level, EIBI resulted in improved outcomes (primarily measured by IQ) compared to comparison groups. At an individual level, however, there was considerable variability in outcome, with some evidence that initial IQ (but not age) was related to progress. This review provides evidence for the effectiveness of EIBI for some, but not all, preschool children with autism.

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Management strategies for atrial fibrillation and flutter in patients with transthyretin cardiac amyloidosis

European Heart Journal ◽

10.1093/eurheartj/ehab724.1810 ◽

2021 ◽

Vol 42 (Supplement_1) ◽

Author(s):

Z Dale ◽

P Chandrashekar ◽

L Al-Rashdan ◽

M Kim ◽

A Masri ◽

...

Keyword(s):

Atrial Fibrillation ◽

Rate Control ◽

Cardiac Amyloidosis ◽

Control Strategies ◽

Nyha Class ◽

Management Strategies ◽

Symptomatic Improvement ◽

Rhythm Control ◽

Ventricular Rate ◽

Ventricular Response

Abstract Background Atrial fibrillation (AF) and flutter (AFL) are common in transthyretin cardiac amyloidosis (ATTR-CM). Ventricular rate control drugs in ATTR-CM are poorly tolerated but data addressing tolerability and efficacy of rhythm control strategies is limited. Purpose We report characteristics and outcomes of AF/AFL in a cohort with ATTR-CM. Methods A single center observational study of patients seen at our Amyloidosis Center with wild-type or hereditary ATTR-CM diagnosed between 2005–2019. Treatment was prescribed as per treating cardiologists. Results Eighty-four patients with ATTR-CM (average age 74±10 years, 94% male) had mean follow-up of 27.6±22.8 months. AF/AFL occurred in 61 patients (73%). Clinically significant rapid ventricular response (RVR) was common as well attempted rate control with AV node blockers (Table 1). However, discontinuation was frequent (80%), often for adverse effects of hypotension (33%), bradycardia (15%), or presyncope/syncope (10%). Rhythm control was initiated in 64%, most often with cardioversion (DCCV) or ablation (Table 2). Post-DCCV recurrence was common (91%) and time to recurrence did not differ with use of anti-arrhythmic drugs (AAD; 5.8 months (IQR 1.9–12.5) vs without AAD 6.2 months (IQR 1.9–12.5) p=0.83). TEE was performed for 33% of DCCV with thrombus seen in 11% of cases – all patients who were not anticoagulated at the time. TEE was otherwise deferred due to known AF/AFL duration <48 hours (13%) or adequate anticoagulation (54%). Ablation was performed in 23% of patients with AFL (all for typical AFL) with 2 patients (14%) having recurrence after mean of 60.9 months. Pulmonary vein isolation for AF was performed in 12% (86% for persistent AF) with 86% recurrence after median of 6.2 months (IQR 5.6–12.3). Most patients (62%) with rhythm control had subjective improvement (≥1 NYHA class or resolved palpitations). Among AAD, amiodarone was most well tolerated with only 8% of patient discontinuing due to side effects. DCCV and ablation resulted in no direct complications although one patient had a perforation of a previously unknown Zenker diverticulum during TEE pre-DCCV. Conclusions In our ATTR-CM cohort, AF/AFL was common. Rate control was poorly tolerated and often abandoned. While rhythm control of AF/AFL had a favorable safety profile and successful conversion to sinus rhythm led to symptomatic improvement in a majority of cases, durable success with rhythm control was limited, often requiring multiple therapies. DCCV is only modestly successful and not significant improved with AAD. Ablation was successful in cases of cavo-tricuspid isthmus dependent AFL but had limited success in AF. FUNDunding Acknowledgement Type of funding sources: None.

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Cost-effectiveness of Apixaban for Stroke Prevention in Patients with Atrial Fibrillation in Algeria

Journal of Health Economics and Outcomes Research ◽

10.36469/9797 ◽

2017 ◽

Vol 5 (1) ◽

pp. 39-54

Author(s):

Yazid Aoudia ◽

Thitima Kongnakorn ◽

Evie Merinopoulou ◽

Mohamed Said Bettayeb ◽

Sid Ahmed Kherraf

Keyword(s):

Atrial Fibrillation ◽

Cost Effectiveness ◽

Stroke Prevention ◽

Heart Rhythm ◽

Cost Effective ◽

European Medicines Agency ◽

Economic Implications ◽

Life Years ◽

Increased Risk ◽

Randomised Controlled

Background: Atrial fibrillation (AF) is a chronic sustained heart rhythm disorder associated with an increased risk of stroke. Apixaban, a new oral anticoagulant, was approved by the European Medicines Agency for prevention of stroke in patients with AF. The efficacy of apixaban has been investigated in randomised controlled trials. Objectives: The objective of this study was to estimate the economic implications of using apixaban compared to other anti-coagulations to reduce the risk of stroke in patients with AF from the perspective of the Algerian payer. Methods: A previously published Markov model was adapted to the Algerian setting. The model included patients for whom vitamin K antagonist (VKA) treatment is suitable and could initiate on acenocoumarol, rivaroxaban or apixaban, and those unsuitable for VKA treatment who could initiate on aspirin or apixaban. Over a lifetime time horizon, costs were estimated in Algerian dinars (DZD) and outcomes included life-years (LYs), quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratios (ICERs). Results: In the VKA suitable population, apixaban was estimated to be a dominant treatment option over rivaroxaban, providing a higher number of QALYs at lower costs, while when compared with acenocoumarol, an ICER of 3 672 059 DZD per QALY gained was estimated. Amongst those unsuitable for VKA therapy, the ICER was 2 061 863 DZD per QALY gained. Conclusion: Apixaban was found to be a cost-effective choice for stroke prevention in patients with AF in Algeria compared to acenocoumarol and rivaroxaban in the VKA suitable population and compared to aspirin in the VKA unsuitable population.

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How Much Atrial Fibrillation is Enough to Warrant Oral Anticoagulation: Management of Subclinical Atrial Fibrillation?

Canadian Journal of General Internal Medicine ◽

10.22374/cjgim.v13isp1.314 ◽

2018 ◽

Vol 13 (SP1) ◽

Author(s):

Jeff Healey

Keyword(s):

Atrial Fibrillation ◽

Oral Anticoagulation ◽

Continuous Monitoring ◽

Absolute Risk ◽

Oral Anticoagulants ◽

Heart Rhythm ◽

Anticoagulation Management ◽

Specific Patient ◽

Increased Risk ◽

Patient Groups

Stroke due to atrial fibrillation (AF) is common, the cause of significant morbidity and mortality, but is highly preventable with the appropriate use of oral anticoagulants. Recent advances in implantable and wearable electrocardiographic (ECG) technologies now allow continuous monitoring of a patient’s heart rhythm for months or years at a time. Cohort studies have shown that using such methods, it is very common to find asymptomatic, short-lasting episodes of subclinical AF. Subclinical AF is also associated with an increased risk of stroke; however, the risk is lower than with traditional, ECG-detected AF and the absolute risk appears to depend on the overall burden of AF. There is currently great uncertainty as to what duration of AF should trigger the use of oral anticoagulation in specific patient groups. Large randomized trials are underway to help clarify this issue; however, in the meantime, researchers and guideline committees have proposed some guidance to assist clinicians.

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Effect of Long-Term Marine Omega-3 Fatty Acids Supplementation on the Risk of Atrial Fibrillation in Randomized Controlled Trials of Cardiovascular Outcomes: A Systematic Review and Meta-Analysis

Circulation ◽

10.1161/circulationaha.121.055654 ◽

2021 ◽

Author(s):

Baris Gencer ◽

Luc Djousse ◽

Omar T. Al-Ramady ◽

Nancy R. Cook ◽

JoAnn E. Manson ◽

...

Keyword(s):

Atrial Fibrillation ◽

Fatty Acids ◽

Randomized Controlled Trials ◽

Meta Analysis ◽

Cardiovascular Outcomes ◽

Controlled Trials ◽

Omega 3 Fatty Acids ◽

Omega 3 ◽

Randomized Controlled ◽

Increased Risk

Background: Some, but not all, large-scale randomized controlled trials (RCTs) investigating the effects of marine omega-3 fatty acids supplementation on cardiovascular outcomes have reported increased risks of atrial fibrillation (AF). The potential reasons for disparate findings may be dose related. Methods: The MEDLINE and Embase databases were searched for articles and abstracts published between January 1, 2012 and December 31, 2020 in addition to a meta-analysis of large cardiovascular RCTs published in 2019. RCTs of cardiovascular outcomes of marine omega-3 fatty acids that reported results for AF, either as pre-specified outcome, adverse event, or a cause for hospitalization, with a minimum sample size of 500 patients and a median followup of at least one year were included. RCTs specifically examining shorter term effects of omega-3 fatty acids on recurrent AF in patients with established AF or post-operative AF were not included. The hazard ratio (HR) for the reported AF outcomes within each trial was metaanalyzed using random-effects model with Knapp-Hartung adjustment and evaluated a doseresponse relationship with a meta-regression model. Results: Of 4049 screened records, seven studies were included in the meta-analysis. Of those, five were already detected in a previous meta-analysis of cardiovascular RCTs. Among the 81,210 patients from 7 trials, 58,939 (72.6%) were enrolled in trials testing ≤1gram per day (g/d) and 22,271 (27.4%) in trials testing >1g/d of omega-3 fatty acids. The mean age was 65 years and 31,842 (39%) were female. The weighted average follow-up was 4.9 years. In meta-analysis, the use of marine omega-3 fatty acid supplements was associated with an increased risk of AF (n=2,905; HR 1.25, 95%CI 1.07-1.46, P=0.013). In analyses stratified by dose, the HR was greater in the trials testing >1g/d (HR 1.49, 95%CI 1.04-2.15, P=0.042) as compared with those testing ≤1 g/d (HR 1.12, 95%CI 1.03-1.22, P=0.024, P for interaction<0.001). In metaregression, the HR for AF increased per 1 gr increase of omega-3 fatty acids dosage (HR 1.11, 95%CI 1.06-1.15, P=0.001). Conclusions: In RCTs examining cardiovascular outcomes, marine omega-3 supplementation was associated with an increased risk of AF. The risk appeared to be greater in trials testing >1g/d.

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Infark Serebri Tipe Kardioemboli pada Pasien dengan Fibrilasi Atrium

Hang Tuah Medical journal ◽

10.30649/htmj.v17i2.193 ◽

2020 ◽

Vol 17 (2) ◽

pp. 202

Author(s):

ERIC HARTONO TEDYANTO ◽

KEN CHRISTIAN KAWILARANG ◽

FEISAL TANJUNG

Keyword(s):

Atrial Fibrillation ◽

Ct Scan ◽

Blood Clot ◽

Heart Rhythm ◽

Embolic Stroke ◽

Temporal Part ◽

Heart Rhythm Disorders ◽

Increased Risk ◽

Close Supervision ◽

Chief Complaints

ABSTRACTBackground: Stroke is the leading cause of disability and the second most common cause of death in the world. Atrial fibrillation (AF) is the major risk factor for embolic stroke. Patients with atrial fibrillation have a 5 times much more risk of stroke to those who do not have atrial fibrillation.Case Report: A 40-year-old woman came to the Emergency Unit with chief complaints the left-sided limbs suddenly weakened while cooking. On ECG examination there is an irregular rhythm (irregular P-P), leading to an atrial fibrillation. CT scan revealed hypodense lesions on the temporal part of the left side, leading to a cerebral infarction.Discussion: AF puts patients at an increased risk for stroke because blood can ot be properly pumped, which caused stagnation and formed a blood clot. This clot can released from ventricle, then travel to the other organ via artery, including brain and block the blood flow which can result a infarct stroke. Conclusion: Close supervision and routine control are needed for patients with heart rhythm disorders, especially atrial fibrillation to prevent embolic stroke.Keywords: embolic stroke, atrial fibrilation.ABSTRAKLatar Belakang: Stroke adalah penyebab utama kecacatan dan penyebab kematian paling umum kedua di dunia. Fibrilasi atrium (AF) secara numerik merupakan faktor risiko paling penting untuk stroke. Sudah dipastikan bahwa pasien dengan AF memiliki risiko stroke 5 kali lipat relatif terhadap mereka yang tidak.Laporan Kasus: Seorang perempuan 40 tahun datang ke IGD dengan keluhan anggota gerak sisi kiri secara tiba-tiba melemah saat sedang memasak. Pada pemeriksaan EKG didapatkan adanya irama ireguler (P-P ireguler), mengarah ke suatu fibrilasi atrium. Pada pemeriksaan CT Scan didapatkan adanya lesi hipodense di bagian temporal sisi kiri, mengarah ke suatu infark serebri.Diskusi: AF merupakan faktor resiko tinggi untuk stroke karena darah mungkin tidak dipompa dengan baik dari jantung, yang dapat menyebabkannya mengumpul dan membentuk gumpalan di dalam ventrikel. Gumpalan ini kemudian dapat lepas dan mengalir ke otak dan memblokir aliran darah ke bagian otak yang dapat menyebabkan stroke.Kesimpulan: Pengawasan ketat dan kontrol yang rutin sangat diperlukan bagi pasien penderita gangguan irama jantung khususnya fibrilasi atrium untuk mencegah terjadinya stroke emboli.Kata Kunci: stroke emboli, fibrilasi atrium

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