Arrhythmias/Electrophysiology
RCT: Pulmonary Vein Isolation Reduces Atrial Fibrillation Burden and Improves Quality of Life vs. Sham Procedure
7 Sep, 2024 | 17:24h | UTCStudy Design and Population: This double-blind, randomized clinical trial (SHAM-PVI) compared pulmonary vein isolation (PVI) via cryoablation to a sham procedure in 126 patients with symptomatic paroxysmal or persistent atrial fibrillation (AF). The study, conducted in two UK tertiary centers, enrolled patients between January 2020 and March 2024. Major exclusions included long-standing persistent AF, prior left atrial ablation, and ejection fraction below 35%. Patients were monitored using implantable loop recorders.
Main Findings: At 6 months, the PVI group demonstrated a significant reduction in AF burden (60.31%) compared to the sham group (35.0%), with a geometric mean difference of 0.25 (95% CI, 0.15-0.42; P < .001). Quality-of-life scores also improved more in the PVI group, with an 18.39-point difference (95% CI, 11.48-25.30). Symptom improvement was also marked, with a reduction in the Mayo AF-Specific Symptom Inventory frequency score of −6.36 points (95% CI, −8.46 to −4.26).
Implications for Practice: PVI significantly reduces AF burden and improves both symptoms and quality of life in patients with symptomatic AF, compared to a sham procedure. These findings support the efficacy of PVI beyond a placebo effect, making it a compelling option for managing AF in patients not responsive to antiarrhythmic drugs.
Reference: Dulai, R., Sulke, N., Freemantle, N., Lambiase, P. D., Farwell, D., Srinivasan, N. T., et al. (2024). Pulmonary vein isolation vs sham intervention in symptomatic atrial fibrillation: The SHAM-PVI randomized clinical trial. JAMA. http://doi.org/10.1001/jama.2024.17921
Link: https://jamanetwork.com/journals/jama/fullarticle/2823283
RCT: Edoxaban Monotherapy Reduces Bleeding Events in Atrial Fibrillation with Stable CAD Compared to Dual Therapy
7 Sep, 2024 | 13:03h | UTCStudy Design and Population: This multicenter, open-label, adjudicator-masked randomized trial enrolled 1,040 patients with atrial fibrillation (AF) and stable coronary artery disease (CAD) across 18 sites in South Korea. Patients were randomly assigned to receive either edoxaban monotherapy (n=524) or dual antithrombotic therapy (edoxaban plus a single antiplatelet agent; n=516). The mean age was 72.1 years, with a mean CHA2DS2-VASc score of 4.3, reflecting a moderate to high stroke risk.
Main Findings: At 12 months, the primary composite outcome occurred in fewer patients in the edoxaban monotherapy group (6.8%) than in the dual therapy group (16.2%) (HR, 0.44; 95% CI, 0.30–0.65; P<0.001). The reduction was largely driven by a significantly lower incidence of major bleeding or clinically relevant non-major bleeding (4.7% vs. 14.2%; HR, 0.34; 95% CI, 0.22–0.53). In contrast, the incidence of major ischemic events was similar between the two groups.
Implications for Practice: Edoxaban monotherapy provides a safer antithrombotic option for patients with AF and stable CAD by significantly reducing bleeding without increasing ischemic events compared to dual therapy. These findings suggest that monotherapy could be a preferable long-term treatment strategy in this population.
RCT: AF Screening Does Not Reduce Stroke Hospitalizations in Elderly Patients
6 Sep, 2024 | 22:18h | UTCStudy Design and Population: The GUARD-AF trial was a prospective, randomized controlled trial conducted across 149 primary care sites in the U.S. It enrolled 11,905 participants aged 70 and older, with a median age of 75 years, 56.6% of whom were female. Participants were randomized 1:1 to either screening for atrial fibrillation (AF) using a 14-day continuous electrocardiographic patch monitor or usual care. The primary outcome was all-cause stroke hospitalization, with bleeding as a key safety outcome.
Main Findings: After a median follow-up of 15.3 months, AF diagnosis was higher in the screening group (5%) compared to the usual care group (3.3%), and anticoagulation initiation was also more frequent (4.2% vs. 2.8%). However, the risk of stroke hospitalization was not significantly different between the screening and usual care groups (0.7% vs. 0.6%; HR: 1.10, 95% CI: 0.69-1.75). Similarly, there was no significant difference in bleeding risk (1.0% vs. 1.1%; HR: 0.87, 95% CI: 0.60-1.26).
Implications for Practice: The findings suggest that screening for AF using continuous electrocardiographic monitoring in elderly patients does not reduce stroke hospitalizations despite an increased detection of AF. Given the low event rates and premature termination of enrollment due to COVID-19, further studies are needed to confirm these results and explore alternative strategies for stroke prevention in this population.
2024 ESC Guidelines for the Management of Atrial Fibrillation – Eur Heart J
31 Aug, 2024 | 19:34h | UTCIntroduction: The 2024 guidelines for the management of atrial fibrillation (AF) were developed by the European Society of Cardiology (ESC) in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS) and other specialized associations. These guidelines aim to provide evidence-based recommendations for the diagnosis, treatment, and management of AF, with a focus on improving patient outcomes through a multidisciplinary approach.
Key Points:
1 – Patient-Centered Care and Education:
– Education directed at patients, caregivers, and healthcare professionals is essential for optimizing shared decision-making. This approach ensures that treatment options are discussed openly, considering both the benefits and risks.
2 – Comorbidity and Risk Factor Management:
– Diuretics are recommended for patients with AF, heart failure (HF), and congestion to alleviate symptoms and improve AF management.
– Sodium-glucose cotransporter-2 inhibitors (SGLT2 inhibitors) are recommended for patients with AF and HF, regardless of left ventricular ejection fraction (LVEF), to reduce the risk of hospitalization and cardiovascular death.
3 – Stroke Prevention and Anticoagulation:
– Oral anticoagulation is recommended for all patients with clinical AF and elevated thromboembolic risk, particularly those with a CHA2DS2-VA score of 2 or more.
– Direct oral anticoagulants (DOACs) are preferred over vitamin K antagonists (VKAs) in eligible patients undergoing cardioversion.
4 – Rate and Rhythm Control:
– Beta-blockers, diltiazem, verapamil, or digoxin are recommended as first-choice drugs for heart rate control in patients with AF and LVEF >40%.
– Catheter ablation is recommended as a first-line treatment option in patients with paroxysmal AF to reduce symptoms and prevent AF progression.
Conclusion: The 2024 ESC guidelines emphasize a patient-centered, multidisciplinary approach to AF management, with a strong focus on the early identification and management of comorbidities and risk factors. The guidelines also advocate for the use of DOACs in stroke prevention and recommend specific strategies for rate and rhythm control to enhance patient outcomes.
Subgroup Analysis Insights: Apixaban vs. aspirin in subclinical atrial fibrillation based on CHA2DS2-VASc score – J Am Coll Cardiol
27 May, 2024 | 20:21h | UTCStudy Design and Population: This study is a subgroup analysis of the ARTESiA trial, which compared the efficacy and safety of apixaban versus aspirin in preventing stroke and systemic embolism (SE) in patients with subclinical atrial fibrillation (SCAF). The analysis focused on 4,012 patients categorized by their baseline CHA2DS2-VASc scores: <4 (39.4%), 4 (33.6%), and >4 (27.0%).
Main Findings: For patients with a CHA2DS2-VASc score >4, apixaban significantly reduced the stroke/SE rate to 0.98%/year compared to 2.25%/year with aspirin, preventing 1.28 strokes/SE per 100 patient-years while causing 0.68 major bleeds. In patients with scores <4, the stroke/SE prevention was minimal (0.12 strokes/SE per 100 patient-years) with a similar rate of major bleeds. Patients with a score of 4 had intermediate results, with a moderate reduction in stroke/SE (0.32 per 100 patient-years) and a comparable risk of major bleeding.
Implications for Practice: The study suggests that for patients with SCAF and a CHA2DS2-VASc score >4, the benefits of apixaban in preventing stroke/SE outweigh the risks of major bleeding. For those with scores <4, aspirin might be a safer option. Patients with a score of 4 fall into an intermediate category, where individual patient preferences should guide the treatment decision.
Reference (link to abstract – $ for full-text):
Cohort Study: Higher serious bleeding rates linked to diltiazem in elderly atrial fibrillation patients on anticoagulation
26 Apr, 2024 | 12:35h | UTCStudy Design and Population:
This retrospective cohort study analyzed data from 204,155 Medicare beneficiaries aged 65 years or older diagnosed with atrial fibrillation. The study focused on new users of the anticoagulants apixaban or rivaroxaban who commenced treatment with either diltiazem or metoprolol between January 2012 and November 2020, with follow-up extending up to 365 days.
Main Findings:
Patients treated with diltiazem exhibited a significantly increased risk of serious bleeding, including bleeding-related hospitalization and death, compared to those treated with metoprolol. The hazard ratio (HR) for serious bleeding events was 1.21, with a rate difference (RD) of 10.6 per 1000 person-years. Notably, the risk escalated with diltiazem doses exceeding 120 mg/day, indicating a dose-response relationship. Secondary outcomes, such as ischemic stroke or systemic embolism, did not show significant differences between the treatment groups.
Implications for Practice:
The findings suggest that in older adults with atrial fibrillation treated with apixaban or rivaroxaban, diltiazem increases the risk of serious bleeding, especially at higher doses. These results underscore the importance of cautious medication management and might influence clinical decisions regarding the choice of ventricular rate control in this population.
Reference (link to abstract – $ for full-text):
Nested Case-Control Study: Increased risk of major bleeding in atrial fibrillation patients with concomitant SSRI and oral anticoagulant use
23 Mar, 2024 | 20:48h | UTCStudy Design and Population
This nested case-control study investigated the association between the concomitant use of selective serotonin reuptake inhibitors (SSRIs) and oral anticoagulants (OACs) on the risk of major bleeding among patients with atrial fibrillation. Conducted within the UK’s Clinical Practice Research Datalink, the study included 42,190 cases of major bleeding matched to 1,156,641 controls based on age, sex, cohort entry date, and follow-up duration. Patients initiating OACs between January 2, 1998, and March 29, 2021, were included, with risk-set sampling utilized for control selection.
Main Findings
The study found that concomitant use of SSRIs and OACs was associated with a 33% increased risk of major bleeding compared to OAC use alone, with the highest risk observed within the first 30 days of concurrent use. The increased risk was consistent across different ages, sexes, and patient histories, including those with chronic kidney disease or previous bleeding events. Notably, the elevated risk of bleeding extended up to 6 months of concomitant use but did not vary significantly with the potency of SSRIs or the type of OAC used (direct OACs or vitamin K antagonists).
Implications for Practice
These findings underscore the need for healthcare professionals to closely monitor patients with atrial fibrillation who are prescribed SSRIs in addition to OACs, particularly during the initial months of treatment. This study highlights the importance of managing bleeding risk factors and suggests reconsidering the necessity and duration of concomitant SSRI and OAC use. Future research should focus on strategies to mitigate this bleeding risk and explore alternative treatments for managing depression in patients requiring anticoagulation.
Reference
Observational Study: Association of antiarrhythmic drug use with increased risk of pacemaker implantation and syncope in new-onset atrial fibrillation patients
23 Mar, 2024 | 20:08h | UTCStudy Design and Population
This observational study utilized data from the Korean National Health Insurance Service to evaluate the impact of antiarrhythmic drugs (AADs) on the risk of pacemaker implantation or syncope in patients diagnosed with new-onset atrial fibrillation (AF) between 2013 and 2019. A total of 770,977 new-onset AF cases were identified, with 142,141 patients prescribed AADs within one year of diagnosis. The study compared the risk of these outcomes between AAD users and nonusers.
Main Findings
The study found that the use of AADs was associated with a significantly increased risk of pacemaker implantation or syncope, with adjusted risks being 3.5 times higher for either outcome, 2.0 times higher for syncope alone, and 5.0 times higher for pacemaker implantation. These associations were consistent across various patient subgroups, and propensity score-matched analysis supported these findings. Notably, women were found to be more susceptible to the adverse effects of AADs than men.
Implications for Practice
The findings suggest a need for careful evaluation of the risks associated with AAD use in patients with new-onset AF, particularly regarding the potential for pacemaker implantation or syncope. These results highlight the importance of individualized patient assessment before prescribing AADs to mitigate these risks effectively. Further research is needed to explore the mechanisms behind these associations and to develop strategies to minimize adverse outcomes in this patient population.
Reference
Meta-Analysis: No mortality benefit of early vs. delayed/selective coronary angiography in out-of-hospital cardiac arrest without ST-elevation
21 Mar, 2024 | 11:40h | UTCStudy Design and Population: This article presents a systematic review and meta-analysis of five randomized controlled trials comparing early/immediate versus delayed/selective coronary angiography (CAG) in 1512 patients who experienced out-of-hospital cardiac arrest (OHCA) without ST-segment elevation. The population had a mean age of 67 years, with 26% female and 23% having a prior myocardial infarction. Follow-up duration was at least 30 days across included studies.
Main Findings: The analysis revealed no significant difference in the odds of all-cause death between early/immediate and delayed/selective CAG strategies (Odds Ratio [OR] 1.12, 95% CI 0.91–1.38). Similar results were found for the composite outcome of all-cause death or neurological deficit (OR 1.10, 95% CI 0.89–1.36). Subgroup analysis showed no significant effect modification based on age, initial cardiac rhythm, history of coronary artery disease, the presumed ischemic cause of arrest, or time to return of spontaneous circulation. Interestingly, a trend toward increased odds of death was observed in women receiving early CAG compared to men, although this finding approached but did not reach statistical significance.
Implications for Practice: The findings suggest that for OHCA patients without ST-segment elevation, an early/immediate CAG strategy does not confer a mortality benefit over a delayed/selective approach across major subgroups. Notably, the potential for increased mortality risk in women with early CAG warrants further investigation. Clinicians should consider these results when deciding on the timing of CAG in this patient population, keeping in mind the overall lack of mortality benefit and the nuanced differences among subgroups.
Reference: Fardin Hamidi et al. (2023). Early versus delayed coronary angiography in patients with out-of-hospital cardiac arrest and no ST-segment elevation: a systematic review and meta-analysis of randomized controlled trials. Clinical Research in Cardiology, 113(561–569). Access the study here: [Link]
RCT: Propafenone leads to quicker sinus rhythm restoration than amiodarone in supraventricular arrhythmias related to septic shock
1 Oct, 2023 | 15:19h | UTCStudy Design & Population: The research was a two-center, prospective, controlled parallel-group, double-blind trial involving 209 septic shock patients who had new-onset supraventricular arrhythmia and a left ventricular ejection fraction above 35%. Patients were randomized to receive either intravenous propafenone (70 mg bolus followed by 400–840 mg/24 h) or amiodarone (300 mg bolus followed by 600–1800 mg/24 h).
Main Findings: The primary outcomes focused on the proportion of patients in sinus rhythm 24 hours post-infusion, time to the first sinus rhythm restoration, and arrhythmia recurrence rates. No significant difference was observed in 24-hour sinus rhythm rates between the propafenone (72.8%) and amiodarone (67.3%) groups (p=0.4). Time to the first rhythm restoration was significantly shorter for the propafenone group (median 3.7 hours) compared to the amiodarone group (median 7.3 hours, p=0.02). Recurrence of arrhythmia was notably lower in the propafenone group (52%) than in the amiodarone group (76%, p<0.001). In the subgroup of patients with a dilated left atrium, amiodarone appeared to be more effective.
Implications & Limitations: The study suggests that while propafenone doesn’t offer better rhythm control at 24 hours compared to amiodarone, it does provide faster cardioversion and fewer arrhythmia recurrences, especially in patients with a non-dilated left atrium. No significant differences were observed in clinical outcomes, such as ICU or long-term mortality, between propafenone and amiodarone in the trial. Limitations include potential underpowering of the study and the inability to fully account for the impact of multiple covariates involved in the complex therapy of septic shock.
Commentary on Twitter:
Propafenone?70 mg bolus+ 400-840 mg/24h vs amiodarone?300 mg + by 600-1800 mg/24h for SVA in septic shock, RCT
?propafenone not better for rhythm control at 24h but excellent hemodynamic safety profile, cardioverting faster & fewer recurrences#FOAMCc
?https://t.co/GVuoxPD7Hy pic.twitter.com/rRlj00x71p— Intensive Care Medicine (@yourICM) September 13, 2023
RCT – 2ry analysis | Omega-3 supplementation linked to increased AF risk in post-MI patients
3 Aug, 2023 | 13:45h | UTCRelated:
M-A: Omega-3 fatty acids supplementation is associated with increased risk of atrial fibrillation.
Commentary from the author on Twitter (thread – click for more)
RCT data consistently show that Omega-3 suppl increase AF risk https://t.co/LQVHfPNtKL
In this substudy of the #OMEMI trial we add novel data from thumb-ECG screening and serum EPA/DHA, supporting a causal relation between omega-3 (EPA) and AF!https://t.co/B9VoDNQpZi
? 1/4 pic.twitter.com/GFYGfVaNMq
— Peder L. Myhre ? (@pmyhre) July 28, 2023
RCT | High-power radiofrequency improves AF ablation results vs. standard-power, but may increase asymptomatic cerebral emboli
26 Jul, 2023 | 13:16h | UTCA Randomized Trial of High vs Standard Power Radiofrequency Ablation for Pulmonary Vein Isolation: SHORT-AF – JACC: Clinical Electrophysiology (link to abstract – $ for full-text)
RCT | Self-administered intranasal etripamil superior to placebo for acute supraventricular tachycardia conversion
12 Jul, 2023 | 13:54h | UTC
RCT | Supplementing CPVI with low-voltage-area ablation lowers atrial arrhythmia recurrence in elderly with paroxysmal AF
12 Jul, 2023 | 13:31h | UTCCircumferential Pulmonary Vein Isolation With vs Without Additional Low-Voltage-Area Ablation in Older Patients With Paroxysmal Atrial Fibrillation: A Randomized Clinical Trial – JAMA Cardiology (link to abstract – $ for full-text)
See also: Visual Abstract
Review | Management of premature ventricular complexes in the outpatient setting
7 Jul, 2023 | 16:22h | UTCManagement of Premature Ventricular Complexes in the Outpatient Setting – Mayo Clinic Proceedings
Review | Silent cerebral lesions following catheter ablation for atrial fibrillation
29 Jun, 2023 | 13:51h | UTC
Commentary on Twitter
What's the risk of silent cerebral lesions following catheter ablation for #AF?? https://t.co/GJsUziHLeu@EuropaceEiC @GiulioConte9 @AAuricchioMD @Dominik_Linz @FraSantoroMD @AndyZhangMD @marcovitoloMD @DhirajGuptaBHRS #AF #ablation #europace pic.twitter.com/ZYQP7oS9sS
— European Society of Cardiology Journals (@ESC_Journals) June 21, 2023
Cohort Study | Five-year safety and efficacy of leadless pacemakers
20 Jun, 2023 | 12:40h | UTCFive-year safety and efficacy of leadless pacemakers in a Dutch cohort – Heart Rhythm
SSAI Guideline | New-onset atrial fibrillation in critically ill adult patients
6 Jun, 2023 | 14:31h | UTC
RCT | Early initiation of DOACs not statistically superior to later use in atrial fibrillation-related stroke
31 May, 2023 | 14:17h | UTCEarly versus Later Anticoagulation for Stroke with Atrial Fibrillation – New England Journal of Medicine (link to abstract – $ for full-text)
Commentaries:
ELAN: Early DOACs Safe, May Help After Ischemic Stroke in AF Patients – TCTMD
Commentary on Twitter
Late breaking at #ESOC2023: In the ELAN trial, the estimated incidence of stroke, systemic embolism, hemorrhage, or death was 2.8 percentage points lower to 0.5 percentage points higher with early than with later use of direct oral anticoagulants. Full results:
— NEJM (@NEJM) May 24, 2023
Cohort Study | Amiodarone linked to higher bleeding risk vs. flecainide or sotalol in atrial fibrillation patients on anticoagulants
30 May, 2023 | 12:01h | UTCRisk for Bleeding-Related Hospitalizations During Use of Amiodarone With Apixaban or Rivaroxaban in Patients With Atrial Fibrillation: A Retrospective Cohort Study – Annals of Internal Medicine (link to abstract – $ for full-text)
Commentary on Twitter
A study of older adults with #AFib who were treated with #anticoagulants found #amiodarone during apixaban/rivaroxaban use was associated with greater risk for bleeding-related #hospitalizations compared to flecainide or sotalol: https://t.co/cFb1rgGqjt pic.twitter.com/gKlgLXBdb2
— Annals of Int Med (@AnnalsofIM) May 25, 2023
Subepicardial Cardiomyopathy: a disease underlying J-wave syndromes and idiopathic ventricular fibrillation
29 May, 2023 | 10:38h | UTC
Commentary on Twitter
#StateOfTheArt: Subepicardial cardiomyopathy – a disease underlying J-wave syndromes and idiopathic ventricular fibrillation @BehrElijah @Chiara_Scrocco @bjboukens @DrCJMiles #AHAJournals https://t.co/brITevJfIh pic.twitter.com/HWw8gcmE33
— Circulation (@CircAHA) May 26, 2023
Consensus Statement | Management of arrhythmias during pregnancy
23 May, 2023 | 13:00h | UTC2023 HRS Expert Consensus Statement on the Management of Arrhythmias During Pregnancy – Heart Rhythm
News Release: Management of Arrhythmias During Pregnancy Consensus Statement Emphasizes Shared Decision-Making – European Heart Rhythm
Consensus Statement | Practical management of the remote device clinic
23 May, 2023 | 12:58h | UTC
Guideline | Cardiac physiologic pacing for the avoidance and mitigation of heart failure
23 May, 2023 | 12:55h | UTCNews Release: New clinical practice guideline on cardiac physiological pacing – Elsevier
Atrial fibrillation incidence associated with exposure to anticancer drugs used as monotherapy in clinical trials
10 May, 2023 | 15:54h | UTCEditorials:
Atrial Fibrillation With Modern Cancer Treatment: More Common Than We Think – JACC: CardioOncology
Commentary on Twitter
Annual incidence rate of #AFib assoc w/ anticancer drugs were ⬆️ in pts w/ hematologic malig. It was found for #ibrutinib 4.92 (95% CI: 2.91-8.31), #clofarabine 2.38 (95% CI: 0.66-8.55), & #ponatinib 2.35 (95% CI: 1.78-3.12) per 100 person-yrs https://t.co/W2RGMrE37F… pic.twitter.com/NnbmUVcci5
— JACC Journals (@JACCJournals) April 27, 2023