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Arrhythmias/Electrophysiology

Cohort Study: Higher serious bleeding rates linked to diltiazem in elderly atrial fibrillation patients on anticoagulation

26 Apr, 2024 | 12:35h | UTC

Study 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):

Ray, W. A., Chung, C. P., Stein, C. M., et al. (2024). Serious Bleeding in Patients With Atrial Fibrillation Using Diltiazem With Apixaban or Rivaroxaban. JAMA, Published online April 15, 2024. doi:10.1001/jama.2024.3867

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 | UTC

Study 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

Rahman AA, Platt RW, Beradid S, et al. (2024). Concomitant Use of Selective Serotonin Reuptake Inhibitors With Oral Anticoagulants and Risk of Major Bleeding. JAMA Netw Open, 7(3):e243208. DOI: 10.1001/jamanetworkopen.2024.3208.

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 | UTC

Study 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

Yun Gi Kim et al. (2024). Association of Antiarrhythmic Drug Therapy With Syncope and Pacemaker Implantation in Patients With Atrial Fibrillation. Journal of the American College of Cardiology, 83(11), 1027-1038. DOI: 10.1016/j.jacc.2024.01.013.

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 | UTC

Study 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 | UTC

Study 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.

Article: Balik, M., Maly, M., Brozek, T. et al. Propafenone versus amiodarone for supraventricular arrhythmias in septic shock: a randomised controlled trial. Intensive Care Med (2023)

 

Commentary on Twitter:

 

RCT – 2ry analysis | Omega-3 supplementation linked to increased AF risk in post-MI patients

3 Aug, 2023 | 13:45h | UTC

Omega-3 fatty acid supplements and risk of atrial fibrillation and ‘micro-atrial fibrillation’: A secondary analysis from the OMEMI trial – Clinical Nutrition

Related:

M-A: Omega-3 fatty acids supplementation is associated with increased risk of atrial fibrillation.

M-A: Omega-3 fatty acids supplementation increases the risk of atrial fibrillation in patients with lipid disorders.

More data suggests no cardiovascular benefit from Omega-3 supplementation – secondary analysis of STRENGHT trial did not show an association between achieved Omega-3 fatty acid levels and major adverse cardiovascular outcomes in patients with high cardiovascular risk.

RCT: Omega-3 supplements do not reduce cardiovascular events in elderly patients after myocardial infarction

#AHA20 – Randomized trial: High-dose Omega-3 fatty acids did not reduce the risk of cardiac events in patients at high cardiovascular risk

Meta-Analysis of Randomized Trials: Little Benefit from Omega-3 Intake to Reduce Cardiovascular Disease Risk

 

Commentary from the author on Twitter (thread – click for more)

 

RCT | High-power radiofrequency improves AF ablation results vs. standard-power, but may increase asymptomatic cerebral emboli

26 Jul, 2023 | 13:16h | UTC

A Randomized Trial of High vs Standard Power Radiofrequency Ablation for Pulmonary Vein Isolation: SHORT-AF – JACC: Clinical Electrophysiology (link to abstract – $ for full-text)

Commentary: A Randomized Trial of High vs Standard Power Radiofrequency Ablation for Pulmonary Vein Isolation – SHORT-AF – American College of Cardiology

 

RCT | Self-administered intranasal etripamil superior to placebo for acute supraventricular tachycardia conversion

12 Jul, 2023 | 13:54h | UTC

Self-administered intranasal etripamil using a symptom-prompted, repeat-dose regimen for atrioventricular-nodal-dependent supraventricular tachycardia (RAPID): a multicentre, randomised trial – The Lancet

 

RCT | Supplementing CPVI with low-voltage-area ablation lowers atrial arrhythmia recurrence in elderly with paroxysmal AF

12 Jul, 2023 | 13:31h | UTC

Circumferential 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 | UTC

Management 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

Silent cerebral lesions following catheter ablation for atrial fibrillation: a state-of-the-art review – EP Europace

 

Commentary on Twitter

 

Cohort Study | Five-year safety and efficacy of leadless pacemakers

20 Jun, 2023 | 12:40h | UTC

Five-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

New-onset atrial fibrillation in critically ill adult patients—an SSAI clinical practice guideline – Acta Anaesthesiologica Scandinavica

 

RCT | Early initiation of DOACs not statistically superior to later use in atrial fibrillation-related stroke

31 May, 2023 | 14:17h | UTC

Early 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

Early Versus Late Initiation of Direct Oral Anticoagulants in Post-Ischemic Stroke Patients With Atrial Fibrillation – ELAN – American College of Cardiology

 

Commentary on Twitter

 

Cohort Study | Amiodarone linked to higher bleeding risk vs. flecainide or sotalol in atrial fibrillation patients on anticoagulants

30 May, 2023 | 12:01h | UTC

Risk 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)

News Release: Amiodarone used with anticoagulant therapy linked to more bleeding-related hospitalizations than flecainide or sotalol – American College of Physicians

Commentary: Amiodarone increases bleeding compared with flecainide or sotalol in patients on anticoagulant therapy – ACP Internist

 

Commentary on Twitter

 

Subepicardial Cardiomyopathy: a disease underlying J-wave syndromes and idiopathic ventricular fibrillation

29 May, 2023 | 10:38h | UTC

Subepicardial Cardiomyopathy: A Disease Underlying J-Wave Syndromes and Idiopathic Ventricular Fibrillation – Circulation

 

Commentary on Twitter

 

Consensus Statement | Management of arrhythmias during pregnancy

23 May, 2023 | 13:00h | UTC

2023 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

2023 HRS/EHRA/APHRS/LAHRS expert consensus statement on practical management of the remote device clinic – Heart Rhythm

 

Guideline | Cardiac physiologic pacing for the avoidance and mitigation of heart failure

23 May, 2023 | 12:55h | UTC

2023 HRS/APHRS/LAHRS guideline on cardiac physiologic pacing for the avoidance and mitigation of heart failure – Heart Rhythm

News 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 | UTC

Atrial Fibrillation Incidence Associated With Exposure to Anticancer Drugs Used as Monotherapy in Clinical Trials – JACC: CardioOncology

Editorials:

Atrial Fibrillation With Modern Cancer Treatment: More Common Than We Think – JACC: CardioOncology

Atrial Fibrillation in Patients With Cancer: A Persistent and Increasing Challenge – JACC: CardioOncology

 

Commentary on Twitter

 

Review | Causes of sudden death

9 May, 2023 | 14:16h | UTC

Causes of sudden death – European Heart Journal Supplements

See all articles in the series here

 

Review | The bidirectional association between atrial fibrillation and myocardial infarction

8 May, 2023 | 12:54h | UTC

The bidirectional association between atrial fibrillation and myocardial infarction – Nature Reviews Cardiology (if the link is paywalled, try this one)

 

Commentary on Twitter

 

M-A | Direct oral anticoagulants versus warfarin across the spectrum of kidney function in patients with AF

3 May, 2023 | 15:32h | UTC

Direct Oral Anticoagulants Versus Warfarin Across the Spectrum of Kidney Function: Patient-Level Network Meta-Analyses From COMBINE AF – Circulation (free for a limited period)

 

Commentary on Twitter

 

Oral anticoagulation in patients with advanced CKD and atrial fibrillation: beyond anticoagulation

2 May, 2023 | 13:20h | UTC

Oral Anticoagulation in Patients With Advanced Chronic Kidney Disease and Atrial Fibrillation: Beyond Anticoagulation – Mayo Clinic Proceedings

 

RCT | Comparison of three different substrate ablation strategies for persistent atrial fibrillation

26 Apr, 2023 | 14:18h | UTC

Multi-centre, prospective randomized comparison of three different substrate ablation strategies for persistent atrial fibrillation – EP Europace

 

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