Dear editor,We read with pleasure the well-designed study by Butler et al of electrical cardioversion of emergency department patients with atrial fibrillation.^([1])We appreciate their analysis of the distinctives of...Dear editor,We read with pleasure the well-designed study by Butler et al of electrical cardioversion of emergency department patients with atrial fibrillation.^([1])We appreciate their analysis of the distinctives of procedural sedation when employed for this indication.Understanding the dosing adjustments to propofol undertaken by展开更多
Atrial fibrillation(AF) is a common arrhythmia with rising incidence.Obstructive sleep apnea(OSA) is prevalent among patients with AF.This observation has prompted significant research in understanding the relationshi...Atrial fibrillation(AF) is a common arrhythmia with rising incidence.Obstructive sleep apnea(OSA) is prevalent among patients with AF.This observation has prompted significant research in understanding the relationship between OSA and AF.Multiple studies support a role of OSA in the initiation and progression of AF.This association has been independent of obesity,body mass index and hypertension.Instability of autonomic tone and wide swings in intrathoracic pressure are seen in OSA.These have been mechanistically linked to initiation of AF in OSA patients by lowering atrial effective refractory period,promoting pulmonary vein discharges and atrial dilation.OSA not only promotes initiation of AF but also makes management of AF difficult.Drug therapy and electrical cardioversion for AF are less successful in presence of OSA.There has been higher rate of early and overall recurrence after catheter ablation of AF in patients with OSA.Treatment of OSA with continuous positive airway pressure has been shown to improve control of AF.However,additional studies are needed to establish a stronger relationship between OSA treatment and success ofAF therapies.There should be heightened suspicion of OSA in patients with AF.There is a need for guidelines to screen for OSA as a part of AF management.展开更多
Background Asian population are at increased risk of bleeding during the warfarin treatment,so the recommended optimal international normalized ratio(INR)level may be lower in Asians than in Westerners.The aim of this...Background Asian population are at increased risk of bleeding during the warfarin treatment,so the recommended optimal international normalized ratio(INR)level may be lower in Asians than in Westerners.The aim of this prospective multicenter study was to determine the optimal INR level in Thai patients with non-valvular atrial fibrillation(NVAF).Methods Patients with NVAF who were on warfarin for stroke prevention were recruited from 27 hospitals in the nationwide COOL-AF registry in Thailand.We collected demographic data,medical history,risk factors for stroke and bleeding,concomitant disease,electrocardiogram and laboratory data including INR and antithrombotic medications.Outcome measurements included ischemic stroke/transient ischemic attack(TIA)and major bleeding.Optimal INR level was assessed by the calculation of incidence density for six INR ranges(<1.5,1.5–1.99,2–2.49,2.5–2.99,3–3.49,and≥3.5).Results A total of 2,232 patients were included.The mean age of patients was 68.5±10.6 years.The mean follow-up duration was 25.7±10.6 months.There were 63 ischemic stroke/TIA and 112 major bleeding events.The lowest prevalence of ischemic stroke/TIA and major bleeding events occurred within the INR range of 2.0–2.99 for patients<70 years and 1.5–2.99 for patients≥70 years.Conclusions The INR range associated with the lowest risk of ischemic stroke/TIA and bleeding in the Thai population was 2.0–2.99 for patients<70 years and 1.5–2.99 for patients≥70 years.The rates of major bleeding and ischemic stroke/TIA were both higher than the rates reported in Western population.展开更多
BACKGROUND The quality of warfarin therapy can be determined by the time in the therapeutic range(TTR)of international normalized ratio(INR).The estimated minimum TTR needed to achieve a benefit from warfarin therapy...BACKGROUND The quality of warfarin therapy can be determined by the time in the therapeutic range(TTR)of international normalized ratio(INR).The estimated minimum TTR needed to achieve a benefit from warfarin therapy is≥60%.AIM To determine TTR and the predictors of poor TTR among atrial fibrillation patients who receive warfarin therapy.METHODS A retrospective observational study was conducted at a cardiology referral center in Selangor,Malaysia.A total of 420 patients with atrial fibrillation and under follow-up at the pharmacist led Warfarin Medication Therapeutic Adherence Clinic between January 2014 and December 2018 were included.Patients’clinical data,information related to warfarin therapy,and INR readings were traced through electronic Hospital Information system.A data collection form was used for data collection.The percentage of days when INR was within range was calculated using the Rosendaal method.The poor INR control category was defined as a TTR<60%.Predictors for poor TTR were further determined by using logistic regression.RESULTS A total of 420 patients[54.0%male;mean age 65.7(10.9)years]were included.The calculated mean and median TTR were 60.6%±20.6%and 64%(interquartile range 48%-75%),respectively.Of the included patients,57.6%(n=242)were in the good control category and 42.4%(n=178)were in the poor control category.The annual calculated mean TTR between the year 2014 and 2018 ranged from 59.7%and 67.3%.A high HAS-BLED score of≥3 was associated with poor TTR(adjusted odds ratio,2.525;95%confidence interval:1.6-3.9,P<0.001).CONCLUSION In our population,a high HAS-BLED score was associated with poor TTR.This could provide an important insight when initiating an oral anticoagulant for these patients.Patients with a high HAS-BLED score may obtain less benefit from warfarin therapy and should be considered for other available oral anticoagulants for maximum benefit.展开更多
Atrial fibrillation is a cardiac arrhythmia of high prevalence in the population, especially in the elderly. Its main electrical characteristics are the interval between two successive irregular R waves, absence of P ...Atrial fibrillation is a cardiac arrhythmia of high prevalence in the population, especially in the elderly. Its main electrical characteristics are the interval between two successive irregular R waves, absence of P waves and presence of f waves between QRS complexes. The most common symptoms of atrial fibrillation are irregular palpitations associated with dyspnea, dizziness, feeling tired, fatigue and general malaise, but not all patients have any symptoms. The present report presents the history of an elderly patient who arrived at the hospital’s emergency department with irregular heart rhythm and palpitations. The patient’s symptoms, associated with the electrocardiogram results, indicated paroxysmal atrial fibrillation. Electrical cardioversion was performed, and after, cardiac ablation via the femoral vein at the hospital’s cardiology service. There were no complications during the procedure. As a routine imaging exam after ablation, control esophagogastroduodenoscopy was requested to verify that there was no formation of atrio-esophageal fistula developed by the invasive ablation procedure and electrocardiogram, which showed normal sinus rhythm. The patient remained in the cardiac intensive care unit for observation for 24 hours. After the electrical cardioversion and catheter ablation procedures, the patient improved his clinical picture of atrial fibrillation and was discharged after 24 hours of hospitalization. He received treatment to perform at home, to reduce acid reflux into the esophagus and to prevent thrombosis. He did not present pulmonary thromboembolism after hospital discharge. It is believed, therefore, that this form of treatment and management of paroxysmal atrial fibrillation is effective for the solution of the proposed problem and can also serve as a reference for other professionals within the cardiology service.展开更多
BACKGROUND Anderson-Fabry disease(AFD)is an X-linked lysosomal storage disorder that results from a deficiency ofα-galactosidase A enzyme activity in which glycosphingolipids gradually accumulate in multi-organ syste...BACKGROUND Anderson-Fabry disease(AFD)is an X-linked lysosomal storage disorder that results from a deficiency ofα-galactosidase A enzyme activity in which glycosphingolipids gradually accumulate in multi-organ systems.Cardiac manifestations are the leading cause of mortality in patients with AFD.Among them,arrhythmias comprise a large portion of the heart disease cases in AFD,most of which are characterized by conduction disorders.However,atrial fibrillation as a presenting sign at the young age group diagnosed with AFD is uncommon.CASE SUMMARY We report a case of a 26-year-old man who was admitted with chest discomfort.Left ventricular hypertrophy was fulfilled in the criteria by the Sokolow-Lyon index and atrial fibrillation on the 12 Leads-electrocardiography(ECG)that was documented in the emergency room.After spontaneously restored to normal sinus rhythm,relationships between P and R waves,including a shorter PR interval on the ECG,were revealed.The echocardiographic findings showed thickened interventricular septal and left posterior ventricular walls.Based on the clues mentioned earlier,we realized the possibility of AFD.Additionally,we noticed the associated symptoms and signs,including bilateral mild hearing loss,neuropathic pain,anhidrosis,and angiokeratoma on the trunk and hands.He was finally diagnosed with classical AFD,which was confirmed by the gene mutation and abnormal enzyme activity ofα-galactosidase A.CONCLUSION This case is a rare case of AFD as a presentation with atrial fibrillation at a young age.Confirming the relationship between P and Q waves on the ECG through sinus rhythm conversion may help in differential diagnosis of the cause of atrial fibrillation and hypertrophic myocardium.展开更多
Atrial fibrillation (AF) is estimated that by 2010, approximately 2.6 million people will be affected in USA;by 2050, that number may increase to 10 million patients. Generally, rate control alone is reasonable in som...Atrial fibrillation (AF) is estimated that by 2010, approximately 2.6 million people will be affected in USA;by 2050, that number may increase to 10 million patients. Generally, rate control alone is reasonable in some AF patients, especially asymptomatic patients. Restoration and maintenance of sinus rhythm (SR) may be achieved by means of cardioversion, drugs or/ and catheter ablation. Pharmacological therapy can be useful to maintain SR and prevent tachycardia-induced cardiomyopathy. All patients with AF regardless of whether a rhythm or rate control strategy recommend anticoagulant, antiplatelet or both combined therapy for prevention of thromboembolism, except those with lone AF or contraindications. Drug selection should be based upon the absolute risk of stroke, bleeding, the relative risk and benefit for a given patient. Biventricular pacing may overcome many of the adverse hemodynamic effects associated with RV pacing alone. A target individual ectopic foci ablation within the pulmonary vein (PV) has evolved to circumferential electrical isolation of the entire PV musculature. Cavotricuspid isthmus should be considered as first-line therapy for patients with typical atrial flutter. Completely non-fluoroscopic ablation guided by Real-Time Magnetic Resonance Imaging (RTMRI) using a steerable and non-ferromagnetic catheter is a promising novel technology in interventional electrophysiology.展开更多
This case report highlights a recent case in the Rotunda Hospital of a patient of 33 weeks’ gestation with fast atrial fibrillation. She had an unusual presentation given that she had no prior cardiac history or obvi...This case report highlights a recent case in the Rotunda Hospital of a patient of 33 weeks’ gestation with fast atrial fibrillation. She had an unusual presentation given that she had no prior cardiac history or obvious aetiology. She underwent successful DC cardioversion and was well on discharge. Follow-up with cardiology has been arranged.展开更多
BACKGROUND: Atrial fibrillation(AF) is the most common arrhythmia treated in the emergency department(ED), with primary electrical cardioversion(PEC) the preferred method of rhythm control. Anecdotally, patients under...BACKGROUND: Atrial fibrillation(AF) is the most common arrhythmia treated in the emergency department(ED), with primary electrical cardioversion(PEC) the preferred method of rhythm control. Anecdotally, patients undergoing ED procedural sedation(EDPS) for PEC differ from those requiring EDPS for other procedures: they are at higher risk of adverse events, and require fewer drugs and lower doses. We attempt to verify this using an EDPS registry at a Canadian, tertiary care teaching hospital.METHODS: This is a retrospective review of patients that underwent EDPS for the period of June 2006 to September 2014. We compared demographics, medication use and intra-procedural adverse events between those receiving EDPS for PEC for AF compared to that for other indications. We report the asssociation between AEs and predictors using logistic regression.RESULTS: A total of 4 867 patients were included, 714 for PEC for AF and 4 153 for other indications. PEC patients were more likely male(58.5% vs. 47.1%), older(59.5 years vs. 48.1 years), and less likely to be ASA I(46.6% vs. 69.0%). PEC patients received smaller doses of propofol and less likely to receive adjuvant analgesic therapy(11.5% vs. 78.2%). PEC patients were more likely to experience hypotension(27.6% vs. 16.5%) but respiratory AEs(apnea, hypoxia and airway intervention) were not different.CONCLUSION: EDPS for PEC differs from that conducted for other purposes: patients tend to be less healthy, receive smaller doses of medication and more likely to suffer hypotension without an increase in respiratory AEs. These factors should be considered when performing EDPS.展开更多
Atrial fibrillation(AF)is the most common arrhythmia in the elderly and its incidence increases with aging.[1]Electrical cardioversion is used as a strategy for rhythm control in patients with supraventricular arrhyth...Atrial fibrillation(AF)is the most common arrhythmia in the elderly and its incidence increases with aging.[1]Electrical cardioversion is used as a strategy for rhythm control in patients with supraventricular arrhythmias.In octagenarians,there are challenges associated with the indication for electrical cardioversion,such as the use of appropriate sedation and anticoagulant agents.Most decisions in clinical practice for these patients derive from observational data and personal experience,since octagenarians represent a minority of patients included in randomized clinical trials.Little evidence is available regarding the clinical context of electrical cardioversion in this vulnerable population.Therefore,we aimed to describe the clinical profile of octagenarians undergoing electrical cardioversion in a cardiology reference center from 2014 to 2018.展开更多
Background Long-term maintenance of sinus rhythm after successful conversion of chronic atrial fibrillation （CAF）, often ameliorates patients＇ symptoms, reduces the risk of ischemic stroke and improves cardiovascul...Background Long-term maintenance of sinus rhythm after successful conversion of chronic atrial fibrillation （CAF）, often ameliorates patients＇ symptoms, reduces the risk of ischemic stroke and improves cardiovascular hemodynamics. This prospective study aims to evaluate the long-term efficacy and safety of very low-dose amiodarone （100 mg daily） for the maintenance of sinus rhythm after successful direct-current （DC） cardioversion in patients with CAF and rheumatic heart disease （RHD） post intervention. Methods This study was a randomized prospective trial. One day after successful DC cardioversion （remained normal sinus rhythm） in patients with CAF and RHD post intervention for more than six months and adequate anticoagulation, all were randomly administered either amiodarone 200 mg daily in group A or amiodarone 100 mg dally in group B. Results A total of 76 patients （40 men and 36 women） were examined from February 1998 to December 1999. The mean age of the patients was （664- 10） years, and the mean follow-up was （674-8） months （range 61 to 84 months）. Actuarial rates of the maintenance of sinus rhythm were similar in the two groups after 5 years of follow-up. Four patients （11%） in group A but none in group B experienced significant adverse effects that necessitated withdrawal of amiodarone. No death occurred during the study period. Conclusion A very low dose of amiodarone results in adequate long-term efficacy and is safe for maintaining sinus rhythm in patients with CAF and RHD post intervention after successful DC cardioversion.展开更多
Objective To identify predictors of left atrial appendage stunning after the use of electrical cardioversion to restore sinus rhythm in patients with non-valvular atrial fibrillation. Methods A total of 68 consecutive...Objective To identify predictors of left atrial appendage stunning after the use of electrical cardioversion to restore sinus rhythm in patients with non-valvular atrial fibrillation. Methods A total of 68 consecutive patients (45 men,23 women,60.5±8.7 years of age) with non-valvular atrial fibrillation undergoing electrical cardioversion were enlisted in this study. Clinical and echocardiographic variables were analyzed by univariate regression and multivariate logistic regression to investigate the relationship between occurrences of left atrial appendage stunning and these factors. Results Univariate analysis revealed that,in comparing patients without and with left atrial appendage stunning,there were significant differences in the duration of atrial fibrillation > 8 weeks (32.3% vs 75.5%,P <0.001),left atrial diameter > 50 mm (29.0% vs 54.1%,P <0.05),left atrial emptying fraction (31.5%±7.8% vs 27.1%±8.5%,P <0.05),left ventricular ejection fraction < 50% (38.7% vs 67.6%,P <0.05),maximum electrical energy (96.8 J±65.8 J vs 156.8 J±100.8 J,P <0.01),cumulative electrical energy 146.8 J±142.6 J vs 290.5 J±242.1 J, P <0.01) and number of electrical cardioversion shocks (1.7±0.9 vs 2.43±1.20,P <0.05). However,backward stepwise multivariate logistic regression analysis identified as significant and independent predictors of left atrial appendage stunning only duration of atrial fibrillation > 8 weeks (OR=7.249,95%CI=1.998-26.304, P <0.01),left atrial diameter > 50 mm (OR=3.896,95%CI=1.105-13.734,P <0.05),left ventricular ejection fraction < 50% (OR=4.465,95%CI=1.51713.140, P <0.01) and cumulative energy of electrical cardioversion (OR=1.004,95%CI=1.000-1.008, P <0.05). Conclusions Duration of atrial fibrillation >8 weeks,left atrial diameter >50 mm,left ventricular ejection fraction <50%,and cumulative energy of electrical cardioversion are independent predictors of left atrial appendage stunning. Anticoagulation treatment should be individualized for patients undergoing electrical cardioversion to reduce the risk of both cardioversion-related thromboembolic events and hemorrhagic complications caused by warfarin treatment.展开更多
文摘Dear editor,We read with pleasure the well-designed study by Butler et al of electrical cardioversion of emergency department patients with atrial fibrillation.^([1])We appreciate their analysis of the distinctives of procedural sedation when employed for this indication.Understanding the dosing adjustments to propofol undertaken by
文摘Atrial fibrillation(AF) is a common arrhythmia with rising incidence.Obstructive sleep apnea(OSA) is prevalent among patients with AF.This observation has prompted significant research in understanding the relationship between OSA and AF.Multiple studies support a role of OSA in the initiation and progression of AF.This association has been independent of obesity,body mass index and hypertension.Instability of autonomic tone and wide swings in intrathoracic pressure are seen in OSA.These have been mechanistically linked to initiation of AF in OSA patients by lowering atrial effective refractory period,promoting pulmonary vein discharges and atrial dilation.OSA not only promotes initiation of AF but also makes management of AF difficult.Drug therapy and electrical cardioversion for AF are less successful in presence of OSA.There has been higher rate of early and overall recurrence after catheter ablation of AF in patients with OSA.Treatment of OSA with continuous positive airway pressure has been shown to improve control of AF.However,additional studies are needed to establish a stronger relationship between OSA treatment and success ofAF therapies.There should be heightened suspicion of OSA in patients with AF.There is a need for guidelines to screen for OSA as a part of AF management.
基金the Health System Research Institute(59-053)the Heart Association of Thailand under the Royal Patronage of H.M.the King.All authors had no conflicts of interest to disclose.The authors gratefully acknowledge Pontawee Kaewcomdee and Olaree Chaiphet for data management,and all investigators and nurse coordinators of the COOL-AF registry.
文摘Background Asian population are at increased risk of bleeding during the warfarin treatment,so the recommended optimal international normalized ratio(INR)level may be lower in Asians than in Westerners.The aim of this prospective multicenter study was to determine the optimal INR level in Thai patients with non-valvular atrial fibrillation(NVAF).Methods Patients with NVAF who were on warfarin for stroke prevention were recruited from 27 hospitals in the nationwide COOL-AF registry in Thailand.We collected demographic data,medical history,risk factors for stroke and bleeding,concomitant disease,electrocardiogram and laboratory data including INR and antithrombotic medications.Outcome measurements included ischemic stroke/transient ischemic attack(TIA)and major bleeding.Optimal INR level was assessed by the calculation of incidence density for six INR ranges(<1.5,1.5–1.99,2–2.49,2.5–2.99,3–3.49,and≥3.5).Results A total of 2,232 patients were included.The mean age of patients was 68.5±10.6 years.The mean follow-up duration was 25.7±10.6 months.There were 63 ischemic stroke/TIA and 112 major bleeding events.The lowest prevalence of ischemic stroke/TIA and major bleeding events occurred within the INR range of 2.0–2.99 for patients<70 years and 1.5–2.99 for patients≥70 years.Conclusions The INR range associated with the lowest risk of ischemic stroke/TIA and bleeding in the Thai population was 2.0–2.99 for patients<70 years and 1.5–2.99 for patients≥70 years.The rates of major bleeding and ischemic stroke/TIA were both higher than the rates reported in Western population.
文摘BACKGROUND The quality of warfarin therapy can be determined by the time in the therapeutic range(TTR)of international normalized ratio(INR).The estimated minimum TTR needed to achieve a benefit from warfarin therapy is≥60%.AIM To determine TTR and the predictors of poor TTR among atrial fibrillation patients who receive warfarin therapy.METHODS A retrospective observational study was conducted at a cardiology referral center in Selangor,Malaysia.A total of 420 patients with atrial fibrillation and under follow-up at the pharmacist led Warfarin Medication Therapeutic Adherence Clinic between January 2014 and December 2018 were included.Patients’clinical data,information related to warfarin therapy,and INR readings were traced through electronic Hospital Information system.A data collection form was used for data collection.The percentage of days when INR was within range was calculated using the Rosendaal method.The poor INR control category was defined as a TTR<60%.Predictors for poor TTR were further determined by using logistic regression.RESULTS A total of 420 patients[54.0%male;mean age 65.7(10.9)years]were included.The calculated mean and median TTR were 60.6%±20.6%and 64%(interquartile range 48%-75%),respectively.Of the included patients,57.6%(n=242)were in the good control category and 42.4%(n=178)were in the poor control category.The annual calculated mean TTR between the year 2014 and 2018 ranged from 59.7%and 67.3%.A high HAS-BLED score of≥3 was associated with poor TTR(adjusted odds ratio,2.525;95%confidence interval:1.6-3.9,P<0.001).CONCLUSION In our population,a high HAS-BLED score was associated with poor TTR.This could provide an important insight when initiating an oral anticoagulant for these patients.Patients with a high HAS-BLED score may obtain less benefit from warfarin therapy and should be considered for other available oral anticoagulants for maximum benefit.
基金funded in part by the Coordination of Improvement of Higher Level Personnel—Brazil(CAPES)—Finance Code 001 by the National Council of Scientific and Technological Development—Brazil(CNPq)—Doctorate GDby Research Foundation of the State of Rio Grande do Sul(FAPERGS).
文摘Atrial fibrillation is a cardiac arrhythmia of high prevalence in the population, especially in the elderly. Its main electrical characteristics are the interval between two successive irregular R waves, absence of P waves and presence of f waves between QRS complexes. The most common symptoms of atrial fibrillation are irregular palpitations associated with dyspnea, dizziness, feeling tired, fatigue and general malaise, but not all patients have any symptoms. The present report presents the history of an elderly patient who arrived at the hospital’s emergency department with irregular heart rhythm and palpitations. The patient’s symptoms, associated with the electrocardiogram results, indicated paroxysmal atrial fibrillation. Electrical cardioversion was performed, and after, cardiac ablation via the femoral vein at the hospital’s cardiology service. There were no complications during the procedure. As a routine imaging exam after ablation, control esophagogastroduodenoscopy was requested to verify that there was no formation of atrio-esophageal fistula developed by the invasive ablation procedure and electrocardiogram, which showed normal sinus rhythm. The patient remained in the cardiac intensive care unit for observation for 24 hours. After the electrical cardioversion and catheter ablation procedures, the patient improved his clinical picture of atrial fibrillation and was discharged after 24 hours of hospitalization. He received treatment to perform at home, to reduce acid reflux into the esophagus and to prevent thrombosis. He did not present pulmonary thromboembolism after hospital discharge. It is believed, therefore, that this form of treatment and management of paroxysmal atrial fibrillation is effective for the solution of the proposed problem and can also serve as a reference for other professionals within the cardiology service.
文摘BACKGROUND Anderson-Fabry disease(AFD)is an X-linked lysosomal storage disorder that results from a deficiency ofα-galactosidase A enzyme activity in which glycosphingolipids gradually accumulate in multi-organ systems.Cardiac manifestations are the leading cause of mortality in patients with AFD.Among them,arrhythmias comprise a large portion of the heart disease cases in AFD,most of which are characterized by conduction disorders.However,atrial fibrillation as a presenting sign at the young age group diagnosed with AFD is uncommon.CASE SUMMARY We report a case of a 26-year-old man who was admitted with chest discomfort.Left ventricular hypertrophy was fulfilled in the criteria by the Sokolow-Lyon index and atrial fibrillation on the 12 Leads-electrocardiography(ECG)that was documented in the emergency room.After spontaneously restored to normal sinus rhythm,relationships between P and R waves,including a shorter PR interval on the ECG,were revealed.The echocardiographic findings showed thickened interventricular septal and left posterior ventricular walls.Based on the clues mentioned earlier,we realized the possibility of AFD.Additionally,we noticed the associated symptoms and signs,including bilateral mild hearing loss,neuropathic pain,anhidrosis,and angiokeratoma on the trunk and hands.He was finally diagnosed with classical AFD,which was confirmed by the gene mutation and abnormal enzyme activity ofα-galactosidase A.CONCLUSION This case is a rare case of AFD as a presentation with atrial fibrillation at a young age.Confirming the relationship between P and Q waves on the ECG through sinus rhythm conversion may help in differential diagnosis of the cause of atrial fibrillation and hypertrophic myocardium.
文摘Atrial fibrillation (AF) is estimated that by 2010, approximately 2.6 million people will be affected in USA;by 2050, that number may increase to 10 million patients. Generally, rate control alone is reasonable in some AF patients, especially asymptomatic patients. Restoration and maintenance of sinus rhythm (SR) may be achieved by means of cardioversion, drugs or/ and catheter ablation. Pharmacological therapy can be useful to maintain SR and prevent tachycardia-induced cardiomyopathy. All patients with AF regardless of whether a rhythm or rate control strategy recommend anticoagulant, antiplatelet or both combined therapy for prevention of thromboembolism, except those with lone AF or contraindications. Drug selection should be based upon the absolute risk of stroke, bleeding, the relative risk and benefit for a given patient. Biventricular pacing may overcome many of the adverse hemodynamic effects associated with RV pacing alone. A target individual ectopic foci ablation within the pulmonary vein (PV) has evolved to circumferential electrical isolation of the entire PV musculature. Cavotricuspid isthmus should be considered as first-line therapy for patients with typical atrial flutter. Completely non-fluoroscopic ablation guided by Real-Time Magnetic Resonance Imaging (RTMRI) using a steerable and non-ferromagnetic catheter is a promising novel technology in interventional electrophysiology.
文摘This case report highlights a recent case in the Rotunda Hospital of a patient of 33 weeks’ gestation with fast atrial fibrillation. She had an unusual presentation given that she had no prior cardiac history or obvious aetiology. She underwent successful DC cardioversion and was well on discharge. Follow-up with cardiology has been arranged.
文摘BACKGROUND: Atrial fibrillation(AF) is the most common arrhythmia treated in the emergency department(ED), with primary electrical cardioversion(PEC) the preferred method of rhythm control. Anecdotally, patients undergoing ED procedural sedation(EDPS) for PEC differ from those requiring EDPS for other procedures: they are at higher risk of adverse events, and require fewer drugs and lower doses. We attempt to verify this using an EDPS registry at a Canadian, tertiary care teaching hospital.METHODS: This is a retrospective review of patients that underwent EDPS for the period of June 2006 to September 2014. We compared demographics, medication use and intra-procedural adverse events between those receiving EDPS for PEC for AF compared to that for other indications. We report the asssociation between AEs and predictors using logistic regression.RESULTS: A total of 4 867 patients were included, 714 for PEC for AF and 4 153 for other indications. PEC patients were more likely male(58.5% vs. 47.1%), older(59.5 years vs. 48.1 years), and less likely to be ASA I(46.6% vs. 69.0%). PEC patients received smaller doses of propofol and less likely to receive adjuvant analgesic therapy(11.5% vs. 78.2%). PEC patients were more likely to experience hypotension(27.6% vs. 16.5%) but respiratory AEs(apnea, hypoxia and airway intervention) were not different.CONCLUSION: EDPS for PEC differs from that conducted for other purposes: patients tend to be less healthy, receive smaller doses of medication and more likely to suffer hypotension without an increase in respiratory AEs. These factors should be considered when performing EDPS.
文摘Atrial fibrillation(AF)is the most common arrhythmia in the elderly and its incidence increases with aging.[1]Electrical cardioversion is used as a strategy for rhythm control in patients with supraventricular arrhythmias.In octagenarians,there are challenges associated with the indication for electrical cardioversion,such as the use of appropriate sedation and anticoagulant agents.Most decisions in clinical practice for these patients derive from observational data and personal experience,since octagenarians represent a minority of patients included in randomized clinical trials.Little evidence is available regarding the clinical context of electrical cardioversion in this vulnerable population.Therefore,we aimed to describe the clinical profile of octagenarians undergoing electrical cardioversion in a cardiology reference center from 2014 to 2018.
基金This research was funded by internal funds at the Armed Forces Taichung General Hospital, Taiwan, China.
文摘Background Long-term maintenance of sinus rhythm after successful conversion of chronic atrial fibrillation （CAF）, often ameliorates patients＇ symptoms, reduces the risk of ischemic stroke and improves cardiovascular hemodynamics. This prospective study aims to evaluate the long-term efficacy and safety of very low-dose amiodarone （100 mg daily） for the maintenance of sinus rhythm after successful direct-current （DC） cardioversion in patients with CAF and rheumatic heart disease （RHD） post intervention. Methods This study was a randomized prospective trial. One day after successful DC cardioversion （remained normal sinus rhythm） in patients with CAF and RHD post intervention for more than six months and adequate anticoagulation, all were randomly administered either amiodarone 200 mg daily in group A or amiodarone 100 mg dally in group B. Results A total of 76 patients （40 men and 36 women） were examined from February 1998 to December 1999. The mean age of the patients was （664- 10） years, and the mean follow-up was （674-8） months （range 61 to 84 months）. Actuarial rates of the maintenance of sinus rhythm were similar in the two groups after 5 years of follow-up. Four patients （11%） in group A but none in group B experienced significant adverse effects that necessitated withdrawal of amiodarone. No death occurred during the study period. Conclusion A very low dose of amiodarone results in adequate long-term efficacy and is safe for maintaining sinus rhythm in patients with CAF and RHD post intervention after successful DC cardioversion.
文摘Objective To identify predictors of left atrial appendage stunning after the use of electrical cardioversion to restore sinus rhythm in patients with non-valvular atrial fibrillation. Methods A total of 68 consecutive patients (45 men,23 women,60.5±8.7 years of age) with non-valvular atrial fibrillation undergoing electrical cardioversion were enlisted in this study. Clinical and echocardiographic variables were analyzed by univariate regression and multivariate logistic regression to investigate the relationship between occurrences of left atrial appendage stunning and these factors. Results Univariate analysis revealed that,in comparing patients without and with left atrial appendage stunning,there were significant differences in the duration of atrial fibrillation > 8 weeks (32.3% vs 75.5%,P <0.001),left atrial diameter > 50 mm (29.0% vs 54.1%,P <0.05),left atrial emptying fraction (31.5%±7.8% vs 27.1%±8.5%,P <0.05),left ventricular ejection fraction < 50% (38.7% vs 67.6%,P <0.05),maximum electrical energy (96.8 J±65.8 J vs 156.8 J±100.8 J,P <0.01),cumulative electrical energy 146.8 J±142.6 J vs 290.5 J±242.1 J, P <0.01) and number of electrical cardioversion shocks (1.7±0.9 vs 2.43±1.20,P <0.05). However,backward stepwise multivariate logistic regression analysis identified as significant and independent predictors of left atrial appendage stunning only duration of atrial fibrillation > 8 weeks (OR=7.249,95%CI=1.998-26.304, P <0.01),left atrial diameter > 50 mm (OR=3.896,95%CI=1.105-13.734,P <0.05),left ventricular ejection fraction < 50% (OR=4.465,95%CI=1.51713.140, P <0.01) and cumulative energy of electrical cardioversion (OR=1.004,95%CI=1.000-1.008, P <0.05). Conclusions Duration of atrial fibrillation >8 weeks,left atrial diameter >50 mm,left ventricular ejection fraction <50%,and cumulative energy of electrical cardioversion are independent predictors of left atrial appendage stunning. Anticoagulation treatment should be individualized for patients undergoing electrical cardioversion to reduce the risk of both cardioversion-related thromboembolic events and hemorrhagic complications caused by warfarin treatment.
