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Atrial fibrillation (AF) and flutter (AFL) are the most common clinically significant arrhythmias in older adults with an increasing disease burden due to an aging population. However, up-to-date trends in disease burden and regional variation remain unknown. In an observational study utilizing the Global Burden of Disease (GBD) database, age-standardized mortality and incidence rates for AF overall and for each state in the United States (US) from 1990 to 2017 were determined. All analyses were stratified by gender. The relative change in age-standardized incidence rate (ASIR) and age-standardized death rate (ASDR) over the observation period were determined. Trends were analyzed using Joinpoint regression analysis. The mean ASIR per 100,000 population for men was 92 (+/-8) and for women was 62 (+/-5) in the US in 2017. The mean ASDR per 100,000 population for men was 5.8 (+/-0.3) and for women was 4.4 (+/-0.4). There were progressive increases in ASIR and ASDR in all but 1 state. The states with the greatest percentage change in incidence were New Hampshire (+13.5%) and Idaho (+16.0%) for men and women, respectively. The greatest change regarding mortality was seen in Mississippi (+26.3%) for men and Oregon (+53.8%) for women. In conclusion these findings provide updated evidence of increasing AF and/or AFL incidence and mortality on a national and regional level in the US, with women experiencing greater increases in incidence and mortality rates. This study demonstrates that the public health burden related to AF in the United States is progressively worsening but disproportionately across states and among women., Competing Interests: Declaration of Interests The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021. Published by Elsevier Inc.)

Limited data exist concerning risk factors for cardiovascular (CV) hospitalization in patients with atrial fibrillation (AF) or atrial flutter (AFL). The aim of this retrospective cohort evaluation was to assess whether patient characteristics and risk factors, including CHADS(2) (congestive heart failure, hypertension, age ≥75 years, type 2 diabetes, and previous stroke or transient ischemic attack [doubled]) and CHA(2)DS(2)-VASc (congestive heart failure; hypertension; age ≥75 years [doubled]; type 2 diabetes; previous stroke, transient ischemic attack, or thromboembolism [doubled]; vascular disease; age 65 to 75 years; and sex category) scores, identified patients with AF or AFL at risk for CV hospitalization. Claims data (January 2003 to June 2009) were evaluated to identify patients aged ≥40 years with ≥1 inpatient or ≥2 (within 30 days of each other) outpatient diagnoses of AF or AFL and an absence of diagnosis codes related to cardiac surgery within 30 days of AF or AFL diagnosis. Risk factors for first CV hospitalization in the 2-year period after diagnosis were assessed using univariate and multivariate analyses. Overall, 377,808 patients (mean age 73.9 ± 12.1 years) were identified, of whom 128,048 had CV hospitalizations. CHADS(2) and CHA(2)DS(2)-VASc scores were the top 2 predictors of first CV hospitalization after AF or AFL diagnosis. Hospitalization risk was increased 2.3- to 2.7-fold in patients with CHADS(2) scores of 6 and approximately 3.0-fold in patients with CHA(2)DS(2)-VASc scores of 9 compared to patients with a score of 0. These increases were maintained essentially unchanged throughout the 2-year follow-up period. In conclusion, CHADS(2) and CHA(2)DS(2)-VASc scores were predictive of first CV hospitalization in patients with AF or AFL and may be helpful in identifying "at-risk" patients and guiding therapy., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Dronedarone is a multi-channel-blocking drug for the treatment of patients with atrial fibrillation (AF) or atrial flutter (AFL) with rate- and rhythm-controlling properties. A Placebo-Controlled, Double-Blind, Parallel Arm Trial to Assess the Efficacy of Dronedarone 400 mg b.i.d. for the Prevention of Cardiovascular Hospitalization or Death from Any Cause in Patients With Atrial Fibrillation/Atrial Flutter (ATHENA) demonstrated that dronedarone reduced the risk for first cardiovascular hospitalization or death from any cause. The aim of this post hoc analysis was to evaluate the rhythm- and rate-controlling properties of dronedarone in the ATHENA trial. Patients were randomized to dronedarone 400 mg twice daily (n = 2,301) or placebo (n = 2,327). Electrocardiographic tracings were classified for AF or AFL or sinus rhythm. Patients with AF or AFL on every postbaseline electrocardiogram were classified as having permanent AF or AFL. All electrical cardioversions were documented. The use of rate-controlling medications was equally distributed in the 2 treatment groups. The median time to first AF or AFL recurrence of patients in sinus rhythm at baseline was 498 days in placebo patients and 737 days in dronedarone patients (hazard ratio 0.749, 95% confidence interval 0.681 to 0.824, p <0.001). In the dronedarone group, 339 patients (15%) had ≥1 electrical cardioversion, compared to 481 (21%) in the placebo group (hazard ratio 0.684, 95% confidence interval 0.596 to 0.786, p <0.001). The likelihood of permanent AF or AFL was lower with dronedarone (178 patients [7.6%]) compared to placebo (295 patients [12.8%]) (p <0.001). At the time of first AF or AFL recurrence, the mean heart rates were 85.3 and 95.5 beats/min in the dronedarone and placebo groups, respectively (p <0.001). In conclusion, dronedarone demonstrated both rhythm- and rate-controlling properties in ATHENA. These effects are likely to contribute to the reduction of important clinical outcomes observed in this trial., (Copyright © 2011 Elsevier Inc. All rights reserved.)

We aimed to determine whether smoking status affects the recurrence of atrial fibrillation or atrial flutter in patients after cardioversion. The clinical data of patients undergoing cardioversion for atrial flutter from January 1, 2000 to December 31, 2005 were prospectively collected. Arrhythmia recurrences were detected by retrospective review of comprehensive medical records and were determined using electrocardiography. The smoking history was prospectively collected through a standardized clinical form and subsequently categorized as lifetime nonsmoker, exsmoker, or current smoker. Univariate and multivariate associations with end points for clinical and lifestyle variables were assessed with Cox proportional hazards models. Women who were current smokers at cardioversion had a greater risk of atrial arrhythmia recurrence than did nonsmokers (hazard ratio 1.71, 95% confidence interval 1.10 to 2.67, p = 0.02). The increased risk of arrhythmia recurrence in female smokers was not seen in male smokers. Compared to lifetime nonsmokers, the mortality hazard ratio among men was 1.18 (95% confidence interval 0.88 to 1.58; p = 0.28) in exsmokers and 1.93 (95% confidence interval 1.20 to 3.11; p = 0.007) in current smokers. The risk of death after cardioversion was not increased in women. In conclusion, smoking is an independent predictor of atrial arrhythmia recurrence after cardioversion in women; however, an increased mortality risk, but not arrhythmia recurrence risk, was seen in men.

This report presents the outcome of a cohort of 94 patients with atrial fibrillation from the Canadian Registry of Atrial Fibrillation, in which we paid particular attention to the probability of stroke and death. We also evaluated warfarin use over time and compared left atrial dimensions in patients with atrial flutter with those with atrial fibrillation.

We sought to establish the safety and feasibility of a clinical pathway for the outpatient initiation of antiarrhythmic medications (AAMs) for the maintenance of sinus rhythm in patients with atrial fibrillation (AF) or atrial flutter (AFl). AAMs are frequently utilized to maintain sinus rhythm in patients with AF or AFl. Although they are often initiated in an outpatient setting, there is little prospective evidence for the safety of this approach. Patients with a history of AF or AFl were prospectively monitored with an event recorder during 409 AAM initiation trials. All AAMs were initiated in sinus rhythm. Patients transmitted a recording (30 seconds) once daily for 10 consecutive days. Amiodarone was used for 212 patients (51.8%), 127 (31.1%) received a type 1C AAM, 37 (9.0%) received sotalol, and 33 (8.1%) received a type 1A AAM. Adverse events occurred in 17 patients (3 died, 3 had bradycardia that required permanent pacemaker implantation, and 11 had bradycardia requiring a decrease in the dose of antiarrhythmic or rate-controlling medication). Most events were due to bradycardia in patients who received amiodarone. There was a significant association between amiodarone-associated bradycardia and women. The only event that occurred during the first 48 hours was an episode of bradycardia in a patient who received amiodarone and was managed as an outpatient. The outpatient initiation of AAMs for patients with a history of AF or AFl while in sinus rhythm is associated with significant risk. Most adverse events occurred beyond the usual time period for in-hospital monitoring of the initiation of AAMs.

The purpose of this study was to show that multipolar electrographic recordings along the subeustachian isthmus (SI) can better differentiate slow conduction from complete isthmus block after atrial flutter ablation, leading to a lower incidence of recurrent atrial flutter (Afl). Despite the presence of various techniques to identify bidirectional conduction block (BDB) after isthmus ablation for typical Afl, several studies, including a report from a national registry, suggest that radiofrequency ablation is still associated with a 15% recurrence rate. Thus, techniques that can distinguish slow conduction from complete isthmus block have the potential for reducing long-term recurrences. We evaluated patients who underwent radiofrequency ablation for typical isthmus-dependent Afl. Patients were separated into 2 groups. Group A underwent assessment of BDB with conventional methods. In group B, BDB was assessed by placing a multipolar catheter along the floor of the SI, pacing adjacent to the line of radiofrequency application, and assessing electrographic activation on either side. One hundred thirty-one cases of Afl ablation were analyzed (86 in group A, 45 in group B). Over a mean follow-up period of 17 months, recurrence rates of Afl were 16.5% in group A and 4.3% in group B (p = 0.043). Thus, assessment of BDB by placement of a multipolar catheter across the SI after ablation of typical Afl is associated with a significant reduction in long-term recurrence of Afl.

We determined the prevalence of sustained atrial tachyarrhythmia (AT) in adults late after repair of tetralogy of Fallot (ToF) and examined its impact on subsequent heart failure, reoperation, and mortality. Ventricular arrhythmias are associated with increased morbidity and mortality in patients with repair of ToF. The clinical impact of AT in this population has not been established. A retrospective cohort study of 242 patients with repaired ToF identified 29 patients (prevalence of 12%) with sustained episodes of AT. Patients with repaired ToF but without sustained arrhythmia (n = 213) constituted a comparison group. Baseline characteristics and clinical outcomes in the 2 groups were compared. An echocardiographic analysis compared 15 patients with AT and 15 matched for age at operation and timing of echocardiography. The development of AT was associated with substantial morbidity including congestive heart failure, reoperation, subsequent ventricular tachycardia, stroke, and death (combined events, 20 of 29 patients [69%]). The rate of combined events (congestive heart failure, stroke, and deaths) in the 213 "arrhythmia-free" patients was 30% (64 of 213 patients). Event-free survival after repair was 18 +/- 2 years for the AT group and 28 +/- 1 years for the arrhythmia-free group (p < 0.001). Patients with AT were older at surgical repair (25 +/- 16 vs 10 +/- 9 years, p = 0.001), and at most recent assessment were aged 48 +/- 12 vs 32 +/- 10 years (p = 0.001). The AT group had a higher mean right atrial volume and proportion of significant pulmonary regurgitation than matched controls. The development of AT in the adult late after ToF repair identifies patients at risk and is associated with older age at repair, a higher frequency of hemodynamic abnormalities, and increased morbidity.

An abrupt decrease in the pacing rate in patients with dual-chamber pacemakers tracking atrial tachyarrhythmias carries a high risk of malignant ventricular arrhythmia. The pacing rate should be reduced by multistep programming over several days.