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Background Atrial fibrillation (AF) is the most commonly encountered arrhythmia in clinical practice, even more so among patients with heart failure (HF). Results of the recent CABANA and CASTLE-AF trials indicate significant improvements in ejection fraction, HF readmissions as well as overall mortality with the incorporation of rhythm control strategies in HF patients. These findings challenge existing notions of equivalency of rate vs rhythm control strategies. In this study, we analyzed the impact of this evidence on treatment practices and the short term outcomes of ablation in this patient cohort. Methods We conducted a retrospective study using the AHRQ-HCUP National Readmission Database for the years 2005–2014. ICD 9 diagnosis codes were used to identify all adult patients (≥18 years) undergoing AF ablation procedures as well as a sub-cohort of patients with existing HF. Trends in the use of ablation procedures, patient characteristics as well as details of short term procedural outcomes were studied. Multivariate regression analysis was utilized to adjust for confounders. Complications were defined as per the Agency for healthcare research and quality guidelines. Independent risk factors for in-hospital mortality were identified using proportional hazards model. Results Our results indicate a trend of rising rates of AF ablation procedures overall with a peak in 2011 at 20,046 and gradual downtrend thereafter (10,195 in 2005 to 11735 in 2014). Our data revealed a consistent rise in ablation procedures among heart failure patients during the same period (832 to 2245). A definite reduction in peri-procedural mortality is noted (0.24% in 2005 to 0.17% in 2014, p=0.2) – an improvement that is maximally apparent in the heart failure group (2.49% to 0.4%, p=0.07). Overall complication rates however are significantly increased overall with a proportional rise noted among HF patients. Conclusions Our data from a nationally representative registry indicates an increasing utilization of ablation as a therapeutic modality in the management of atrial fibrillation in HF. Future prospective studies are required to assess the positive impact of these changes in clinical practice as offset by their associated complications. 10 year AF ablation trends in HF Funding Acknowledgement Type of funding source: None

Background In 2011, the Institute of Medicine (IOM) published standards for developing trustworthy clinical practice guidelines. It is recommended that “Whenever possible guideline development group members should not have conflicts of interest (COIs). In some circumstances, a guideline development group may not be able to perform its work without members who have COIs, such as relevant clinical specialists. Members with COIs should represent not more than a minority of the guideline development group members. The chair or cochairs should not be a person with COIs.” Aim Aim of the present study was to assess if the ESC guidelines for the management of atrial fibrillation are in accordance with the standards proposed by the IOM. Methods The declaration of COIs from task force members (TFM) and reviewers of the 2010 and 2016 ESC atrial fibrillation guidelines were retrieved from the ESC homepage. The number and the type of COIs were assessed for each guideline and compared. Results Regarding the 2010 guidelines, 8 of the 25 TFM (32%) reported no COI. In the remaining 17 TFM, 148 COIs were reported (8.7±10.2 per member, range 1–44). The chairperson declared 11 COIs. Consulting and advising was reported by 15 and research contacts by 13 TFM. Among the guideline reviewers, 12/26 (46%) reported no COI, and 14 reviewers declared 72 COIs (5.1±3.3 per reviewer, range 2–14). Regarding the 2016 guidelines, 3 of the 17 TFM (18%) reported no COI. The remaining 14 TFM declared 182 COIs (13.0±10.4 per member, range 1–32). The chairperson of the task force had the second most COIs (n=30). Direct personal payment was reported by 14 and research funding of the department by 10 TFM. Among the guideline reviewers, 16/79 (20%) reported no COI, and 63 reviewers declared 473 COIs (7.5±6.8 per reviewer, range 1–34). Comparing the 2010 and the 2016 guidelines, there was an increase of TFM with COIs (from 68% to 82%), of the number of COIs per TFM (from 8.7±10.2 to 13.0±10.4) and the COIs of the chairperson (from 11 to 30). Moreover, the proportion of TFM receiving personal payment (60% vs 82%) and the number of COIs due to personal payment (5.9±7.3 vs 7.7±7.4) were higher in the 2016 guidelines. In addition, more guideline reviewers had COIs in 2016 (54% vs 80%). Conclusion The high and increasing rate of TFM and reviewers with COIs is not in accordance with the recommendations of the IOM. Since COIs can influence healthcare decision makers and may consciously or unconsciously influence choices made throughout the guideline development process, the ESC should follow the standards of the IOM. Funding Acknowledgement Type of funding source: None

[EN] In the management of atrial fibrillation (AF), electrical cardioversion (ECV) is a common treatment. Although its initial success rate is high, many patients present AF recurrence after some weeks or months. Hence, being able to identify patients at low chance of mid-term sinus rhythm maintenance is important for a rationale therapeutic strategy. To this end, several parameters assessing fibrillatory (f-) waves have been introduced, however, with limited predictive ability. Moreover, the cardiovascular system exhibits nonlinear dynamics at different time-scales that these indices do not account for. Hence, the present work evaluates the ability of the multiscale entropy (MSE) analysis of the f-waves to improve preoperative forecasts of ECV outcome. Both traditional MSE and a refined version (RMSE) were applied to the main f waves component obtained for standard lead V1. As a reference, previously proposed predictors were also computed. Results revealed that RMSE was able to anticipate AF recurrence after 1 month of ECV with an accuracy around 78%. Moreover, a Naive Bayes model combining previous parameters and RMSE indices reported a discriminant ability 10% higher than single metrics. It could then be concluded that analysis of nonlinear dynamics at large time-scales can enhance ECV outcome predictions., This research was funded by projects: DPI2017-83952-C3 from MINECO/AEI/FEDER EU, SBPLY/17/180501000411 from Junta de Castilla la Mancha and AICO/2019/036 from Generalitat Valenciana.

Background: The implementation of quality indicators in the atrial fibrillation (AF) care should be considered to improve quality of management and patient outcome. Methods: In the post-hoc analysis of the BALKAN-AF dataset, we assessed concordance with quality indicators for AF management. Available domains for AF management [patient assessment (baseline), anticoagulation, rate control strategy, rhythm control strategy and risk factor management] were identified and assessed at baseline visit. Results: Among 132 patients with a CHA2DS2-VASc score of 0 (men) or 1 (women), 75 (56.8%) were prescribed oral anticoagulation (OAC). Of 2539 patients with a CHA2DS2-VASc score ≥ 1 for men and ≥ 2 for women, 1890 (74.4%) were prescribed OAC. Among 1088 patients with permanent AF, 110 (10.1%) individuals were prescribed antiarrhythmic drugs (AADs). Of 1616 patients with structural heart disease, 37 (2.2%) were prescribed class IC AADs. Of 1624 patients with paroxysmal or persistent AF, 59 (3.6%) were offered catheter ablation. Among 2712 AF patients, 2121 (78.2%) had hypertension, 671 (24.7%) were obese, 53 (2.0%) had obstructive sleep apnoea, 110 (4.0%) had alcohol abuse and 340 (12.5%) were smokers. Conclusions: In the BALKAN-AF cohort, the use of OAC for stroke prevention was poorly associated with patients stroke risk. The use of AADs in patients with permanent AF was low. The prescription of class IC AADs to patients with structural heart disease was infrequent. A large proportion of AF patients had their modifiable risk factors identified.

Atrial fibrillation (AFIB) is the most common heart rhythm abnormality and is associated with significant morbidity and mortality. While the treatment of AFIB involves strategies of rate with or without rhythm control, it is also essential to strategize appropriate therapies to prevent thromboembolic complications arising from AFIB. Previously, anticoagulation was the main treatment option which exposed patients to higher than usual risk of bleeding. However, with the advent of new technology, novel therapeutic options aimed at surgical or percutaneous exclusion or occlusion of the left atrial appendage in preventing thromboembolic complications from AFIB have evolved. This review evaluates recent advances and therapeutic options in treating AFIB with a special focus on both surgical and percutaneous interventions which can reduce and/or eliminate thromboembolic complications of AFIB.

Aims Digital health can transform the management of atrial fibrillation (AF) and enable patients to take a central role in detecting symptoms and self-managing AF. There is a gap in understanding factors that support sustained use of digital health tools for patients with AF. This study identified predictors of Alivecor® KardiaMobile ECG monitor usage among patients with AF enrolled in the iPhone®Helping Evaluate Atrial fibrillation Rhythm through Technology (iHEART) randomized controlled trial. Methods and results We analysed data from 105 English and Spanish-speaking adults with AF enrolled in the intervention arm of the iHEART trial. The iHEART intervention included smartphone-based electrocardiogram self-monitoring with Alivecor® KardiaMobile and triweekly text messages for 6 months. The primary outcome was use of Alivecor® categorized as: infrequent (≤5 times/week), moderate (>5 times and ≤11 times/week), and frequent (>11 times/week). We applied multinomial logistic regression modelling to characterize frequency and predictors of use. Of the 105 participants, 25% were female, 75% were White, and 45% were ≥65 years of age. Premature atrial contractions (PACs) [adjusted odds ratio (OR): 1.23, 1.08–1.40, P = 0.002] predicted frequent as compared to infrequent use. PACs (adjusted OR: 1.17, 95% confidence interval 1.06–1.30, P = 0.003), lower symptom burden (adjusted OR: 1.06, 1.01–1.11, P = 0.02), and less treatment concern (adjusted OR: 0.96, 0.93–0.99, P = 0.02) predicted moderate as compared to infrequent use. Conclusions Frequent use of AliveCor® is associated with AF symptoms and potentially symptomatic cardiac events. Symptom burden and frequency should be measured and incorporated into analyses of future digital health trials for AF management.

The management of atrial fibrillation (AF) is multifaceted and treatment paradigms have changed significantly in the last century. The treatment of AF requires a comprehensive approach which goes beyond the treatment of the arrhythmia alone. Risk factor management has been introduced as a crucial pillar of AF management. As a result, the landscape of care delivery is changing as well, and novel models of comprehensive care delivery for AF have been introduced. This article reviews the evidence for the role of risk factor management in AF, how this can be integrated and implemented in clinical practice by applying novel models of care delivery, and finally identifies areas for ongoing research and potential healthcare reform to comprehensively manage the burgeoning AF population.

Management of atrial fibrillation (AF) may be challenging in clinical practice. Given the complexity of AF patients and the continuous advances in AF clinical management, there is a need for standardized programmes aimed at collecting so-called ‘real-world clinical practice data’ regarding the epidemiology, diagnostic/therapeutic/management practices and assessing adherence to guidelines. Over the past 20 years, the number of registries and surveys based on real-world AF patients has been dramatically increased. In Europe, based on the Euro Heart Survey (EHS) and the EURObservational Research Programme (EORP), a large series of studies based on these prospective, observational, large-scale multicentre registries on AF have been published. This narrative review gives an overview of these two projects on AF led by the European Society of Cardiology, focusing mainly on the contribution that these studies have provided to AF management and patient outcomes. Both the EHS and the EORP registries have collected a large amount of data regarding contemporary clinical practice, and despite some limitations, mainly related to their observational nature, these registries have contributed to our knowledge and clinical management of AF patients.

Background Mechanistic studies suggest that mitochondria DNA (mtDNA) dysfunction may be associated with increased risk of atrial fibrillation (AF). The association between mtDNA copy number (mtDNA-CN) and incident AF in the general population, however, remains unknown. Methods We conducted prospective analyses of 19,709 participants from the Atherosclerosis Risk in Communities Study (ARIC), the Multi-Ethnic Study of Atherosclerosis (MESA), and the Cardiovascular Health Study (CHS). mtDNA-CN from the peripheral blood was calculated from probe intensities on the Affymetrix Genome-Wide Human single nucleotide polymorphisms (SNP) Array 6.0 in ARIC and MESA and from multiplexed real-time quantitative polymerase chain reaction (qPCR) in CHS. Incident AF cases were identified through electrocardiograms, review of hospital discharge codes, Medicare claims, and death certificates. Results The median follow-up time was 21.4 years in ARIC, 12.9 years in MESA, and 11.0 years in CHS, during which 4021 participants developed incident atrial fibrillation (1761 in ARIC, 790 in MESA, and 1470 in CHS). In fully adjusted models, participants with the lowest quintile of mitochondria DNA copy number had an overall 13% increased risk (95% CI 1 to 27%) of incident atrial fibrillation compared to those with the highest quintile. Dose-response spline analysis also showed an inverse association between mitochondria DNA copy number and hazard for atrial fibrillation for all three cohorts. These associations were consistent across subgroups. Conclusions Mitochondria DNA copy number was inversely associated with the risk of AF independent of traditional cardiovascular risk factors. These findings implicate mitochondria DNA copy number as a novel risk factor for atrial fibrillation. Further research is warranted to understand the underlying mechanisms and to evaluate the role of mitochondria DNA copy number in the management of atrial fibrillation risk.

The left atrial appendage is thought to be responsible for the majority of embolic strokes, and has become an important target in the surgical management of atrial fibrillation. We present an original clip-and-loop technique using an AtriClip via a left minithoracotomy for post-stroke patients with atrial fibrillation. This procedure was performed in 43 cases between March 2018 and January 2020. No patient had a thrombus at the edge of the clip or communication into the left atrial appendage 3 months after surgery. Anticoagulant could be discontinued in all patients. Follow-up at 23 ± 10 months showed no recurrence of stroke.

The Canadian Cardiovascular Society (CCS) atrial fibrillation (AF) guidelines program was developed to aid clinicians in the management of these complex patients, as well as to provide direction to policy makers and health care systems regarding related issues. The most recent comprehensive CCS AF guidelines update was published in 2010. Since then, periodic updates were published dealing with rapidly changing areas. However, since 2010 a large number of developments had accumulated in a wide range of areas, motivating the committee to complete a thorough guideline review. The 2020 iteration of the CCS AF guidelines represents a comprehensive renewal that integrates, updates, and replaces the past decade of guidelines, recommendations, and practical tips. It is intended to be used by practicing clinicians across all disciplines who care for patients with AF. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system was used to evaluate recommendation strength and the quality of evidence. Areas of focus include: AF classification and definitions, epidemiology, pathophysiology, clinical evaluation, screening and opportunistic AF detection, detection and management of modifiable risk factors, integrated approach to AF management, stroke prevention, arrhythmia management, sex differences, and AF in special populations. Extensive use is made of tables and figures to synthesize important material and present key concepts. This document should be an important aid for knowledge translation and a tool to help improve clinical management of this important and challenging arrhythmia.

Assessment of risk factors for stroke and applying anticoagulation accordingly is one of the crucial fundamentals of comprehensive management of atrial fibrillation (AF). As the most prevalent sustained cardiac arrhythmia, AF is known to confer a fivefold increased risk of thromboembolic complications such as ischaemic stroke or transient ischaemic attack.1 International practice guidelines recommend the use of the CHA2DS2-VASc (C - Congestive heart failure; H - Hypertension, A - Age 75 and above, D - Diabetes Mellitus, S - prior Stroke or Transiant Ischaemic Attack or thromboembolism, V - Vascular disease history, A - Age 65-74, S - Female sex) score to predict the yearly risk of stroke and to determine if treatment with oral anticoagulation is warranted. Vitamin K antagonists as well as non-vitamin K antagonist oral anticoagulants (NOACs) are effective for the prevention of strokes in AF. However, regardless of the choice of anticoagulant, stringent adherence to the treatment regimen is crucial. Patients should play an active role in the decision to commence anticoagulation, and patient preferences should be taken into consideration, aiming to tailor the treatment as much as possible which may consequently improve treatment adherence.1 Unfortunately, adherence and persistence with anticoagulation treatment regimens is often suboptimal.2 The management of AF has become complex and the traditional healthcare consultation may no longer allow one healthcare professional enough time to educate the patient about stroke prevention therapy, engage in shared decision making and discuss the importance of adherence for optimal outcomes. Nevertheless, engaging with patients to identify their values, preferences and beliefs, explaining the rationale of stroke prevention as part of AF management and providing information about treatment options, is crucial to reach an informed or …

Atrial fibrillation is a common clinical manifestation in hospitalized patients with coronavirus disease 2019 (COVID‐19). Medications used to treat atrial fibrillation, such as antiarrhythmic drugs and anticoagulants, may have significant drug interactions with emerging COVID‐19 treatments. Common unintended nontherapeutic target effects of COVID‐19 treatment include potassium channel blockade, cytochrome P 450 isoenzyme inhibition or activation, and P‐glycoprotein inhibition. Drug‐drug interactions with antiarrhythmic drugs and anticoagulants in these patients may lead to significant bradycardia, ventricular arrhythmias, or severe bleeding. It is important for clinicians to be aware of these interactions, drug metabolism changes, and clinical consequences when choosing antiarrhythmic drugs and anticoagulants for COVID‐19 patients with atrial fibrillation. The objective of this review is to provide a practical guide for clinicians who are managing COVID‐19 patients with concomitant atrial fibrillation.

Introduction The European Society of Cardiology guidelines on the management of Atrial Fibrillation (AF) advocate the use of direct oral anticoagulants (DOACs) over warfarin. Their use is also licenced for the treatment of pulmonary embolism and deep vein thrombosis. DOACs have superior efficacy in stroke reduction, reduced rates of intracranial haemorrhage and improved overall mortality. DOACs are safer, easier to use and don’t require monitoring. Aims We sought to describe changes in prescriptions for anticoagulants over the 20 years from 1998-2018 and to describe the financial implications of the shift away from warfarin. Methods We conducted a comprehensive nationwide retrospective study. Data were obtained from the Prescription Cost Analysis system, which holds information on every prescription dispensed in the community in England, covering a population of more than 50 million people. We obtained data for warfarin, dabigatran, rivaroxaban, apixaban and edoxaban from 1998 to 2018. Results There was a linear increase in warfarin prescriptions from 1998 to 2014 but this plateaued in 2015. Thereafter there has been a linear decrease in prescriptions for warfarin. Conversely, total prescriptions for all DOACs combined has increased exponentially in the same time frame and for the first time, there were more prescriptions for DOACs than warfarin in 2018 (9.3 million prescriptions for DOACs vs. 8.2 million prescriptions for warfarin). Rivaroxaban and Apixaban are the most commonly prescribed DOACs by a significant margin. In 2018 the cost of prescriptions for all DOACs combined was £458.6 million compared to £8.9 million for warfarin prescriptions. Conclusion In 2016 prescriptions for warfarin fell for the first time in 18 years. Within 2 years, DOAC prescriptions have surpassed warfarin prescriptions and warfarin use has continued to decline. This trend has a financial cost in terms of prescriptions with spending on DOACs being 50-fold more than those of warfarin in 2018. The additional cost of warfarin, however, includes anticoagulation clinics and there is no data available to suggest that there has been a reduction in the number of anticoagulation clinics in line with the reduction in warfarin use. Despite this increased cost, the overall safety benefits, ease of use and lack of monitoring supports the continued use of DOACs and there seems no reason to think these trends are likely to change in the near future. Conflict of Interest nil

Patients who have suffered an acute ischemic stroke (AIS) and are smokers may have a better outcome following thrombolytic therapy when compared with non-smokers. While this finding is controversial, data on baseline clinical risk factors to predict treatment efficacy of thrombolytic therapy using ambulatory status in patients who suffered AIS and are smokers is not common.Between 2010 and 2016, retrospective data on patients who have suffered an AIS and received recombinant tissue plasminogen activator (rtPA) were obtained from Greenville health system registry. Assessment of clinical risk factors and the likelihood of an improvement in post-stroke ambulation among smokers and non-smokers was carried out using multivariate logistic regression.Of 1001 patients, 70.8% were smokers and 29.2% non-smokers. Among the smokers and non-smokers, 74.6% and 84.6% improvement in ambulation respectively at discharge. The odds of improved ambulation decrease among smokers as age group increases compared to those below 50 [(60-69 years, aOR, 0.30, 95% C.I, 0.108-0.850, p0.05), (70-79 years aOR, 0.27, 95% C.I, 0.096-0.734, p0.05), (80+ years aOR, 0.16, 95% C.I, 0.057-0.430, P0.01). Patients with National Institute of Health Stroke Scale Score (NIHSS) score7 (reference7) were 91% less likely to have improved ambulation among smokers and non-smokers (aOR, 0.09, 95% C.I, 0.055-0.155, P = 0.01), and (aOR, 0.08, 95% C.I, 0.027-0.214, P = 0.01) respectively. Atrial fibrillation was an independent predictor of decreased improvement in ambulation only among smokers (aOR, 0.58, 95% C.I, 0.356-0.928 P0.05).Our findings suggest that elderly smokers with atrial fibrillation would benefit more from aggressive management of atrial fibrillation than non-smokers.

Atrial fibrillation is the most common arrhythmia in the world with continued rising prevalence, significant morbidity and mortality, and a substantial financial burden. It has been associated with numerous modifiable risk factors and chronic medical conditions. Treatment of these modifiable risk factors has improved rhythm control of atrial fibrillation as well as demonstrated cost-effectiveness. Primary prevention of underlying chronic disease should be incorporated into the treatment paradigm for AF. Comprehensive management with integrated care including the patient, allied health professionals, primary care physicians, and specialists will be needed to reverse the epidemiological trends, improve quality of life, and mortality.

This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the effectiveness and safety of pharmacological agents, placebo and no intervention for rate control of AF in adults presenting to the ED with AF and rapid ventricular response. To rank pharmacological agents for rate control of AF in adults presenting to ED with AF and rapid ventricular response, according to their relative effectiveness and safety.

Atrial fibrillation is a common arrhythmia which may cause symptoms that significantly impact quality of life and is associated with increased risk of stroke, heart failure, and sudden death. Over the past three decades many surgical techniques as well as catheter-bases procedures have been developed to treat atrial fibrillation. In this review we describe the indications, treatments, outcomes, surgical techniques, and technical advances reported in the literature.

Atrial fibrillation and acute heart failure frequently co-exist and can exacerbate each other. Their combination leads to increased morbidity and mortality. However, the prevalence and significance, as well as the treatment, of atrial fibrillation in acute heart failure are not well studied. Management of atrial fibrillation in acute heart failure requires a multidisciplinary team approach. Treatment of underlying disease(s), identification and treatment of potentially correctable causes and precipitating factors and anticoagulation are crucial. In this article, current evidence on atrial fibrillation in the setting of acute heart failure is summarised. The recommendations on management of atrial fibrillation in the prehospital stage, the treatment of reversible causes, when and how to use rate or rhythm control, maintenance of sinus rhythm, catheter ablation and pacing, anticoagulation, as well as measures on prevention of atrial fibrillation are provided.

BACKGROUND: Atrial fibrillation is currently managed with a variety of rate controlling and antiarrhythmic agents. Often, magnesium is used as adjunctive therapy, however, the benefit it provides in managing Afib with RVR has been debated. This study aimed to determine if IV MgSO4 administration in conjunction with standard therapy provides any synergistic effect in acute and prolonged control of Afib with RVR. METHODS: This was a retrospective study involving ninety patients with episodes of Afib with RVR during their hospitalization. The treatment group included those that had received magnesium (n=32) along with standard management and the control group (n=58) received only standard management. Heart rates at different time intervals were collected. Dose dependent effects of IV MgSO4 on heart rates were also evaluated. RESULTS: Patients that received magnesium had a lower mean heart rate (85 BPM versus 96 BPM, P

Atrial Fibrillation (AF) is very common among patients with severe aortic stenosis. Moreover, new onset AF (NOAF) is a frequent finding after Transcatheter Aortic Valve Replacement (TAVR). There is a significant impact of AF on outcomes in patients undergoing TAVR including mortality, thrombo-embolic and bleeding events. There is lack of clear evidence about the optimal management of AF in TAVR patients. This review aims to summarize the epidemiology, predictors, prognosis, therapeutic considerations and challenges in the management of AF in patients undergoing TAVR.

Contains fulltext : 235301.pdf (Publisher’s version ) (Closed access) During the coronavirus 2019 (COVID-19) pandemic, outpatient visits in the atrial fibrillation (AF) clinic of the Maastricht University Medical Centre (MUMC+) were transferred into teleconsultations. The aim was to develop anon-demand app-based heart rate and rhythm monitoring infrastructure to allow appropriatmanagement of AF through teleconsultation. In line with the fundamental aspects of integrated care, including actively involving patients in the care process and providing comprehensive care by a multidisciplinary team, we implemented a mobile health (mHealth) intervention to support teleconsultations with AF patients: TeleCheck-AF. The TeleCheck-AF approach guarantees the continuity of comprehensive AF management and supports integrated care through teleconsultation during COVID-19. It incorporates three important components: (i) a structured teleconsultation ('Tele'), (ii) a CE-marked app-based on-demand heart rate and rhythm monitoring infrastructure ('Check'), and (iii) comprehensive AF management ('AF'). In this article, we describe the components and implementation of the TeleCheck-AF approach in an integrated and specialized AF-clinic through teleconsultation. The TeleCheck-AF approach is currently implemented in numerous European centres during COVID-19.

Objective Amiodarone is a widely used drug in the emergency department (ED) for control of atrial fibrillation, but it has a delayed onset of action and slow metabolism, leading to longer length of ED stay. The aim of this study was to compare the length of ED stay of atrial fibrillation patients who were treated with or without amiodarone. Methods We undertook a multicenter, observational, cohort study of the URGFAICS registry of older adults with atrial fibrillation who presented to five Spanish EDs and compared patients who had received amiodarone with those who had not. Afterward, we performed a propensity score matched analysis of atrial fibrillation to determine the ED length of stay related to amiodarone. Results Of the 1199 patients included in the registry, 225 patients (18.8%) were treated with amiodarone while 974 (81.2%) were not. We performed a univariate study depending on amiodarone administration followed by propensity score calculation according to the 14 statistically different features found previously and six significant variables, obtaining 150 patients (75 for each group) suitable for the analysis. The length of ED stay was analyzed using box plot, with a P

Over the past 20 years, multiple studies have demonstrated the superiority of percutaneous catheter-based pulmonary vein isolation (PVI) in the management of atrial fibrillation (AF). Unfortunately, the results of catheter ablation can be limited by arrhythmia recurrence, which is often a result of a failure to achieve durable lesions around the pulmonary vein ostia. In response, significant efforts have been directed toward developing technologies to achieve safer and more durable PVI, including the development of dedicated catheters capable of achieving PVI with a single ablation lesion (eg, the Arctic Front Cryoballoon; Medtronic CryoCath, Pointe-Claire, Canada). The purpose of this review is to discuss the contemporary role of cryoballoon ablation in the invasive management of AF, with a focus on the characteristics that differentiate cryoballoon from radiofrequency ablation.

Study objective To define the association between atrial fibrillation case volume in the emergency department and death or all-cause hospitalization at 30 days and 1 year in patients with new atrial fibrillation. Secondary objectives examined repeat ED visits and the management of atrial fibrillation within 90 days. Methods We identified all adults presenting to an ED in Alberta, Canada, with a new primary diagnosis of atrial fibrillation/flutter between 2009 and 2015 using International Classification of Diseases, 10th Revision code I48. Volume was classified in tertiles weighted by annual ED number of atrial fibrillation cases. The association between volume and outcomes was evaluated using generalized linear mixed models, adjusting for prognostically important covariates as fixed effects and ED as a random effect to account for potential clustering within EDs. Results The tertiles consisted of 4 high, 9 medium, and 68 low atrial fibrillation volume EDs, with 4,217, 4,193, and 4,112 patients, respectively. Volume was not independently associated with the primary outcome or individual components. However, medium- and high-volume EDs had fewer repeat ED visits at 30 days (respective adjusted odds ratio [aOR] 0.75 [95% confidence interval {CI} 0.66 to 0.87] and 0.64 [0.52 to 0.79]) and 1 year (respective aOR 0.77 [95% CI 0.67 to 0.90] and 0.71 [0.56 to 0.90]). Fewer patients were admitted from medium- (37.1%) and high- (32.0%) compared with low-volume (39.5%) EDs. Patients attending medium- and high-volume EDs were more likely to be cardioverted (aOR 3.28 [95% CI 1.94 to 5.53] and 3.81 [1.39 to 10.48] for medium- and high-volume EDs, respectively). Conclusion Treatment in higher volume EDs was associated with significantly lower admission rates and repeat ED visits but no difference in survival.

Catheter ablation has become an important element in the management of atrial fibrillation. Several technical advances allowed for better safety profiles and lower recurrence rates, leading to an increasing number of ablations worldwide. Despite that, major complications are still reported, and esophageal thermal injury remains a significant concern as atrioesophageal fistula (AEF) is often fatal. Recognition of the mechanisms involved in the process of esophageal lesion formation and the identification of the main determinants of risk have set the grounds for the development and improvement of different esophageal protective strategies. More sensitive esophageal temperature monitoring, safer ablation parameters and catheters, and different energy sources appear to collectively reduce the risk of esophageal thermal injury. Adjunctive measures such as the prophylactic use of proton-pump inhibitors, as well as esophageal cooling or deviation devices, have emerged as complementary methods with variable but promising results. Nevertheless, as a multifactorial problem, no single esophageal protective measure has proven to be sufficiently effective to eliminate the risk, and further investigation is still warranted. Early screening in the patients at risk and prompt intervention in the cases of AEF are important risk modifiers and yield better outcomes.

Purpose of Review Cardiotoxicity by anticancer agents has emerged as a multifaceted issue and is expected to affect both mortality and morbidity. This review summarizes clinical challenges in the management of oncological patients requiring anticoagulants for atrial fibrillation (AF) also considering the current outbreak of the COVID-19 (coronavirus disease 2019) pandemic, since this infection can add challenges to the management of both conditions. Specifically, the aims are manyfold: (1) describe the evolving use of direct oral anticoagulants (DOACs) in AF patients with cancer; (2) critically appraise the risk of clinically important drug-drug interactions (DDIs) between DOACs and oral targeted anticancer agents; (3) address expected DDIs between DOACs and candidate anti-COVID drugs, with implications on management of the underlying thrombotic risk; and (4) characterize the proarrhythmic liability in cardio-oncology in the setting of COVID-19, focusing on QT prolongation. Recent Findings AF in cardio-oncology poses diagnostic and management challenges, also due to the number of anticancer drugs recently associated with AF onset/worsening. Oral targeted drugs can potentially interact with DOACs, with increased bleeding risk mainly due to pharmacokinetic DDIs. Moreover, the vast majority of oral anticancer agents cause QT prolongation with direct and indirect mechanisms, potentially resulting in the occurrence of torsade de pointes, especially in susceptible patients with COVID-19 receiving additional drugs with QT liability. Summary Oncologists and cardiologists must be aware of the increased bleeding risk and arrhythmic susceptibility of patients with AF and cancer due to DDIs. High-risk individuals with COVID-19 should be prioritized to target preventive strategies, including optimal antithrombotic management, medication review, and stringent monitoring.

A presentation of a young man with hypertrophic cardiomyopathy and atrial fibrillation. Management considerations are reviewed.

Atrial fibrillation is the most common cardiac arrhythmia and is associated with significant morbidity. Medical management of atrial fibrillation is often suboptimal and is challenged by many patient-related or therapy-related difficulties. Surgical options for atrial fibrillation aim to provide an improved efficacy therapy that avoids the shortcomings of lifelong anticoagulation and anti-arrhythmic therapy and/or lifestyle change. The introduction of ablation devices has revolutionized the surgical treatment of AF making procedures available to a wider patient population.

Supraventricular tachycardia is a commonly encountered condition. Atrial fibrillation has a particularly high incidence in the aging population of industrialized nations. While medical therapy was the mainstay of treatment for several decades, improvements in invasive catheter ablation have made this the preferred therapy in many cases. With an impetus provided by the very high incidence, prevalence, and clinical burden of atrial fibrillation, techniques to improve the safety and efficacy of atrial fibrillation ablation have progressed rapidly over the last two decades. This chapter initially outlines supraventricular tachycardia mechanisms, diagnostic testing, and the therapies. It then focuses in depth on emerging technologies in invasive management of atrial fibrillation.

Management of atrial fibrillation (AF) in patients with advanced chronic kidney disease (CKD) poses a complex conundrum because of higher risks for both thromboembolic and bleeding complications compared to the general population. This makes it particularly important for clinicians to carefully weigh the risks versus benefits of anticoagulation therapy to determine the individualized net clinical benefit for every patient. During the past few years, 4 non-vitamin K-dependent oral anticoagulant (NOAC) agents have supplemented warfarin in the therapeutic armamentarium for the prevention of systemic thromboembolism in nonvalvular AF. However, the use of NOACs in CKD specifically mandates a nuanced understanding due to their varying dependence on renal clearance, with resultant safety implications related to either underdosing (thromboembolism) or excessive drug exposure (bleeding). This pragmatic review highlights unique considerations pertaining to accurate estimation and temporal monitoring of kidney function in the context of NOAC use with specific clinical deliberations and variables when determining whether an NOAC is appropriate for a patient with CKD. The dependence of NOACs on renal clearance and several troubling safety signals in the published literature suggest that it is vital for nephrologists to be active members of a multidisciplinary team caring for these high-risk patients with CKD and AF.

Untreated atrial fibrillation is associated with an increased risk of all-cause mortality and morbidity. Despite the current guidelines recommending surgical ablation of atrial fibrillation at the time of coronary artery bypass surgery, most patients with concomitant atrial fibrillation and coronary artery disease do not receive surgical ablation for their atrial fibrillation. This review reports the efficacy of different surgical ablation techniques used for the treatment of atrial fibrillation during coronary artery bypass. PubMed was systematically searched for studies reporting outcomes of concomitant surgical ablation in coronary artery bypass patients between January 2002 and March 2018. Data were independently extracted and analyzed by two investigators. Twenty-four studies were included. Twelve studies exclusively reported outcomes of surgical ablation in patients undergoing coronary artery bypass, whereas the remaining 12 reported outcomes of concomitant cardiac surgery with subgroup analysis. Only four studies performed the concomitant Cox-Maze procedure. Freedom from atrial tachyarrhythmia was reported as high as 98% at 1 year and 76% at 5 years with Cox-Maze procedure, whereas lesser lesion sets had more variable outcomes, ranging from 35% to 93%. In most studies, the addition of surgical ablation was not associated with increased morbidity and mortality. Although the Cox-Maze procedure had the greatest short- and long-term success rates, most studies comprising the evidence documenting the safety and efficacy of adding surgical ablation were of low or moderate quality. There was a great deal of heterogeneity among study populations, follow-up times, methods, and definition of failure. To establish a consensus regarding a surgical ablation technique for atrial fibrillation in coronary artery bypass population, larger multicenter randomized controlled studies need to be designed.

The Canadian Cardiovascular Society (CCS) Atrial Fibrillation Guidelines Committee provides periodic reviews of new data to produce focused updates that address clinically important advances in atrial fibrillation (AF) management. This 2018 Focused Update addresses: (1) anticoagulation in the context of cardioversion of AF; (2) the management of antithrombotic therapy for patients with AF in the context of coronary artery disease; (3) investigation and management of subclinical AF; (4) the use of antidotes for the reversal of non-vitamin K antagonist oral anticoagulants; (5) acute pharmacological cardioversion of AF; (6) catheter ablation for AF, including patients with concomitant AF and heart failure; and (7) an integrated approach to the patient with AF and modifiable cardiovascular risk factors. The recommendations were developed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) standards. Individual studies and literature were reviewed for quality and bias; the literature review process and evidence tables are included as Supplementary Material and are available on the CCS Web site. Details of the updated recommendations are presented, along with their background and rationale. This document is linked to an updated summary of all CCS AF guidelines recommendations, from 2010 to the present 2018 Focused Update, which is provided in the Supplementary Material.

Mitral stenosis (MS) is a condition which happened because of congenital or acquired event. The most common etiology of MS in Indonesia is Rheumatic Heart Disease (RHD). Chronic inflammation on the mitral valve could lead to stenosis from mild to severe degree. Mitral stenosis could lead to many complications such as pulmonary hypertension and atrial fibrillation (AF). The prevalence of AF in patients with MS is related to the severity of valve obstruction and patient age. AF event in patient with MS could be happen because of Left Atrial (LA) dilatation of the patient. The mechanism that responsible for AF in patient with MS is a complex one. AF even with or without atrial flutter episode could lead a deterioration of patient hemodynamic. In the other way, the patient also predisposes to left atrial thrombus formation and systemic embolic events. Good awareness in diagnosis and management of atrial fibrillation in patient with MS are mandatory to reduce the morbidity and mortality.

Background Atrial fibrillation (AF) may result in procedure cancellations and emergency department (ED) referrals for patients presenting for outpatient GI endoscopic procedures. Such cancellations and referrals delay patient care and can lead to inefficient use of resources. Methods All consecutive patients presenting in AF for a colonoscopy or upper endoscopy to the University of Wisconsin Digestive Health Center between October 2013 and September 2014 were defined as the pre-intervention group (Group 1). In 2015, a protocol was initiated for peri-procedural management of patients presenting in AF, new onset or previously known. All consecutive patients after initiation of the protocol from October 2015 to September 2016 were analyzed as the post intervention group (Group 2). Patients with heart failure, hypotension, or chest pain were excluded from the protocol. Results One hundred nine and 141 patients were included in Groups 1 and Group 2, respectively. Following protocol initiation, patients were less likely to present to the ED (6.4% Group 1 vs. 1.4% Group 2, RR 0.22, p = 0.04). There was also a trend towards a reduction in procedure cancelations (5.5% Group 1 vs. 1.4% Group 2, RR 0.26, p = 0.08). All attempted procedures were completed and there were no complications in the intervention group. Conclusions Implementation of a standardized protocol for management of atrial fibrillation in patients presenting for outpatient gastrointestinal endoscopic procedures resulted in a significant decrease in emergency department visits with an additional trend toward decreased procedural cancellations without an increased risk of complications.

The term ‘flutter’ and ‘fibrillation’ were first coined to differentiate the differences between fast, regular contractions in Atrial Flutter (AFLUT) with irregular, vermiform contractions of Atrial Fibrillation (AFIB). Management of these two diseases has been a challenge for physicians. Rate control (along with rhythm control) is the first line of management for symptomatic AFIB/AFLUT with Rapid Ventricular Rate (RVR). In some situations, atrial rhythms may not be well controlled by these anti-arrhythmic drugs, making cardioversion to sinus rhythm necessary. Anti-coagulation therapy in both the disease population is essential. Catheter ablation is an effective treatment option in certain patients that have AFIB/AFLUT refractory to medical management. Newer techniques like left atrial appendage (LAA) has been developed and is a highly attractive concept for the future in the management of AFIB/AFLUT. Newer novel drugs targeting specific ion channels are approaching the stages of clinical investigation. However, while advances in technologies have helped elucidate many aspects of these diseases, many mysteries still remain. This literature review serves as one of the guideline papers for current up-to-date management on both AFIB and AFLUT.

Atrial fibrillation (AF) is a recognised arrhythmic risk of endurance sports participation, predominantly affecting middle-aged men who are lifelong athletes. Affected athletes were historically included in the category of lone AF, although specific pathophysiological processes apply to this condition, referred to as exercise-related AF. Younger non-endurance athletes may also present with AF, particularly when associated with co-existing cardiomyopathy or arrhythmia syndrome. Management of exercise-related AF is largely based on evidence from randomised trials in non-athletes. Cornerstones of treatment are, thus, thromboembolic risk reduction and risk factor modification. Rhythm control is generally preferred over rate control due to frequent presentation with symptomatic AF during the paroxysmal phase. Many therapies specific to athletes are based on expert consensus alongside observational data in athletic populations. These include: recommendations to detrain; treatment of symptomatic oesophageal reflux; and preferential use of anticholinergic antidysrhythmic agents to address the predominance of "vagal" AF in athletes. Ongoing research involving cardiac ion channel remodelling and systemic inflammation as mediators of AF genesis may provide future novel therapeutic targets for exercise-related AF. Ablative therapy shows promise in the athletic population with AF, although evidence remains limited. International consensus guidance for disqualification from competitive sports exists to guide medical management alongside athletes' preferences to continue to participate. This review focusses on isolated exercise-related AF and reviews the evidence supporting postulated management recommendations of this unique patient population.

Background: Rheumatic heart disease has a strong association with mitral valve stenosis. Atrial fibrillation is one of the most common complications of this condition and is a poor prognostic factor. Early detection and prompt management of atrial fibrillation can help to improve the quality of life and increase the life expectancy of the patients. We carried out this study to investigate the significance of left atrial volumetric changes in mitral stenosis and its correlation with atrial fibrillation. Methodology: We audited the data of 60 patients of rheumatic heart disease who had mitral valve stenosis. The patients were randomized into atrial fibrillation (Group A) and normal sinus rhythm (Group B). We conducted this cross-sectional analytical study at Cardiology Department, Mayo Hospital, Lahore, from 1st February 2017 to 31st January 2018. We only included those patients who consented to be a part of this study and fulfilled our predefined inclusion criteria. Left atrial volume was measured by prolate ellipse method and biplane methods on echocardiography. The Data was analyzed on SPSS v20. Results: Sixty patients were included in the study. Among the subjects, thirty-six (60%) were males, and twenty-four (40%) were females. Atrial fibrillation was noted in 43.33% of the patients of mitral valve stenosis. There was a marked difference in the mean volume of the left atrium among the two groups. We observed that the mean area of the mitral valve for Group A patients was larger than that of patients in Group B. Our study showed an inverse correlation between left atrial volume and mitral valve area among Group A patients. Conclusion: Patients of mitral stenosis are at an increased risk of developing atrial fibrillation if the left atrial volume is increasing. All patients with mitral stenosis should have routine echocardiography & measurement of left atrial volumes, so that proper treatment can be started if the left atrial volume is increasing, to prevent atrial fibrillation.

The European Heart Rhythm Association (EHRA) and European Renal Association/European Dialysis and Transplantation Association (ERA/EDTA) jointly conducted a physician-based survey to gain insight into the management of atrial fibrillation (AF) in patients with chronic kidney disease (CKD) and adherence to current European Society of Cardiology AF Guidelines in contemporary clinical practice. Physician-based survey conducted during an 8-week period using an internet-based questionnaire sent to all EHRA and ERA/EDTA members, with voluntary and anonymous responses. Among 306 physicians (160 EHRA and 146 ERA/EDTA members; 56 countries), a multidisciplinary team for management of AF-CKD patients was available to only 20/300 respondents (6.7%) and 132/295 (44.7%) routinely screened CKD patients for AF. Oral anticoagulation (OAC) use was based on individual stroke risk in mild/moderate CKD but on shared decision-making in advanced CKD. The CHA2DS2-VASc score-based decisions were more common among cardiologists, with substantial intra- and inter-specialty heterogeneity in the use and dosing of specific OAC drugs across CKD stages, heterogeneous strategies for OAC monitoring (especially among nephrologists) and a modest impact of CKD on rate and rhythm control treatment decisions. The HAS-BLED score was generally not a determinant of OAC prescribing. Our survey provided important insights into contemporary management of AF patients with CKD in clinical practice, revealing certain differences between nephrologists and cardiologists and highlighting shared and specific knowledge gaps and unmet needs. These findings emphasize the need for streamlining the care for AF patients across different specialties and may inform development of tailored education interventions.

Catheter ablation has gained a prominent role in the management of atrial fibrillation (AF), with recent data providing positive evidence on hard outcomes, including hospitalization and mortality. Ablation, however, exposes the patient to a rather unique situation, combining risks for both major bleeding and thromboembolic events. In this setting, the critical importance of rigorous anticoagulation during the procedure has been underlined, and the latest international guidelines now recommend performing AF catheter ablation with uninterrupted non-vitamin K antagonist oral anticoagulants (NOACs) and concomitant administration of unfractionated heparin adjusted to achieve and maintain a target activated clotting time of ≥300 seconds. Whereas observational studies and randomized controlled trials support the safety and efficacy of uninterrupted NOAC strategy for AF catheter ablation, recent experiences have questioned this point, showing a greater unfractionated heparin requirement in NOAC-treated patients compared with vitamin K antagonists–treated patients to achieve the target activated clotting time. Important gaps in evidence regarding optimal intraprocedural anticoagulation management need to be acknowledged. A thorough appreciation of the physiology of anticoagulation during AF catheter ablation and the relevant differences between vitamin K antagonists and NOACs is required, while also understanding the limitations of activated clotting time measurement with regard to accurate intraprocedural anticogulation monitoring. This review aims to provide a critical look at this relatively ignored aspect of AF catheter ablation, especially pitfalls in NOAC monitoring, and to identify gaps in knowledge that need to be addressed in the near future.

INTRODUCTION Atrial fibrillation (AF) is increasing in prevalence and is associated with significant morbidity and mortality. The optimal diagnostic and treatment strategies for AF are continually evolving and care for patients requires confidence in integrating these new developments into practice. These clinical practice guidelines will assist Australian practitioners in the diagnosis and management of adult patients with AF. Main recommendations: These guidelines provide advice on the standardised assessment and management of patients with atrial fibrillation regarding: screening, prevention and diagnostic work-up; acute and chronic arrhythmia management with antiarrhythmic therapy and percutaneous and surgical ablative therapies; stroke prevention and optimal use of anticoagulants; and integrated multidisciplinary care. Changes in management as a result of the guideline: Opportunistic screening in the clinic or community is recommended for patients over 65 years of age. The importance of deciding between a rate and rhythm control strategy at the time of diagnosis and periodically thereafter is highlighted. β-Blockers or non-dihydropyridine calcium channel antagonists remain the first line choice for acute and chronic rate control. Cardioversion remains first line choice for acute rhythm control when clinically indicated. Flecainide is preferable to amiodarone for acute and chronic rhythm control. Failure of rate or rhythm control should prompt consideration of percutaneous or surgical ablation. The sexless CHA2DS2-VA score is recommended to assess stroke risk, which standardises thresholds across men and women; anticoagulation is not recommended for a score of 0, and is recommended for a score of ≥ 2. If anticoagulation is indicated, non-vitamin K oral anticoagulants are recommended in preference to warfarin. An integrated care approach should be adopted, delivered by multidisciplinary teams, including patient education and the use of eHealth tools and resources where available. Regular monitoring and feedback of risk factor control, treatment adherence and persistence should occur.

Pulmonary vein isolation (PVI) with Arctic Front cryoballoon has been an effective treatment for paroxysmal atrial fibrillation.1 The recent 2016 European Society of Cardiology guidelines and Heart Rhythm Society Guideline on the management of atrial fibrillation have established PVI as a cornerstone catheter ablation strategy during the primary index ablation for patients with symptomatic and drug-refractory atrial fibrillation.2 Furthermore, these guidelines recognized that cryoballoon catheter ablation can be an effective alternative to the traditional radiofrequency ablation catheters that have been historically used.2 The performance of PVI is typically achieved via the inferior vena cava (IVC) through the access of the femoral veins; however, congenital anomalies or venous occlusion may inhibit the use of this approach. In these rare circumstances, access to the cardiac chambers may be achieved via the superior vena cava or via retrograde aortic approaches. Unfortunately, these approaches are less favorable owing to reduced catheter control, manipulation, and stability.3, 4, 5 The purpose of this case report is to illustrate the safety and efficacy of performing PVI with the Arctic Front cryoballoon catheter via the transhepatic approach among patients with congenital anomalies. Access to the right atrium via the percutaneous transhepatic approach is an alternative method when traditional means are not feasible. The percutaneous transhepatic approach has been shown to be effective, with a complication rate of

Aims To assess the number of admissions to the emergency room (ER) of patients with atrial fibrillation (AF) or atrial flutter (af) and their subsequent management. To evaluate the clinical profile and the use of antithrombotics and antiarrhythmic therapy in patients with AF admitted to cardiology wards. Methods and results BLITZ-AF is a multicentre, observational study conducted in 154 centres on patients with AF/af. In each centre, data were collected, retrospectively for 4 weeks in ER and prospectively for 12 weeks in cardiology wards. In ER, there were 6275 admissions. Atrial fibrillation was the main diagnosis in 52.9% of the cases, af in 5.9%. Atrial fibrillation represented 1.0% of all ER admissions and 1.7% of all hospital admissions. A cardioversion has been performed in nearly 25% of the cases. Out of 4126 patients, 52.2% were admitted in cardiology ward; mean age was 74 ± 11 years, 41% were females. Patients with non-valvular AF were 3848 (93.3%); CHA2DS2-VASc score was ≥2 in 87.4%. Cardioversion was attempted in 38.8% of the patients. In-hospital mortality was 1.2%. At discharge, 42.6% of the patients were treated with vitamin K antagonists, 39.5% with direct oral anticoagulants, 13.6% with other antithrombotic drugs, and 4.2% did not take any antithrombotic agent. Rate control strategy was pursued in 47.2%, rhythm control in 44.0%, 45.6% were discharged in sinus rhythm. Conclusion Atrial fibrillation still represents a significant burden on health care system. Oral anticoagulant use increased over time even if compliance with guidelines, with respect to prevention of the risk of stroke, remains suboptimal.

Background: Limited data are available on the clinical management of atrial fibrillation (AF) and its outcomes from an Australian perspective. Objective: To describe the appropriateness of antithrombotic prescribing for patients who presented with a diagnosis of AF to the Hawkesbury St John of God Hospital, New South Wales, Australia. Methods: This retrospective observational study reviewed patients admitted to St John of God Hawkesbury Hospital with AF between June 2016 and June 2017. We calculated stroke risk using the CHA2DS2-VASc score based on medical records and reviewed the appropriateness of oral anticoagulant (OAC) prescribing compared to the 2016 European Society of Cardiology guidelines. Patients were excluded if they had only 1 episode of AF that reverted either spontaneously or upon cardioversion without any documented recurrences. Results: A total of 200 patients (18 years) were included, with 180 (90%) deemed eligible for anticoagulation. Of these 72.8% (n = 131) were prescribed an OAC. A total of 40.0% of patients at low risk of stroke and 68.4% at intermediate risk were prescribed an OAC, respectively. Apixaban was the direct OAC of choice with 36.6% of patients prescribed an OAC receiving apixaban. Warfarin was prescribed for 25.1% of the patients who were prescribed an OAC. Conclusions: The underutilization of anticoagulant medication in high-risk groups and over utilization in low-risk groups remains an ongoing issue in contemporary AF management, and it highlights the need to improve AF-related stroke prevention in our jurisdiction.

The Integrated Management Program Advancing Community Treatment of Atrial Fibrillation (IMPACT-AF) is an investigator designed, prospective, randomized, un-blinded, cluster design clinical trial, conducted in the primary care setting of Nova Scotia, Canada. Its aim is to evaluate whether an electronic Clinical Decision Support System (CDSS) designed to assist both practitioners and patients with evidence-based management strategies for Atrial Fibrillation (AF) can improve process of care and outcomes in a cost-efficient manner as compared to usual AF care. At least 200 primary care providers are being recruited and randomized at the level of the practice to control (usual care) or intervention (eligible to access to CDSS) cohorts. Over 1,000 patients of participating providers with confirmed AF will be managed per their provider's respective assignment. The targeted primary clinical outcome is a reduction in the composite of unplanned cardiovascular (CV) or major bleeding hospitalizations and AF-related emergency department visits. Secondary clinical outcomes, process of care, patient and provider satisfaction as well as economic costs at the system and patient levels are being examined. The trial is anticipated to report in 2018.

Background Global differences exist in the management of atrial fibrillation (AF), and cultural differences may influence patients' expectations and perceptions of healthcare. This survey investigated whether country-specific differences in patients' perceptions of AF and oral anticoagulation (OAC) exist and if recent stroke influences these perceptions. Methods Cross-sectional survey of 937 adults with nonvalvular AF receiving OAC for stroke prevention was conducted across United States, Canada, Germany, France, and Japan. Thirty-minute online interviews conducted between April and November 2015 included AF patients with recent stroke, and newly diagnosed AF and established AF, both without recent stroke. Results U.S. patients and those with recent stroke perceived AF as more serious (54.0 and 55.2%, respectively) and were more concerned about stroke (50.0 and 68.0%, respectively). Japanese patients were more likely to perceive AF as not serious (41.0%), but 50.4% were frequently concerned about stroke. Patients in the United States, Canada, and Germany and those without recent stroke preferred to be involved in OAC treatment decisions (either shared decision making or patient's choice), while French and Japanese patients and those with recent stroke preferred their doctor to choose. For all country groups, stroke prevention was the most important factor when choosing OAC. Conclusion In this international cohort of AF patients, country-specific differences exist in patients' perceptions of AF, concerns about stroke, and preference for involvement in OAC treatment decisions; recent experience of stroke significantly influenced patients' values and preferences regarding AF and treatment. Stroke prevention was rated as the most important factor when choosing OAC treatment.

Despite the huge progress made in the both understanding the mechanisms and the management of atrial fibrillation (AF) this arrhythmia still represents an important health and social burden. Atrial fibrillation is increasing in frequency and is a major cause of death, stroke, heart failure, cognitive decline, and hospitalizations. New data have emerged emphasizing the multidisciplinary approach to better management of this common arrhythmia. Despite the availability of AF management guidelines, practice among European centres may differ from the current guideline recommendations. The scope of the current European Heart Rhythm Association (EHRA) survey is to evaluate the extent of the disparities between clinical practice and the 2016 AF European Society of Cardiology (ESC) guidelines. Our survey examined important topics such as screening for AF, initial therapy, rhythm strategy, and stroke and bleeding risk assessment. In general, there was a high adherence to the new ESC AF guidelines among European cardiologists.

Catheter ablation is widely utilized for the management of atrial fibrillation (AF), particularly in patients who are refractory to medical therapy. The left atrium appears to play a dominant role in the condition of most patients with AF and, in particular, the posterior wall and pulmonary veins frequently harbor sources of fibrillation. Currently, the role of posterior wall isolation during catheter ablation of AF is controversial. In this review, we will examine the mechanistic role of the posterior left atrium, discuss the technical challenges of ablating in the posterior wall and the evolution of strategies to achieve isolation with catheter approaches, and review the relevant literature to date.

Atrial fibrillation (AF) is a common arrhythmia associated with increased risk of morbidity and mortality. There is evidence that lifestyle interventions may serve as complementary treatments to reduce AF burden. The objective of this review was to summarize the efficacy of lifestyle interventions for the management of AF. Studies which included patients with systolic heart failure (ejection fraction ≤40%), and those limited to an examination of vigorous physical activity were excluded from our search. Studies were identified through a search of the following databases: MEDLINE, EMBASE, CINAHIL, and PubMed, run from inception through August 2016. All studies were graded for quality using the Oxford Centre for Evidence-based Medicine recommendations. Meta-analyses of the studies were not performed due to the heterogeneity of the studies. From a total of 1,811 publications, 10 articles were identified and included. Selected publications included 1 study on yoga, 2 studies on acupuncture, 3 studies that examined weight loss programs, and 4 studies that evaluated the impact of moderate physical activity. Yoga was associated with less symptomatic AF episodes and improved quality of life. Acupuncture was associated with reduced AF occurrence in patients with persistent and paroxysmal AF. Weight loss was associated with a significant reduction AF burden and symptoms. Moderate exercise resulted in greater arrhythmia free survival and a mean reduction in AF burden. In conclusion, evidence exists to suggest that yoga, weight loss, and moderate exercise are associated with reductions in AF burden and symptoms. Evidence is greatest for weight loss and moderate exercise.