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Atrial fibrillation (AF) is the most common and sustained cardiac arrhythmia rated by cardiologists as one of the most difficult conditions to manage. Traditionally, AF management has focused on the three pillars of rate control, rhythm control and anticoagulation. However, more recently, cardiovascular risk-factor management in AF has emerged as a fourth and essential pillar, delivering improved patient outcomes. In the UK, AF is a condition that is often managed poorly, with patients reporting a lack of understanding of their condition and treatment options. Many aspects of assessment and communication in AF management are time consuming. Failure to address those aspects may negatively affect the quality of care. Nurse-led clinics can contribute significantly in the areas of patient education and sustained follow-up care, improving outcomes and addressing current deficiencies in AF risk-factor management due to scarcity of medical resources. This article discusses the major cardiovascular risk factors associated with AF, drawing on evidence from the literature, and considers the effectiveness and implications for practice of introducing community-based nurse-led clinics for risk-factor management in patients with AF. [ABSTRACT FROM AUTHOR]

The purpose of this study is to test the efficacy of bioactive natural product berberine in the treatment of patients with atrial fibrillation (AF). Data of 45 paroxysmal AF patients treated with berberine and 43 age, gender, New York Heart Association functional classification score, and concomitant cardiovascular disease matched patients treated with amiodarone were analyzed retrospectively to examine conversion rate, average conversion time, average heart rate, and echocardiographic parameters. There was no statistical difference between berberine and amiodarone on conversion rate or echocardiographic parameters. Berberine treatment showed a significantly longer average time to conversion and higher heart rate during sinus rhythm (SR) than amiodarone. Echocardiographic parameters showed that E/A ratio and left atrial diameter were significantly improved after 6- and 12-month berberine treatment, but only E/A ratio improved significantly at the same time points after amiodarone treatment. This is the first report to specifically compare efficacy of berberine and amiodarone in the treatment of patients with AF. We find that berberine and amiodarone are equally effective for conversion of AF and maintenance of normal SR. [ABSTRACT FROM AUTHOR]

Background: The aldosterone inhibitor eplerenone (EPL) has been shown to reduce the incidence of atrial fibrillation (AF) in patients with systolic heart failure, but the mechanism is unknown.Objectives: This study hypothesized that by reducing atrial dilation and fibrosis in the absence of heart failure, EPL also reduces AF burden and prevents AF perpetuation.Methods: The authors conducted a randomized controlled study in 34 sheep that were atrially tachypaced (13 ± 1 week). They compared daily oral EPL (n = 19) versus sugar pill (SP) treatment (n = 15) from the start of tachypacing. The endpoint was a continuous 7-day stretch of persistent AF (n = 29) or completion of 23 weeks tachypacing (n = 5).Results: EPL significantly reduced the rate of left atrial dilation increase during AF progression. Atria from EPL-treated sheep had less smooth muscle actin protein, collagen-III expression, interstitial atrial fibrosis, and cell hypertrophy than SP-treated sheep atria did. However, EPL did not modify the AF-induced increase in the rate of dominant frequency and ion channel densities seen under SP treatment, but rather prolonged the time to persistent AF in 26% of animals. It also reduced the degree of fibrillatory conduction, AF inducibility, and AF burden.Conclusions: In the sheep model, EPL mitigates fibrosis and atrial dilation, modifies AF inducibility and AF complexity, and prolongs the transition to persistent AF in 26% of animals, but it does not prevent AF-induced electrical remodeling or AF persistence. The results highlight structural remodeling as a central upstream target to reduce AF burden, and the need to prevent electrical remodeling to avert AF perpetuation. [ABSTRACT FROM AUTHOR]

Background: Atrial fibrillatory cycle length has been considered one of the indices of atrial electrical remodelling during atrial fibrillation (AF), which can be assessed from surface ECG by computer-assisted calculation of atrial fibrillatory rate (AFR). Horses have been suggested as a bona fide model for AF studies since horses too, develop lone AF, however data on AF characteristics in horses are extremely sparse and non-invasive characterization of AF complexity using surface ECG processing has not been reported.Aim: The aim was to study characteristics of induced AF and its modification by flecainide.Methods: The study group consisted on 3 horses with spontaneous persistent AF and 13 with pace-induced AF. Seven horses were treated with saline (control) and eight with flecainide (2 mg/kg). ECGs were analysed using spatiotemporal cancellation of QRST complexes and calculation of AFR from the residual atrial signal.Results: At AF onset, AFR was 295 ± 52 fibrillations per minute (fpm) in the horses with induced AF treated with flecainide, 269 ± 36 fpm in the control group (ns), and 364 ± 26 fpm in the horses with spontaneous persistent AF (P < 0.05 compared to the control group). Flecainide caused a decrease in AFR in all animals and restored sinus rhythm in the animals with induced AF. In the control animals, AFR increased from 269 ± 36 fpm to a plateau of 313 ± 14 fpm before decreasing to 288 ± 28 fpm during the last 10% of the AF episodes preceding spontaneous conversion (P < 0.05).Conclusion: AFR in horses with induced AF resembles AFR in humans with paroxysmal AF. Flecainide caused a rapid decrease in AFR in all horses, further supporting the method to be a non-invasive technique to study the effect of antiarrhythmic compounds. [ABSTRACT FROM AUTHOR]

Background: Although mortality after cardiac surgery has significantly decreased in the last decade, patients still experience clinically relevant postoperative complications. Among others, atrial fibrillation (AF) is a common consequence of cardiac surgery, which is associated with prolonged hospitalization and increased mortality. Methods: We retrospectively analyzed data from patients who underwent coronary artery bypass grafting, valve surgery or a combination of both at the University Hospital Muenster between April 2014 and July 2015. We evaluated the incidence of new onset and intermittent/permanent AF (patients with pre- and postoperative AF). Furthermore, we investigated the impact of postoperative AF on clinical outcomes and evaluated potential risk factors. Results: In total, 999 patients were included in the analysis. New onset AF occurred in 24.9% of the patients and the incidence of intermittent/permanent AF was 59.5%. Both types of postoperative AF were associated with prolonged ICU length of stay (median increase approx. 2 days) and duration of mechanical ventilation (median increase 1 h). Additionally, new onset AF patients had a higher rate of dialysis and hospital mortality and more positive fluid balance on the day of surgery and postoperative days 1 and 2. In a multiple logistic regression model, advanced age (odds ratio (OR) = 1.448 per decade increase, p < 0.0001), a combination of CABG and valve surgery (OR = 1.711, p = 0.047), higher C-reactive protein (OR = 1.06 per unit increase, p < 0.0001) and creatinine plasma concentration (OR = 1.287 per unit increase, p = 0.032) significantly predicted new onset AF. Higher Horowitz index values were associated with a reduced risk (OR = 0.996 per unit increase, p = 0.012). In a separate model, higher plasma creatinine concentration (OR = 2.125 per unit increase, p = 0.022) was a significant risk factor for intermittent/permanent AF whereas higher plasma phosphate concentration (OR = 0.522 per unit increase, p = 0.003) indicated reduced occurrence of this arrhythmia. Conclusions: New onset and intermittent/permanent AF are associated with adverse clinical outcomes of elective cardiac surgery patients. Different risk factors implicated in postoperative AF suggest different mechanisms might be involved in its pathogenesis. Customized clinical management protocols seem to be warranted for a higher success rate of prevention and treatment of postoperative AF. [ABSTRACT FROM AUTHOR]

Objectives The aim of this study was to investigate the association between adipose tissue content of total saturated fatty acids including myristic (C14:0), palmitic (C16:0) and stearic (C18:0) acid, as a measure of exposure to saturated fatty acids and the risk of incident atrial fibrillation. Materials and methods A total of 57 053 Danish men and women aged 50-64 years participating in the Diet, Cancer and Health cohort had an adipose tissue biopsy taken at baseline, and this was analysed for saturated fatty acids content by gas chromatography. Follow-up was registry based and in this case-cohort study we used all cases and a randomly drawn subcohort of 3500 participants representative for the entire cohort. Results Data were analysed using weighted Cox proportional hazards regression. During a median follow-up of 14.6 years, a total of 4722 cases of incident atrial fibrillation were diagnosed. For both men and women, no association between adipose tissue content of total saturated fatty acids and the risk of atrial fibrillation could be demonstrated. Conclusion We did not find an association between adipose tissue content of total saturated fatty acids and the risk of incident atrial fibrillation. [ABSTRACT FROM AUTHOR]

Background: Chest tubes are used in every case of coronary artery bypass grafting (CABG) to evacuate shed blood from around the heart and lungs. This study was designed to assess the effective of Jackson-Pratt drain in compare with conventional chest drains after CABG. Materials and Methods: This was a randomized controlled trial that conducted on 218 patients in Chamran hospital from February to December 2016. Eligible patients were randomized in a 1:1 ratio. Jackson-Pratt drain group had 109 patients who received a chest tube insertion in the pleural space of the left lung and a Jackson-Pratt drain in mediastinum, and Chest tube drainage group had 109 patients who received double chest tube insertion in the pleural space of the left lung and the mediastinum. Results: The incidence of pleural effusions in Jackson-Pratt drain group and chest tube group were not statistically different. The pain score at 2-h in Drain group was significantly higher than chest tube group (P = 0.001), but the trend of pain score between groups was not significantly different (P = 0.097). The frequency of tamponade and atrial fibrillation (AF) were significantly lower in Jackson-Pratt drain group (P < 0.05). Conclusion: The Jackson-Pratt drain is equally effective for preventing cardiac tamponade, pleural effusions, and pain intensity in patients after CABG when compared with conventional chest tubes, but was significantly superior regarding efficacy to hospital and Intensive Care Unit length of stay and the incidence of AF. [ABSTRACT FROM AUTHOR]

Objectives: Comparisons between remote magnetic (RMN) and manual catheter navigation for atrial fibrillation (AF) ablation have earlier been reported with controversial results. However, these reports were based on earlier generations of the RMN system.Design: To evaluate the outcomes of the most current RMN system for AF ablation in a larger patient population with longer follow-up time, 112 patients with AF (78 paroxysmal, 34 persistent) who underwent AF ablation utilizing RMN (RMN group) were compared to 102 AF ablation patients (72 paroxysmal, 30 persistent) utilizing manual technique (Manual group).Results: The RMN group was associated with significantly shorter fluoroscopy time (10.4 ± 6.4 vs. 16.3 ± 10.9 min, p < .001) but used more RF energy (64.1 ± 19.4KJ vs. 54.3 ± 24.1 KJ, p < .05), while total procedure time showed no significant difference (201 ± 35 vs. 196 ± 44 min, NS). After 39 ± 9/44 ± 10 months of follow-up, AF-free rates at 1year, 2 years and 3.5 years post ablation were 63%, 46% and 42% in the RMN group vs. 60%, 32% and 30% (survival analysis p < .05) in the Manual group, whereas clinically effective rates were 82%, 73% and 70% for the former vs. 70%, 56% and 49% for the latter (survival analysis p < .005).Conclusion: Differing from previous reports, our data from a larger patient population and longer follow-up time demonstrates that compared to manual technique, the most current RMN technique is associated with better procedural and clinical outcomes for AF ablation. [ABSTRACT FROM AUTHOR]

Background: Although atrial fibrillation (AF) guidelines indicate that pharmacological blockade of the renin-angiotensin system may be considered for primary AF prevention in hypertensive patients, previous studies have yielded conflicting results. We sought to determine whether randomization to lisinopril reduces incident AF or atrial flutter (AFL) compared with chlorthalidone in a large clinical trial cohort with extended post-trial surveillance.Methods and Results: We performed a secondary analysis of the ALLHAT (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial), a randomized, double-blind, active-controlled clinical trial that enrolled hypertensive individuals ≥55 years of age with at least one other cardiovascular risk factor. Participants were randomly assigned to receive amlodipine, lisinopril, or chlorthalidone. Individuals with elevated fasting low-density lipoprotein cholesterol levels were also randomized to pravastatin versus usual care. The primary outcome was the development of either AF or AFL as diagnosed by serial study ECGs or by Medicare claims data. Among 14 837 participants without prevalent AF or AFL, 2514 developed AF/AFL during a mean 7.5±3.2 years of follow-up. Compared with chlorthalidone, randomization to either lisinopril (hazard ratio, 1.04; 95% confidence interval, 0.94-1.15; P=0.46) or amlodipine (hazard ratio, 0.93; 95% confidence interval, 0.84-1.03; P=0.16) was not associated with a significant reduction in incident AF/AFL.Conclusions: Compared with chlorthalidone, treatment with lisinopril is not associated with a meaningful reduction in incident AF or AFL among older adults with a history of hypertension.Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00000542. [ABSTRACT FROM AUTHOR]

Electrical turbulence in cardiac tissue is associated with arrhythmias such as life-threatening ventricular fibrillation. Recent experimental studies have shown that a sequence of low-energy electrical far-field pulses is able to terminate fibrillation more gently than a single high-energy pulse which causes severe side effects. During this low-energy antifibrillation pacing (LEAP), only tissue near sufficiently large conduction heterogeneities, such as large coronary arteries, is activated. In order to optimize LEAP, we performed extensive simulations of cardiac tissue perforated by blood vessels, employing two alternative cellular models that exhibit electrical turbulence at a similar length scale. Moreover, the scale of blood vessels in our two-dimensional simulations was chosen such that the threshold for single pulse defibrillation matches experimental values. For each of the 100 initial conditions, we tested different electrical field strengths, pulse shapes, numbers of pulses, and periods between the pulses. LEAP is successful for both models, albeit with substantial differences. One model exhibits a spectrum of chaotic activity featuring a narrow peak around a dominant frequency. In this case, the optimal period between low-energy pulses matches this frequency and LEAP greatly reduces the required energy for successful defibrillation. For pulses with larger energies, the system is perturbed such that underdrive pacing becomes advantageous. The spectrum of the second model features a broader peak, resulting in a less pronounced optimal pacing period and a decreased energy reduction. In both cases, pacing with five or six pulses which are separated by the dominant period maximizes the energy reduction. [ABSTRACT FROM AUTHOR]

Background & Aims Information is lacking regarding whether cirrhosis is associated with atrial fibrillation development. We aimed to investigate the incidence and clinical significance of atrial fibrillation in cirrhotic patients. Methods Cirrhotic patients (n=3596; mean age, 54.7±12.3 years; male, 72.5%) without previous atrial fibrillation were selected from the Korean National Health Insurance Service National Sample Cohort database between 2004 and 2008. Age- and sex-matched controls (n=17 980) were randomly sampled in a 5:1 ratio from non-cirrhotic individuals. Both cohorts were followed up for incident atrial fibrillation and death until 2013. Results During 9 years of follow-up, atrial fibrillation was newly detected in 113 (3.1%) cirrhosis patients and 385 (2.1%) controls (incidence: 3.48 and 2.16 per 1000 person-years respectively). Cirrhotic patients were at higher risk for atrial fibrillation development compared to controls (hazard ratio, 1.46; 95% confidence interval, 1.18-1.80) after multivariate adjustment. On subgroup analysis, cirrhosis increased the risk for atrial fibrillation, especially in younger (age younger than 65 years) men without comorbidities ( CHA2 DS2- VASc score, 0). Cirrhotic patients showed increased overall mortality compared to controls (hazard ratio, 4.80; 95% confidence interval, 4.47-5.15) as well as increased cardiovascular mortality (hazard ratio, 1.37; 95% confidence interval, 1.07-1.75). However, there was no significant association between development of atrial fibrillation and increased mortality in cirrhosis patients ( P=.188 and .260). Conclusions Cirrhosis was an independent risk factor for atrial fibrillation development, especially in younger, otherwise healthy men, stressing the importance of cardiac assessment in cirrhotic patients. Meanwhile, atrial fibrillation development in cirrhosis patients was not associated with increased mortality. [ABSTRACT FROM AUTHOR]

Study Objective: Atrial fibrillation (AF) is associated with mortality after cardiac surgery. Several studies have reported that landiolol might help to prevent postoperative AF. The objective of this study was to investigate whether low-dose landiolol is useful in terms of balance of benefit and risk.Design: We conducted a meta-analysis after systematically searching the PubMed, the Cochrane library and the ICHUSHI to identify randomized, controlled trials investigating the preventive effect of landiolol on incidence of AF after cardiac surgery.Patients: Six randomized trial with 571 patients were included.Measurements: The primary outcome was incidence of AF after surgery, while secondary outcomes were mortality and complications.Main Results: Incidence of AF within 1week after surgery was significantly lower in the landiolol group than in the control group (odds ratio, 0.27; 95% confidence interval, 0.18-0.42; p<0.001). Three of the 6 studies reported data regarding in-hospital mortality and complications, showing no significant differences between groups (0.7 vs 3.0%; OR, 0.45; 95% CI, 0.07-2.74; p=0.39; and 4.5 vs 9.7%; OR, 0.45; 95% CI, 0.16-1.23; p=0.12, respectively).Conclusions: Our systematic review revealed that low-dose landiolol might help to prevent AF after cardiac surgery and further large trials are needed to evaluate safety because mortality and morbidity rate were very low in included studies. [ABSTRACT FROM AUTHOR]

Aims: In patients with cavotricuspid isthmus (CTI) ablation for atrial flutter (AFL), the decision to hold oral anticoagulation (OAC) often becomes an issue. The purpose of this study was to describe the incidence of the development of atrial fibrillation (AF) after CTI ablation in patients with documented AFL with and without a previous history of AF and to identify risk predictors for the occurrence of AF after CTI.Methods and Results: We included 364 consecutive patients undergoing successful CTI ablation. Thereof, 230 patients (170 male; age 66 ± 11 years) had AFL only (AFL group) and 134 patients (94 male; age 65 ± 11 years) had AFL and previously documented AF (AFL and AF group). Over a mean follow-up of 22 ± 20 months, 163 (71%) patients in the AFL group and 67 (50%) patients in the AFL and AF groups had no documentation of a recurrent atrial arrhythmia (P < 0.001). AF developed in 51 patients (22%) in the AFL group and in 57 (43%) patients in the AFL and AF groups (P < 0.001). In patients without history of AF, left atrial diameter was the only predictor of development of AF (HR 1.058 [95%CI 1.011-1.108], P = 0.016). Multivariate analysis of the total population identified history of AF (HR 1.918 [95%CI 1.301-2.830], P = 0.001) and BMI as predictors for AF development (HR 1.052 [95%CI 1.012-1.093], P = 0.011).Conclusion: Our results indicate that new-onset AF develops in a significant proportion of patients undergoing CTI for AFL. One should therefore be careful to withhold OAC. Furthermore, pulmonary vein isolation should be considered in conjunction with CTI, particularly in patients with previously documented AF. [ABSTRACT FROM AUTHOR]

Background: Oral anticoagulants are used for stroke prevention in patients with atrial fibrillation, the most common cardiac arrhythmia in older adults. The aim of our study was to identify the evidence on the risks and benefits of anticoagulant use among adults aged ≥65 years with atrial fibrillation and to develop recommendations to reduce inappropriate use with a primary focus on new oral anticoagulants. Methods: Systematic review (SR) with search in six databases (up to 12/2016). We included SRs/meta-analyses (MAs) with participants ≥65 years old with atrial fibrillation treated with oral anticoagulation. Two independent reviewers performed study selection, data extraction and quality appraisal. Recommendations were developed based on the evidence identified following a modified GRADE approach. Results: Thirty-eight SRs/MAs were included, drawing on evidence from 74 individual experimental studies. The mean age ranged from 68.2 to 73 years. Treatments investigated included vitamin K antagonists (VKA), new oral anticoagulants (NOACs), platelet aggregation inhibitors (PAI), placebo and no treatment. Comorbidities were reported in 23 SRs, but none reported on frailty status, cognitive status or polypharmacy. Sixteen SRs based on only 3-8 RCTs and thus conveying a significant overlap of studies evaluated the effectiveness of NOACs compared to warfarin. NOACs demonstrated at least equivalent ability to reduce stroke as VKA and a considerably lower risk (OR 0.37 to RR 0.50) of haemorrhagic stroke/intracranial bleeding. Seven SRs were identified comparing VKA to placebo. These revealed a substantial reduction in risk of stroke and mortality for VKA (RR 0.30-0.46)), outweighing an increased risk of bleeding (RR 1.04-3.63) associated with anticoagulation. Eight SRs evaluated the efficacy of VKA compared to PAI: overall, VKA were associated with a lower risk of stroke (OR 0.51-0.68)) and a comparable risk of major bleeding. Conclusions: Anticoagulation treatment using VKA in older people with atrial fibrillation appears beneficial in comparison to PAI and placebo. New oral anticoagulants appear to reduce haemorrhagic strokes and intracranial bleedings more effectively than VKAs and should be considered especially in patients with low TTR (time in therapeutic range)/labile INR (International Normalized Ratio). However, to determine if these results are applicable to all older people, further studies should provide information on frailty, significant impaired renal function, polypharmacy and cognitive status of the participants. Funded by the 7th framework programme of the European Union. [ABSTRACT FROM AUTHOR]

Introduction Safety and efficacy data on patent foramen ovale (PFO) closure with the Occlutech Figulla Flex II device are lacking. We undertook a fully monitored prospective Registry on PFO closure using this device. Methods 100 patients undergoing PFO closure were enrolled into the OPPOSE Registry at 6 UK centres. The primary endpoint was PFO closure (grade 0 or 1 shunt) at 6-month BCTTE assessed by Corelab. Secondary endpoints included implantation success, complications, and atrial fibrillation during follow-up. Results 100 patients aged 43.8 ± 11.5 years, 53% male, were recruited. Indications for PFO closure included stroke (56%), TIA (29%) systemic embolism (4%) and MI (3%). Closure was undertaken under GA (44%) or LA (56%), with TOE (45%), ICE (31%), no imaging (20%) or TTE (3%). Balloon sizing was used in 98% of cases and showed a tunnel length of 7.3 ± 3.6 mm, primum-secundum separation of 7.0 ± 2.9 mm and basal inlet width of 8.5 ± 3.5 mm. Implantation was successful in all cases using 18 mm (9%), 25 mm (80%), 30 mm (10%) and 35 mm (1%) devices. 5 patients were lost to follow-up. 92 patients underwent six-month BCTTE. The primary endpoint of PFO closure (grade 0 or 1 shunt) at six months was 79.3%. One patient developed major bleeding (BARC 3b), one patient required vascular surgery, and in one patient device embolization was noted at six months and a larger device implanted. There was one case of new atrial fibrillation. Conclusions This first prospective monitored data for the Occlutech Figulla Flex II device demonstrates good safety and efficacy data at implant and six-month follow-up. [ABSTRACT FROM AUTHOR]

Background: Controversy exists regarding the benefits and risks of warfarin therapy in chronic kidney disease (CKD) and end-stage renal disease (ESRD) patients. In this study, we assessed mortality and cardiovascular outcomes associated with warfarin treatment in patients with stages 3-5 CKD and ESRD admitted to the University of California-Irvine Medical Center.Methods: In a retrospective matched cohort study, we identified 59 adult patients with stages 3-6 CKD initiated on warfarin during the period 2011-2013, and 144 patients with stages 3-6 CKD who had indications for anticoagulation therapy but were not initiated on warfarin. All-cause mortality risk associated with warfarin treatment was estimated using Cox proportional hazard regression analysis, and the risk of significant bleeding and major adverse cardiovascular events were analyzed with Poisson regression analysis. Adjustment models were used to account for age, gender, diabetes mellitus, use of antiplatelet agents, and preexisting cardiovascular disease, and stratified by pre-dialysis CKD stages 3-5 vs. ESRD.Findings: During 5.8 years of follow-up, unadjusted mortality risk was higher in CKD patients on warfarin therapy (hazard ratio [HR] 2.34 with 95% CI 1.25-4.39; p < 0.01). After multivariate adjustment and stratification by CKD stage, the mortality risk remained significant in ESRD patients receiving warfarin (HR 6.62 with 95% CI 2.56-17.16; p < 0.001). Furthermore, adjusted rates of significant bleeding (incident rate ratio, IRR 3.57 with 95% CI 1.51-8.45; p < 0.01) and myocardial infarction (IRR 4.20 with 95% CI 1.78-9.91; p < 0.01) were higher among warfarin users. No differences in rates of ischemic or hemorrhagic strokes were found between the 2 groups.Conclusions: Warfarin use was associated with several-fold higher risk of death, bleeding, and myocardial infarction in dialysis patients. If additional studies suggest similar associations, the use of warfarin in dialysis patients warrants immediate reconsideration. [ABSTRACT FROM AUTHOR]

Background Development of atrial fibrillation after certain cardiac procedures is a common medical problem. The inflammatory process plays an important role in the pathogenesis of post-cardiac procedure atrial fibrillation (PCP-AF). Colchicine, a potent anti-inflammatory agent, has been used in several studies to reduce the risk of PCP-AF. This meta-analysis of randomized controlled trials (RCTs) was conducted to assess the efficacy of colchicine in prevention of PC-PAF. Methods We searched PubMed, EMBASE, Web of Science, Cochrane Library database and Google Scholar for RCTs, using terms “Atrial fibrillation, atrial, or fibrillation and colchicine”. The primary end-point was the occurrence of AF post cardiac procedure, which includes cardiac surgery or pulmonary vein isolation. The safety end point was the occurrence of any side effects. Estimated odds ratios (OR) and 95% confidence intervals (CI) were evaluated. Results A total of six RCTs were included in this meta-analysis, enrolling a total of 1257 patients. Colchicine significantly reduced the odds of PCP-AF (OR 0.52; 95% CI, 0.40–0.68, P < 0.001, I 2 = 0%). However, occurrence of side effects was significantly higher with colchicine when compared to placebo (OR 2.10; 95% CI, 1.34–3.30, P < 0.001, I 2 = 0%). The number needed to treat is 7 and the number needed to harm is 11.2. The proportion of patients discontinuing treatment was 16%. Conclusion This meta-analysis shows that colchicine is an effective drug for prevention of PCP-AF. Colchicine could be considered as a prophylaxis to reduce PCP-AF, with some risk of treatment discontinuation due to the poor gastrointestinal tolerance (diarrhea). [ABSTRACT FROM AUTHOR]

AimTo examine the choices Canadian family medicine residents make for oral anticoagulation (OAC) for patients with nonvalvular atrial fibrillation (AF).BackgroundAF increases the risk of strokes. An important consideration in AF management is risk stratification for stroke and prescription of appropriate OAC. Family physicians provide the vast majority of OAC prescriptions.MethodsWe administered a survey to residents in multiple Canadian family medicine training programmes. Questions explored the experiences and attitudes towards risk stratification and choices of OAC when presented with standardized clinical scenarios. In each scenario, a novel oral anticoagulant (NOAC) would be the preferred treatment according to the contemporary Canadian and European guidelines.FindingsA total of 247 residents participated in the survey. Most used the congestive heart failure, hypertension, age ≥ 75, diabetes mellitus, stroke or TIA (2 points) (81%) and congestive heart failure, hypertension, age ≥ 75 (2 points) or age 65-74 (1 point), diabetes mellitus, stroke or TIA, vascular disease including peripheral arterial disease, myocardial infarction, or aortic plaque, sex (female) (67%) risk stratification schemes while the preferred bleeding risk stratification scheme was hypertension, abnormal liver or renal function, stroke, bleeding, labile international normalized ratio, elderly (age ≥ 65), drugs or alcohol (84%). In the clinical scenarios, residents generally preferred warfarin in favour of NOACs, independent of training level. Residents ranked the risk of adverse events and the cost to the patient as their most and least important consideration when prescribing OAC, respectively. Therefore in patients with nonvalvular AF, Canadian family medicine residents prefer warfarin in comparison with NOACs despite the latest Canadian and European guideline recommendations. This knowledge gap may be enhanced by multiple factors, including a sometimes magnified fear of adverse events and a rapidly changing landscape in stroke prophylaxis. [ABSTRACT FROM PUBLISHER]

Objective: Systemic inflammation is a recognised contributory factor in the pathogenesis of de novo post-operative atrial fibrillation after cardiac surgery. This study aims to determine whether serum soluble vascular endothelial cell adhesion molecule (sVCAM-1) may predict the onset of POAF in patients under going coronary artery bypass grafting.Methods: 34 patients undergoing non-emergent, on-pump CABG were prospectively recruited. Plasma was obtained at 24 h pre-operatively and at 48 and 96 h post-operatively. POAF was defined by continuous Holter recording. Inter-group comparisons were performed using student t-test or ANOVA as appropriate.Results: Thirteen (13/34) patients developed POAF at a mean of 2.5 days post-operatively. Serum sVCAM-1 was significantly increased in the pre-operative serum of POAF when compared to non-POAF patients (p = 0.022). No significant difference was observed between the groups at 48 h (p = 0.073) or 96 h (p = 0.135) post-operatively. sVCAM-1 had a sensitivity of 60.0% and specificity of 77.27%, with an overall diagnostic accuracy of 75.2% in predicting POAF.Conclusions: sVCAM-1 concentration in the pre-operative serum of patients undergoing CABG may accurately predict the onset of de novo POAF. As such, serum sVCAM-1 may be used as a predictive biomarker for this common arrhythmia. Further work must now perform prospective, targeted validation of these results in a larger patient cohort. [ABSTRACT FROM AUTHOR]

Patients with atrial fibrillation and prior stroke or transient ischemic attack exhibit a very high risk of recurrence. Secondary prevention with oral anticoagulants is mandatory. Overall, clinical guidelines recommend the use of target-specific oral anticoagulants over vitamin K antagonists for secondary prevention of stroke in patients with atrial fibrillation. However, many patients with atrial fibrillation and previous stroke are not receiving the appropriate antithrombotic treatment, perhaps due to the perceived risks of anticoagulation including the risk of hemorrhagic transformation of an ischemic stroke. The ENGAGE AF-TIMI 48 trial showed that although edoxaban 60 mg and warfarin reduced the risk of stroke to a similar extent, edoxaban exhibited a lesser risk of bleeding, particularly intracranial hemorrhage. Importantly, these data were independent of the presence of prior stroke or transient ischemic attack. Therefore, edoxaban can be used in both primary and secondary prevention of stroke in patients with non-valvular atrial fibrillation. The aim of this review was to update the available evidence about edoxaban in the clinical management of secondary prevention in individuals with non-valvular atrial fibrillation. [ABSTRACT FROM AUTHOR]

Objective: This study aimed to evaluate whether fluvastatin therapy could decrease the probability of atrial fibrillation (AF) progression from paroxysmal AF to permanent AF and decrease the recurrence frequency of AF. Methods: Analyses were performed using two-tailed Student's t test or Mann-Whitney U tests. Categorical variables were compared with the χ2 statistics or Fisher's exact test. Patients with paroxysmal AF were randomized case-control, prospective into either the fluvastatin group (n=61) or control group (n=57). Patients were followed up for 24 months. The primary endpoint event was paroxysmal AF that progressed to permanent AF. Secondary endpoints were AF recurrence, cardiac dysfunction, stroke, or death. Results: There were no differences in AF progression (fluvastatin group, 8.19% vs. control group, 12.51%; p>0.05) and stroke (fluvastatin group. 6.55% vs. control group. 8.77%; p>0.05). Patients in the fluvastatin group had a lower rate of AF recurrence (fluvastatin group, 24.59% vs. control group, 49.12%; p<0.05) and a lower rate of cardiac dysfunction (fluvastatin group, 6.55% vs. control group, 19.29%; p<0.05). Death did not occur in both the groups. After 1 week of fluvastatin therapy, C-reactive protein (CRP) and homocysteine (HCY) levels were lower in the fluvastatin group than in the control group. At 24 months of follow-up, CRP and HCY levels remained lower in the fluvastatin group than in the control group. The number of endothelial progenitor cells (EPCs) increased in the fluvastatin group compared with that in the control group (fluvastatin group, 72.27±12.49 counts/105 vs. control group, 57.45±8.24 counts/105, p=0.001). Conclusion: Fluvastatin therapy could not decrease AF progression. However, it could decrease the recurrence frequency of paroxysmal AF and cardiac dysfunction. This may occur because of depressing inflammation and improving circulating EPCs. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the association between chocolate intake and incident clinically apparent atrial fibrillation or flutter (AF).Methods: The Danish Diet, Cancer, and Health Study is a large population-based prospective cohort study. The present study is based on 55 502 participants (26 400 men and 29 102 women) aged 50-64 years who had provided information on chocolate intake at baseline. Incident cases of AF were ascertained by linkage with nationwide registries.Results: During a median of 13.5 years there were 3346 cases of AF. Compared with chocolate intake less than once per month, the rate of AF was lower for people consuming 1-3 servings/month (hazard ratio (HR) 0.90, 95% confidence interval (CI) 0.82 to 0.98), 1 serving/week (HR 0.83, 95% CI 0.74 to 0.92), 2-6 servings/week (HR 0.80, 95% CI 0.71 to 0.91) and ≥1 servings/day (HR 0.84, 95% CI 0.65 to 1.09; p-linear trend <0.0001), with similar results for men and women.Conclusions: Accumulating evidence indicates that moderate chocolate intake may be inversely associated with AF risk, although residual confounding cannot be ruled out. [ABSTRACT FROM AUTHOR]

Background: Atrial fibrillation (AF) after cardiac surgery is a common complication that may influence patients' early and long term outcomes and hospital costs. The purpose of this study was to assess the effect of fish oil on occurrence of AF following coronary artery bypass graft surgery (CABG).Methods: This study was a single-center, randomized, double blinded, placebo-controlled clinical trial. Four-hundred and one patients undergoing coronary artery bypass graft surgery were randomly assigned to receive 2 g/d fish oil or placebo (olive oil) for at least 5 days before surgery. The primary end point was defined as time to AF improvement After AF incidence following isolated CABG or a need for pharmacologic therapy or cardioversion.Results: The time to AF improvement in intervention group was shorter than control group (HR: 2.05; 95% CI = 0.70-6.22, P = 0.20). The incidence of AF in the intervention and control groups was 8.40% vs. 14.07% respectively (p = 0.07). Mean total duration of AF was 20.96 ± 4.71 h in intervention groups and 46.87 ± 7.44 h in control groups (p = 0.04). Mean duration of stay in the ICU and total hospital stay showed a significant reduction in the intervention group (p = 0.003 and p = 0.04, respectively).Conclusion: The consumption of PUFA leads to a shorter time to AF improvement, which was not statistically significant. The incidence of AF in patients undergoing CABG surgery was decreased by approximately 5.7%; which was statistically on the borderline. Fish oil reduced median length of stay in the ICU and hospital. Further well-designed studies are needed to overcome the limitations of the existing trials and provide conclusive conclusions. [ABSTRACT FROM AUTHOR]

Atrial fibrillation (AF) represents one of the most common preventable causes of stroke, conferring a fivefold increased risk of stroke. The risk of stroke caused by AF is underestimated, many AF episodes being asymptomatic. Embolic strokes caused by AF can be prevented using anticoagulant therapy. The ESC (European Society of Cardiology) guidelines for patients with AF recommend anticoagulant therapy if the risk for embolic stroke / systemic embolism, evaluated with the CHA2DS2-VASc score, is high. Bleeding is the major complication of anticoagulant therapy. For every patient taking anticoagulant medication, HAS-BLED score assessing the risk of bleeding needs to be performed. The priorities in treating patients with atrial fibrillation are protection against embolic events and minimal risk of hemorrhagic events. Vitamin K antagonists, despite their accessibility and long term use, have important limitations. New/direct oral anticoagulants are better options, with alt least identical efficacy and higher safety profile. In real life, the choice of the appropriate anticoagulant agent could be challenging. [ABSTRACT FROM AUTHOR]

Study Objective: To determine whether perioperative landiolol administration suppresses postoperative atrial fibrillation (AF) and the plasma cytokines elevation in patients undergoing esophageal cancer surgery.Design: A prospective, randomized controlled trial.Setting: Akita University Hospital, Akita, Japan, from April 2012 to January 2015.Patients: Forty American Society of Anesthesiologists grade I-II patients undergoing elective esophagectomy.Interventions: Patients were randomly divided into two groups, landiolol group (landiolol: 5μg/kg/min) and control group (the same volume of covered saline). Landiolol or saline was infused continuously from the induction of anesthesia until next morning.Measurements: We examined the new onset of AF and sinus tachycardia, and measured plasma concentrations of cytokines (IL-1β, IL-6, IL-8, IL-10, and TNF-α) just before surgery, at the end of surgery, the next day, and 2days after surgery. Data (mean±SD) were analyzed using two-way ANOVA followed by the Bonferroni"s test for post hoc comparison; a P<0.05 was considered statistically significant.Main Results: Demographic data were similar between the landiolol and the control groups. The incidence of AF was significantly lower in the landiolol group (1/19=5.3%) compared with the control group (7/20=35%) as well as sinus tachycardia (landiolol group, 0/19=0% vs. control group, 5/20=25%). Plasma IL-6 level at the end of surgery was significantly lower in the landiolol group compared with the control group, but the other plasma cytokines levels were similar between the two groups during the entire study period.Conclusions: Perioperative landiolol administration suppressed the incidence of new-onset of AF as well as sinus tachycardia, and the plasma IL-6 elevation in patients undergoing esophageal cancer surgery. [ABSTRACT FROM AUTHOR]

Objectives: Atrial fibrillation (AF) is associated with increased morbidity and mortality in patients with hypertrophic cardiomyopathy (HCM). The primary aim of this study (HCM Risk-AF) was to determine the predictors of AF in a large multicentre cohort of patients with HCM. Exploratory analyses were performed to investigate the association between AF and survival and the efficacy of antiarrhythmic therapy in maintaining sinus rhythm (SR).Methods: A retrospective, longitudinal cohort of patients recruited between 1986 and 2008 in seven centres was used to develop multivariable Cox regression models fitted with preselected predictors. HCM was defined as unexplained hypertrophy (maximum left ventricular wall thickness of ≥15 mm or in accordance with published criteria for the diagnosis of familial disease). 28% of patients (n=1171) had coexistent hypertension. The primary end point was paroxysmal, permanent or persistent AF detected on ECG, Holter monitoring or implantable device interrogation.Results: Of the 4248 patients with HCM without pre-existing AF, 740 (17.4%) reached the primary end point. Multivariable Cox regression revealed an association between AF and female sex, age, left atrial diameter, New York Heart Association (NYHA) class, hypertension and vascular disease. The proportion of patients with cardiovascular death at 10 years was 4.9% in the SR group and 10.9% in the AF group (difference in proportions=5.9%; 95% CI (4.1% to 7.8%)). The proportion of patients with non-cardiovascular death at 10 years was 3.2% in the SR group and 5.9% in the AF group (difference in proportions=2.8%; 95% CI (0.1% to 4.2%)). An intention-to-treat propensity score analysis demonstrated that β-blockers, calcium channel antagonists and disopyramide initially maintained SR during follow-up, but their protective effect diminished with time. Amiodarone therapy did not prevent AF during follow-up.Conclusion: This study shows that patients with HCM who are at risk of AF development can be identified using readily available clinical parameters. The development of AF is associated with a poor prognosis but there was no evidence that antiarrhythmic therapy prevents AF in the long term. [ABSTRACT FROM AUTHOR]

Background: A strategy of limited preoperative fasting, with carbohydrate (CHO) loading and intraoperative infusion of omega-3 polyunsaturated fatty acids (ω-3 PUFA), has seldom been tried in cardiovascular surgery. Brief fasting, followed by CHO intake 2 h before anesthesia, may improve recovery from CABG procedures and lower perioperative vasoactive drug requirements. Infusion of ω-3 PUFA may reduce occurrences of postoperative atrial fibrillation (POAF) and shorten hospital stays. The aim of this study was to assess morbidity (especially POAF) in ICU patients after coronary artery bypass grafting (CABG)/cardiopulmonary bypass (CPB) in combination, if preoperative fasts are curtailed in favor of CHO loading, and ω-3 PUFA are infused intraoperatively.Methods: Fifty-seven patients undergoing CABG were randomly assigned to receive 12.5% maltodextrin (200 ml, 2 h before anesthesia), without infusing ω-3 PUFA (CHO, n = 14); water (200 ml, 2 h before anesthesia), without infusing ω-3 PUFA (controls, n = 14); 12.5% maltodextrin (200 ml, 2 h before anesthesia) plus intraoperative ω-3 PUFA (0.2 mcg/kg) (CHO + W3, n = 15); or water (200 ml, 2 h before anesthesia) plus intraoperative ω-3 PUFA (0.2 mcg/kg) (W3, n = 14). Perioperative clinical variables and mortality were analyzed, examining the incidence of POAF, as well as the need for inotropic vasoactive drugs during surgery and in ICU.Results: Two deaths occurred (3.5%), but there were no instances of bronchoaspiration and mediastinitis. Neither ICU stays nor total postoperative stays differed by group (P > 0.05). Patients given preoperative CHO loads (CHO and CHO + W3 groups) experienced fewer instances of hospital infection (RR = 0.29, 95%CI 0.09-0.94; P = 0.023) and were less reliant on vasoactive amines during surgery (RR = 0.60, 95% CI 0.38-0.94; P = 0.020). Similarly, the number of patients requiring vasoactive drugs while recovering in ICU differed significantly by group (P = 0.008), showing benefits in patients given CHO loads. The overall incidence of POAF was 29.8% (17/57), differing significantly by group (P = 0.009). Groups given ω-3 PUFA (W3 and CHO + W3 groups) experienced significantly fewer instances of POAF (RR = 4.83, 95% CI 1.56-15.02; P = 0.001).Conclusion: Preoperative curtailment of fasting was safe in this cohort. When implemented in conjunction with CHO loading and infusion of ω-3 PUFA during surgery, expedited recovery from CABG with CPB was observed.Trial Registration: NCT: 03017001. [ABSTRACT FROM AUTHOR]

Atrial fibrillation (AF) is an increasing burden worldwide. However, AF prevention has not been emphasized enough in clinical practice or guidelines. In this paper, the authors review the associations of modifiable lifestyle factors, including alcohol abuse, smoking, physical inactivity, and unhealthy psychological stress, with the risk for AF development. The authors also review the associations of cardiovascular risk factors that can be better managed, including obesity and overweight, high blood pressure, diabetes, dyslipidemia, obstructive sleep apnea, and other cardiovascular diseases, with the risk for AF. The conclusion is that a high proportion of AF can be prevented by combining strategies, focusing on the high-risk population for better risk factor management, and emphasizing healthy lifestyle choices in the whole population. [ABSTRACT FROM AUTHOR]

Background/purpose: In the past, warfarin was the drug of choice for stroke prevention in patients with atrial fibrillation (AF). Recently, non-vitamin K antagonist oral anticoagulants (NOACs) have been approved as an alternative to warfarin in nonvalvular AF. However, there is a limited amount of real-world data on how NOACs are currently being used in Taiwan. This study was conducted to investigate the factors driving the initiation of anticoagulants and the selection of different anticoagulants in patients with AF.Methods: We used National Taiwan University Hospital's electronic database to identify all nonvalvular AF patients from January 1, 2007 to December 31, 2013. Multivariate logistic regression models were used to examine the factors driving the initiation of anticoagulants and the selection of different anticoagulants.Results: Among AF patients, 66.4% of anticoagulants users used NOACs instead of warfarin after the era of NOACs. Patients with female sex, hypertension, ischemic heart disease, cancer, hepatic disease, renal disease, bleeding history, and aspirin use were less likely to be anticoagulant users but are more likely to be anticoagulant users with a history of stroke (odds ratio = 2.64; 95% confidence interval, 2.02-3.45). Older age, ischemic heart disease, and aspirin use were the factors associated with NOACs usage, whereas hepatic disease showed the opposite results (odds ratio = 0.09; 95% confidence interval, 0.02-0.42).Conclusion: Stroke history was associated with anticoagulant use, whereas comorbidities associated with increased risk of bleeding showed the opposite result. Patients with hepatic disease were less likely to use NOACs. [ABSTRACT FROM AUTHOR]

Background With an increasing number of options for atrial fibrillation (AF) stroke prophylaxis, there are several medication-related factors to consider. This study aimed to gain a better understanding of which preference factors influence patient decisions when selecting AF stroke prophylaxis. Objective To determine the factors that influence patient stroke prophylaxis decisions and preferred therapeutic options. Methods A questionnaire about AF stroke prophylaxis medication options was distributed to participants at risk of AF. Preferences were elicited through ranking and rating medication preference factor statements, then selecting most and least preferred treatment options. Results Reduced stroke risk and lowest risk of an intracranial haemorrhage (ICH) had the highest median preference factor ranking of 2 (IQR, 1-3.5 for stroke reduction; 2-4 for ICH risk). Reducing stroke risk, availability of a lab test to assess drug effect, and availability of an antidote were the preference factors with the highest ratings. Apixaban was the most preferred treatment option (44% blinded to drug name, 37% unblinded) while 'No treatment' was the least preferred option (48% blinded, 52% unblinded). Conclusions Reducing stroke risk and limiting ICH risk were the most important medication factors to participants. High inter-participant preference variability suggests the importance of including the patient in decision-making when selecting AF stroke prophylaxis. [ABSTRACT FROM AUTHOR]

Background: The risk of sudden cardiac death (SCD) in patients with heart failure after coronary artery bypass graft surgery (CABG) has not been examined in a contemporary clinical trial of surgical revascularization. This analysis describes the incidence, timing, and clinical predictors of SCD after CABG.Methods: Patients enrolled in the STICH trial (Surgical Treatment of Ischemic Heart Failure) who underwent CABG with or without surgical ventricular reconstruction were included. We excluded patients with prior implantable cardioverter-defibrillator and those randomized only to medical therapy. The primary outcome was SCD as adjudicated by a blinded committee. A Cox model was used to examine and identify predictors of SCD. The Fine and Gray method was used to estimate the incidence of SCD accounting for the competing risk of other deaths.Results: Over a median follow-up of 46 months, 113 of 1411 patients who received CABG without (n = 934) or with (n = 477) surgical ventricular reconstruction had SCD; 311 died of other causes. The mean left ventricular ejection fraction at enrollment was 28±9%. The 5-year cumulative incidence of SCD was 8.5%. Patients who had SCD and those who did not die were younger and had fewer comorbid conditions than did those who died of causes other than SCD. In the first 30 days after CABG, SCD (n=5) accounted for 7% of all deaths. The numerically greatest monthly rate of SCD was in the 31- to 90-day time period. In a multivariable analysis including baseline demographics, risk factors, coronary anatomy, and left ventricular function, end-systolic volume index and B-type natriuretic peptide were most strongly associated with SCD.Conclusions: The monthly risk of SCD shortly after CABG among patients with a low left ventricular ejection fraction is highest between the first and third months, suggesting that risk stratification for SCD should occur early in the postoperative period, particularly in patients with increased preoperative end-systolic volume index or B-type natriuretic peptide.Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT0002359. [ABSTRACT FROM AUTHOR]

Background and Objectives: The aim of this study was to evaluate the cost effectiveness of novel oral anticoagulants (NOACs) for stroke prevention among atrial fibrillation (AF) patients by incorporating Taiwanese demographic information derived from a population-based database, the National Health Insurance Research Database (NHIRD), into cost-effectiveness analysis. Methods: From 1 January to 31 December 2012, 98,213 AF patients were selected from the NHIRD database. A Markov model was constructed that combined published secondary data with the Taiwan NHIRD to compare the cost and incremental cost effectiveness of apixaban 5 mg twice daily, dabigatran 110 or 150 mg twice daily, rivaroxaban 20 mg once daily, and warfarin. Results: The lifetime costs of warfarin, dabigatran 110 mg, dabigatran 150 mg, rivaroxaban 20 mg, and apixaban 5 mg were US$10,660, US$13,693, US$13,426, US$13,455, US$15,965, respectively. Apixaban resulted in an incremental cost effectiveness of US$39,351, US$27,039, US$41,298, and US$48,896 per quality-adjusted life-year (QALY) compared with warfarin, dabigatran 110 mg, dabigatran 150 mg, and rivaroxaban 20 mg, respectively. In Monte-Carlo analyses, apixaban 5 mg, rivaroxaban 20 mg, warfarin, and dabigatran 110 mg were cost effective in 83, 10.4, 7, and 0.8%, respectively, of the simulations using a willingness-to-pay (WTP) threshold of US$50,000 per QALY. Conclusions: Apixaban was more cost effective than warfarin, dabigatran, and rivaroxaban for stroke prevention in patients with AF. Among the anticoagulant therapies, the WTP threshold of apixaban was about US$50,000 per QALY gained. These cost-effectiveness estimations provide useful information to aid clinical decision making in stroke prevention for AF patients. [ABSTRACT FROM AUTHOR]

Purpose. Recently published practice guidelines and research reports on pharmacotherapy in critical care patient populations are summarized. Summary. The Critical Care Pharmacotherapy Literature Update (CCPLU) Group is composed of over 50 experienced critical care pharmacists who evaluate 31 peer-reviewed journals monthly to identify literature pertaining to pharmacotherapy in critical care populations. Articles are chosen for summarization in a monthly CCPLU Group publication on the basis of applicability and relevance to clinical practice and strength of study design. From January to December 2015, a total of 121 articles were summarized; of these, 3 articles presenting clinical practice guidelines and 12 articles presenting original research indings were objectively selected for inclusion in this review based on their potential to change or reinforce current evidence-based practice. The reviewed guidelines address the management of intracranial hemorrhage (ICH), adult advanced cardiac life support (ACLS) and post--cardiac arrest care, and the management of supraventricular tachycardia (SVT). The reviewed research reports address topics such as nutrition in critically ill adults, administration of β-lactams for severe sepsis, anticoagulant selection in the context of continuous renal replacement therapy, early goal-directed therapy in septic shock, magnesium use for neuroprotection in acute stroke, and progesterone use in patients with traumatic brain injury. Conclusion. Important recent additions to the critical care pharmacy literature include updated joint clinical practice guidelines on the management of spontaneous ICH, ACLS, and SVT. [ABSTRACT FROM AUTHOR]

Aims: Previous studies indicate that South Asians (SAs) may have a reduced risk of developing atrial fibrillation (AF) despite having a higher prevalence of traditional cardiovascular risk factors. This observational study was designed to explore the relative differences between SAs and Whites in a well-defined, multi-ethnic population with careful consideration of traditional cardiovascular risk factors that are thought to contribute to the development of AF.Methods and results: Anonymized data from 417 575 adults were sourced from primary care records within Bradford Metropolitan District, UK. Atrial fibrillation diagnosis was indicated by the presence on the AF Quality Outcomes Framework register. Self-reported ethnicity was mapped to census ethnic codes. The age-standardized prevalence rates of AF were calculated for comparison between the White and SA populations; our study sample presented relative proportions of 2.39 and 0.4%. Multivariable logistic regression analysis was performed to estimate the odds of developing AF given SA ethnicity. Adjustment for age, sex, and established risk factors found a 71% reduction in odds of AF in SAs when compared with Whites [odds ratio (OR): 0.29, 95% confidence interval (CI): 0.26-0.32]. When stratified by ethnicity, analyses revealed significantly different odds of AF for patients with diabetes; diabetes was not associated with the development of AF in the SA population (0.81, 95% CI: 0.63-1.05).Conclusion: This study, in a multi-ethnic population, presents ethnicity as a predictor of AF in which prevalence is significantly lower in SAs when compared with Whites. This is despite SAs having a higher frequency of established risk factors for the development of AF, such as ischaemic heart disease, heart failure, hypertension, and type 2 diabetes. These findings are consistent with previous literature and add weight to the need for further investigation, although this is the first study to investigate the differential associations of individual risk factors with development of AF. [ABSTRACT FROM AUTHOR]

Bradycardia, atrial stretch and dilatation, autonomic nervous system disorders, and the presence of triggers such as atrial premature contractions, are factors which predispose a person to paroxysmal AF. Atrial pacing not only eliminates bradycardia but also prevents atrial premature contractions and dispersion of refractoriness, which are a substrate for atrial fibrillation. As the prolonged duration of atrial activation during pacing, especially from locations changing the physiological pattern of this activation (right atrium lateral wall, right atrium appendage), negatively influences both a mechanical and an electrical function of the atria, the atrial pacing site affects an atrial arrhythmogenesis. A conventional atrial lead location in the right atrium appendage causes non-physiological activation propagation, resulting in a prolongation of the activation time of both atria. This location is optimal according to a passive fixation of the atrial lead but the available contemporary active fixation leads could potentially be located in any area of the atrium. There is growing evidence of the benefit of pacing, imitating the physiological propagation of impulses within the atria. It seems that the Bachmann's bundle pacing is the best pacing site within the atria, not only positively influencing the atrial mechanical function but also best fulfilling the so-called atrial resynchronization function, in particular in patients with interatrial conduction delay. It can be effectively achieved using only one atrial electrode, and the slight shortening of atrioventricular conduction provides an additional benefit of this atrial pacing site. [ABSTRACT FROM AUTHOR]

Atrial fibrillation (AF) remains an important clinical problem with severe complications such as stroke, which especially harms those with risk factors as calculated by the CHADS2 or CHA2DS2-VASc. Until now, no therapy has proven 100% effective against AF. Since the left atrial appendage (LAA) is the most prominent nonvalvular AF-related thromboembolic source and (novel) oral anticoagulant [(N)OAC] carries the hazard of bleeding, LAA occlusion may be an alternative, especially in patients who are ineligible for (N)OAC therapy. In this review, we discuss several LAA occlusion techniques with a focus on the Watchman device since this device is the most thoroughly studied device of all. [ABSTRACT FROM AUTHOR]

Background: GLORIA-AF (Global Registry on Long-Term Oral Antithrombotic Treatment in Patients with Atrial Fibrillation) is a prospective, global registry program describing antithrombotic treatment patterns in patients with newly diagnosed nonvalvular atrial fibrillation at risk of stroke. Phase 2 began when dabigatran, the first non-vitamin K antagonist oral anticoagulant (NOAC), became available.Objectives: This study sought to describe phase 2 baseline data and compare these with the pre-NOAC era collected during phase 1.Methods: During phase 2, 15,641 consenting patients were enrolled (November 2011 to December 2014); 15,092 were eligible. This pre-specified cross-sectional analysis describes eligible patients' baseline characteristics. Atrial fibrillation disease characteristics, medical outcomes, and concomitant diseases and medications were collected. Data were analyzed using descriptive statistics.Results: Of the total patients, 45.5% were female; median age was 71 (interquartile range: 64, 78) years. Patients were from Europe (47.1%), North America (22.5%), Asia (20.3%), Latin America (6.0%), and the Middle East/Africa (4.0%). Most had high stroke risk (CHA2DS2-VASc [Congestive heart failure, Hypertension, Age ≥75 years, Diabetes mellitus, previous Stroke, Vascular disease, Age 65 to 74 years, Sex category] score ≥2; 86.1%); 13.9% had moderate risk (CHA2DS2-VASc = 1). Overall, 79.9% received oral anticoagulants, of whom 47.6% received NOAC and 32.3% vitamin K antagonists (VKA); 12.1% received antiplatelet agents; 7.8% received no antithrombotic treatment. For comparison, the proportion of phase 1 patients (of N = 1,063 all eligible) prescribed VKA was 32.8%, acetylsalicylic acid 41.7%, and no therapy 20.2%. In Europe in phase 2, treatment with NOAC was more common than VKA (52.3% and 37.8%, respectively); 6.0% of patients received antiplatelet treatment; and 3.8% received no antithrombotic treatment. In North America, 52.1%, 26.2%, and 14.0% of patients received NOAC, VKA, and antiplatelet drugs, respectively; 7.5% received no antithrombotic treatment. NOAC use was less common in Asia (27.7%), where 27.5% of patients received VKA, 25.0% antiplatelet drugs, and 19.8% no antithrombotic treatment.Conclusions: The baseline data from GLORIA-AF phase 2 demonstrate that in newly diagnosed nonvalvular atrial fibrillation patients, NOAC have been highly adopted into practice, becoming more frequently prescribed than VKA in Europe and North America. Worldwide, however, a large proportion of patients remain undertreated, particularly in Asia and North America. (Global Registry on Long-Term Oral Antithrombotic Treatment in Patients With Atrial Fibrillation [GLORIA-AF]; NCT01468701). [ABSTRACT FROM AUTHOR]

Atrial fibrillation (AF) is the most common cardiac arrhythmia, which is related to many cardiac and cerebral vascular diseases, especially stroke. It can therefore increase cardiovascular mortality and all-cause death. The current treatments of AF remain to be western drugs and radiofrequency ablation which are limited by the tolerance of patients, adverse side effects, and high recurrence rate, especially for the elderly. On the contrary, traditional Chinese medicine (TCM) with long history of use involves various treatment methods, including Chinese herbal medicines (CHMs) or bioactive ingredients, Chinese patent medicines, acupuncture, Qigong, and Tai Chi Chuan. With more and more researches reported, the active roles of TCM in AF management have been discovered. Then it is likely that TCM would be effective preventive means and valuable additional remedy for AF. The potential mechanisms further found by numerous experimental studies showed the distinct characteristics of TCM. Some CHMs or bioactive ingredients are atrial-selective, while others are multichannel and multifunctional. Therefore, in this review we summarized the treatment strategies reported in TCM, with the purpose of providing novel ideas and directions for AF management. [ABSTRACT FROM AUTHOR]

Background: Postoperative atrial fibrillation/flutter (POAF) is associated with significant morbidity and mortality after general thoracic surgery, but the need for and the best agent for prophylaxis remains obscure.Methods: A systematic literature search was performed to identify randomized controlled trials that compared regimens for POAF prophylaxis after general thoracic surgery. Random-effects meta-analyses with trial sequential analyses were performed to compare the effects of medical prophylaxis vs placebo/usual care. The risk of POAF among patients receiving various prophylactic regimens was subjected to Bayesian network meta-analysis.Results: Twenty-two trials (2,891 patients and 11 regimens) were included. Overall, medical prophylaxis reduced the incidence of POAF (OR, 0.33; 95% CI, 0.22-0.49) but not short-term mortality (OR, 0.85; 95% CI, 0.41-1.73). There was no significant difference in patient withdrawal due to adverse events (OR, 1.67; 95% CI, 0.67-4.16). Trial sequential analysis showed that as of 2012, sufficient evidence had accrued in support of the effectiveness of medical prophylaxis in reducing POAF after general thoracic surgery. In network meta-analysis, β-blockers, angiotensin-converting enzyme inhibitors, amiodarone, magnesium, and calcium channel blockers significantly reduced the risk of POAF compared with placebo/usual care. β-Blockers had the highest probability of being the most effective agents (OR, 0.12; 95% credible interval [CrI], 0.05-0.27; probability of being best, 77.7%; number needed to treat, 5.2).Conclusions: The current literature supports the effectiveness and tolerability of medical prophylaxis and the superiority of β-blockers in preventing POAF after general thoracic surgery. β-Blockers are recommended, taking into consideration the status of the bronchopulmonary system. [ABSTRACT FROM AUTHOR]

Purpose. The effect of perioperative supplementation of polyunsaturated omega-3 fatty acid (PUFA) on the frequency of atrial fibrillation (AF) in patients without a history of AF was evaluated. Methods. A total of 561 patients were randomized to receive either 1 g of PUFA or placebo twice daily. Treatment was started up to five days before surgery or within 24 hours after surgery, depending on when consent was received. Treatment was continued until the patient's follow-up visit with the cardiologist up to four weeks after surgery. The primary endpoint of the study was AF before hospital discharge. Secondary endpoints included AF within one week after surgery, AF within one month after surgery, length of hospital stay, postoperative bleeding complications, and readmission within one month after surgery. Results. No significant reduction in the risk of AF was observed at hospital discharge (relative risk [RR], 0.98; p = 0.922) or at three weeks after surgery (RR, 0.98; p = 0.844). After restricting the analysis to treatment-adherent patients, the association remained nonsignificant at hospital discharge (RR, 0.90; p = 0.374) and at three weeks after surgery (RR, 0.90; p = 0.330). No significant differences were observed between treatments for rates of readmission, death, and bleeding complications or the length of hospital stay. Conclusion. Perioperative supplementation with PUFA did not decrease the risk of AF in the immediate postoperative period. PUFA also had no effect on the length of hospital stay, postoperative bleeding complications, and readmissions within one month after surgery. [ABSTRACT FROM AUTHOR]

Objectives: Antioxidant supplement is an option in preventing postoperative atrial fibrillation (AF) after cardiac surgery. However, the benefits and adverse effects of vitamin C have not been well assessed. We aimed to systematically evaluate the efficacy and safety of vitamin C in preventing postoperative AF in adult patients after cardiac surgery.Methods: PubMed, EMBASE, and the Cochrane library databases from inception to September 2016 were searched. Randomized controlled trials (RCTs) that evaluated the efficacy and safety of vitamin C in preventing postoperative AF in adult patients after cardiac surgery were identified. The primary outcome was the incidence of postoperative AF. Secondary outcomes included the length of intensive care unit (ICU) stay, length of hospital stay, and stroke events.Results: Eight RCTs incorporating 1060 patients were included. Compared with placebo group, vitamin C treatment was associated with a substantial reduction in postoperative AF (OR, 0.47; 95% CI, 0.36-0.62; evidence rank: moderate), with no significant heterogeneity (I2 44%; P = 0.09). Trial sequential analysis showed that the cumulative Z-curve crossed the trial sequential monitoring boundary for benefit, establishing sufficient and conclusive evidence. In addition, vitamin C administration was not associated with any length of stay, including in the ICU (evidence rank: low) and hospital (evidence rank: low), respectively.Conclusions: Short-term treatment with vitamin C is safe, and may reduce the incidence of postoperative AF after cardiac surgery. Future studies as well as more high quality RCTs are still warranted to confirm the effects of different durations of vitamin C on cardiac surgery. [ABSTRACT FROM AUTHOR]

Purpose. Results of a systematic review and meta-analysis of published data on use of ascorbic acid to prevent postoperative atrial fibrillation (POAF) after cardiac surgery are presented. Methods. MEDLINE and other sources were searched for reports on trials evaluating the effects of preoperative and/or postoperative use of ascorbic acid in patients undergoing cardiac surgery. For each study selected for meta-analysis, an assessment for risks of methodological bias was performed. Data on POAF frequency and length of stay (LOS) outcomes were pooled and analyzed via random-effects modeling. Results. The 11 identified studies involved patients receiving coronary artery bypass grafts with or without valve replacement; both i.v. and oral ascorbic acid formulations were used. Analysis of pooled outcomes data on treatment and control groups indicated that ascorbic acid prophylaxis was associated with reductions in POAF frequency (odds ratio, 0.44; 95% confidence interval [CI], 0.32 to 0.61), intensive care unit (ICU) LOS (difference in means, -0.24 day; 95% CI, -0.45 to -0.03 day), and total hospital LOS (difference in means, -0.94 day; 95% CI, -1.65 to -0.23 day). Significant statistical, methodological, and clinical heterogeneity were observed. Conclusion. A meta-analysis revealed that, compared with use of a placebo or a nonplacebo control, perioperative administration of ascorbic acid to patients undergoing cardiac surgery was associated with a reduced frequency of POAF and a shorter ICU LOS and total hospital LOS. [ABSTRACT FROM AUTHOR]

The aim of the present study was to confirm the effect of Tanshinone IIA (TAN) on the prevention of AF in chronic heart failure (CHF), and to elucidate the underlying electrophysiological mechanisms for the antiarrhythmic effects of TAN at the level of the atrium in an experimental model of CHF. In 10 female rabbits, CHF was induced by rapid ventricular pacing, leading to a significant decrease in ejection fraction in the presence of a dilated left ventricle and atrial enlargement. Twelve rabbits were sham-operated and served as controls. Isolated hearts were perfused using the Langendorff method. Burst pacing was used to induce AF. Monophasic action potential recordings showed an increase of atrial action potential duration (aAPD) and effective refractory period (aERP) in CHF hearts compared with sham hearts. Infusion of acetylcholine (1 μm) and isoproterenol (1 μm) led to AF in all failing hearts and in 11 sham hearts. Simultaneous infusion of TAN (10 μm) remarkably reduced inducibility of AF in 50% of sham and 50% of failing hearts. TAN had no effect on aAPD but significantly increased aERP, leading to a marked increase in atrial post-repolarization refractoriness. Moreover, TAN application moderately increased interatrial conduction time. TAN has been shown to be effective in reducing the inducibility of AF in an experimental model of AF. The antiarrhythmic effect is mainly due to prolongations of atrial post-repolarization refractoriness and a moderate increase in interatrial conduction time. [ABSTRACT FROM AUTHOR]

The article offers information on a study which aims to automatically distinguish scomplex fractionated atrial electrogram originating from active versus passive tissue sites by means of directly quantifying how recurrent a electrogram confirmation is. It mentions use of monophasic action potential catheters to measure the local refractoriness of atrial tissue; and also mentions use of recurrence quantification analysis, technique used to evaluate recurring patterns within complex signals.

A best evidence topic in cardiac surgery was written according to a structured protocol addressing the question 'for post‐cardiac surgery atrial fibrillation (AF), do clinical outcomes differ between rate or rhythm control strategies?' Altogether, 2174 papers were found using the reported searches, of which 5 represented the best evidence to answer the clinical question. Hospital length of stay ranged from 5.0 to 13.2 days for rate control and 5.2 to 10.3 days for rhythm control. Freedom from AF at follow up was achieved in 84.2–91 and 84.2–96% in rate and rhythm control groups respectively. Minimal serious adverse events were noted in all studies analysed and there was no difference between rate and rhythm control groups. We conclude that in the management of post‐cardiac surgery, AF, rate control and rhythm control are equivalent in terms of hospital length of stay, freedom from arrhythmia at follow up and complication rates. [ABSTRACT FROM AUTHOR]

The article presents a case study of a 47‐year‐old man who came for a second opinion on recently diagnosed atrial fibrillation (AF). Topics discussed include the CHADS‐VASc risk score of the patient; the last known electrocardiogram of the patient; and the use of drugs to control the heart rate of the patient. Also mentioned is the cardioversion performed on the patient to restore sinus rhythm.