Search

Aims A strategy of systematic, early rhythm control (ERC) improves cardiovascular outcomes in patients with atrial fibrillation (AF). It is not known how this outcome-reducing effect is mediated. Methods and results Using the Early treatment of Atrial Fibrillation for Stroke prevention Trial (EAST—AFNET 4) data set, potential mediators of the effect of ERC were identified in the total study population at 12-month follow up and further interrogated by use of a four-way decomposition of the treatment effect in an exponential model predicting future primary outcome events. Fourteen potential mediators of ERC were identified at the 12-month visit. Of these, sinus rhythm at 12 months explained 81% of the treatment effect of ERC compared with usual care during the remainder of follow up (4.1 years). In patients not in sinus rhythm at 12 months, ERC did not reduce future cardiovascular outcomes (hazard ratio 0.94, 95% confidence interval 0.65–1.67). Inclusion of AF recurrence in the model only explained 31% of the treatment effect, and inclusion of systolic blood pressure at 12 months only 10%. There was no difference in outcomes in patients who underwent AF ablation compared with those who did not undergo AF ablation. Conclusion The effectiveness of early rhythm control is mediated by the presence of sinus rhythm at 12 months in the EAST-AFNET 4 trial. Clinicians implementing ERC should aim for rapid and sustained restoration of sinus rhythm in patients with recently diagnosed AF and cardiovascular comorbidities.

Background: The randomized EAST-AFNET4 (Early Treatment of Atrial Fibrillation for Stroke Prevention Trial–Atrial Fibrillation Network) demonstrated that early rhythm control (ERC) reduces adverse cardiovascular outcomes in patients with recently diagnosed atrial fibrillation and stroke risk factors. The effectiveness and safety of ERC in patients with multiple cardiovascular comorbidities is not known. Methods: These prespecified subanalyses of EAST-AFNET4 compared the effectiveness and safety of ERC with usual care (UC) stratified into patients with higher (CHA 2 DS 2 -VASc score ≥4) and lower comorbidity burden. Sensitivity analyses ignored sex (CHA 2 DS 2 -VA score). Results: EAST-AFNET4 randomized 1093 patients with CHA 2 DS 2 -VASc score ≥4 (74.8±6.8 years, 61% female) and 1696 with CHA 2 DS 2 -VASc score 2 DS 2 -VASc score ≥4 (ERC, 127/549 patients with events; UC, 183/544 patients with events; hazard ratio [HR], 0.64 [0.51–0.81]; P < 0.001) but not in patients with CHA 2 DS 2 -VASc score P =0.56, P interaction =0.037). The primary safety outcome (death, stroke, or serious adverse events of rhythm control therapy) was not different between study groups in patients with CHA 2 DS 2 -VASc score ≥4 (ERC, 112/549 patients with events; UC, 132/544 patients with events; HR, 0.84 [0.65, 1.08]; P =0.175), but occurred more often in patients with CHA 2 DS 2 -VASc scores P =0.019, P interaction =0.008). Life-threatening events or death were not different between groups (CHA 2 DS 2 -VASc score ≥4, ERC, 84/549 patients with event, UC, 96/544 patients with event; CHA 2 DS 2 -VASc scores 2 DS 2 -VA score), the P interaction was not significant for the primary efficacy outcome ( P =0.25), but remained significant ( P =0.044) for the primary safety outcome. Conclusions: Patients with recently diagnosed atrial fibrillation and CHA 2 DS 2 -VASc score ≥4 should be considered for ERC to reduce cardiovascular outcomes, whereas those with fewer comorbidities may have less favorable outcomes with ERC. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01288352. URL: https://www.clinicaltrialsregister.eu ; Unique identifier: 2010-021258-20. URL: https://www.isrctn.com/ ; Unique identifier: ISRCTN04708680.

Non-vitamin K antagonist oral anticoagulants (NOACs) are well-established as inhibitors of factor Xa (FXa) and thrombin in the treatment and prevention of thrombosis. However, there is growing evidence that beneficial outcomes might be based on additional pleiotropic effects beyond anticoagulation. FXa and thrombin are also known to activate protease-activated receptors (PARs), which can mediate pro-inflammatory and pro-fibrotic effects. Since PAR‑1 and PAR‑2 play an important role in the development of atherosclerosis, the inhibition of this pathway represents an interesting potential target for preventing the progression of atherosclerosis and fibrosis. This review focuses on potential pleiotropic effects of FXa inhibition with edoxaban seen in a variety of studies in different in vitro and in vivo test systems. As common findings from these experiments, edoxaban was able to attenuate FXa- and thrombin-induced pro-inflammatory and pro-fibrotic effects and decrease pro-inflammatory cytokine expression. In some, but not all experiments edoxaban was also shown to decrease the levels of PAR‑1 and PAR‑2 expression. Further studies are required to clarify the clinical implications of the pleiotropic effects mediated by NOACs.

MELAS syndrome is defined as a combination of mitochondrial myopathy, encephalopathy, lactic acidosis and stroke-like episodes resulting from mutations in mitochondrial DNA. All medical interventions in these patients appear challenging due to a high risk of lactate acidosis or anesthesiological complications. Of note, previous reports suggest that these patients have a higher incidence of Wolff-Parkinson-White (WPW) syndrome. Here, a case of successful catheter ablation of a posteroseptal bypass tract using analgosedation in a patient with MELAS syndrome combined with WPW syndrome is presented.Das MELAS-Syndrom ist eine Kombination aus mitochondrialer Myopathie, Enzephalopathie, Laktatazidosen und Schlaganfallsymptomen, bedingt durch Mutationen in der Mitochondrien-DNA. Da die betroffenen Patienten gehäuft zu bedrohlichen Laktatazidosen oder anästhesiologischen Komplikationen neigen, sind alle Interventionen oder Operationen mit einem hohen Risiko behaftet. Frühere Berichte deuten bemerkenswerterweise darauf hin, dass bei Patienten mit MELAS-Syndrom die Inzidenz des Wolff-Parkinson-White(WPW)-Syndroms erhöht ist. Wir berichten in der vorliegenden Kasuistik über die erfolgreiche Katheterablation einer posterolateralen akzessorischen Leitungsbahn unter Analgosedierung bei einer Patientin mit MELAS- und WPW-Syndrom.

ZUSAMMENFASSUNGVorhofflimmern (VHF) ist mit dem Auftreten von ischämischen Schlaganfällen assoziiert. Orale Antikoagulation kann das Auftreten von Schlaganfällen verhindern. Das Screening auf ein bislang nicht entdecktes VHF erscheint daher ein vielversprechender Ansatz, um das Auftreten von Schlaganfällen zu verhindern. Neben zahlreichen anderen wissenschaftlichen Studien liegen seit August 2021 die Ergebnisse von 2 Studien mit klinischen Endpunkten vor, die STROKESTOP- und die LOOP-Studie. Weitere wissenschaftliche Untersuchungen zu dieser Fragestellung befinden sich in der Durchführung.

Aims Clinical practice guidelines restrict rhythm control therapy to patients with symptomatic atrial fibrillation (AF). The EAST-AFNET 4 trial demonstrated that early, systematic rhythm control improves clinical outcomes compared to symptom-directed rhythm control. Methods and results This prespecified EAST-AFNET 4 analysis compared the effect of early rhythm control therapy in asymptomatic patients (EHRA score I) to symptomatic patients. Primary outcome was a composite of death from cardiovascular causes, stroke, or hospitalization with worsening of heart failure or acute coronary syndrome, analyzed in a time-to-event analysis. At baseline, 801/2633 (30.4%) patients were asymptomatic [mean age 71.3 years, 37.5% women, mean CHA2DS2-VASc score 3.4, 169/801 (21.1%) heart failure]. Asymptomatic patients randomized to early rhythm control (395/801) received similar rhythm control therapies compared to symptomatic patients [e.g. AF ablation at 24 months: 75/395 (19.0%) in asymptomatic; 176/910 (19.3%) symptomatic patients, P = 0.672]. Anticoagulation and treatment of concomitant cardiovascular conditions was not different between symptomatic and asymptomatic patients. The primary outcome occurred in 79/395 asymptomatic patients randomized to early rhythm control and in 97/406 patients randomized to usual care (hazard ratio 0.76, 95% confidence interval [0.6; 1.03]), almost identical to symptomatic patients. At 24 months follow-up, change in symptom status was not different between randomized groups (P = 0.19). Conclusion The clinical benefit of early, systematic rhythm control was not different between asymptomatic and symptomatic patients in EAST-AFNET 4. These results call for a shared decision discussing the benefits of rhythm control therapy in all patients with recently diagnosed AF and concomitant cardiovascular conditions (EAST-AFNET 4; ISRCTN04708680; NCT01288352; EudraCT2010-021258-20).

The present paper summarizes and comments on the latest 2022 ESC guidelines on ventricular tachycardia and sudden cardiac death. Most relevant recommendations for acute cardiovascular care physicians are addressed, particularly, in the fields of coronary artery disease, dilated cardiomyopathy, and inflammatory diseases. New recommendations encompass the implantation of a defibrillator (ICD) in the setting of acute myocarditis. Furthermore, the pathophysiology of the electrical storm including involved molecular pathways as well as the angry Purkinje fibre syndrome is presented and discussed.

Supplemental Digital Content is available in the text., Background: Even on optimal therapy, many patients with heart failure and atrial fibrillation experience cardiovascular complications. Additional treatments are needed to reduce these events, especially in patients with heart failure and preserved left ventricular ejection fraction. Methods: This prespecified subanalysis of the randomized EAST-AFNET4 trial (Early Treatment of Atrial Fibrillation for Stroke Prevention Trial) assessed the effect of systematic, early rhythm control therapy (ERC; using antiarrhythmic drugs or catheter ablation) compared with usual care (allowing rhythm control therapy to improve symptoms) on the 2 primary outcomes of the trial and on selected secondary outcomes in patients with heart failure, defined as heart failure symptoms New York Heart Association II to III or left ventricular ejection fraction [LVEF]

Patients with atrial fibrillation and a history of stroke are at high risk of recurrent stroke and cardiovascular complications. In the EAST-AFNET 4 trial we showed that a systematic strategy of early rhythm control was associated with a lower risk of cardiovascular outcomes than usual care in patients with atrial fibrillation diagnosed in the past 12 months. In this pre-specified subgroup analysis we aimed to assess whether a strategy of early rhythm control is safe and can prevent adverse cardiovascular outcomes compared with usual care in such patients.EAST-AFNET 4 was a randomised, open-label trial with blinded-outcome assessment done at 135 hospitals and secondary care practices in 11 European countries. Adults with early atrial fibrillation (ie, diagnosed ≤12 months before enrolment) were randomly assigned (1:1) to either early rhythm control or usual care, with stratification according to site and variable block lengths used for concealment. The first primary outcome was time to first occurrence of the composite of cardiovascular death, ischaemic or haemorrhagic stroke, or hospital admission with worsening of heart failure or acute coronary syndrome. The second primary outcome was the number of nights spent in hospital in 1 year. The primary safety outcome was the composite of any death, stroke, or serious adverse events related to rhythm-control therapy. Here we present the results of these outcomes in patients with a history of stroke. Analyses were done in the intention-to-treat population. EAST-AFNET 4 is registered with ClinicalTrials.gov (NCT01288352), EudraCT (2010-021258-20), and ISRCTN (ISRCTN04708680).Between July 28, 2011, and Dec 30, 2016, 2789 patients were randomly assigned in the EAST-AFNET 4 trial to either early rhythm control (n=1395) or usual care (n=1394). Of these patients, five had no information on history of stroke and were excluded from this subgroup analysis. 217 (8%) patients had a history of stroke, of whom 110 were assigned to early rhythm control and 107 to usual care. The median age of participants with a history of stroke was 72·0 years (IQR 66·0-76·0). 95 (44%) participants were female and 122 (56%) were male. During a median follow-up of 4·7 years (3·5-6·4) for patients with a history of stroke, a first primary outcome event occurred in 18 (16%) of 110 patients in the early rhythm-control group (3·7 per 100 person-years) and 33 (31%) of 107 in the usual care group (7·4 per 100 person-years; hazard ratio [HR] 0·52, 95% CI 0·29-0·93). The mean number of nights spent in hospital per year was 5·1 (SD 13·2) for patients with a history of stroke assigned to early rhythm control and 6·6 (10·1) for those assigned to usual care (incidence rate ratio 0·87, 95% CI 0·55-1·38). Among patients with a history of stroke, primary safety events occurred in 17 (15%) patients in the early rhythm-control group versus 30 (28%) in the usual care group.In this prespecified subgroup analysis in patients with recently diagnosed atrial fibrillation and a history of stroke, the effects of early rhythm control were consistent with the findings of the primary analysis. As the evidence from this subgroup analysis is considered supportive and exploratory, further research is needed to confirm the safety and efficacy of this approach in patients with a history of stroke.German Ministry of Education and Research, German Center for Cardiovascular Research (DZHK), Atrial Fibrillation Network (AFNET), European Heart Rhythm Association, St Jude Medical-Abbott, Sanofi, and the German Heart Foundation.

Thrombotic thrombocytopenic purpura (TTP), which comprises thrombocytopenia, elevated lactate dehydrogenase levels, and anemia in the combination of organ involvement, is a rare but life-threatening condition associated with an extremely high lethality in the acute phase if left untreated. Using the example of a 49-year-old woman admitted to the hospital with unexplained abdominal symptoms and subfebrile temperatures, recommendations for the emergency situation are presented. Increased awareness of the disease and targeted further diagnostics with determination of the PLASMIC score or ADAMTS13 activity may lead directly to diagnosis of TTP; delayed diagnosis is usually associated with secondary complications.Das Vorliegen einer thrombotisch-thrombozytopenischen Purpura (TTP) als Kombination aus Thrombozytopenie, LDH-Erhöhung und Anämie in Kombination mit einer Organbeteiligung ist eine seltene, aber lebensbedrohliche Erkrankung, die unbehandelt mit einer extrem hohen Letalität in der Akutphase einhergeht. Wir stellen in dem vorliegenden Beitrag den Fall einer 49-jährigen Patientin vor, die mit unklaren abdominellen Beschwerden und subfebrilen Temperaturen stationär aufgenommen wurde, und leiten daraus Empfehlungen für die Notfallsituation ab. Ein erhöhtes Bewusstsein für die Erkrankung und die zielgerichtete weiterführende Diagnostik mit Bestimmung des PLASMIC-Scores bzw. der ADAMTS13-Aktivität führt ggf. direkt zur TTP, deren verzögerte Diagnostik regelhaft zu Sekundärkomplikationen führen würde.

Objectives To model the cost-effectiveness of the TYRX Absorbable Antibacterial Envelope when used in patients at increased risk of cardiac implantable electronic device (CIED) infection in the context of 3 European healthcare systems: Germany, Italy, and England. Methods A decision tree model with a lifetime horizon was populated using data from the Worldwide Randomized Antibiotic Envelope Infection Prevention Trial, a large multicenter randomized controlled trial. Use of the antibacterial envelope adjunctive to standard of care was compared to standard of care infection prevention alone. Patients in the model were divided into subgroups based on presence of factors known to increase infection risk. Results The antibacterial envelope had the most favorable cost-effectiveness profile when patients had previously experienced CIED infection, had a history of immunosuppressive therapy, or had a Prevention of Arrhythmia Device Infection Trial (PADIT) score indicating high risk of infection (scores ≥6) at cost-effectiveness thresholds of €50 000 in Germany (assumed in the absence of an official threshold), €40 000 in Italy, and £30 000 in England. Probabilistic sensitivity analysis indicated that the antibacterial envelope was likely to be cost-effective in patients with other risk factors (including replacement of high power CIEDs, generator replacement with lead modification, and PADIT scores indicating intermediate risk of infection) when used with some device types and in some countries. Conclusions The absorbable antibacterial envelope was associated with cost-effectiveness ratios below European benchmarks in selected patients at increased risk of infection, suggesting the envelope provides value for European healthcare systems by reducing CIED infections.

Atrial fibrillation (AF) is the most common arrhythmia in the intensive care unit (ICU) and is associated with increased mortality. The AF is classified into five different forms, initially diagnosed AF, paroxysmal AF, persistent AF, long-standing persistent AF and permanent AF. Studies could confirm that the first manifestation of AF (new onset AF) is of particular importance in intensive care patients. The mortality and costs are much higher than for patients with chronic AF. This important clinical difference of the AF pattern should be taken into consideration in the treatment of intensive care patients. The treatment of comorbidities is essential in the treatment concept on the ICU. In patients with an increased risk of thromboembolic complications, therapeutic anticoagulation is indicated, although the greatly increased risk of bleeding during intensive care treatment should be considered in individual cases. In cases of hemodynamic instability electrical cardioversion should immediately be carried out. Otherwise, pharmacological cardioversion can also be carried out. Apart from a few exceptions, amiodarone is the antiarrhythmic drug of choice for rhythm control due to the contraindications for other drugs.Vorhofflimmern (VHF) ist die häufigste Rhythmusstörung auf der Intensivstation und mit einer erhöhten Mortalität assoziiert. Es wird in verschiedene Formen unterteilt: erstdiagnostiziertes, paroxysmales, persistierendes, langanhaltend persistierendes und permanentes VHF. Studien konnten belegen, dass die Erstmanifestation von VHF eine besondere Bedeutung bei Intensivpatienten hat. Die Mortalität und Kosten sind deutlich höher als bei Patienten mit chronischem VHF. Dieser wichtige klinische Unterschied der VHF-Muster sollte in der Therapie von Intensivpatienten bedacht werden. Die Behandlung von Komorbiditäten ist wesentlicher Bestandteil des Therapiekonzepts auf der Intensivstation. Bei erhöhtem Risiko für thrombembolische Komplikationen ist eine therapeutische Antikoagulation indiziert, wobei das deutlich erhöhte Blutungsrisiko während der Intensivtherapie im Einzelfall bedacht werden muss. Bei hämodynamischer Instabilität sollte eine unmittelbare elektrische Kardioversion erfolgen. Ansonsten kann auch eine pharmakologische Kardioversion durchgeführt werden. Bei der Wahl des Antiarrhythmikums zur Rhythmuskontrolle kommt aufgrund der jeweiligen Kontraindikationen bis auf wenige Ausnahmen Amiodaron zur Anwendung.

Simulators and simulator training are commonly used in many areas of industry and medicine. Simulators offer excellent training modalities for interventional cardiology to practice certain procedures and the handling of associated complications. In the field of electrophysiology, there are currently initial approaches to using simulators specifically for training purposes. A realistic simulator system does not yet exist in electrophysiology.Simulatoren und Simulatortraining sind von großer Bedeutung in vielen Bereichen der Industrie und Medizin. In der interventionellen Kardiologie stehen Simulatoren zur Verfügung, um spezielle Techniken zu erlernen oder auch um das Handling von Komplikationen im ganzen Team zu üben. In der Elektrophysiologie gibt es aktuell erste Ansätze, um Simulatoren gezielt zum Training einzusetzen. Ein realitätsnahes Simulatorsystem existiert bisher in der Elektrophysiologie nicht.

Aim The Prevention of Arrhythmia Device Infection Trial (PADIT) infection risk score, developed based on a large prospectively collected data set, identified five independent predictors of cardiac implantable electronic device (CIED) infection. We performed an independent validation of the risk score in a data set extracted from U.S. healthcare claims. Methods and results Retrospective identification of index CIED procedures among patients aged ≥18 years with at least one record of a CIED procedure between January 2011 and September 2014 in a U.S health claims database. PADIT risk factors and major CIED infections (with system removal, invasive procedure without system removal, or infection-attributable death) were identified through diagnosis and procedure codes. The data set was randomized by PADIT score into Data Set A (60%) and Data Set B (40%). A frailty model allowing multiple procedures per patient was fit using Data Set A, with PADIT score as the only predictor, excluding patients with prior CIED infection. A data set of 54 042 index procedures among 51 623 patients with 574 infections was extracted. Among patients with no history of prior CIED infection, a 1 unit increase in the PADIT score was associated with a relative 28% increase in infection risk. Prior CIED infection was associated with significant incremental predictive value (HR 5.66, P, Graphical Abstract

Aims The risk of developing atrial fibrillation (AF) and its complications continues to increase, despite good progress in preventing AF-related strokes. Methods and results This article summarizes the outcomes of the 7th Consensus Conference of the Atrial Fibrillation NETwork (AFNET) and the European Heart Rhythm Association (EHRA) held in Lisbon in March 2019. Sixty-five international AF specialists met to present new data and find consensus on pressing issues in AF prevention, management and future research to improve care for patients with AF and prevent AF-related complications. This article is the main outcome of an interactive, iterative discussion between breakout specialist groups and the meeting plenary. AF patients have dynamic risk profiles requiring repeated assessment and risk-based therapy stratification to optimize quality of care. Interrogation of deeply phenotyped datasets with outcomes will lead to a better understanding of the cardiac and systemic effects of AF, interacting with comorbidities and predisposing factors, enabling stratified therapy. New proposals include an algorithm for the acute management of patients with AF and heart failure, a call for a refined, data-driven assessment of stroke risk, suggestions for anticoagulation use in special populations, and a call for rhythm control therapy selection based on risk of AF recurrence. Conclusion The remaining morbidity and mortality in patients with AF needs better characterization. Likely drivers of the remaining AF-related problems are AF burden, potentially treatable by rhythm control therapy, and concomitant conditions, potentially treatable by treating these conditions. Identifying the drivers of AF-related complications holds promise for stratified therapy.

Currently, four non-vitamin K antagonists oral anticoagulants (NOACs) are available for stroke prevention in atrial fibrillation (AF). These have been in clinical use for up to 10 years now. Besides data of the initial phase III clinical trials, now clinical data, several sub-studies, meta-analyses, and studies in special clinical settings and specific patient populations are available. This review shall give an overview on the history of NOAC development, sum up study data and ‘real-world’ clinical data as well as discuss several special clinical settings like NOAC treatment in patients that require coronary artery stenting or cardioversion (CV). Furthermore, treatment considerations in special patient populations like patients with renal impairment, obesity, or patients requiring NOACs for secondary prevention are discussed. The significance of NOAC treatment will be discussed under consideration of the recently published 2020 ESC/EACTS Guidelines for the diagnosis and management of AF.

International audience

BackgroundDespite improvements in the management of atrial fibrillation, patients with this condition remain at increased risk for cardiovascular complications. It is unclear whether early rhythm-control therapy can reduce this risk. MethodsIn this international, investigator-initiated, parallel-group, open, blinded-outcome-assessment trial, we randomly assigned patients who had early atrial fibrillation (diagnosed

Aims The GOLD AF Registry has been designed to prospectively assess the population, indications, and outcomes using second-generation phased radiofrequency (RF) ablation (pulmonary vein ablation catheter GOLD) in a global examination of standard-of-care use for the treatment of paroxysmal and persistent atrial fibrillation (AF). Methods and results GOLD AF (NCT02433613) is a prospective, observational, multi-centre registry designed to characterize efficacy and safety of phased RF ablation in patients with AF. The primary endpoint was freedom from AF recurrence at 12-month follow-up after a 90-day blanking period. Ancillary objectives include safety, procedural efficiency, and quality of life (QoL). The QoL assessment using the Atrial Fibrillation Effect on QualiTy-of-Life (AFEQT) and the European Heart Rhythm Association (EHRA) Score of AF-related symptoms was collected at baseline and 12 months. In total, 1054 patients were included in this analysis (age 60.6, 67.6% male, 26.5% PersAF). Kaplan–Meier estimate of freedom from AF recurrence was 77.7% at 12 months. Peri-procedural device or procedure-related complications were observed in 26 (2.5%) patients, with a low stroke rate of 0.3%. One-year post-ablation, the EHRA AF Symptom score decreased in 68% of patients. The AFEQT score improvement was observed in 88.4% and 90.4% of patients who completed the questionnaire in-person or interviewed by phone at 12 month follow-up, respectively. Conclusion Phased RF ablation for the treatment of paroxysmal and persistent AF demonstrated a 77.7% freedom from AF recurrence at 12 months in addition to a significant reduction in arrhythmia symptoms and clinically meaningful improved QoL. Low peri-procedural complication rate of

Background:The traumatic burden of the Covid-19 pandemic during its early phases posed significant psychological threats particularly for medical frontline personal. It is unclear whether the medical workforce with the passage of time has adapted to these threats or whether emotional perturbations have generalized to wider medical settings.Participants and Methods: An online survey was conducted among 1,476 physicians. Valid data were achieved from 1,327 participants. A pandemic induced job context score was built by nine items. Depression and anxiety were screened with the PHQ-2 and the GAD-2.Results:Among a subtotal of 1,139 (86.6%) physicians with personal treatment experiences with Covid-19 patients, 553 (84.8%) worked in a private practice (PP) and 586 (88.3%) in a hospital (HP). Covid-19 provoked profound conflicts between professional and ethical values: more physicians in PPs than HPs reported external constraints on their medical care being in conflict with the code of medical ethics (39.1% vs. 34.4%, pConclusions:Major Covid-19 induced stress job content issues have broadened to more medical disciplines beyond frontline workers. Mental health deteriorations and feelings of helplessness among physicians have become frequent. (248)

Europace : the European journal of pacing, arrhythmias and cardiac electrophysiology euac062 (2022). doi:10.1093/europace/euac062, Published by Oxford Univ. Press, Oxford

Introduction: USA and European guidelines recognize that an oral antiarrhythmic drug (AAD) for acute conversion of symptomatic atrial fibrillation (AF) can be effective in AF termination, provided a drug with rapid effect is used and safety precautions are followed. How the ‘pill in the pocket’ (PIP) approach is used in physicians’ practices has not been examined. We performed a survey to understand clinicians’ AAD PIP prescription practices in the USA and Europe. Methods: An online physician survey of 629 cardiologists and interventional electrophysiologists (EPs) was conducted in the USA, Germany, Italy, Sweden, and the UK. Respondents were treating ≥10 AF patients who received AAD therapy and/or had received or were referred for ablation. This exploratory survey contained 96 questions on physician demographics, AF types, and drug treatment practices. Results: Respondents in the USA and Europe, reported PIP use in 24% and 19% of their patients, respectively. Frequency of PIP use was greatest in paroxysmal AF without structural heart disease (SHD; 41%) vs paroxysmal AF with SHD (16%). In contrast to guideline recommendations, PIP was used in persistent AF (pers-AF) in 18% without SHD and in 12% with SHD. Use for pers-AF was highest in the USA and by EPs. For AF without SHD, class IC AADs were used most often (flecainide, 77%; propafenone, 32%), but there was notable use of amiodarone (Amio) (13%) and sotalol (Sot) (13%), the latter more in the USA and by EPs. For AF with SHD, class IC use diminished considerably. PIP was given with a rate control agent (new or chronically, beta blocker > calcium channel blocker) in 71%, while 29% gave PIP AADs without concomitant rate control agents. Optimal arrhythmia frequencies for PIP were felt to be: monthly (13%), q2-3 months (46%), q4-6 months (26%), q7-12 months (11%), and yearly or less (4%), with no notable differences between the USA and Europe, or cardiologists and EPs. Conclusions: Our survey revealed that clinicians in both the USA and Europe use PIP in almost a quarter of their patients, mostly for AF with minimal or no heart disease (guideline appropriate). However, Amio and Sot use for PIP and use of PIP for pers-AF was evident, highlighting the need for further interventions on the appropriate and optimal use of the PIP strategy.

Background The 2020 European Society of Cardiology (ESC) guidelines provide detailed recommendations for the management of patients with atrial fibrillation (AF). In symptomatic patients, AADs are advised for rhythm control. Purpose This study was designed to investigate AAD treatment practices and adherence to guidelines in four European countries. Methods An online survey (n=321) of cardiologists or cardiac electrophysiologists (CDs) and interventional electrophysiologists (EPs) was conducted in Germany (DE; n=83), Italy (IT; n=95), Sweden (SE; n=60) and the UK (n=83). Respondents were actively treating ≥10 patients with AF. Results (1) The majority of physicians considered guidelines to be the most important non-patient factor influencing their AF management practices (pooled: 65%; range: 55–72%), with 96% (range: 89–100%) following ESC guidelines. Although amiodarone use was most frequent in heart failure with reduced left ventricular (LV) ejection fraction (pooled: 91%; range: 88–93%) where it is a recommended first-line option, non-adherent AAD selection was common. Amiodarone was frequently selected as a typical treatment choice for minimal/no structural heart disease (SHD) where it is not recommended for initial therapy; this was particularly common in the UK versus SE (Figure 1). Other deviations included use of class 1C drugs in those with coronary artery disease (CAD) (with the exception of SE; Figure 1) and other SHD, as well as use of sotalol in LV hypertrophy (pooled: 30%) and renal impairment (Figure 1). Furthermore, absence of inpatient initiation of sotalol was generally high, with the exception of SE (Figure 1). (2) Sotalol and dronedarone use in CAD varied between country (pooled: 28% [range: 16–41%] and pooled: 19% [range: 10–54%], respectively). (3) CDs and EPs used rhythm control as initial therapy in most patients with paroxysmal AF (PAF); however, other than SE, this was not the case for persistent AF (Figure 2). (4) AADs were preferred over ablation as initial therapy for individuals with infrequent, mildly symptomatic PAF (pooled: 61%), with the exception of SE (48%). Ablation was favoured for most patients with frequent, symptomatic PAF; however, in SE, AADs were preferred for infrequent, highly symptomatic PAF (53%) and frequent, symptomatic PAF (53%). (5) Rhythm control therapies were selected for asymptomatic or subclinical AF; AADs were used more often (average: 41% [range: 22–60%]; ablation was used less frequently (average: 11% [range: 2–18%]). Conclusion Despite assertion that guidelines are the primary determinant for rhythm control treatment decisions, non-adherence was notable in European practice. While deviation may be reasonable in select individual patients, in general, non-adherence could compromise patient safety. As such, establishing the drivers of non-adherent practices is key, and education directed at clinicians to improve optimal and safe use of AADs is warranted in Europe. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Sanofi

In spontaneously hypertensive rats (SHR) atrial remodeling has been shown to involve increase in endothelin (ET) signaling. Furthermore, inflammatory processes may further contribute to tissue remodeling. The aimed of this study was to investigate whether an endothelin receptor antagonist, macitentan, could reduce left atrial (LA) remodeling in arterial hypertension.Molecular characterization of atria was performed in SHR at the age of 8 months and their age-matched normotensive control rats (WKY). SHR were treated with macitentan and, for comparison with a blood pressure reducing drug, with doxazosin. After two months of treatment, molecules involved in endocardial inflammation and atrial calcium handling were assessed. The molecular changes provoked by rapid-pacing (RAP) were analyzed in atrial tissue slices.Doxazosin reduced the systolic blood pressure compared with the untreated SHR (159 ± 26 vs. 176 ± 17;Macitentan reversed pro-inflammatory remodeling in hypertensive atria in a blood pressure-independent manner, which might prevent endocardial dysfunction and thereby, thrombogenesis in arterial hypertension.

Aims Treatment patterns were compared between randomized groups in EAST-AFNET 4 to assess whether differences in anticoagulation, therapy of concomitant diseases, or intensity of care can explain the clinical benefit achieved with early rhythm control in EAST-AFNET 4. Methods and results Cardiovascular treatment patterns and number of visits were compared between randomized groups in EAST-AFNET 4. Oral anticoagulation was used in >90% of patients during follow-up without differences between randomized groups. There were no differences in treatment of concomitant conditions between groups. The type of rhythm control varied by country and centre. Over time, antiarrhythmic drugs were given to 1171/1395 (84%) patients in early therapy, and to 202/1394 (14%) in usual care. Atrial fibrillation (AF) ablation was performed in 340/1395 (24%) patients randomized to early therapy, and in 168/1394 (12%) patients randomized to usual care. 97% of rhythm control therapies were within class I and class III recommendations of AF guidelines. Patients randomized to early therapy transmitted 297 166 telemetric electrocardiograms (ECGs) to a core lab. In total, 97 978 abnormal ECGs were sent to study sites. The resulting difference between study visits was low (0.06 visits/patient/year), with slightly more visits in early therapy (usual care 0.39 visits/patient/year; early rhythm control 0.45 visits/patient/year, P Conclusion The clinical benefit of early, systematic rhythm control therapy was achieved using variable treatment patterns of antiarrhythmic drugs and AF ablation, applied within guideline recommendations.

Stroke prophylaxis with non-vitamin K-dependent oral anticoagulants (NOAKs) in patients with non-valvular atrial fibrillation (nvVHF) is now firmly established in routine clinical practice. The definition of nvVHF includes the absence of a mechanical heart valve and AF not associated with moderate- or high-grade mitral valve stenosis. The management of oral anticoagulation (OAC) requires a high degree of interdisciplinarity. Not least for this reason, uncertainties are repeatedly observed in practice, which can have far-reaching consequences for the individual patient. For this reason, a committee consisting of representatives from general medicine, geriatrics, cardiology, nephrology and neurology has gathered to identify aspects of practical relevance from the various disciplines and to jointly develop practical guidelines to improve therapy safety for patients in everyday life.Die Schlaganfallprophylaxe mit nicht von Vitamin K abhängigen oralen Antikoagulanzien (NOAKs) bei Patienten mit nichtvalvulärem Vorhofflimmern (nvVHF) hat heute einen festen Platz in der klinischen Routine. Die Definition des nvVHF umfasst die Abwesenheit einer mechanischen Herzklappe und ein nicht mit einer mittel- oder hochgradigen Mitralklappenstenose einhergehendes Vorhofflimmern. Das Management der oralen Antikoagulation (OAK) erfordert eine starke Interdisziplinarität. Nicht zuletzt aus diesem Grund sind in der Praxis immer wieder Unsicherheiten zu beobachten, die für den einzelnen Patienten weitreichende Folgen haben können. Deshalb hat sich ein Gremium aus Vertretern von Allgemeinmedizin, Geriatrie, Kardiologie, Nephrologie und Neurologie versammelt, um praxisrelevante Aspekte aus den verschiedenen Disziplinen zu identifizieren und gemeinsam praktische Handreichungen zu erarbeiten, die die Therapiesicherheit für die Patienten im Alltag verbessern sollen (Übersicht siehe Abb. 1).

Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): Sanofi Introduction In the recent 2020 European Society of Cardiology (ESC) guidelines, sotalol was downgraded from a Class IA to a llbA recommendation and advised not to be prescribed in patients with specific co-morbidities. All patients given sotalol should also be closely monitored for proarrhythmic risk factors. To date, American guidelines have not changed. Our study sought to understand the use of sotalol in AF patients and monitoring compliance across the USA and in the EU, with regards to the recent ESC guideline change. Method An online physician survey of cardiologists, cardiac electrophysiologists (EPs) and interventional EPs (N = 569) was conducted in the USA, Germany, Italy and the UK. All respondents were actively treating ≥10 AF patients who received drug therapy and/or who had received or were referred for ablation. This survey included topics on AF types and antiarrhythmic drug (AAD) treatment practices in those with AF +/- co-morbidities (including left ventricular hypertrophy [LVH], LV heart failure, and sinus node dysfunction or renal impairment). Results Sotalol was prescribed across all patient sub-groups, with high use in those with hypertension (49% of physicians) and revascularised coronary artery disease (44%). Sotalol use was consistently higher among US respondents than EU clinicians across co-morbidity categories (heart failure with reduced ejection fraction: 25% vs 14% [guideline deviation]; hypertension: 53% vs 44%; valve disease: 33% vs 23%; recent myocardial infarction [MI]: 44% vs 22%; old MI: 52% vs 31%, respectively). Use was also generally higher among EPs compared with cardiologists, but remained low in patients with minimal or no structural heart disease across all groups. Many respondents prescribed sotalol in those with LVH (35%) or renal impairment (22%), despite guidelines advising against this due to proarrhythmia risk. This contrasts with expressed respondent concerns, as 43% cited ventricular proarrythmia risk as a reason for not using sotalol. Although respondents noted concern over such risks, as per the new guidelines, routine monitoring for these factors was not performed as follows: electrocardiograms (ECG) (19% [US: 23%; EU: 15%]), renal function assessment (42% [US: 36%; EU: 50%]) or electrolyte monitoring (48% [US: 49%; EU: 46%]). Respondents reported sotalol is typically initiated in hospital (45% of patients) or in outpatients with intensive ECG monitoring (37%), but is also being started in non-monitored outpatients (19%). Conclusions Although sotalol use among EU clinicians was lower compared with the USA, which may reflect recent ESC guideline changes, the extent of monitoring practices that would indicate avoidance in those with proarrhythmic risk factors was insufficient. The lack of routine monitoring for specific factors, such as renal impairment or electrolytes, and unmonitored outpatient initiation highlights an ongoing need for further education on maximising safety when using AADs. Abstract Figure.

Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): Sanofi Introduction The 2020 European Society of Cardiology and the 2019 USA (AHA/ACC/HRS) guidelines recommend the use of AADs for rhythm control in patients with symptomatic AF. This study sought to understand AAD treatment practices and adherence to guidelines across the EU and the USA. Method An online physician survey of cardiologists, cardiac electrophysiologists and interventional electrophysiologists (N = 569) was conducted in the USA, Germany, Italy and the UK. All respondents were actively treating ≥10 AF patients who received drug therapy and/or who had received or were referred for ablation. This extensively detailed survey explored questions on physician demographics, AF types, and drug treatment and ablation practices. Results: Of the responses obtained (1) Amiodarone was used frequently across co-morbidity categories (highest use in those with heart failure with reduced left ventricular ejection fraction [LVEF] [80%]), including in those in which it is not indicated for initial therapy (minimal or no structural heart disease: 26%). Other deviations from guideline recommendations, include: class 1C drugs were used with structural heart disease, including coronary artery disease (CAD) (average class 1C use in CAD-related comorbidities: 6%); sotalol was used with renal dysfunction (22%); and drugs such as sotalol and dofetilide were initiated out of hospital (56% and 17% of respondents, respectively). (2) Nonetheless, a majority of respondents (53%) considered guidelines as the most important non-patient factor in influencing their choice of AF management. (3) Rhythm control was selected more frequently as primary therapy for paroxysmal AF (PAF) (59% of patients) while rate control was used more often for persistent AF (53%). (4) For PAF, AADs were preferred as 1st line more often than ablation, especially if PAF was infrequent and mildly symptomatic (59% of respondents) while ablation was preferred more if frequent symptomatic PAF and for recurrent persistent AF. (5) Rhythm control (AAD or ablation) was chosen in notable numbers for asymptomatic AF and subclinical AF (AADs: 36% and 37%, respectively; ablation: 9% and 14%, respectively). (6) AAD use for those with a first or recurrent episodes of symptomatic AF was 60% or 47%, respectively. (7) Efficacy and safety were chosen as the most important considerations for choice of specific rhythm control therapy (49% and 33%, respectively), and reduction of mortality and cardiovascular hospitalisation (23%) were as important as maintaining sinus rhythm (26%) for rhythm therapy goals. Conclusions Although surveyed clinicians consider guidelines important, deviations in patient types and treatments chosen that compromise safety or were not indicated were common. Findings suggest a lack of understanding of the pharmacology and safe use of AADs, highlighting an important need for further education. Abstract Figure.

Atrial fibrillation (AF) is the most common cause of thromboembolic complications. The risk of suffering a thromboembolic complication correlates with the CHA2DS2-VASc score identifying patients at increased risk. It is based on patient age, prior thromboembolic events, and clinical comorbidities, but not based on pathophysiological changes in different types of atrial cardiomyopathy (ACM) as classified in the expert consensus on ACM published in 2016. The impact of different types of ACM has also been acknowledged in the expert consensus statement on catheter ablation of atrial fibrillation. The aim of this review is to review data on clinical importance of ACMs.

Sin financiación 4.153 JCR (2019) Q2, 35/138 Cardiac & Cardiovascular Systems 2.902 SJR (2019) Q1, 17/362 Cardiology and Cardiovascular Medicine No data IDR 2019 UEM