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Objectives: The objectives of this study are to study the risk of developing cardiac arrhythmia and its subtypes over time in patients with systemic sclerosis (SSc), to assess potential risk factors for arrhythmia in SSc and to explore whether arrhythmia is associated with mortality., Methods: We used nationwide Swedish registers to identify patients with incident SSc 2004-2019 and matched general population comparators (1:10). The primary outcome was incident arrhythmia. Follow-up started at the date of SSc diagnosis and ended at the primary outcome, death, emigration or 31 December 2019. We estimated the incidence of arrhythmia overall and stratified by subtype and explored the relative risk in relation to time since diagnosis using flexible parametric models. We used Cox regression to study risk factors for arrhythmia and the association of arrhythmia with mortality., Results: We identified 1565 patients and 16 009 comparators. The overall incidence of arrhythmia was 255 (95% CI 221 to 295) and 119 (95% CI 112 to 127) per 10 000 person years in patients with SSc and comparators, respectively, corresponding to an IRR of 2.1 (95% CI 1.8 to 2.5). The greatest hazard difference between patients with SSc compared with the comparators was seen in the first year of follow-up (HR for arrhythmia 3.0; 95% CI 2.3 to 3.8). Atrial fibrillation and flutter were the most common arrhythmia subtypes. Male sex, index age and pulmonary arterial hypertension were significant risk factors for arrhythmia in SSc. Incident arrhythmia was significantly associated with mortality (HR 2.2; 95% CI 1.6 to 3.0)., Conclusion: SSc is associated with higher incidence of cardiac arrhythmia compared with general population. Arrhythmia seems to be an early manifestation of SSc and is associated with higher mortality., Competing Interests: Competing interests: RH is an employee at Boehringer Ingelheim AB. MH is on the Advisory Board for the Myositis Association. MB, ZD and PA have nothing to declare., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Atrial fibrillation and flutter (AFF) are the most common cardiac arrhythmias globally, contributing to substantial morbidity and mortality. The Middle East and North Africa (MENA) region face unique challenges in managing cardiovascular diseases, including AFF, due to diverse sociodemographic factors and healthcare infrastructure variability. This study aims to comprehensively evaluate the burden of AFF in MENA from 1990 to 2019., Methods: Data were obtained from the Global Burden of Diseases Study 2019, a comprehensive source incorporating diverse data inputs. The study collected global, regional, and national Age-Standardized Incidence Rate (ASIR), Age-Standardized Mortality Rate (ASMR), and Age-Standardized Disability-Adjusted Rate (ASDR), Mortality across sex, age groups, and years. LOESS regression was employed to determine the relationship between age-standardized rates attributed to AFF and Socio-Demographic Index (SDI)., Results: The study found minimal change in ASIR of AFF in MENA from 1990 to 2019, with a slight increase observed in ASMR and ASDR during the same period. Notably, AFF burden was consistently higher in females compared to males, with age showing a direct positive relationship with AFF burden. Iraq, Iran, and Turkey exhibited the highest ASIR, while Qatar, Bahrain, and Oman had the highest ASMR and ASDR in 2019. Conversely, Kuwait, Libya, and Turkey displayed the lowest ASMR and ASDR rates., Conclusion: This study underscores the persistent burden of AFF in MENA and identifies significant disparities across countries. High systolic blood pressure emerged as a prominent risk factor for mortality in AFF patients. Findings provide crucial insights for policy-making efforts, resource allocation, and intervention strategies aimed at reducing the burden of cardiovascular diseases in the MENA region., (© 2024. The Author(s).)

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

Background: Hospitalization for nonvalvular atrial fibrillation (NVAF) is common and results in substantial cost burden. Current national data trends for the incidence, stroke risk profiles, and mortality of hospitalization for NVAF and atrial flutter (AFL) are sparse., Methods: The Canadian Institute of Health Information Discharge Abstract Database was used to identify patients ≥ 20 years with incident NVAF/AFL (NVAF, ICD-9 code 427.3 or ICD-10 I48) in any diagnosis field from 2006 to 2015 in Canada, except Québec. National and provincial trends in rate over time (rate ratio, 95% confidence interval [CI]) were calculated for age-sex standardized hospitalizations. Trends in stroke risk profiles and in-hospital mortality rates adjusted for stroke risk factors were also calculated., Results: A total of 578,947 patients were hospitalized with incident NVAF/AFL. The median age was 77 years (interquartile range: 68-84), 82% were ≥ 65 years, 54% were men, 54% had a CHADS2 ≥ 2, and 69% had a CHA2DS2-Vasc ≥ 3. The overall age- and sex-standardized rate of NVAF/AFL hospitalization was 315 per 100,000 population and declined by 2% per year (P < 0.001). There was an annual rate decline in NVAF/AFL hospitalizations in every province. The majority of hospitalized patients are at high risk of stroke, and this risk remained unchanged. The average adjusted in-hospital mortality was 8.80 per 100 patients 95% CI, 8.80-8.81 with a 2% annual decline in rate (P < 0.001)., Conclusion: Between 2006 and 2015, we found national and provincial hospitalization rates for incident NVAF/AFL are declining. The majority of patients are at high risk for stroke. In-hospital mortality has declined but remains substantial., (Copyright © 2020 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Introduction: The impact of atrial arrhythmias on coronavirus disease 2019 (COVID-19)-associated outcomes are unclear. We sought to identify prevalence, risk factors and outcomes associated with atrial arrhythmias among patients hospitalized with COVID-19., Methods: An observational cohort study of 1053 patients with severe acute respiratory syndrome coronavirus 2 infection admitted to a quaternary care hospital and a community hospital was conducted. Data from electrocardiographic and telemetry were collected to identify atrial fibrillation (AF) or atrial flutter/tachycardia (AFL). The association between atrial arrhythmias and 30-day mortality was assessed with multivariable analysis., Results: Mean age of patients was 62 ± 17 years and 62% were men. Atrial arrhythmias were identified in 166 (15.8%) patients, with AF in 154 (14.6%) patients and AFL in 40 (3.8%) patients. Newly detected atrial arrhythmias occurred in 101 (9.6%) patients. Age, male sex, prior AF, renal disease, and hypoxia on presentation were independently associated with AF/AFL occurrence. Compared with patients without AF/AFL, patients with AF/AFL had significantly higher levels of troponin, B-type natriuretic peptide, C-reactive protein, ferritin and d-dimer. Mortality was significantly higher among patients with AF/AFL (39.2%) compared to patients without (13.4%; p < .001). After adjustment for age and co-morbidities, AF/AFL (adjusted odds ratio [OR]: 1.93; p = .007) and newly detected AF/AFL (adjusted OR: 2.87; p < .001) were independently associated with 30-day mortality., Conclusion: Atrial arrhythmias are common among patients hospitalized with COVID-19. The presence of AF/AFL tracked with markers of inflammation and cardiac injury. Atrial arrhythmias were independently associated with increased mortality., (© 2020 Wiley Periodicals LLC.)

Aims: We investigated the association between potassium levels and 90-day all-cause mortality in atrial fibrillation or flutter (AF) patients co-treated with diuretics and rate- or rhythm-controlling drugs., Methods and Results: During 2000-12, first-time AF patients treated with beta-blockers, amiodarone, sotalol, verapamil, or digoxin combined with any diuretic within 90 days post-AF discharge were included. Following co-treatment, a potassium measurement within 90 days after initiating diuretic treatment was required. Mortality risk associated with potassium <3.5, 3.5-3.7, 3.8-4.0, 4.5-4.7, 4.8-5.0, and >5.0 mmol/L (reference: 4.1-4.4 mmol/L) was assessed using multivariable Cox regression. In total, 14 425 AF patients were included (median age: 78 years; women: 52%). Patients most often received beta-blocker monotherapy (29%), beta-blockers and digoxin combined (25%), digoxin monotherapy (24%), amiodarone monotherapy (3%), and verapamil monotherapy (3%). Increased 90-day mortality risk was associated with <3.5 mmol/L [hazard ratio (HR) 2.05, 95% confidence interval (CI) 1.68-2.50], 3.5-3.7 mmol/L (HR 1.28, 95% CI 1.05-1.57), 4.5-4.7 mmol/L (HR 1.20, 95% CI 1.02-1.41), 4.8-5.0 mmol/L (HR 1.37, 95% CI 1.14-1.66), and >5.0 mmol/L: (HR 1.84, 95% CI 1.53-2.21). Compared with beta-blocker monotherapy, rate- or rhythm-controlling drugs did not modify the association between potassium groups and mortality risk., Conclusion: In addition to hypo- and hyperkalaemia, low and high normal range potassium levels were associated with increased 90-day mortality risk in AF patients co-treated with diuretics and rate- or rhythm-controlling drugs. These associations were independent of rate- or rhythm-controlling drugs., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: journals.permissions@oup.com.)

Background: The benefit of combining aspirin and direct oral anticoagulants on the reduction of cardiovascular events in atrial fibrillation or flutter is not well studied. We aimed to assess whether concurrent aspirin and direct oral anticoagulant therapy for atrial fibrillation or flutter will result in less coronary, cerebrovascular and systemic ischemic events compared to direct oral anticoagulant therapy alone., Methods: Retrospective study of adult patients between 18 and 100 years old who have nonvalvular atrial fibrillation or flutter and were started on a direct oral anticoagulant (apixaban, rivaroxaban, or dabigatran), between January 1, 2010 and September 1, 2015 within the Beaumont Health System. Exclusions were history of venous thromboembolic disease and use of other antiplatelet therapies such as P2Y12 inhibitors. Patients were classified into two groups based on concurrent aspirin use and observed for a minimum of 2 years. Primary outcome was major adverse cardiac events, defined as acute coronary syndromes, ischemic strokes, and embolic events. Secondary outcomes were bleeding and death., Results: Six thousand four patients were in the final analysis, 57% males and 80% Caucasians, median age 71, interquartile range (63-80). The group exposed to aspirin contained 2908 subjects, and the group unexposed to aspirin contained 3096 subjects. After using propensity scores to balance the baseline characteristics in both groups, the analysis revealed higher rate of major adverse cardiac events in the exposed group compared to the unexposed group, (HR 2.11, 95% CI (1.74-2.56)) with a number needed to harm of 11 (95% CI [9-11]). The rate of bleeding was also higher in the exposed group, (HR 1.30, 95% CI (1.11-1.52)). The rate of death was not statistically different between the groups, (HR 0.87, 95% CI (0.61-1.25))., Conclusions: In this observational analysis of patients with atrial fibrillation and flutter, the concomitant use of direct oral anticoagulants and aspirin was associated with an increased risk of both major adverse cardiac and bleeding events when compared to the use of direct oral anticoagulants alone. These findings underscore the potential harm of this combination therapy when used without a clear indication.

Introduction: The phase 3 EURIDIS and ADONIS studies evaluated dronedarone for atrial fibrillation (AF)/atrial flutter (AFL) recurrence in patients with nonpermanent AF. Here we assessed whether patient characteristics and/or treatment outcomes in these studies differed based on the need for cardioversion before randomization., Methods: Time to adjudicated first AF/AFL recurrence, symptomatic recurrence, cardiovascular hospitalization/death, and AF hospitalization, and safety were assessed by cardioversion status., Results: Of 1237 patients randomized (2:1 dronedarone:placebo), 364 required baseline cardioversion (dronedarone 243, placebo 121). Patients requiring cardioversion had a greater prevalence of cardiovascular comorbidities and shorter times to first AF/AFL recurrence compared with those not requiring cardioversion. Dronedarone was associated with longer median time to first AF/AFL recurrence vs placebo regardless of cardioversion status (cardioversion: 50 vs 15 days, hazard ratio [HR] 0.76; 95% confidence interval [CI], 0.59-0.97; P = .02; non-cardioversion: 150 vs 77 days, HR 0.76; 95% CI, 0.64-0.90; P < .01). Dronedarone was similarly associated with prolonged median time to symptomatic recurrence vs placebo in the cardioversion (347 vs 87 days, HR 0.65; 95% CI, 0.49-0.87) and non-cardioversion (288 vs 120 days, HR 0.74; 95% CI, 0.62-0.90) populations. Risk of cardiovascular hospitalization/death and first AF hospitalization was lower with dronedarone vs placebo regardless of cardioversion status, but differences were not statistically significant. The safety of dronedarone was similar in both groups., Conclusion: Patients requiring baseline cardioversion represent a distinct population, having more underlying cardiovascular disease and experiencing a shorter time to AF/AFL recurrences. Dronedarone was associated with improved efficacy vs placebo regardless of cardioversion status., (© 2020 The Authors. Journal of Cardiovascular Electrophysiology Published by Wiley Periodicals, Inc.)

Background: Whilst antithrombotic therapy is recommended in people with atrial fibrillation, little is known about the survival benefits of antithrombotic treatment in those with both high ischaemic and bleeding risk scores. We aim to describe the distribution of these risk scores in those with a prior diagnosis of atrial fibrillation who have suffered stroke and to determine the net clinical benefit of antithrombotic treatment., Methods: We used regional stroke register data in the UK. Patients with a prior diagnosis of atrial fibrillation and ischaemic or haemorrhagic stroke patients were selected and their ischaemic stroke risk score (CHA 2 DS 2 -VAS c ) and bleeding risk score (HEMORR 2 HAGES) scores retrospectively calculated. Logistic regression and Cox proportional hazards models were constructed to determine the association between antithrombotic therapy prior to stroke and in-hospital and long-term mortality., Results: A total of 1928 stroke patients (mean age 81.3 years (standard deviation 8.5), 56.8% women) with prior atrial fibrillation were included. Of these, 1761 (91.3%) suffered ischaemic stroke. The most common phenotype (64%) was of those with both high CHA 2 DS 2 -VAS c (≥2) and high HEMORR 2 HAGES score (≥4). In our fully adjusted model, patients on antithrombotic treatment with both high ischaemic and bleeding risk had a significant reduction in odds of 31% for in-hospital mortality (odds ratio 0.69 (95% confidence interval 0.48-1.00: p  = 0.049)) and 17% relative risk reduction for long-term mortality (hazard ratio 0.83 (95% confidence interval 0.71-0.97: p  = 0.02))., Conclusions: Our study suggests that antithrombotic treatment has a prognostic benefit following incident stroke in those with both high ischaemic risk and high bleeding risk. This should be considered when choosing treatment options in this group of patients.

Background: The role of antiarrhythmic drugs for atrial fibrillation/atrial flutter (AF/AFL) after catheter ablation is not well established., Hypothesis: We hypothesized that changing the myocardial substrate by ablation may alter the responsiveness to dronedarone., Methods: We assessed the efficacy and safety of dronedarone in the treatment of paroxysmal/persistent atrial fibrillation/atrial flutter (AF/AFL) post-ablation, based on a post hoc analysis of the ATHENA study. A total of 196 patients (dronedarone 90, placebo 106) had an ablation for AF/AFL before study entry. In these patients, the effect of treatment on the first hospitalization because of cardiovascular (CV) events/all-cause death was assessed, as was AF/AFL recurrence in individuals with sinus rhythm at baseline. The safety of dronedarone vs placebo was also determined., Results: In patients with prior ablation, dronedarone reduced the risk of AF/AFL recurrence (hazard ratio [HR]: 0.65 [95% confidence interval [CI]: 0.42, 1.00]; P < .05) as well as the median time to first AF/AFL recurrence (561 vs 180 days) compared with placebo. The HR for first CV hospitalization/all-cause death with dronedarone vs placebo was 0.98 (95% CI: 0.62, 1.53; P = .91). Rates of treatment-emergent adverse events were 83.1% vs 75.5% and rates of serious TEAEs were 27.0% vs 18.9% in the dronedarone and placebo groups, respectively. One death occurred with dronedarone (not treatment-emergent) and five occurred with placebo., Conclusion: In patients with prior ablation for AF/AFL, dronedarone reduced the risk of AF/AFL recurrence compared with placebo, but not the risk of first CV hospitalization/all-cause death. Safety outcomes were consistent with those of the overall ATHENA study., (© 2019 The Authors. Clinical Cardiology published by Wiley Periodicals, Inc.)

Background: Atrial arrhythmia is a late complication after tetralogy of Fallot (TOF) repair, but arrhythmia outcomes data are limited., Objectives: The purpose of the study was to describe atrial arrhythmia presentations, outcomes of antiarrhythmic therapy, and impact of arrhythmia on transplant-free survival., Methods: We reviewed the MACHD (Mayo Adult Congenital Heart Disease) Registry and identified 113 patients (age 49 ± 13 years) with documented arrhythmia, and 302 patients without history of arrhythmia, 1990-2017. We classified arrhythmias into atrial fibrillation and atrial flutter/tachycardia based on the rhythm on the first abnormal electrocardiogram., Results: At the time of first documented arrhythmia, 58(51%) had atrial fibrillation while 55(49%) had atrial flutter/tachycardia. Of the 113 patients, 14(12%) received rhythm control with class I/III antiarrhythmic drugs (AAD), 79(70%) had direct current cardioversion, 9(8%) received rate control with class II/IV AAD, and 11(10%) received only anticoagulation. Successful cardioversion occurred in 100(89%) patients, and arrhythmia recurrence rate was 16 per 100 patient-years. The multivariate risk factors for death and/or heart transplant were atrial fibrillation (HR 1.94, CI 1.10-3.15, P = .031) and older age (HR 1.63, CI 1.12-2.43, P = .019) per 5 year increment., Conclusions: Atrial fibrillation, but not atrial flutter, was associated with reduced survival in our repaired TOF cohort. Further studies are required to determine if more aggressive antiarrhythmic therapy will improve survival in patients with atrial fibrillation., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Aims: Guidelines recommend initial rate control in haemodynamically stable patients with atrial fibrillation (AF) or atrial flutter (AFL) and acute decompensated heart failure (ADHF). There is limited data on early inpatient rhythm control. We investigated the outcomes of patients managed with early TOE-guided DC cardioversion (DCCV) or ablation., Methods: We retrospectively analysed patients admitted to a single centre with AF or AFL and ADHF with LVEF≤40% that underwent inpatient TOE-guided DCCV or ablation. The primary endpoint was the one year composite outcome of mortality or rehospitalisation for heart failure., Results: We identified 79 patients, including 33 with AF (32 DCCV, one ablation) and 46 with AFL (22 DCCV, 24 ablation). The primary endpoint occurred in 20%. One-year mortality was 2.5%. There were significantly fewer rehospitalisations for arrhythmia or heart failure with AFL-ablation compared to AFL-DCCV (21% vs 64%, p=<0.01). Clinical recurrence of AF or AFL was 43%. At follow-up LV assessment, LVEF>40% was found in 75% (p=<0.01), including 87% of patients without known cardiomyopathy and 82% of patients in sinus rhythm., Conclusion: Early inpatient DCCV or ablation for AF or AFL and ADHF had low mortality rates and rehospitalisation for heart failure with substantial improvement in LV function at follow-up., Competing Interests: Nil.

Background: An implantable loop recorder (ILR) assists in the diagnosis of unexplained syncope and atrial fibrillation (AF). Both become prevalent with age. Limited data exist describing the incidence of AF as the diagnostic rhythm underlying syncope in the elderly. This study aims to report the incidence of AF in older adults with ILRs for unexplained syncope and identify clinical characteristics associated with AF in this population., Methods: Retrospective observational study on patients with unexplained syncope seen in syncope clinics from two Canadian centers. Participants were ≥65 years old, without a history of AF, and received an ILR for unexplained syncope. Data were collected from patient's clinic charts. Arrhythmia diagnosis was based on ILR electrocardiogram reading during syncope (symptom-rhythm correlation). Fisher's exact test and the Student's t test were used to compare participants with and without AF., Results: In our cohort of 222 patients, 124 were females and 98 were males. Mean age at implant was 80 ± 8 years. Arrhythmia was diagnosed in 98 patients (44.1%). Median time to diagnosis was 18 months. AF was diagnosed in 17 (7.7%) participants. There were fewer males in the AF group than the no AF group (11.8%, 46.8%, p = 0.01). Age, baseline EKG, and prevalence of hypertension, diabetes, stroke, or ischemic heart disease were not statistically different between patients with AF and without AF., Conclusions: Atrial fibrillation was a common diagnostic rhythm in this cohort of adults, aged 65 and older, with ILRs for unexplained syncope. It was observed more frequently in females., (© 2019 Wiley Periodicals, Inc.)

Dofetilide is a class III antiarrhythmic agent approved by the Food and Drug Administration for the conversion of atrial fibrillation and atrial flutter and maintenance of sinus rhythm in symptomatic patients with persistent arrhythmia. Drug trials showed neutral mortality in post-myocardial infarction patients and those with heart failure. This is a review of postmarket data, including real-world efficacy and safety in a variety of populations. Dofetilide has been used off-label with success in patients with paroxysmal atrial fibrillation and atrial flutter, as well as atrial tachycardia and ventricular tachycardia. The real-world acute conversion rate of atrial fibrillation and atrial flutter is higher than that reported in clinical trials. Dofetilide has an acceptable safety profile when initiated (or reloaded) under hospital monitoring and dosed according to creatinine clearance. Dofetilide is well tolerated and a good choice for patients with acceptable renal function and a normal QT interval, especially if atrioventricular nodal blockade needs to be avoided.

Aims: Atrial fibrillation (AFib) and atrial flutter (AFlut) are common arrhythmias with increased use of invasive procedures. A steady re-evaluation of relevant safety endpoints is recommended and both quality management and pay-for-performance programs are evolving. Therefore, the aims of this study were (i) to investigate and report overall in-hospital mortality and mortality of invasive arrhythmia-related procedures and (ii) to identify mortality predictors in a German-wide hospital network., Methods and Results: Administrative data provided by 78 Helios hospitals between 2010 and 2017 were examined using International Statistical Classification of Diseases and Related Health Problems- and Operations and Procedures-codes to identify patients with AFib or AFlut as main discharge diagnosis or secondary diagnosis combined with invasive arrhythmia-related interventions. In 161 502 patients, in-hospital mortality was 0.6% with a significant decrease from 0.75% to 0.5% (P < 0.01) during the observational period. In multivariable analysis, age [odds ratio (OR) 2.69, 95% confidence interval (CI) 2.36-3.05; P < 0.01], high centre volume (OR 0.57, 95% CI 0.50-0.65; P < 0.01), emergency hospital admission (OR 1.57, 95% CI 1.38-1.79; P < 0.01), and Charlson Comorbidity Index (CCI, OR 4.95, 95% CI 4.50-5.44; P < 0.01) were found as independent predictors of in-hospital mortality. Mortality rates were 0.05% for left atrial catheter ablation (CA, n = 21 744), 0.3% for right atrial CA (n = 9972), and 0.56% for implantation of a left atrial appendage occluder (n = 2309), respectively., Conclusion: We analysed for the first time in-hospital mortality rates of patients with atrial arrhythmias in a German-wide, multi-centre administrative dataset. This allows feasible, comparable, and up-to-date performance measurement of clinically important endpoints in a real-world setting which may contribute to quality management programs and towards value-based healthcare.

Aims: The aim of this study was to study the risk of death and development of arrhythmia and/or subsequently heart failure after an atrial flutter ablation procedure compared with an atrial fibrillation (AF) ablation procedure., Methods: This observational study is based on data from Danish nationwide health databases. Patients with a first-time ablation procedure for either atrial flutter or AF in the period 2000-2016 were included. Rates of renewed arrhythmia, heart failure or death were compared and reported as adjusted hazard ratios (HR)., Results: The study population consisted of 2,004 and 3,803 patients with an incident atrial flutter or AF ablation procedure, respectively. All-cause mortality among atrial flutter patients was significantly higher compared with the AF group (HR 1.80, 95% confidence interval [CI] 1.39-2.35). The incidence of renewed arrhythmia without heart failure was lower in atrial flutter (HR 0.76, 95% CI 0.69-0.84). Renewed atrial flutter ablation and pacemaker implantations were significantly more frequent (HR 2.42, 95% CI 2.02-2.91 and HR 1.42, 95% CI 1.13-1.79, respectively) in atrial flutter compared with AF. The risk of heart failure was higher for atrial flutter, both after the initial ablation (HR 1.48, 95% CI 1.08-2.03), and after a further arrhythmia management event (HR 1.98, 95% CI 1.33-2.94)., Conclusion: There was a higher mortality risk after atrial flutter ablation procedures compared with patients undergoing AF ablation. Rates of heart failure and further renewed (non-AF) arrhythmia management were higher in atrial flutter., (© 2018 John Wiley & Sons Ltd.)

Background: Left lateral mitral isthmus (LLMI) linear ablation is a safe and effective technique for treating left mitral flutter. LLMI linear ablation with pulmonary vein isolation may reduce the recurrence of persistent atrial fibrillation. However, epicardial ablation within the coronary sinus (CS) is often required to create the LLMI block line. If the necessity for epicardial ablation is checked before ablation, complications may be reduced., Methods: We recruited 135 patients who underwent their first LLMI ablation and divided them into two groups, one group not requiring epicardial ablation for creating a conduction block at the LLMI (Endo group) and another requiring it (Epi group). These two groups were compared in terms of the electrogram characteristics of the CS., Results: Bidirectional block through the LLMI was achieved in 94.8% of patients. In 42% of these patients, not only the endocardium but also the epicardium was ablated. As for the electrogram, the Endo group had lower atrium voltage and atrioventricular voltage ratios (p = 0.009) than the Epi group before LLMI ablation. By contrast, there were no significant differences in the atrium voltage and the atrioventricular voltage ratio between these two groups after LLMI ablation., Conclusions: For creating a conduction block at the LLMI, the atrium voltage and the atrioventricular voltage ratio in the CS before ablation are important. The atrioventricular voltage ratio is a crucial criterion for determining whether epicardial ablation is necessary; furthermore, the atrioventricular voltage ratio in the CS must be reduced with or without epicardial ablation.

Alterations of normal intra- and interatrial conduction are a common outcome of multiple cardiovascular conditions. They arise most commonly in the context of advanced age, cardiovascular risk factors, organic heart disease, atrial fibrosis, and left atrial enlargement. Interatrial block (IAB), the most frequent and extensively studied atrial conduction disorder, affects up to 20% of the general primary care population. IAB can be partial (P wave duration ≥ 120 ms on any of the 12 ECG leads) or advanced (P wave ≥ 120 ms and biphasic morphology (positive-negative) in inferior leads). Advanced IAB is an independent risk factor for supraventricular tachyarrhythmias and embolic stroke in a variety of clinical settings. Advanced IAB is a cause of left atrial electromechanical dysfunction and left atrioventricular dyssynchrony and has been associated with left ventricular diastolic dysfunction. P wave duration is associated with cardiovascular and all-cause mortality in the general population. Atrial conduction abnormalities should be identified as markers of atrial remodeling, prognostic indicators, and, in the case of advanced IAB, a true arrhythmologic syndrome. IAB and other P wave abnormalities should prompt the search for associated conditions, the treatment of which may partially reverse atrial remodeling or prevent it if administered upstream. Future studies will help define the role of preventive therapeutic interventions in high-risk patients, including antiarrhythmic drug therapy and oral anticoagulation. Implications for the treatment of heart failure and for pacing should also be further investigated.

Background: Heart failure and atrial fibrillation share common mechanisms that may contribute to hypercoagulability and thrombotic risk. Elevated von Willebrand factor (vWF) concentration has been associated with increased risk of thromboembolism and cardiovascular events., Aim: To investigate whether increased vWF plasma concentration predicts occurrence of a composite endpoint (all-cause death and stroke) in patients with non-valvular atrial fibrillation (NVAF)., Methods: We prospectively studied 122 patients (mean age 70±14years; 46% men) hospitalized with NVAF, and followed over a median (interquartile range) of 5.4 (2.3-9.0)years. Cox proportional models were used to estimate the association of vWF concentration with time to stroke and death., Results: Forty-three patients (35%) had at least a stroke or died during the 5-year follow-up. Kaplan-Meier curves using vWF plasma concentration tertiles (≤191IU/dL;>191 to≤295IU/dL;>295IU/dL) showed that vWF plasma concentrations discriminated groups of patients with higher cardiovascular event rates (log-rank P=0.01). In the multivariable analysis, higher vWF concentrations (middle tertile hazard ratio [HR] 4.59, 95% confidence interval [CI] 1.55-13.50 [P=0.006]; upper tertile HR 4.10, 95% CI 1.43-11.75 [P=0.009]), age≥75years (HR 5.02, 95% CI 1.53-16.49; P=0.008), heart failure (HR 2.05, 1.01-4.19; P=0.048), C-reactive protein, log 2 per unit increase (HR 1.29, 95% CI 1.04-1.61; P=0.021), no warfarin at discharge (HR 4.96, 95% CI 2.02-12.20; P<0.0001) and no aspirin at discharge (HR 4.41, 95% CI 1.71-11.97; P=0.002) were independently associated with an increased risk of stroke and all-cause death, whereas female sex was a protective factor (HR 0.35, 0.16-0.78; P=0.01)., Conclusions: High vWF plasma concentrations may discriminate patients with NVAF at greater risk of stroke or all-cause death., (Copyright © 2017. Published by Elsevier Masson SAS.)

Introduction: The aim of this study was to compare the risk of ischemic stroke in patients who have atrial fibrillation and patients who have atrial flutter., Methods: Using inpatient and outpatient Medicare claims data from 2008 to 2014 for a 5% sample of all beneficiaries 66 years of age or older, we identified patients diagnosed with atrial fibrillation and those diagnosed with atrial flutter. The primary outcome was ischemic stroke. In the primary analysis, patients with atrial flutter were censored upon converting to fibrillation; in a secondary analysis, they were not. Survival statistics were used to compare incidence of stroke in patients with flutter and patients with fibrillation. Cox proportional hazards analysis was used to compare the associations of flutter and fibrillation with ischemic stroke after adjustment for demographics and risk factors., Results: We identified 14,953 patients with flutter and 318,138 with fibrillation. During a mean follow-up period of 2.8 (±2.3) years, we identified 18,900 ischemic strokes. The annual incidence of ischemic stroke in patients with flutter was 1.38% (95% confidence interval [CI] 1.22%-1.57%) compared with 2.02% (95% CI 1.99%-2.05%) in patients with fibrillation. After adjustment for demographics and stroke risk factors, flutter was associated with a lower risk of stroke compared with fibrillation (hazard ratio .69; 95% CI .60-.79, P < .05). Within 1 year, 65.7% (95% CI 64.9%-66.4%) of patients with flutter converted to fibrillation but remained at a lower risk of ischemic stroke (hazard ratio .85; 95% CI .78-.92)., Conclusions: Patients with atrial flutter faced a lower risk of ischemic stroke than patients with atrial fibrillation., (Published by Elsevier Inc.)

Background: Radiofrequency catheter ablation (RFCA) of the cavo-tricuspid isthmus (CTI) is a common treatment for atrial flutter (AFL). However, achieving bi-directional CTI conduction block may be difficult, partly due to catheter instability., Objective: To evaluate the safety and efficacy of the Amigo® Remote Catheter System (RCS) compared to manual catheter manipulation, during CTI ablation for AFL., Methods: Fifty patients (pts) were prospectively randomized to robotically (25 pts) versus manually (25 pts) controlled catheter manipulation during CTI ablation, using a force-contact sensing, irrigated ablation catheter. The primary outcome was recurrence of CTI conduction after a 30-min waiting period. Secondary outcomes included total ablation, procedure, and fluoroscopy times, contact force measurement, and catheter stability., Results: Recurrence of CTI conduction 30 min after ablation was less with robotically (0/25) versus manually (6/25) controlled ablation (p = 0.023). Total ablation and procedure times to achieve persistent CTI block (6.7 ± 3 vs. 7.4 ± 2.5 min and 14.9 ± 7.5 vs. 15.2 ± 7 min, respectively) were not significantly different (p = 0.35 and p = 0.91, respectively). There was a non-significant trend toward a greater force time integral (FTI in gm/s) with robotically versus manually controlled CTI ablation (571 ± 278 vs. 471 ± 179, p = 0.13). Fluoroscopy time was longer with robotically versus manually controlled CTI ablation (6.8 ± 4.4 min vs. 3.8 ± 2.3 min, p = 0.0027). There were no complications in either group., Conclusion: Robotically controlled CTI ablation resulted in fewer acute recurrences of CTI conduction compared to manually controlled CTI ablation, and a trend toward higher FTI. The longer fluoroscopy time during robotically controlled ablation was likely due to a steep learning curve., Trial Registration: Clinicaltrials.gov Identifier: NCT02467179.

Background: Atrial flutter (AFL) has been identified to be equivalent to atrial fibrillation (AF) in terms of preventing ischemic stroke, although differences exist in atrial rate, substrate, and electrophysiological mechanisms. This study aimed to investigate differences in clinical outcomes between nonvalvular AF and AFL., Methods and Results: AF and AFL patients without any prescribed anticoagulation were enrolled from a 13-year national cohort database. Under series exclusion criteria, ischemic stroke, heart failure hospitalization, and all-cause mortality were compared between the groups in real-world conditions and after propensity score matching. We identified 175 420 patients in the AF cohort and 6239 patients in the AFL cohort, and the prevalence of most comorbidities and frequency of medications were significantly higher in the AF group than the AFL group. In the real-world setting the AF patients had higher incidence rates of ischemic stroke, heart failure hospitalization, and all-cause mortality than the AFL patients (all P <0.001). After propensity score matching, the incidence rate of ischemic stroke in the AF cohort was 1.63-fold higher than in the AFL cohort ( P <0.001), the incidence rate of heart failure hospitalization in the AF cohort was 1.70-fold higher than in the AFL cohort ( P <0.001), and the incidence rate of all-cause mortality in the AF cohort was 1.08-fold higher than in the AFL cohort ( P =0.002)., Conclusions: There were differences between AF and AFL in comorbidities and prognosis with regard to ischemic stroke, heart failure hospitalization, and all-cause mortality., (© 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.)

Aims: The aim of this study was to investigate whether there is a similar mortality and thrombo-embolic risk, after an atrial ablation procedure, compared with an atrial fibrillation (AF) procedure., Methods and Results: Using data from nationwide Danish health registries, we identified patients aged 18-75 years undergoing a first-time atrial flutter or an AF ablation procedure in the period 2000-13. Cox proportional hazards regression was used to calculate hazard ratios (HRs) after 5 years of follow-up, adjusting for concomitant risk factors. A total of 1096 and 2266 patients underwent an ablation for atrial flutter or AF, respectively. Age distribution was similar in the two, but atrial flutter patients had more co-morbidities. During 5 years of follow-up, we observed 38 and 36 deaths in the atrial flutter and AF groups, corresponding to an almost two-fold higher mortality rate among atrial flutter patients [crude HR 1.92, 95% confidence interval (CI) 1.22-3.03]. The higher mortality rate persisted after adjustment for age, sex, diabetes mellitus, and hypertension (adjusted HR 1.68, 95% CI 1.05-2.69). The rate of thrombo-embolic events was similar in the two groups (crude HR 1.34, 95% CI 0.71-2.56; adjusted HR 1.22, 95% CI 0.62-2.41)., Conclusion: In this observational study, patients with atrial flutter had a significantly higher all-cause mortality rate compared with those with AF after an ablation procedure, but similar thrombo-embolic event rates. Future studies should elucidate the reason for this difference in mortality., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2016. For permissions please email: journals.permissions@oup.com.)

Purpose: The purpose of the study was to assess polysomnographic indicators of increased mortality risk in patients with stroke or a transient ischemic attack (TIA)., Methods: We performed polysomnographies in 63 acute stroke/TIA patients. Mortality data were collected from a national database after a 19-37-month follow-up period., Results: Of the 57 stroke and 6 TIA patients, 9 stroke patients died during follow-up. All nine had moderate or severe sleep-related breathing disorders (SRBDs). Binarily divided, the group with the highest apnea hypopnea index (AHI) had an almost 10-fold higher mortality risk (hazard ratio (HR) 9.71; 95 % confidence interval (CI) 1.20-78.29; p = 0.033) compared to the patients with the lowest AHI. The patients with the longest versus shortest nocturnal wake time had a higher mortality (HR 8.78; 95 % CI 1.1-71.8; p = 0.0428). Lung disease increased mortality (HR 9.92; 95 % CI 2.00-49.23; p = 0.005), and there was a trend toward a higher mortality risk with atrial fibrillation/flutter (HR 3.63; 95 % CI 0.97-13.51; p = 0.055)., Conclusions: In stroke patients, the AHI and nocturnal wake time are indicators of increased mortality risk. SRBDs in stroke patients should receive increased attention.

Aims: To analyse outcomes of supraventricular tachycardia (SVT) ablations performed within a prospective German Ablation Quality Registry., Methods and Results: Data from 12 566 patients who underwent catheter ablation of SVT between January 2007 and January 2010 to treat atrial fibrillation (AFIB, 37.2% of procedures), atrial flutter (AFL, 29.9%), atrioventricular nodal re-entrant tachycardia (AVNRT, 23.2%), atrioventricular re-entrant tachycardia (6.3%), and focal atrial tachycardia (AT, 3.4%) were prospectively collected. Patients were followed for at least 1 year. The periprocedural success rate was 96.3%, ranging from 84.3% (focal AT) to 98.9% (AVNRT). Kaplan-Meier mortality estimate at 1 year was 1.4% overall, and as high as 2.6% in the AFL group and 2.8% in the focal AT group. Recurrence of ablated or another symptomatic SVT was observed in 3783 (32.6%) of patients, ranging from 17.2% (AVNRT) to 45.6% (AFIB). Repeat ablation was performed in 12.0% of patients. After 1 year, 74.1% of survivors perceived ablation therapy as successful, 15.7% as partly successful, and 9.6% as unsuccessful. Even in those patients with arrhythmia recurrence, 76.0% perceived ablation as successful or partly successful and 89.6% would still undergo repeat ablation in the same institution., Conclusion: Ablation therapy for SVT is a safe procedure bringing symptomatic improvement and satisfaction to three quarters of patients after 1 year. Even in patients with arrhythmia recurrence, a high satisfaction level and adherence to the ablating institution could be documented. Strikingly high mortality and stroke rates in follow-up were observed in AFL patients, who apparently need consistent long-term anticoagulation and more medical attention., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2017. For permissions, please email: journals.permissions@oup.com.)

Background: Each encounter of asymptomatic individuals with the healthcare system presents an opportunity for improvement of cardiovascular disease (CVD) awareness and sudden cardiac death (SCD) risk assessment. ECG sign deep terminal negativity of the P wave in V1 (DTNP V1 ) was shown to be associated with an increased risk of SCD in the general population., Objective: To evaluate association of DTNP V1 with all-cause mortality and newly diagnosed atrial fibrillation (AFib) in the large tertiary healthcare system patient population., Methods: Retrospective double cohort study compared two levels of exposure (automatically measured amplitude of P-prime (Pp) in V1): DTNP V1 (Pp from -100μV to -200μV) and ZeroPpV1 (Pp=0). An entire healthcare system (2010-2014) ECG database was screened. Medical records of children and patients with previously diagnosed AFib/atrial flutter (AFl), implanted pacemaker or cardioverter-defibrillator were excluded. DTNP V1 (n=3,413) and ZeroPpV1 (n=3,405) cohorts were matched by age and sex. Primary outcome was all-cause mortality. Secondary outcomes were newly diagnosed AFib/AFl. Median follow-up was 2.5 y., Results: DTNP V1 was associated with all-cause mortality (HR 1.95(1.64-2.31); P<0.0001) and newly diagnosed AFib (HR 1.29(1.04-1.59); P=0.021) after adjustment for CVD, comorbidities, other ECG parameters, medications, and index ECG referral. Index ECG referral by a cardiologist was independently associated with 34% relative risk reduction of mortality (HR 0.66(0.52-0.84); P=0.001), as compared to ECG referral by a non-cardiologist., Conclusion: DTNP V1 is independently associated with twice higher risk of all-cause death, as compared to patients without P prime in V1. Life-saving effect of the index ECG referral by a cardiologist requires further study., Competing Interests: The authors report no relationships that could be construed as a conflict of interest. Conflict of Interest Disclosures: None., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Background: Characteristics and outcomes of concurrently diagnosed new rapid atrial fibrillation (AF) or atrial flutter (AFL) and new heart failure with reduced left ventricular ejection fraction (LVEF) are not well described., Methods: A retrospective cohort study of subjects referred for expedited transesophageal echocardiography-guided rhythm-control strategies for concurrent new rapid AF/AFL and new LVEF ≤ 40% diagnosed during the same admission was analyzed., Results: Twenty-five subjects (median age 57 years; 96% male; 96% Caucasian; median CHA 2 DS 2 -VASc = 2) presented with new AF (n = 18) or AFL (n = 7) with rapid ventricular rate (median 135 beats/min) and new reduced LVEF (median 27%; range, 10-37.5%). Seven (28%) subjects had left atrial appendage thrombi (LAAT) and five (20%) subjects had heavy or binge alcohol use. Baseline characteristics were similar between those with and without LAAT. Thirteen subjects with AF and without LAAT underwent direct-current cardioversion (DCCV) and 10 (77%) had AF recurrence within 90 days. Improvement of long-term LVEF to >40% was comparable for subjects with and without initial LAAT (83% vs 94%; P = 0.46). Three of four subjects who received primary prophylaxis implantable cardioverter-defibrillators improved their LVEF to >35% after sinus rhythm maintenance. The median long-term follow-up time was 3.0 years., Conclusions: Subjects with concurrently diagnosed new rapid AF/AFL and new reduced LVEF are characterized by a high prevalence of LAAT and significant alcohol use. AF subjects without initial LAAT who underwent DCCV had a high 90-day AF recurrence rate. The presence of LAAT did not have a prognosticative effect on eventual LVEF improvement, which was observed in almost all subjects., (© 2016 Wiley Periodicals, Inc.)

Introduction: Indications for implantable cardioverter defibrillators (ICDs) in young patients have expanded and differ from those in older adults. We sought to provide descriptive characteristics and data regarding ICD therapy and outcomes among younger and older ICD recipients., Methods and Results: Demographics, device type and programming, remotely transmitted data, shock events, and survival were compared among younger (≤30 years) and older (>30 years) cohorts with ICDs from a single manufacturer followed on a remote network. The younger cohort included 904 patients (1.6% of all implants). This group had more females (46% vs. 25%; P < 0.01), single-coil leads (21% vs. 4%; P < 0.01), and single-chamber devices (46% vs. 34%; P < 0.01). Shock incidence was higher (40% younger vs. 32% older at 4 years; P < 0.01) and survival was better over comparable follow-up (88% vs. 72%; P < 0.01). Remote monitoring was associated with improved survival in both groups (93% vs. 86% ≤ 30 years, P < 0.01; 73% vs. 66% > 30 years, P < 0.01). Shock for polymorphic ventricular tachycardia/fibrillation (VT/VF) was more frequent in younger patients (12% vs. 5%; P < 0.01); 39% of all shocks were inappropriate. A 10-fold increased risk of mortality was seen among young patients with shocks for atrial fibrillation/flutter (AF/AFL)., Conclusions: Differences in survival, shock incidence, and prognostic significance of VT/VF and AF/AFL exist between younger and older ICD recipients. These suggest distinct differences in myocardial substrates and diseases that ultimately impact ICD management., (© 2016 Wiley Periodicals, Inc.)

Background: Atrial flutter (AFL) ablation has been increasingly offered as first-line therapy and safely performed over the last decades. However, limited data exist regarding current utilization and trends in adverse outcomes arising from this procedure., Objective: The aim of our study was to examine the frequency of adverse events attributable to AFL ablation and influence of hospital volume on safety outcomes., Methods: Data were obtained from the Nationwide Inpatient Sample, the largest all-payer inpatient dataset in the United States. Patients with AFL who underwent catheter ablation from 2000 to 2011 were identified using ICD-9 codes. In-hospital death and common complications were identified, including cardiac perforation and tamponade, pneumothorax, stroke, transient ischemic attack, and vascular access complications., Results: A total of 89,638 AFL patients were treated with catheter ablation during our study period. Total number of ablations performed increased by 154% from 2000 to 2011. The in-hospital mortality rate was 0.17% and the overall complication rate was 3.17%. Cardiac complications (1.44%) were the most frequent, followed by respiratory (0.88%), vascular (0.78%), and neurological complications (0.05%). Low hospital volume (<50 procedures/year) was significantly associated with increased adverse outcomes. Overall frequency of complications per 100 ablation procedures increased from 2.86 in 2000 to 5.39 in 2011 (P < .001)., Conclusions: The overall complication rate was 3.17% in patients undergoing AFL ablation. There was a significant association between low hospital volume and increased adverse outcomes. This suggests a need for future research into identifying the safety measures in AFL ablations and instituting appropriate interventions to improve overall AFL ablation outcomes., (Copyright © 2016 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Background: Although dofetilide is widely used in the United States for rhythm control of atrial fibrillation, there is limited postapproval safety data in the atrial fibrillation population despite its known risk of Torsade de pointes (TdP)., Methods and Results: We conducted a retrospective chart review of a cohort of 1404 patients initially loaded on dofetilide for atrial fibrillation suppression at the Cleveland Clinic from 2008 to 2012 to evaluate the incidence and risk factors for in-hospital adverse events and the long-term safety of continued use. Of the 17 patients with TdP during loading (1.2%), 10 had a cardiac arrest requiring resuscitation (1 death), 5 had syncope/presyncope, and 2 were asymptomatic. Dofetilide loading was stopped for 105 patients (7.5%) because of QTc prolongation or TdP. Variables correlated with TdP were (1) female sex, 2) 500-μg dose, (3) reduced ejection fraction, and (4) increase in QTc from baseline. One-year all-cause mortality was higher in patients who continued dofetilide compared with those who discontinued use (hazard ratio, 2.48; 95% confidence interval, 1.08-5.71; P=0.03). Those patients who had a TdP event had higher one-year all-cause mortality than those who did not (17.6% versus 3% at 1 year; P<0.001)., Conclusions: Dofetilide loading has a low but finite risk of TdP and other adverse events that warrant the current Food and Drug Administration-mandated practice of inpatient monitoring during drug loading. In this cohort, all-cause mortality was higher at 1 year in those patients continued on dofetilide and in those patients who experienced TdP while loading., (© 2015 American Heart Association, Inc.)

Little is known about the long-term prognosis of or predictors for the different clinical types of atrial fibrillation (AF) in Korean populations. The aim of this study was to validate a risk stratification to assess the probability of AF progression from paroxysmal AF (PAF) to persistent AF (PeAF) or permanent AF. A total of 434 patients with PAF were consecutively enrolled (mean age; 71.7 ± 10.7 yr, 60.6% male). PeAF was defined as episodes that are sustained > 7 days and not self-terminating, while permanent AF was defined as an ongoing long-term episode. Atrial arrhythmia during follow-up was defined as atrial premature complex, atrial tachycardia, and atrial flutter. During a mean follow-up of 72.7 ± 58.3 months, 168 patients (38.7%) with PAF progressed to PeAF or permanent AF. The mean annual AF progression was 10.7% per year. In univariate analysis, age at diagnosis, body mass index, atrial arrhythmia during follow-up, left ventricular ejection fraction, concentric left ventricular hypertrophy, left atrial diameter (LAD), and severe mitral regurgitation (MR) were significantly associated with AF progression. In multivariate analysis, age at diagnosis (P = 0.009), atrial arrhythmia during follow-up (P = 0.015), LAD (P = 0.002) and MR grade (P = 0.026) were independent risk factors for AF progression. Patients with younger age at diagnosis, atrial arrhythmia during follow-up, larger left atrial chamber size, and severe MR grade are more likely to progress to PeAF or permanent AF, suggesting more intensive medical therapy with close clinical follow-up would be required in those patients.

Background: Atrial arrhythmias (AAs) early after lung transplant are frequent and have a significant impact on morbidity and mortality. However, the pathogenesis of AAs after lung transplant remains incompletely understood. In this study we aimed to determine the prevalence of atrial fibrillation (AF) and other AAs, as well as risk factors, clinical outcomes and possible underlying mechanisms associated with AAs after lung transplant., Methods: A retrospective analysis was performed on 382 patients who underwent lung transplantation from 2000 to 2010. A 12-lead electrocardiogram (ECG) was obtained and AAs classified as AF and other AAs (atrial flutter [AFL] and supraventricular tachycardia [SVT]). Multivariate logistic regression analysis was performed to determine predictors, and Kaplan-Meier survival curves were constructed., Results: The incidence of AAs was 25%; 17.8% developed AF and 7.6% other AAs (AFL/SVT). The major indication for transplant was idiopathic pulmonary fibrosis (IPF, 35%). Significant predictors of AF were as follows: age; IPF; left atrial enlargement; diastolic dysfunction; and history of coronary artery disease (CAD). Risk factors for other AAs (AFL/SVT) were: age; right ventricle dysfunction; right ventricular enlargement; and elevated right atrial pressure (RAP). One-year mortality was higher in the arrhythmia group (21.5% arrhythmia vs 15.7% no-arrhythmia group; p < 0.05). In addition, patients treated with anti-arrhythmic medications had higher mortality (p < 0.05)., Conclusions: AAs are common after lung transplantation. Risk factors for developing either AF or other AAs (AFL/SVT) are different. The development of early AAs post-transplant is associated with prolonged post-operative stay and increased mortality. A rate-control strategy should be used as first-line therapy and anti-arrhythmic agents reserved for those patients who do not respond to the initial treatment., (Copyright © 2014 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.)

Aims: To report trends in mortality rates for atrial fibrillation/flutter (AF), using all the certified causes of death mentioned on death certificates (conventionally known as 'mentions') as well as the underlying cause of death, in the national population of England (1995-2010) and in a regional population with longer coverage of all-mentions mortality (1979-2010)., Methods and Results: Analysis of death registration data in England and in the Oxford record linkage study. In England between 1995 and 2010, AF was mentioned as a cause of death (either as an underlying cause or as a contributory cause) in 192 770 registered deaths in people aged 45 years of age and over (representing 0.254% of all registered deaths in this age group). Atrial fibrillation was given as the underlying cause of death in 21.4% of all deaths in which it was mentioned (41 298 of 192 770). In England, age-standardized death rates for mentions of AF increased almost three-fold between 1995 and 2010, from 202.5 deaths per million (1995) to 554.1 deaths per million (2010), with an average annual percentage change of 6.6% (95% confidence interval: 6.3, 7.0). Mortality rates for AF did not increase substantially until the mid-1990s: rates in Oxford were 145.4 deaths per million in 1979, 178.1 in 1995, and 505.1 in 2010., Conclusion: Atrial fibrillation has become much more common as a certified cause of death. The reasons for this are likely to be multifactorial, with changes in demographics, lifestyle, advances in therapeutics, and altered perception of the importance of the condition by certifying doctors all likely to be contributing factors., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2013. For permissions please email: journals.permissions@oup.com.)

Background: Measuring postpacing intervals (PPIs) is the standard maneuver for localizing reentrant tachycardia circuits. However, changes or termination of the tachycardia during entrainment pacing, or difficulties in defining the correct local activity, limit the use of PPIs., Methods and Results: We hypothesized that the number of pacing stimuli needed to entrain (NNE) was useful for mapping intra-atrial reentrant tachycardias. First, 10 patients with typical atrial flutter were studied to characterize the NNE. Next, 317 entrainment attempts in 30 patients with 76 intra-atrial reentrant tachycardias were analyzed to determine the efficacy of the NNE. The NNE was small at sites within the reentrant circuit (median 2) and large at remote sites during typical atrial flutter. The NNE depended on the pacing cycle length and coupling interval of the initial paced beat, where the NNE became smaller at shorter pacing cycle lengths and coupling intervals. The NNE highly correlated with the difference between the PPI and tachycardia cycle length (r = 0.906; P<0.001). When the pacing cycle length and coupling interval were 16 to 30 ms below the tachycardia cycle length, a NNE ≤2 and >3 predicted a PPI-tachycardia cycle length ≤20 and >20 ms, respectively, with 100% accuracy. Thirty-six (11%) entrainment attempts changed or terminated intra-atrial reentrant tachycardia. Importantly, the NNE remained valid in those cases. Furthermore, the NNE provided additional information in cases with some difficulties with PPI measurements., Conclusions: The NNE is a simple and reliable criterion, which facilitates mapping intra-atrial reentrant tachycardia., Clinical Trial Registration Url: http://www.clinicaltrials.gov. Unique identifier: NCT001747., (© 2014 American Heart Association, Inc.)

Background: Contemporary clinical risk stratification schemata for predicting stroke and thromboembolism in patients with atrial fibrillation (AF) are largely derived from western cohorts. The purpose of the present study is to assess the potential risk factors for stroke and major adverse cardiac events (MACE) in a large population of Chinese AF patients presenting to emergency department., Methods: The Chinese AF registry is a multicenter, prospective, observational study with 1 year follow up. Patients who presented to an emergency department with atrial fibrillation or atrial flutter were recruited from November 2008 to October 2011. The MACE included all cause mortality, stroke, non-central nervous system systemic embolism and major bleed., Results: A total of 2016 AF patients (1104 women) were included in the final analysis. Multivariate Cox regression analysis showed that the risk factors for stroke were female gender (1.419 (1.003-2.008), p=0.048), age ≥ 75 (2.576 (1.111-4.268), p<0.001), previous stroke/TIA (2.039 (1.415-2.939), p<0.001), LVSD (1.700 (1.015-2.848), p=0.044) and previous major bleeding (2.481 (1.141-5.397), p=0.022). For MACE, age ≥ 75 (3.042 (2.274-4.071), p<0.001), heart failure (1.371 (1.088-1.728), p=0.008), previous stroke/TIA (1.560 (1.244-1.957), p<0.001), LVSD (1.424 (1.089-1.862), p=0.010) and COPD (1.393 (1.080-1.798), p=0.011) were independent risk factors. History of hypertension and diabetes was not associated with the events, neither stroke nor MACE. For non-anticoagulation patients, the c-statistic for predicting stroke was 0.685 (0.637-0.732) and for MACE was 0.717 (0.687-0.746), respectively., Conclusions: We demonstrated that, except for the traditional risk factors, clinicians should pay more attention to patients with prior major bleeding or COPD in Chinese AF patients presenting to emergency department., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Introduction: Atrial tachyarrhythmias, particularly atrial flutter and fibrillation, are commonly associated with congenital heart disease and are a major cause of morbidity and mortality. The Cox-maze procedure, introduced by Dr. James Cox in 1987, is effective at controlling atrial fibrillation in structurally normal hearts. Though the Cox-maze procedure has been used for atrial tachyarrhythmias in patients with congenital heart disease, few studies have looked at its effectiveness., Methods: A retrospective chart review was performed on 24 patients with congenital heart disease who underwent the Cox-maze procedure at the Medical College of Wisconsin from 2004 through 2010., Results: Mean age at time of Cox-maze procedure for the cohort was 40.9 years (range, 14 to 66 years). The most common congenital heart diseases among the patients included tetralogy of Fallot (n = 8) and atrioventricular septal defect (n = 4). All patients had concomitant cardiac procedures with the most common being right ventricular outflow tract reconstruction (n = 10), tricuspid valve repair (n = 8), and atrial septal defect repair (n = 7). Prior to the Cox-maze procedure, arrhythmias consisted of atrial flutter or intratrial reentrant tachycardia (n = 19) and atrial fibrillation (n = 5). There were three early postoperative deaths and one late postoperative death. Follow-up was available for 19 of 21 (90%) survivors with a mean length to follow-up from Cox-maze procedure of 2.8 years (range, 0.14-5.7 years). At last follow-up, 14 (74%) of the survivors remained arrhythmia-free., Conclusions: In patients with congenital heart disease and atrial tachyarrhythmias, the majority were rendered arrhythmia-free by the Cox-maze procedure., (© 2012 Wiley Periodicals, Inc.)

Background: Left ventricular noncompaction is a cardiomyopathy characterized by excessive trabeculation of the left ventricle, progressive myocardial dysfunction, and early mortality. Left ventricular noncompaction has a heterogeneous clinical presentation that includes arrhythmia and sudden cardiac death., Methods and Results: We retrospectively reviewed all children diagnosed with left ventricular noncompaction at Texas Children's Hospital from January 1990 to January 2009. Patients with congenital cardiac lesions were excluded. Two hundred forty-two children were diagnosed with isolated left ventricular noncompaction over the study period. Thirty-one (12.8%) died, and 13 (5.4%) were received a transplant. One hundred fifty (62%) presented with or developed cardiac dysfunction. The presence of cardiac dysfunction was strongly associated with mortality (hazard ratio, 11; P<0.001). ECG abnormalities were present in 87%, with ventricular hypertrophy and repolarization abnormalities occurring most commonly. Repolarization abnormalities were associated with increased mortality (hazard ratio, 2.1; P=0.02). Eighty children (33.1%) had an arrhythmia, and those with arrhythmias had increased mortality (hazard ratio, 2.8; P=0.002). Forty-two (17.4%) had ventricular tachycardia, with 5 presenting with resuscitated sudden cardiac death. In total, there were 15 cases of sudden cardiac death in the cohort (6.2%). Nearly all patients with sudden death (14 of 15) had abnormal cardiac dimensions or cardiac dysfunction. No patient with normal cardiac dimensions and function without preceding arrhythmias died., Conclusions: Left ventricular noncompaction has a high mortality rate and is strongly associated with arrhythmias in children. Preceding cardiac dysfunction or ventricular arrhythmias are associated with increased mortality. Children with normal cardiac dimensions and normal function are at low risk for sudden death.

Introduction: Higher current density at the proximal end of a six-hole catheter is not irrigated and thus could lead to uneven heating and possibly coagulum and charring. This study tested a novel 12-hole irrigated catheter with six additional holes at the proximal end that provides more uniform cooling during atrial flutter (AFL) ablation., Methods: A total of 188 patients (28 females, 66 ± 11 years) were treated for typical AFL at 22 sites in the USA and Canada using Cool Path Duo at 50 W and 45 °C at an irrigation rate of 13 ml/min. The results were compared to historical data from an AFL study which used a six-hole catheter with similar design., Results: A total of 2,725 RF lesions were applied in 188 patients with a mean RF duration of 18.2 ± 11.7 min per procedure. Procedural success was achieved in 96.3 % (181 of 188) acutely and 98.3 % (173 of 176) patients at 3 months. Steam pops occurred in 0.6 % of lesions (15 of 2,725) without coagulum or charring… Compared to the six-hole irrigated tip catheter, the Cool Path Duo catheter delivered more power (33.8 ± 5.9 vs. 29.7 ± 5.2 W, p < 0.0001) at a lower average tip temperature (34.7 ± 1.5 vs. 37.2 ± 2.1 °C, p < 0.0001) with no statistical differences in either 3-month AFL recurrence or complications., Conclusion: Cool Path Duo™ irrigated tip catheter is safe and effective in treating typical AFL. When compared to a six-hole irrigated tip catheter, the Cool Path Duo catheter delivers more power at a lower temperature.

Introduction: Scant data exist on the epidemiology and clinical characteristics of atrial fibrillation in Kenya. Traditionally, atrial fibrillation (AF) in sub-Saharan Africa is as a result of rheumatic valve disease. However, with the economic transition in sub-Saharan Africa, risk factors and associated complications of this arrhythmia are likely to change., Methods: A retrospective observational survey was carried out between January 2008 and December 2010. Patients with a discharge diagnosis of either atrial fibrillation or flutter were included for analysis. The data-collection tool included clinical presentation, risk factors and management strategy. Follow-up data were obtained from the patients' medical records six months after the index presentation., Results: One hundred and sixty-two patients were recruited (mean age 67 ± 17 years, males 56%). The distribution was paroxysmal (40%), persistent (20%) and permanent AF (40%). Associated co-morbidities included hypertension (68%), heart failure (38%) diabetes mellitus (33%) and valvular abnormalities (12%). One-third presented with palpitations, dizziness or syncope and 15% with a thromboembolic complication as the index AF presentation. Rate-control strategies were administered to 78% of the patients, with beta-blockers and digoxin more commonly prescribed. Seventy-seven per cent had a CHA(2)DS(2)VASC score ≥ 2, but one-quarter did not receive any form of oral anticoagulation. At the six-month follow up, 6% had died and 12% had been re-admitted at least once. Of the high-stroke risk patients on anticoagulation, just over one-half were adequately anticoagulated., Conclusion: Hypertension and diabetes mellitus, not rheumatic valve disease were the more common co-morbidities. Stroke risk stratification and prevention needs to be emphasised and appropriately managed.

Objectives: Atrial fibrillation is common in the emergency department (ED). Mortality rates at 30, 90, and 365 days for ED patients with a main diagnosis of atrial fibrillation are 4, 6, and 11%, respectively; there are no data on the characteristics and outcomes of ED patients with atrial fibrillation who have alternative primary ED diagnoses., Methods: In this single-site, retrospective cohort study, all electrocardiograms (ECGs) with confirmed atrial fibrillation performed in the ED from April 2007 to March 2008 were identified. Repeat ED visits were excluded. ECGs associated with a primary ED diagnosis of atrial fibrillation were excluded, and from the remaining ECGs of patients with a different primary ED diagnosis, half were randomly selected for abstraction. The main outcome measure was all-cause mortality at 30, 90, and 365 days post-ED visit, derived from linkage to a provincewide mortality database. As a secondary analysis, logistic regression was used to compare 90-day mortality of these patients to those with primary ED diagnoses of atrial fibrillation seen during the same time period., Results: Of 768 qualifying index ED visits, 416 charts were abstracted. Mean (± standard deviation [SD]) age was 80.3 (± 11.8) years, and 50.7% were female. Two-thirds had a previous history of atrial fibrillation/flutter, 300 (72.1%) had a CHADS2 score ≥ 2, one died in the ED, and 275 (66.1%) were admitted. The most common primary ED diagnoses were congestive heart failure (12%), pneumonia (6%), and chest pain not yet diagnosed (6%), while most common in-hospital diagnoses were congestive heart failure (15%), chronic obstructive pulmonary disease exacerbation (6%), atrial fibrillation (5%), and pneumonia (5%). Mortalities at 30, 90, and 365 days were 10.6% (95% confidence interval [CI] = 7.8% to 14.0%), 17.4% (95% CI = 13.9% to 21.5%), and 34.2% (95% CI = 29.6% to 39.0%), respectively. In the adjusted analysis, an alternative primary ED diagnosis was associated with an increased risk of death (odds ratio [OR] = 2.75; p = 0.01)., Conclusions: Patients seen in the ED with atrial fibrillation and different primary ED diagnoses are older and have high short- and long-term mortality rates: mortality was three times higher than in patients with primary ED diagnoses of atrial fibrillation. Future studies of atrial fibrillation in the ED should distinguish between these two populations and the potential contribution of atrial fibrillation to mortality in the setting of other primary ED diagnoses., (© 2013 by the Society for Academic Emergency Medicine.)

Background: Dronedarone is a new antiarrhythmic drug used in the treatment of atrial fibrillation (AF). We investigate its efficacy and tolerability in clinical practice., Methods: We identified 208 patients treated with dronedarone for AF at the Northwestern outpatient practice. Charts were reviewed for clinical efficacy and reasons for discontinuation of the drug., Results: The average age was 65.2 ± 10.8 years, 37% females. Paroxysmal, persistent andpermanent AF were noted in 46.2%, 51.9%, and 1.9%, respectively. Average ejection fraction was 56.3 ± 9.1%, 12.8% had a history of congestive heart failure, and 10.3% had valvularheart disease. Dronedarone was discontinued in 25 patients after curative catheter or surgical ablation procedure. Of the remaining 183 patients, dronedarone was discontinued in 48.6% after a mean duration of 6.2 ± 6.3 months because of in efficacy (26.2%), side effects (6%), and other reasons (16.4%). For those remaining on dronedarone (n = 94), after a mean of 11.6 ± 6.6 months, clinical efficacy (resolution of or patient-reported improvement in symptoms) was noted in 45.4% patients. On dronedarone therapy, 57.4% had no AF on follow-up (overallefficacy of 29.5%). To evaluate efficacy, ECG only or long-term monitoring were performed in 62.7% and 37.3%, respectively, and found no AF in 69.2 and 48.4%, respectively. There were 3 deaths and 2 transient ischemic attacks (TIA) off dronedarone vs. 1 death, 1 TIA and 2 strokes on dronedarone., Conclusions: Dronedarone has a significant discontinuation rate due to both inefficacy and side effects in clinical practice. Nevertheless, it has moderate clinical efficacy and tolerability in an outpatient population of patients with AF.

The electrocardiogram's (ECG) ability to aid in the diagnosis and risk stratification of patients with acute coronary syndromes is well established. We sought to investigate the prognostic significance of ECG abnormalities in patients with noncardiac conditions in the emergency department. Patients presenting to the emergency department who were evaluated for possible acute coronary syndrome were consecutively enrolled and an initial ECG was obtained (n = 1024). Only patients with noncardiac diagnoses were reviewed in this analysis (n=493) and 30-month follow-up was obtained. Sinus tachycardia, atrial fibrillation/flutter, ST depression, and left bundle branch block were associated with increased 30-month mortality. After controlling for history of coronary artery disease, age, sex, diabetes mellitus, hypertension, and renal insufficiency, sinus tachycardia and ST-segment depression ≥1 mm were independent predictors of 30-month mortality with a hazard ratio of 2.33 (95% confidence interval, 1.36-4.00; P = 0.002) and 2.49 (95% confidence interval, 1.10-5.67; P = 0.029), respectively. In conclusion, ST-segment depression and sinus tachycardia in patients presenting to the hospital with noncardiac conditions are independently associated with increased 30-month mortality.

Background: Radiofrequency ablation of typical atrial flutter is largely used and is considered as safe. The purpose of the study was to evaluate the prevalence and the causes of severe adverse event (AE) following atrial flutter ablation., Methods: Ablation of typical flutter was performed by conventional method with an 8-mm-tip electrode catheter, a maximum power of 70 W, and a maximum target temperature of 70° for 60 seconds in 883 patients, (685 males and 198 females aged from 18 to 93 years [64 ± 11.5]; 664 had heart disease [HD])., Results: AE occurred in 44 patients (5%). AE was life threatening in 14 patients: poorly tolerated bradycardia (transient complete atrioventricular block [AVB] or sinus bradycardia [SB] <40 beats per minute) associated with cardiac shock and acute renal failure in five patients, tamponade (n = 1), bleeding leading to death (n = 1), various AE-related deaths (n = 2), ventricular tachycardia-related death (n = 1), definitive complete AVB (n = 3), and right coronary artery occlusion-related complete AVB (n = 1). Less serious AE occurred in 30 patients: transitory major SB or second- or third-degree AVB (n = 23), bleeding (n = 4), transient ischemic attack (n = 1), and various AE (n = 2). Most of the bradycardia was related to β-blockers or other antiarrhythmic drugs used to slow atrial flutter. Factors of AE were female gender (36% vs 22%, P < 0.02) and the presence of ischemic (P < 0.03) or valvular HD (P < 0.01)., Conclusions: AE following atrial flutter ablation occurred in 5% of patients. Most of them are avoidable by control of anticoagulants and arrest of rate-control drugs used to slow the rate of atrial flutter., (©2012, The Authors. Journal compilation ©2012 Wiley Periodicals, Inc.)

Continuous monitoring of cardiac rhythm may play an important role in measuring the true symptomatic/asymptomatic atrial fibrillation (AF) burden and improve the management of anti-arrhythmic and anti-thrombotic therapies. Forty-seven patients with mitral valve disease and longstanding persistent AF (LSPAF) underwent a left atrial maze procedure with bipolar radiofrequency and valve surgery. The follow-up data recorded by an implanted loop recorder were analysed after 3, 6 and 12 months. On discharge, 40 (85.1%) patients were in stable sinus rhythm, as documented by in-office electrocardiography (ECG), 4 (8.5%) were in pacemaker rhythm and 3 (6.4%) were in AF. One (2.1%) patient died after 7 months. On 12-month follow-up examination, 30 (65.2%) patients had an AF burden <0.5% and were classified as responders. Three (6.5%) of the 16 non-responders had atrial flutter and 13 (27.7%) had documented AF recurrences with an AF burden >0.5%. Two (4.3%) patients with AF recurrences were completely asymptomatic. Among the symptomatic events stored by the patients, only 27.6% was confirmed as genuine AF recurrences according to the concomitant ECG recorded by the implanted loop recorder. A concomitant bipolar maze procedure during mitral valve surgery is effective in treating AF, as proved by detailed 1-year continuous monitoring.

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

Background: In patients with atrial fibrillation (AF), adherence to guidelines for antithrombotic treatment is poorly followed, and undertreatment (or nonadherence with guidelines) is associated with a worse prognosis. The study objective was to evaluate whether this was also the case in a large contemporary series of unselected patients with AF in real-world clinical practice., Methods: All patients with AF or atrial flutter seen in our institution between 2000 and 2007 were identified in a database and followed up for mortality and stroke. Antithrombotic guideline adherence was assessed according to the 2006 American College of Cardiology/American Heart Association/European Society of Cardiology guidelines., Results: We reviewed outcomes in 3,646 consecutive patients with AF or atrial flutter (aged 71 ± 14 years; mean CHADS(2) [congestive heart failure, hypertension, aged ≥ 75 years, diabetes mellitus, prior stroke or transient ischemic attack] score, 1.5 ± 1.1). Antithrombotic treatment was in agreement with the guidelines in 53% of patients, whereas 31% were classified as undertreated and 16% as overtreated. Among other parameters, nonpermanent AF and atrial flutter were independently associated with an increased risk of undertreatment. After a follow-up of 953 ± 767 days (median, 771 days; interquartile range, 1,286 days), guideline adherence was associated with a lower risk of adverse events (death from all causes or stroke) compared with undertreatment (relative risk, 0.47; 95% CI, 0.40-0.55; P < .0001). Overtreatment was associated with a lower risk of adverse events compared with the guideline-adherent population (relative risk, 0.40; 95% CI, 0.28-0.58; P < .0001). Factors independently associated with increased risk of mortality or stroke were antithrombotic undertreatment, older age, heart failure, renal failure, diabetes, male sex, and previous history of stroke., Conclusions: Guideline nonadherence and undertreatment with antithrombotic agents in unselected real-world patients with AF or atrial flutter are independently associated with a high risk of stroke and mortality.

Background: There is little recent information regarding outcome and its determinants following cardioversion (CV) for atrial fibrillation (AF) or flutter. This study aims to help improve prediction of cardiac rhythm outcome following CV for AF., Methods: Cardiac rhythm at 6 weeks and 12 months was documented following elective (EC; n=496) or immediate (IC; n=52) cardioversion for AF or atrial flutter in a single referral centre., Results: 65 and 58% of IC patients remained in sinus rhythm (SR) 6 weeks and 1 year after CV (respectively) compared with 43% and 30% in EC patients (P<0.001). Independent positive predictors of SR 6 weeks after cardioversion included amiodarone therapy (OR 2.04 [1.28-3.33], P<0.01) and atrial flutter (OR 1.85 [1.09-3.13], P<0.05). Negative predictors included the need for >1 shock to achieve SR (OR 1.61 [1.12-2.37], P=0.011) and arrhythmia duration, (OR 0.96 [0.95-0.97], P<0.001). At 1 year, amiodarone, duration of arrhythmia and the need for >1 shock remained independent predictors of rhythm., Conclusions: The number of shocks required to achieve SR is a newly demonstrated independent predictor of rhythm outcome after elective CV.

New antiarrhythmic drugs are urgently required for the treatment of atrial fibrillation (AF), an increasingly common sustained cardiac arrhythmia seen predominantly in the elderly population. Pharmaceutical companies are generally interested in this important group of patients and a relatively large number of antiarrhythmic agents are under development for several indications relating to AF, predominantly rhythm and rate management. Because of the significant clinical consequences of the arrhythmia, it has been recognized that controlled trials in patients with AF should assess the effect of therapy in several major outcome domains such as mortality, morbidity, and hospitalization, with an emphasis on stroke and heart failure. As part of a regular series of meetings, the European Society of Cardiology recently met with European regulators and representatives of the pharmaceutical industry to review the current status of medical therapies for AF. Special attention has been paid to the debate on the relevant clinical endpoints in future AF trials and their implications for drug indications. The need for large-scale major cardiovascular outcome and comparator studies for the approval of drugs designed to manage rhythm and/or control the rate has been discussed. The requirements for appropriate ancillary studies, including quality of life and left ventricular function assessment and cost-effectiveness analysis, have been identified. This article reports the discussions that were held.