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Background: Long-term treatment with direct oral anticoagulants (DOAC) is required for the majority of patients with nonvalvular atrial fibrillation (AF) to prevent ischemic stroke and systemic embolism. Adherence to therapy may impact clinical outcomes. Therefore, the purpose of this study was to assess the potential impact of structured follow-up on long-term adherence to DOAC therapy compared to standard care. Methods: This is a cross sectional study on the implementation phase of medication adherence to DOACs, comparing patients with AF following completion of structured follow-up of minimally 1 year with those who received standard care. All patients used DOACs for more than 2 years and completed a questionnaire on adherence. Adherence was measured with the Morisky Medication Adherence Scale-8 (MMAS-8) score and assessed via an online web portal. Results: A total of 212 patients were included. The mean MMAS-8 score was 7.55 (SD 0.93) after structured follow-up and 7.25 (SD 1.01) for standard care; p = 0.045. Following structured follow-up 64.1% of patients had a high adherence (MMAS score of 8) compared to 50% receiving standard care; p = 0.05. Patients following structured follow-up on a once daily DOAC regime had higher MMAS-8 scores compared to those on a twice daily regime; 7.74 (SD 0.74) versus 7.00 (SD 1.22); p < 0.001. The rates of minor bleedings were 10.6% versus 21.4% respectively, p = 0.038. Conclusion: In patients on long-term DOAC treatment, adherence to therapy was significantly increased after receiving an initial period of structured follow-up compared to standard care. Additionally, adherence to DOAC therapy was higher with once-daily treatment regimen. Significant more minor bleedings were reported in the standard care group. These results indicate that implementation of structured follow-up of patients with AF using DOACs merits further evaluation.

Atrial fibrillation (AF) patients are commonly classified into five groups, first-diagnosed, paroxysmal, persistent, long-standing persistent, or permanent AF, based on the duration of AF and clinical conventions. Progression of AF to longer-lasting forms is common and has important clinical significance, affecting both the success of sinus rhythm maintenance and the occurrence of major adverse cardiovascular events. As such, there is considerable interest in the underlying mechanisms and therapeutic options to prevent AF progression. This chapter discusses the epidemiology, risk factors, and clinical significance of AF progression. It also provides background on the pathophysiological mechanisms of AF progression and highlights options for its management and prevention.

Control of the heart rate (rate control) is central to atrial fibrillation management, even for patients who ultimately require control of the rhythm. The choice of rate control depends on symptoms and clinical characteristics of the patient, but for all patients with atrial fibrillation, rate control is part of the management. Choice of drugs is patient dependent and driven by the patient-specific rate–symptom relationship as well as associated conditions. Beta blockers, alone or in combination with digoxin, or non-dihydropyridine calcium channel blockers effectively lower the heart rate. Digoxin is least effective, but a reasonable choice for older, physically inactive patients, in whom other therapies are ineffective or contraindicated, and as an additional drug, especially in systolic heart failure. Institution of all rate control drugs should be performed cautiously. Atrioventricular node ablation with pacemaker insertion for rate control should be the approach of last resort. Catheter ablation of atrial fibrillation, however, should be considered before atrioventricular node ablation. No one formula can integrate the best approach to a specific drug or the effects of therapeutic combinations, but one important message is that a lenient approach to rate control is easy, safe, and effective in many patients and should be considered as the initial approach. A stricter rate control approach is adopted when symptoms persist or deterioration of the left ventricular function occurs. Although rate control is the top priority and one of the first management issues for all patients with atrial fibrillation, and has been studied extensively, many issues remain.

Valentin Fuster, MD, PhD, FACC, FAHA, FESC, Co-Chair; Lars E. Ryden, MD, PhD, FACC, FESC, FAHA, Co-Chair; David S. Cannom, MD, FACC; Harry J. Crijns, MD, FACC, FESC; Anne B. Curtis, MD, FACC, FAHA; Kenneth A. Ellenbogen, MD, FACC, FHRS† Jonathan L. Halperin, MD, FACC, FAHA; G. Neal Kay, MD, FACC

Background Depressive disorder in the post-myocardial infarction (MI) period has been associated with increased cardiac morbidity and mortality. Possible pathophysiological mechanisms behind this association are not clear. Major depression in physically healthy subjects has been related to immune abnormalities including increased plasma levels of interleukin-6 (IL-6), tumor necrosis factor alfa (TNF-α) and C-reactive protein (CRP). In patients with MI, increased inflammatory markers, such as CRP and TNF-α, have been associated with increased cardiovascular events. It was the aim of this study to test the hypothesis that depression in post-MI patients is associated with increased inflammation as compared to non-depressed post-MI patients. Methods The cytokines IL-6 and TNF-α ; the soluble cytokine receptors sIL-6R, sTNF-RI and sTNF-RII; neopterin; and the inflammation-sensitive plasma proteins (ISPs) CRP and haptoglobin were assessed in a group of 57 patients with a diagnosis of depression post-MI and in a control group of 46 non-depressed post-MI patients, matched for age, gender and time elapsed since MI. Results Cytokine, neopterin and ISP levels were not statistically different in the depressed post-MI group as compared to the non-depressed post-MI group. Several inflammatory markers were however elevated in both cohorts when compared with levels reported in healthy subjects, indicating persistent inflammation several months after MI. Conclusions There was no indication of increased inflammation in depressed post-MI patients as compared to non-depressed post-MI patients.

The left atrial appendage (LAA) is a key source of thrombi in patients with non-valvular atrial fibrillation (AF) and a major clinical focus for stroke prevention. Current surgical exclusion remains suboptimal and percutaneous approaches targeting the LAA, although well validated, fail to offer complete and durable occlusion for all patients. The high anatomical variability of the LAA demands a more tailored and targeted treatment approach. Epicardial LAA clip occlusion represents an important alternative approach for patients with AF not amenable to catheter closure or where anticoagulation is contraindicated. In this article, we briefly review the clinical evidence for epicardial devices in LAA occlusion, with a focus on the AtriClip and discuss their role in stroke prevention strategies.

Current targeted left ventricular (LV) lead placement strategy is directed at the latest activated region during intrinsic activation. However, cardiac resynchronization therapy (CRT) is most commonly applied by simultaneous LV and right ventricular (RV) pacing without contribution from intrinsic conduction. Therefore, targeting the LV lead to the latest activated region during RV pacing might be more appropriate. We investigated the difference in LV electrical activation sequence between left bundle-branch block (LBBB) and RV apex (RVA) pacing using coronary venous electro-anatomic mapping (EAM).Twenty consecutive CRT candidates with LBBB underwent intra-procedural coronary venous EAM during intrinsic activation and RVA pacing using EnSite NavX. Left ventricular lead placement was aimed at the latest activated region during LBBB according to current recommendations. In all patients, LBBB was associated with a circumferential LV activation pattern, whereas RVA pacing resulted in activation from the apex of the heart to the base. In 10 of 20 patients, RVA pacing shifted the latest activated region relative to LBBB. In 18 of 20 patients, the LV lead was successfully positioned in the latest activated region during LBBB. For the whole study population, LV lead electrical delay, expressed as percentage of QRS duration, was significantly shorter during RVA pacing than during LBBB (72 ± 13 vs. 82 ± 5%, P = 0.035).Right ventricular apex pacing alters LV electrical activation pattern in CRT patients with LBBB, and shifts the latest activated region in a significant proportion of these patients. These findings warrant reconsideration of the current practice of LV lead targeting for CRT.

Atrial fibrillation (AF), the most common sustained cardiac rhythm disturbance, is increasing in prevalence as the population ages. Although it is often associated with heart disease, AF occurs in many patients with no detectable disease. Hemodynamic impairment and thromboembolic events result in significant morbidity, mortality, and cost. Accordingly, the American College of Cardiology (ACC), the American Heart Association (AHA), and the European Society of Cardiology (ESC) created a committee of experts to establish guidelines for management of this arrhythmia. The committee was composed of 8 members representing the ACC and AHA, 4 representing the ESC, 1 from the North American Society of Pacing and Electrophysiology (NASPE), and a representative of the Johns Hopkins University Evidence-Based Practice Center representing the Agency for Healthcare Research and Quality’s report on Atrial Fibrillation in the Elderly. This document was reviewed by 3 official reviewers nominated by the ACC, 3 nominated by the AHA, and 3 nominated by the ESC, as well as by the ACC Clinical Electrophysiology Committee, the AHA ECG and Arrhythmia Committee, NASPE, and 25 reviewers nominated by the writing committee. The document was approved for publication by the governing bodies of the ACC, AHA, and ESC and officially endorsed by NASPE. These guidelines will be reviewed annually by the task force and will be considered current unless the task force revises or withdraws them from distribution. The committee conducted a comprehensive review of the literature from 1980 to June 2000 relevant to AF using the following databases: PubMed/Medline, EMBASE, the Cochrane Library (including the Cochrane Database of Systematic Reviews and the Cochrane Controlled Trials Registry), and Best Evidence. Searches were limited to English language sources and to human subjects. ### A. Atrial Fibrillation AF is a supraventricular tachyarrhythmia characterized by uncoordinated atrial activation with consequent deterioration of atrial mechanical function. On the electrocardiogram (ECG), AF …

Endocardial atrial fibrillation (AF) ablation techniques enable one to characterize the underlying substrate in order to tailor the ablation procedure but these ablation lesions are not always transmural nor long lasting. Surgical AF ablation techniques, on the other hand, create reliable linear lesions but the lesion set is based on empirical assumptions rather than specific patient characteristics. Performed in combination, both approaches seem to be complementary as they overcome their mutual shortcomings. Several hybrid or convergent ablation strategies with the use of various energy sources have been described. Medium and long term results are encouraging, especially in challenging settings such as persistent AF and failed endocardial catheter ablations.

Atrial fibrillation (AF) is an extremely prevalent dynamic chronic disease often associated with underlying heart disease, making the management of AF challenging. The antithrombotic management - and in particular the use of antiplatelet agents herein - is challenging as it depends on the (adequate) assessment of the risk of stroke and major bleeding. We therefore focus on the current (recommended) use of antiplatelet agents, address the caveats, and provide clinical tools to assess risk of stroke and major bleeding. Furthermore, we discuss novel antithrombotic agents to provide a future perspective of the role of antiplatelet agents in the antithrombotic management of AF patients.

The study aim was to determine the prognostic value of a multimarker strategy for risk-assessment in patients presenting to the emergency department (ED) with dyspnea.Combining biomarkers with different pathophysiological backgrounds may improve risk stratification in dyspneic patients in the ED.The study prospectively investigated the prognostic value of the biomarkers N-terminal pro-B-type natriuretic peptide (NT-proBNP), high-sensitivity cardiac troponin T (hs-cTnT), Cystatin-C (Cys-C), high-sensitivity C-reactive protein (hs-CRP), and Galectin-3 (Gal-3) for 90-day mortality in 603 patients presenting to the ED with dyspnea as primary complaint.hs-CRP, hs-cTnT, Cyst-C, and NT-proBNP were independent predictors of 90-day mortality. The number of elevated biomarkers was highly associated with outcome (odds ratio: 2.94 per biomarker, 95% confidence interval [CI]: 2.29 to 3.78, p0.001). A multimarker approach had incremental value beyond a single-marker approach. Our multimarker emergency dyspnea-risk score (MARKED-risk score) incorporating age ≥75 years, systolic blood pressure110 mm Hg, history of heart failure, dyspnea New York Heart Association functional class IV, hs-cTnT ≥0.04 μg/l, hs-CRP ≥25 mg/l, and Cys-C ≥1.125 mg/l had excellent prognostic performance (area under the curve: 0.85, 95% CI: 0.81 to 0.89), was robust in internal validation analyses and could identify patients with very low (3 points), intermediate (≥3,5 points), and high risk (≥5 points) of 90-day mortality (2%, 14%, and 44% respectively; p0.001).A multimarker strategy provided superior risk stratification beyond any single-marker approach. The MARKED-risk score that incorporates hs-cTnT, hs-CRP, and Cys-C along with clinical risk factors accurately identifies patients with very low, intermediate, and high risk.

For new or updated text, view the 2011 Focused Update and the 2011 Focused Update on Dabigatran. Text supporting unchanged recommendations has not been updated. It is important that the medical profession play a significant role in critically evaluating the use of diagnostic procedures and therapies as they are introduced and tested in the detection, management, or prevention of disease states. Rigorous and expert analysis of the available data documenting absolute and relative benefits and risks of those procedures and therapies can produce helpful guidelines that improve the effectiveness of care, optimize patient outcomes, and favorably affect the overall cost of care by focusing resources on the most effective strategies. The American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) have jointly engaged in the production of such guidelines in the area of cardiovascular disease since 1980. The ACC/AHA Task Force on Practice Guidelines, whose charge is to develop, update, or revise practice guidelines for important cardiovascular diseases and procedures, directs this effort. The Task Force is pleased to have this guideline developed in conjunction with the European Society of Cardiology (ESC). Writing committees are charged with the task of performing an assessment of the evidence and acting as an independent group of authors to develop or update written recommendations for clinical practice. Experts in the subject under consideration have been selected from all 3 organizations to examine subject-specific data and write guidelines. The process includes additional representatives from other medical practitioner and specialty groups when appropriate. Writing committees are specifically charged to perform a formal literature review, weigh the strength of evidence for or against a particular treatment or procedure, and include estimates of expected health outcomes where data exist. Patient-specific modifiers, comorbidities, and issues of patient preference that might influence the choice of particular …

The ATHENA study has demonstrated that dronaderone reduces a combined endpoint of cardiovascular hospitalizations and cardiovascular death in patients with paroxysmal or persistent atrial fibrillation or flutter (AF). Two previous studies have demonstrated dronaderone to reduce risk of AF recurrence. Here we examine the impact of dronaderone on hospitalizations. ATHENA is a double-blind, placebo controlled parallel group study. Eligible patients needed to have documented AF as well as documented sinus rhythm within 6 months year prior to randomization. Patients further needed to document increased risk by an age above 75 years or an age above 70 years and additionally either diabetes, prior stroke, hypertension, reduced left ventricular function or an enlarged left atrium. New York heart association class IV was an exclusion criterion. Randomized patients received dronaderone 400 mig bid or matching placebo. Mean follow-up was 21 months. The primary outcome was cardiovascular hospitalization or death. Cardiovascular hospitalization was a secondary outcome. There were 675 first cardiovascular hospitalizations on dronaderone and 859 on placebo, hazard ratio 0.75 (95% cl 0.67– 0.82, p

Sidney C. Smith, Jr, MD, FACC, FAHA, FESC, Chair; Alice K. Jacobs, MD, FACC, FAHA, Vice-Chair; Cynthia D. Adams, MSN, APRN-BC, FAHA; Jeffery L. Anderson, MD, FACC, FAHA; Elliott M. Antman, MD, FACC, FAHA[‡][1]; Jonathan L. Halperin, MD, FACC, FAHA; Sharon Ann Hunt, MD, FACC, FAHA; Rick Nishimura

Objective: A recent meta-analysis suggests that the impact of post-myocardial infarction (MI) depression on cardiac prognosis has decreased over the last decade. We tested whether depression still significantly affects prognosis in the present health care situation.Methods: Four hundred ninety-four MI patients were screened for depression. Patients with depression were compared with patients without on cardiovascular events (fatal or nonfatal) during an average follow-up of 2.5 years. Demographic characteristics and cardiac risk factors were controlled for.Results: We found that depression was associated with the occurrence of cardiovascular events in both univariate [hazard ratio (HR), 1.84; 95% confidence interval, 1.24-2.72] and multivariate analysis (HR, 1.56; 1.02-2.38).Conclusions: Depression still has an independent impact on cardiac prognosis after MI, but this influence is smaller than found in early studies. Improvements in general care for MI and better recognition and treatment of post-MI depression may have decreased the impact of depression on prognosis. (c) 2006 Elsevier Inc. All rights reserved.

High-sensitive troponin T (hs-Trop T) and N-terminal prohormone of brain natriuretic peptide (NT-proBNP) are important clinical markers and could be useful to assess cardiovascular (CV) outcomes in patients with permanent atrial fibrillation (AF). Of 543 (88%) of the total 614 patients randomized