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Purpose This study aimed to assess the relationship between the cardiac rhythm response to ibutilide infusion after pulmonary vein isolation and the recurrence of long-term atrial arrhythmias. Methods One hundred and thirty-eight patients with non-paroxysmal atrial fibrillation who had had their first catheter ablation were retrospectively included. All patients whose atrial fibrillation did not terminate after pulmonary vein isolation were administered intravenous ibutilide (1.0 mg). Those with termination of atrial fibrillation after ibutilide administration were defined as responders (n = 86); those without termination of atrial fibrillation, as non-responders ( n = 52). The primary endpoint was any documented recurrence of atrial arrhythmia lasting more than 30 seconds after the initial catheter ablation. Results Conversion of atrial fibrillation to sinus rhythm, directly or via atrial flutter, with ibutilide administration was achieved in 62.3% of patients. A longer duration of atrial fibrillation was associated with failed termination of atrial fibrillation (odds ratio 1.009, 95% confidence interval 1.002-1.017, p = 0.011). During a median follow-up period of 610 days (interquartile range 475-1 106) post ablation, non-responders (n = 24, 46.2%) had a higher recurrence rate of atrial arrhythmia than the responders (n = 26, 30.2%; log-rank, p = 0.011) after the initial catheter ablation. Multivariate Cox regression analysis revealed that non-responders (hazard ratio 1.994, 95% confidence interval 1.117-3.561, p = 0.020) was significantly correlated with recurrence of atrial arrhythmias. Conclusions In patients whose atrial fibrillation persisted after pulmonary vein isolation, the response to ibutilide administration could predict the recurrence of atrial arrhythmias after catheter ablation, which may be useful for risk stratification for recurrence of atrial fibrillation and individualised management of atrial fibrillation.

Atrial fibrillation complicated by a fast ventricular response rate can cause a significant physiological burden. This is characterised by systolic pump failure, decreased diastolic filling time and hypotension leading to impaired organ perfusion. Considering that most anaesthetic agents are cardiac suppressants, the additive effects of this condition together with anaesthesia may lead to increased perioperative morbidity and mortality. A 79-year-old male patient who presented with atrial fibrillation, caused by chronic obstructive pulmonary disease and pulmonary hypertension, and a fast ventricular response rate was booked for emergency ligation of the sphenopalatine artery for posterior epistaxis, complicated by significant blood loss. Both electrical and pharmacological alternatives exist to address this conundrum, but here we would like to present this case where digoxin was used successfully to rate control this patient perioperatively. Digoxin has recently fallen into disfavour for the chronic management of atrial fibrillation, and even in select cases of acute atrial fibrillation with a fast ventricular response rate, and the purpose of this case study is to highlight a potentially useful indication for this antiquated drug.

The evidence for use of direct oral anticoagulants (DOACs) in the management of post-operative cardiac surgery atrial fibrillation is limited and mostly founded on clinical trials that excluded this patient population. We performed a systematic review and meta-analysis of clinical trials and observational studies to evaluate the hypothesis that DOACs are safe compared to warfarin for the anticoagulation of patients with post-operative cardiac surgery atrial fibrillation. We searched PubMed, EMBASE, Web of Science, clinicaltrials.gov, and the Cochrane Library for clinical trials and observational studies comparing DOAC with warfarin in patients ≥18 years old who had post-cardiac surgery atrial fibrillation. Primary outcomes included stroke, systemic embolization, bleeding, and mortality. We performed a random-effects meta-analysis of all outcomes. The meta-analysis for the primary outcomes showed significantly lower risk of stroke with DOAC use (6 studies, 7143 patients, RR 0.64; 95% CI 0.50–0.81, I2: 0.0%) compared to warfarin, a trend towards lower risk of systemic embolization (4 studies, 7289 patients, RR 0.64, 95% CI 0.41–1.01, I2: 31.99%) and similar risks of bleeding (14 studies, 10182 patients, RR 0.91; 95% CI 0.74–1.10, I2: 26.6%) and mortality (12 studies, 9843 patients, relative risk [RR] 1.01; 95% CI 0.74–1.37, I2: 26.5%). Current evidence suggests that DOACs, compared to warfarin, in the management of atrial fibrillation after cardiac surgery is associated with lower risk of stroke and a strong trend for lower risk of systemic embolization, and no evidence of increased risk for hospital readmission, bleeding and mortality.

PURPOSE OF REVIEW: Atrial fibrillation is the most common sustained rhythm abnormality and is associated with stroke, heart failure, cognitive decline, and premature death. Digital health technologies using consumer-grade mobile technologies (i.e. mHealth) capable of recording heart rate and rhythm can now reliably detect atrial fibrillation using single lead or multilead ECG or photoplethysmography (PPG). This review will discuss how these developments are being used to detect and manage atrial fibrillation. RECENT FINDINGS: Studies have established the accuracy of mHealth devices for atrial fibrillation detection. The feasibility of using mHealth technology to screen for atrial fibrillation has also been established, though the utility of screening is controversial. In addition to screening, key aspects of atrial fibrillation management can also be performed remotely and effectively using mHealth, though with some important limitations. SUMMARY: mHealth technologies have proven disruptive in the diagnosis and management of atrial fibrillation. Healthcare providers can leverage these advances to better care for their atrial fibrillation patients whenever necessary.

Smartphones and other wearable electronic devices increasingly are used for ambulatory cardiac rhythm assessment. These consumer technologies have been evaluated in several studies for diagnosis and management of atrial fibrillation. Diverse mobile health applications, including management of other arrhythmias and medical conditions, are expanding alongside advances in technology. Electronic devices owned by millions of consumers have the potential to alter health care delivery as well as research design and implementation. This review provides an up-to-date discussion of the available mobile health technologies, specific applications and limitations for arrhythmia evaluation, their impact on health care systems, and key areas for future investigation.

Optimized management of atrial fibrillation requires patient-oriented decision making with a multidisciplinary approach. This report incorporates recent authoritative studies to provide detailed recommendations for managing atrial fibrillation in specific clinical settings. The principles of the Atrial fibrillation Better Care (ABC) pathway apply in these clinical settings. In addition, specific considerations are discussed for each of these conditions and populations. (Korean J Med 2021;96:264-295)

The management of atrial fibrillation (AF) in the outpatient setting has become more complex with the utilization of antiarrhythmic drugs (AADs) and increasing complexity of comorbid conditions. The primary care clinician is critically involved in the pharmacologic management of AF, whether it be direct prescription of AADs or managing potential drug-drug interactions with other medications. In this review, we provide instructive, high-yield clinical scenarios and quick clinical references to increase familiarity and comfort with the use of AADs.

Background: The management of atrial fibrillation and/or flutter (AF) patients requiring percutaneous coronary intervention (PCI) has evolved significantly. The Canadian Cardiovascular Society AF guidelines, last updated in 2020, seek to aid physicians in balancing both bleeding and thrombotic risks. Methods: A tertiary academic centre registry of patients with AF who had PCI was examined for the antithrombotic therapy at discharge in 4 time periods (cohort 2010–2011; cohort 2014–2015; cohort 2017; cohort 2019). Discharge prescription patterns were compared among the cohorts, using the χ2 test. In addition, antithrombotic management in cohorts 2017 and 2019 were compared to guideline-expected therapy, using the χ2 test. Results: A total of 576 AF patients undergoing PCI were included. Clinical and procedural characteristics were similar among cohorts, except for an increase in drug-eluting stent use in the most recent cohort (94% vs 99%; P = 0.04). The rate of oral anticoagulation increased over time (75% vs 89%; P < 0.01), driven primarily by an increase in direct oral anticoagulants prescription (63% vs 84%; P < 0.01). In contrast to previous cohorts, there was no significant difference between the observed and the guideline-expected anticoagulation rate in cohort 2019 (89% vs 94%; P = 0.23). Conclusions: A combination of expert guidance and educational initiatives in the past decade contributed to dramatic changes in the management of patients with AF undergoing PCI. Résumé: Introduction: La prise en charge des patients atteints de fibrillation auriculaire et/ou de flutter (FA) qui ont besoin d'une intervention coronarienne percutanée (ICP) a considérablement évolué. La dernière révision, en 2020, des lignes directrices sur la FA de la Société canadienne de cardiologie vise à aider les médecins à établir l’équilibre entre les risques d'hémorragie et de thrombose. Méthodes: Nous avons fouillé le registre d'un centre universitaire en soins tertiaires portant sur des patients atteints de FA qui avaient subi une ICP pour nous pencher sur le traitement antithrombotique offert à la sortie de l'hôpital de quatre périodes (cohorte 2010–2011; cohorte 2014–2015; cohorte 2017; cohorte 2019). Nous avons comparé les pratiques en matière d'ordonnances à la sortie de l'hôpital entre les cohortes à l'aide du test du χ2. De plus, nous avons comparé la prise en charge des cohortes de 2017 et de 2019 qui avaient reçu le traitement antithrombotique à celles qui avaient reçu le traitement prévu dans les lignes directrices à l'aide du test du χ2. Résultats: Nous avons sélectionné un total de 576 patients atteints de FA qui avaient subi une ICP. Les caractéristiques cliniques et interventionnelles étaient similaires entre les cohortes, à l'exception d'une augmentation de l'utilisation d'une endoprothèse médicamentée dans la plus récente cohorte (94 % vs 99 %; P = 0,04). Le taux d'anticoagulation par voie orale qui avait augmenté au fil du temps (75 % vs 89 %; P

Stroke prevention is the cornerstone of management of atrial fibrillation (AF), and non-vitamin K antagonist oral anticoagulants (NOACs) are commonly prescribed. Because routine monitoring of anticoagulant effects of NOACs is not necessary, appropriate dosing following the criteria of each NOACs defined in pivotal randomized trials is important. Real-world data demonstrate that underdosing NOACs is associated with a higher risk of ischemic stroke without a lower risk of major bleeding. Furthermore, renal function of AF patients should be assessed using the Cockcroft-Gault formula to prevent overestimation that could result in overdosing of NOACs. The assessment of bleeding risk is important, and the HAS-BLED score should be used to help identify patients at high risk of bleeding (HAS-BLED score ≥3). Moreover, the HAS-BLED score should be reassessed at periodic intervals to address potentially modifiable bleeding risk factors because bleeding risks of AF patients are not static. When managing NOAC-related bleeding episodes, the possibility of occult malignancies (e.g., grastrointestinal [GI] tract cancers for patients experiencing GI bleeding and bladder cancer for patients with hematuria) should be kept in mind. Addressing all of these issues is crucial to achieving better clinical outcomes for anticoagulated AF patients. More efforts are necessary to incorporate clear and easy-to-follow recommendations about optimal management of anticoagulation into the guidelines to improve AF patient care.

Objective: Guidelines recommend measuring and addressing health-related quality of life in the management of atrial fibrillation (AF); however, a disease-specific questionnaire is lacking for the Turkish language. Our aim was to translate and adapt the Atrial Fibrillation Impact Questionnaire (AFImpact) into Turkish and to explore its psychometric properties. Methods: This cross-sectional study was conducted in two phases, including the translation and cultural adaptation of AFImpact into Turkish language and the analysis of psychometric properties of the translated questionnaire. 98 patients diagnosed with AF were evaluated using the Turkish version of AFImpact, Short Form-36 (SF-36) and Pittsburg Sleep Quality Index (PSQI). Reliability, validity, and factor structure of the Turkish version of AFImpact was explored. Results: Cronbach's alpha coefficients for vitality, emotional distress, and sleep domains of AFImpact was 0.956, 0.955, and 0.819, respectively, indicating good-to-excellent internal consistency. No significant difference was detected between the initial and retest scores, and intraclass correlation coefficients of each domain varied between 0.991 and 0.996, indicating excellent test-retest reliability. Each domain of AFImpact highly correlated with similar domains of SF-36 and PSQI, having correlation coefficients between -0.484 and -0.699. AFImpact was able to discriminate between the patients in different functional classes, confirming know-groups validity. Factor analysis revealed AFImpact had the same factorial structure as the original questionnaire. Conclusion: The Turkish version of AFImpact is a valid and reliable questionnaire for evaluating health-related quality of life in patients with AF.

Objectives Atrial fibrillation is the most common cardiac dysrhythmia in the United States. Our aim was to determine if a novel protocol for management of atrial fibrillation was feasible to implement in an emergency department (ED). Interviews were conducted with ED physicians and physician assistants to identify themes in relation to the clinical use and impleon of the protocol. Methods A novel protocol was developed by a multi-disciplinary team and implemented in an academic ED. The protocol used cardiac computed tomography (CT) to rule out left atrial thrombus in patients with greater than 12 h of symptoms and high risk of thromboembolism, or any patient with greater than 48 h of symptoms. Patients who underwent cardiac CT or electrical cardioversion were followed up at 30 days via telephone to monitor for recurrence or adverse thromboembolic events. Providers were interviewed to identify themes regarding protocol usage, barriers to its use, and future changes to increase utilization. Results Patients with atrial fibrillation in the ED were eligible for inclusion. Twenty-nine patients were treated using the protocol. Seven patients (24%) underwent cardiac CT prior to electrical cardioversion. Cardioversion success rate was 83%, with 69% of patients discharged home. Thirty-day follow-up was completed on 25 patients (86%). Six patients (24%) had reoccurrence of atrial fibrillation requiring subsequent cardioversion. No patients experienced stroke or thromboembolic event. Interviews were conducted with 14 providers. Usage barriers included time, availability, and additional work-up. Six subthemes were identified for future changes including EMR order set, frequent reminders, increased education, increased awareness, activation energy, and EMR pop-ups. Conclusion The Iowa Less Aggressive Protocol is a novel treatment protocol for the ED management of atrial fibrillation that was feasible to implement and use. Providers viewed the protocol favorably and identified areas of improvement for future use.

The 2020 European Society of Cardiology guidelines endorse the Atrial Fibrillation Better Care (ABC) pathway as a structured approach for the management of atrial fibrillation (AF), addressing three principal elements: ‘A’ – avoid stroke (with oral anticoagulation), ‘B’ – patient-focused better symptom management, and ‘C’ – cardiovascular and comorbidity risk factor reduction and management. This review summarizes the definitions used for the ABC criteria in different studies and the impact of adherence/non-adherence on clinical outcomes, from 12 studies on seven different cohorts. All studies consistently showed statistically significant reductions in the risk of stroke, myocardial infarction, and mortality among those with ABC pathway adherent treatment. The ABC pathway provides a simple decision-making framework to enable consistent equitable care from clinicians in primary and secondary/tertiary care. Further research examining the impact of ABC pathway implementation in prospective cohorts utilizing consistent inclusion criteria and definitions of ‘A’, ‘B’, and ‘C’ adherent care is warranted.

Introduction Atrial fibrillation (AF) is the most common cardiac sustained arrhythmia, whose incidence and prevalence increase with age, representing a significant burden for health services in western countries. Older people contribute to the vast majority of patients affected from AF. Evidence acquisition Although oral anticoagulant therapy represents the cornerstone for the prevention of ischemic stroke and its disabling consequences, several other interventions - including left atrial appendage occlusion (LAAO), catheter ablation (CA) of AF, and rhythm control strategy (RCS) - have proved to be potentially effective in reducing the incidence of AF-associated clinical complications. Scientific literature focused on the three items will be discussed. Evidence synthesis Practical treatment of older AF patients is presented, including approach and management of patients with geriatric syndromes, selection of the most appropriate individualized drug treatment, clinical indications and potential clinical benefit of LAAO and CA in selected older AF patients. Conclusions Older people carry the greatest burden of AF in real world practice. Within a shared decision making process, the patient centered approach need to be put in the context of a comprehensive assessment, in order to gain maximal net clinical benefit and avoid futility or harm.

Background: Whether advances in identification and management of atrial fibrillation and atrial flutter (collectively, AF) have led to improved outcomes is unclear. We sought to study trends in clinical outcomes selected as quality indicators for nonvalvular AF in Canada. Methods: We identified hospitalized patients with a first diagnosis of nonvalvular AF between April 2006 and March 2015, in all of Canada except Quebec. We assessed trends in 1-year incidence of stroke/systemic embolism (SSE), major bleeding, and initial heart failure (HF) hospitalization. Results: The cohort included 466,476 patients. The median age was 77 years (interquartile range, 68-84 years), 46% were female, and 68% had a Congestive Heart Failure, Hypertension, Age (≥75 years), Diabetes, Stroke/Transient Ischemic Attack, Vascular Disease, Age (65-74 years), Sex (Female) (CHA2DS2-VASc) score > 3. Within 1 year of discharge, 3.5% were hospitalized for stroke or SSE, 1.6% for major bleeding, and 8.6% for new HF. Over the study period, the crude rate of SSE declined from 3.6% to 3.3% (P = 0.002), whereas the rates of hospitalization for new HF and for major bleeding did not significantly change. After adjustment for CHA2DS2-VASc score, the yearly rates of incident SSE (risk ratio, 0.99; 95% confidence interval [CI], 0.98-0.99; P = 0.002) and HF (risk ratio, 0.99; 95% CI, 0.99-1.00; P = 0.001) declined ≤ 1% absolute, whereas major bleeding remained unchanged (risk ratio, 1.00; 95% CI, 0.99-1.00; P = 0.28). Conclusions: Among hospitalized patients with nonvalvular AF in Canada, the rate of SSE and new HF decreased modestly over a 10-year period, with no significant change in major bleeding. Efforts to study process-based quality indicators, with increased focus on HF prevention, are needed. Résumé: Contexte: On ne sait pas si les avancées en matière de détection et de prise en charge de la fibrillation auriculaire et du flutter auriculaire (collectivement appelés « FA » ci-après) ont permis d’améliorer les résultats pour les patients. Nous avons donc étudié les tendances à l’égard de résultats cliniques particuliers pris comme indicateurs de qualité relatifs à la FA non valvulaire au Canada. Méthodologie: Nous avons recensé les patients hospitalisés au Canada (sauf au Québec) entre avril 2006 et mars 2015 en raison d’une FA non valvulaire nouvellement diagnostiquée. Nous avons évalué les tendances quant à la survenue d’un accident vasculaire cérébral ou d’une embolie systémique (AVC/ES), d’une hémorragie majeure et d’une première hospitalisation pour insuffisance cardiaque. Résultats: La cohorte comprenait 466 476 patients, dont l’âge médian était de 77 ans (intervalle interquartile : 68 à 84 ans); 46 % des patients étaient des femmes, et 68 % avaient un score CHA2DS2-VASc (Congestive Heart Failure [insuffisance cardiaque congestive], hypertension, âge [≥ 75 ans], diabète, Stroke/Transient Ischemic Attack [AVC/accident ischémique transitoire] – maladie vasculaire, âge [65-74 ans], sexe [femmes]) supérieur à 3. Dans l’année suivant la sortie de l’hôpital, 3,5 % des patients ont été hospitalisés en raison d’un AVC ou d’un AVC/ES, 1,6 %, en raison d’une hémorragie majeure et 8,6 %, en raison d’une nouvelle insuffisance cardiaque. Au cours de la période étudiée, le taux brut d’AVC/ES est passé de 3,6 % à 3,3 % (p = 0,002), tandis que les taux d’hospitalisation en raison d’une nouvelle insuffisance cardiaque ou d’une hémorragie majeure n’ont pas changé de manière significative. Après correction pour tenir compte du score CHA2DS2-VASc, les taux annuels de survenue d’un AVC/ES (rapport des risques de 0,99; intervalle de confiance [IC] à 95 % : de 0,98 à 0,99; p = 0,002) et d’une insuffisance cardiaque (rapport des risques de 0,99; IC à 95 % : de 0,99 à 1,00; p = 0,001) ont diminué de ≤ 1 % en valeur absolue, tandis que le taux de survenue d’une hémorragie majeure n’a pas changé (rapport des risques : 1,00; IC à 95 % : de 0,99 à 1,00; p = 0,28). Conclusions: Parmi les patients hospitalisés au Canada en raison d’une FA non valvulaire, les taux d’AVC/ES et de nouvelle insuffisance cardiaque ont affiché une réduction modeste sur une période de 10 ans, tandis que le taux d’hémorragie majeure n’a pas changé de manière significative. D’autres études évaluant les indicateurs de qualité fondés sur les procédés, notamment en matière de prévention de l’insuffisance cardiaque, s’imposent.

Introduction Surgical management of atrial fibrillation (AF) is a well-established method of preventing complications and late mortality in patients presenting with AF before mitral valve (MV) surgery. However, despite a substantial body of evidence and a Class I recommendation to apply surgical ablation (SA) concomitant to MV surgery, the utilization of SA remains low. Methods In this study, we sought to summarize the current trends in the SA of AF during MV surgery and update the medical community on its advantages, including perioperative mortality and morbidity, freedom from AF, as well as long-term survival and stroke rates. Results The data indicate that SA can be added with no increased risk (and perhaps a reduction in perioperative risk) and improved late survival compared to patients with AF left untreated during MV surgery. Discussion Inconsistent application of SA may be related to inaccurate perceptions regarding the complexity of the procedure itself, extended cross-clamp and bypass times with attendant increased risks, views that it is ineffective, and increased need for an early pacemaker. Conclusion Education in the proper performance of SA, including careful placement of the lesions and attainment of the full transmural effect, contributes to procedure success. Propagating the safety and positive outcomes may also address the concerns.

Clinical practice guidelines for the diagnosis and management of atrial fibrillation (AF) are one of the most regularly updated documents by the European Society of Cardiology. The new version of clinical practice guidelines (2020) contains a number of changes regarding anticoagulant therapy in patients with AF who have developed acute cerebrovascular accidents. In this review, we discuss the statements of the updated document on the timing of the start/restart of anticoagulant therapy after ischemic stroke and intracranial hemorrhage in patients with AF, the choice of antithrombotic therapy in patients with cryptogenic stroke, as well as the need for the additional testing to clarify the origin of the embolism. We provide our original position on the possibility of applying these recommendations to the real clinical practice.

Introduction: Atrial Fibrillation (AF), the most commonly sustained arrhythmia, affects approximately 200,000 Canadians and costs an annual $815 million to the Ontario provincial healthcare system. The current model for chronic AF management (favouring infrequent hospital visits) in combination with the challenge of detecting cardiac arrythmias provides opportunity for wearable devices to improve quality of care. Physicians must be aware of available wearable devices, their accuracy, validity, and potential to improve patient care. Methods: PubMed and Google Scholar databases were searched for primary studies involving AF and wearable devices published from database inception to 2020. Due to the heterogeneity of the findings, quantitative synthesis of the information could not be conducted. A narrative synthesis was performed for the obtained results, including a discussion of apparent trends and common study outcome measures: sensitivity, specificity, positive-, and negative-predictive-values. The narrative included comparisons to similar reviews and a discussion on both the current and future research directions. Results: The systematic search produced 214 studies, of which, 7 met the pre-determined eligibility criteria. The studies were published between 2018-2020 in 5 countries. Each eligible study was described and summarized; devices investigated include the Apple Watch with Kardia Band (Atrial fibrillation-sensing watch; AFSW), Huawei wearable devices (Honor 4 wristband, Honor Watch or Watch GT), CardioTracker (CART) + a pulse oximeter, and the RITMA system. Discussion: This systematic review comprehensively examined wearable devices used to deliver care for patients with AF. It was found that currently available wearable technologies for AF detection and management varied greatly in their accuracy, application settings, and accessibility. With technological advancements and further exploration into AF devices’ usability, widespread implementation of wearable technology in AF care is plausible. Successful application of these technologies can improve AF care and contribute to a significant reduction in AF-related healthcare costs. Conclusion: There are many devices available for AF care that show promise for certain applications. Additionally, there remains a demand for large-scale, high-quality research in this field to investigate the advantages and shortcomings of various devices that have shown promise in preliminary research. Future research should focus on randomized controlled trials to generate conclusive findings for wearable technologies in AF.

Background Catheter ablation is increasingly employed in the management of atrial fibrillation (AF). Data regarding safety of ablation of AF is largely derived from controlled clinical trials. Objectives The aim of this study was to analyze safety and complications of AF ablation performed in a "real world" setting outside of clinical trials, and obtain insights on predictors of complications. Methods We utilized the National Inpatient Sample database, to identify all patients who underwent AF ablations between 2015 and 2017 using International Classification of Disease-Tenth revision codes. Complications were defined as per the Agency for Health Care Research and Quality Guidelines. Statistical tests including multivariate logistic regression were performed to determine predictors of complications. Results Among 14,875 cases of AF ablation between 2015 and 2017, a total of 1884 complications were identified among 1080 (7.2%) patients. Patients with complications were likely to be older and female with a higher burden of comorbidities. A 27% increase in complications was observed from 2015 to 2017, driven by an increase in pericardial complications. Multivariate regression analysis revealed that pulmonary hypertension (adjusted odds ratio [aOR]: 1.99, p = .041) and chronic kidney disease (CKD; aOR: 1.67, p = .024), were independent predictors of complications. Centers with higher procedural volumes were associated with lower complication rates. Conclusions Complication rates related to AF ablations remain substantially high. Presence of pulmonary hypertension and CKD are predictive of higher procedural complications. Furthermore, hospital procedure volume is an important factor that correlates with complication rates.

We present two cases that highlight the clinical challenge of anti coagulation in patients with intracerebral haemorrhage (ICH) due to Cerebral Amyloid Angiopathy (CAA) and co-existent non-valvular Atrial Fibrillation (AF). Case 1 78 -Years right-handed functionally independent gentleman presented with right parietal intracerebral haemorrhage (ICH) on Dabigatran that required reversal. He had a background history of hypertension, persistent AF and a previous ICH on warfarin. Post atrial septal defect repair, he had multiple unsuccessful cardioversions for AF, and a failed catheter ablation after the first stroke. Magnetic Resonance Imaging (MRI) brain showed Cerebral Amyloid Angiopathy (CAA), the cause of his recurrent bleeds. Anticoagulation was not started due to severe CAA on imaging and recurrent bleeds. He was referred for left atrial closure device. Case 2 79-Years female presented with left parietal haemorrhage and new onset atrial fibrillation. Work up for ICH showed normal BP readings and clotting profile. Her MRI brain showed a large lobar bleed with mild small vessel disease and evidence of no other imaging features suggestive of CAA. As optimal timing to start anticoagulation after ICH is unknown, she was suggested to take part in a clinical trial. Her family declined the offer of clinical trial and also anti coagulation due to few falls. Her CHAD-VaSc and HAS-BLED score were 4 and 2 respectively. She was then referred to tertiary centre for left atrial appendage closure device. Conclusion Safety and timing to initiate DOAC for AF in this group is not established yet, understanding hemorrhagic risk using Boston Criteria for CAA diagnosis should be considered in addition to HAS-BLED score. Shared decision making and comprehensive discussions with cardiologist are of paramount importance. Non pharmacological intervention studies WATCHMAN and PREVAIL have proven procedural efficacy, however, in elderly population, decision making is complex due to frailty, dementia and co-morbidities.

Background and objective The increasing availability of real-world evidence (RWE) about safety and effectiveness of direct non-vitamin K oral anticoagulants (DOACs) for the management of atrial fibrillation (AF) offers the opportunity to better understand the clinical and economic implications of DOACs versus vitamin K antagonists (VKAs). The objective of this study was to compare the economic implications of DOACs and VKAs using data from real-world evidence in patients with AF. Methods A Markov model simulating the lifetime course of patients diagnosed with non-valvular AF was used to evaluate the cost-effectiveness of DOACs (i.e., rivaroxaban, dabigatran and apixaban) versus VKAs from the Italian National Health System (INHS) perspective. The model was made up of data from the literature and a meta-analysis of RWE on the incidence of stroke/systemic embolism (SE), major bleeding (MB), intracranial haemorrhage (ICH) and all-cause mortality (ACM); direct costs included drug costs, costs for drug monitoring, and management of events from official national lists. One-way and probabilistic sensitivity analyses (PSA) were used to assess the robustness of the results. Results Results from the meta-analysis showed that apixaban had a high probability of being the most effective for stroke/SE, MB and ACM. Despite their higher acquisition costs, the cost-effectiveness analysis showed all DOACs involved a saving when compared with VKAs, with per-patient savings ranging between €4647 (rivaroxaban) to €6086 (apixaban). Moreover, all DOACs indicated a gain both in quality-adjusted life-years and life-years. According to PSA, findings related to apixaban were consistent, while for dabigatran and rivaroxaban PSA revealed a higher degree of uncertainty. Conclusions The beneficial effect of DOACs on containing events showed in RWE had the potential to offset drug-related costs, thus improving the sustainability of treatment for non-valvular AF in daily clinical practice. Supplementary Information The online version contains supplementary material available at 10.1007/s40261-021-01002-z.

Purpose Recently, guidelines recommended the use of direct oral anticoagulants (DOACs) for the management of non-valvular atrial fibrillation (NVAF). Postoperative atrial fibrillation (POAF) is the most common post-surgical complication of cardiac surgery, but the efficacy and safety of DOAC for POAF have rarely been investigated. We conducted a prospective observational study to investigate the efficacy and safety of DOAC administered immediately after POAF. Materials and methods In all, 135 patients that experienced POAF after cardiac surgery were treated with a DOAC. Primary endpoints were either bleeding or thromboembolic events. Secondary endpoints included changes in hemoglobin (Hb), prothrombin time (PT), activated partial thromboplastin time (APTT), serum creatinine (sCr), estimated glomerular filtration rate (eGFR), and pleural/pericardial effusion. Results Patients were treated with apixaban (n = 31), edoxaban (n = 87), and rivaroxaban (n = 17). Major bleeding (p = 0.011) and gastrointestinal (GI) bleeding (p = 0.047) were significantly more frequent in the rivaroxaban group. Stroke was observed in one rivaroxaban group patient and none in the other two groups. Conclusion DOAC as anticoagulation therapy for the early intervention of POAF following cardiac surgery is associated with a low incidence of major bleeding; a favorable safety profile and excellent efficacy were demonstrated for DOAC. Furthermore, our results indicate that the safety and efficacy of apixaban and edoxaban are better than rivaroxaban.

Atrial fibrillation is a common cardiac arrhythmia in which the atria of the heart do not beat synchronously with the ventricles. It affects 2.7 to 6.1 million people in the United States. The erratic beating of the atria can cause blood clots to form in the atria, and if released into the circulation, an embolism can travel to the brain, causing a stroke. The primary goals of care for the management of atrial fibrillation are stroke-risk reduction, control of heart rate, rhythm management, and prevention of cardiac-related morbidity and mortality. This article reviews the guideline for the management of patients with atrial fibrillation by the American College of Cardiology and American Heart Association Task Force on Clinical Practice Guidelines and provides recommendations for home healthcare clinicians.

Objective: Catheter ablation has been a common procedure used for the management of atrial fibrillation (AF). Atrioesophagel fistula (AEF) is one of the most feared complications of AF ablation. Although it is a rare complication, severe esophageal thermal injury must be avoided. It is important to describe a safe method of preventing esophageal injuries without increasing AF recurrence. Methods: A retrospective cohort study of consecutive patients who underwent radiofrequency AF catheter ablation during 1 year-period wa conducted. One hundred and four patients were enrolled divided in two groups: one with a maximum recorded esophageal temperature (ET) < 38 °C and other with a maximum recorded ET ≥ 38 °C. The primary endpoint was detection of endoscopic esophageal lesions after AF ablation and the secondary endpoint was AF recurrence according to the maximum ET reached during the procedure. Results: The maximum ET was on average 37.3 ± 1.0 °C. Only 4 (3.8%) patients had esophageal lesion diagnosed by upper gastrointestinal endoscopy. There were no cases of esophageal perforation. The AF recurrence rate was 9.6% during the follow-up (10 patients, 3 from the ET max < 38 °C group and 7 from the ET max ≥ 38 °C group; p = 0.181). The maximum ET was not associated with AF recurrence after catheter ablation (OR = 1.65, 95% CI = 0.84-3.24, p = 0.14). Conclusions: A low incidence of esophageal injury after AF ablation with the use of a specific esophageal protection protocol was found. There was no esophageal perforation. The AF recurrence rate was similar to that described in the literature.

Belinda Linden presents a quarterly overview of recently published guidance of relevance to cardiovascular nursing. This update reviews the 2020 guidelines from the European Society of Cardiology and the European Association of Cardio-Thoracic Surgery regarding the diagnosis and management of atrial fibrillation.

Background Postoperative atrial fibrillation (POAF) is the most common complication occurring after cardiac surgery. Guidelines for the management of this complication are scarce, often resulting in differences in treatment strategy use among patients. Objective To evaluate the management of POAF in a cardiac surgery department, characterize the extent of its variability, and develop a standardized protocol. Methods This was an observational retrospective study with data from patients who underwent cardiac surgeries with subsequent POAF between January 1, 2017, and June 1, 2018. We assessed the difference in the proportions of patients whose first POAF episodes were treated with a rate control (RaC) strategy, a rhythm control (RhC) strategy, and both among different hospital units. We also assessed the mean duration of POAF episodes, POAF recurrences, and the management of anticoagulation. Results Data from 97 patients were included in this study. The POAF management strategy differed significantly among the 3 types of hospital units ( P = 0.001). Considering all POAF episodes (including all recurrences), 83 of the 97 patients (85.6%) received amiodarone as part of the RhC strategy. Anticoagulation was used in 58 (59.8%) patients and was suboptimal according to the study criteria in 29.5% of the patients included. Based on these results, a hospital working group developed a standardized protocol for POAF management. Conclusions and Relevance POAF management was heterogeneous at our institution. This article highlights the need for clear practice guidelines based on large prospective studies to provide care according to best practices.

Background: Atrial fibrillation (AF) is a common problem in patients undergoing coronary artery bypass graft (CABG). For AF ablation, bipolar radiofrequency ablation (BRA) achieves complete transmural ablation lines and reduces the risk of treatment failure. We analyzed the efficacy of BRA for sinus rhythm restoration in patients with AF undergoing CABG. Methods: This prospective study included patients with permanent or paroxysmal AF scheduled to undergo BRA combined with CABG in our institution from May 2014 to June 2020. After discharge from hospital, all patients were seen every 6 months over 5 years to evaluate survival, sinus rhythm restoration, and New York Heart Association (NYHA) class. Results: We enrolled 168 patients, 97 (57.7%) with permanent AF (group I) and 71 (42.3%) with paroxysmal AF (group II) at 60 months. We found that group II patients had better sinus rhythm restoration rates after BRA with CABG than group I patients (P = .005). Overall mortality at 60 months was significantly lower in group II patients (2 [2.8%]) than patients in group I (14 [14.4%]; P = .01). The survival rate was significantly higher in group II than in group I (94% versus 72%; P = .0003) as shown by Kaplan–Meier analysis. The 95% confidence interval of the Cox hazards survival regression ratio was significantly different between groups (0.1792 [0.04069 to 0.7896]; P = .006). Long-term AF (>3 years) before BRA with CABG and permanent AF type were identified as predictors of post-BRA recurrent AF (P = .0001 and P = .005, respectively). NYHA class improved significantly at 60 months compared with baseline (P < .0001). Conclusions: This study identified preoperative AF type and duration as predictors of the success of BRA combined with CABG.

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

The health crisis due to coronavirus disease 2019 (COVID-19) has shocked the world, with more than 1 million infections and casualties. COVID-19 can present from mild illness to multi-organ involvement, but especially acute respiratory distress syndrome. Cardiac injury and arrhythmias, including atrial fibrillation (AF), are not uncommon in COVID-19. COVID-19 is highly contagious, and therapy against the virus remains premature and largely unknown, which makes the management of AF patients during the pandemic particularly challenging. We describe a possible pathophysiological link between COVID-19 and AF, and therapeutic considerations for AF patients during this pandemic.

Catheter ablation has become the mainstream treatment of atrial fibrillation, but still remains a challenge in those patient with persistent and long standing persistent atrial fibrillation. In addition of isolation of the pulmonary veins, any other areas that can trigger or perpetuate atrial fibrillation need to be isolated. Current technologies may allow to effectively deliver permanently lasting lesions, and therefore improve clinical outcomes after ablation. The specialized conduction system including the Bachmann and septopulmonary bundles, are important substrate targets for the management of atrial fibrillation. The anatomical location of these fibers, and the corresponding approach for ablation are described in this case.

Background So far there has been little evidence on the antithrombotic treatment of patients presenting with atrial fibrillation (AF) and a CHA2DS2-VASc score of 1 in men (2 in women). However, a recently published position paper suggests a personalized approach in weighing individual risk factors and considering additional patient characteristics and biomarkers for the decision for or against antithrombotic treatment in this intermediate-risk AF population. Case summary A 63-year-old male patient with a CHA2DS2-VASc score of 1 due to hypertension presents with a first episode of paroxysmal AF. The European Society of Cardiology (ESC) guidelines on the management of AF do not recommend a general antithrombotic therapy in those patients. Therefore, the decision for or against the initiation of oral anticoagulation (OAC) in the presented case is based on recent treatment recommendations of the ESC, that aim to guide clinicals through the question whether to anticoagulate or not. Discussion Oral anticoagulation in patients presenting with a CHA2DS2-VASc of 1 remains a challenging approach in clinical practice and physicians need to carefully balance the individual benefit of reducing thromboembolic risk with OAC against the potential harm due to an increase in bleeding risk in this patient population. The ESC provided an easily applicable approach for decision-making in patients with AF and a CHA2DS2-VASc score of 1 via consideration of additional risk factors, scoring tools, and established biomarkers. Of note, if an antithrombotic therapy is offered, non-vitamin K antagonist oral anticoagulants should be preferred over vitamin K antagonists based on the beneficial net clinical benefit.

Objective Intravenous push (IVP) diltiazem and metoprolol are commonly used for management of atrial fibrillation (AF) with rapid ventricular rate (RVR) in the emergency department (ED). This study's objective was to determine if there was a significant difference in blood pressure reduction between agents. Methods This was a single-center, retrospective study of adult patients initially treated with IVP diltiazem or metoprolol in the ED from 2008 to 2018. Primary endpoint was mean reduction in systolic blood pressure (SBP) from baseline to nadir during the study period. Study period was defined as time from first dose of IVP intervention to 30 min after last dose of IVP intervention or first dose of maintenance therapy, whichever came first. Results A total of 63 diltiazem patients and 45 metoprolol patients met eligibility criteria. Baseline characteristics were similar except for initial ventricular rate (VR) and home beta-blocker use. Median dose of initial intervention was 10 [10−20] mg and 5 [5–5] mg for diltiazem and metoprolol respectively. Mean SBP reduction was 18 ± 22 mmHg for diltiazem compared to 14 ± 15 mmHg for metoprolol (p = .33). Clinically relevant hypotension was similar between groups 14% vs. 16% (p = .86). Rate control was achieved in 35 (56%) of the diltiazem group and 16 (36%) of the metoprolol group (p = .04). Conclusion IVP diltiazem and metoprolol caused similar SBP reduction and hypotension when used for initial management of AF with RVR in the ED. However, rate control was achieved more often with diltiazem.

In the past 20 years the Netherlands-based RACE trials have investigated important concepts in clinical atrial fibrillation (AF). Their scope ranged from rhythm versus rate control to early or delayed cardioversion and also included early comprehensive management of AF in two trials, one focusing on early ‘upstream therapy’ and risk factor management and the other on integrated chronic nurse-led care. Studies were mostly triggered by simple clinical observations including futility of electrical cardioversion in persistent AF; many patients with permanent AF tolerating day-after-day ‘uncontrolled’ resting heart rates of up till 110 beats/min; patients being threatened more by vascular risks than AF itself; and insufficient guideline-based treatments for AF. Also the observation that recent-onset atrial fibrillation generally converts spontaneously, obviating cardioversion, triggered one of the studies. The RACE trials shifted a number of paradigms and by that could change the AF guidelines. The initial ‘shock-and-forget’ attitude made place for increased attention for anticoagulation, and in turn, broader vascular risks were recognised. In a nutshell, the adage eventually became: ‘look beyond the ECG, treat the patient’. Electronic supplementary material The online version of this article (10.1007/s12471-020-01476-0) contains supplementary material, which is available to authorized users.

Machine learning applications in cardiology have rapidly evolved in the past decade. With the availability of machine learning tools coupled with vast data sources, the management of atrial fibrillation (AF), a common chronic disease with significant associated morbidity and socioeconomic impact, is undergoing a knowledge and practice transformation in the increasingly complex healthcare environment. Among other advances, deep-learning machine learning methods, including convolutional neural networks, have enabled the development of AF screening pathways using the ubiquitous 12-lead ECG to detect asymptomatic paroxysmal AF in at-risk populations (such as those with cryptogenic stroke), the refinement of AF and stroke prediction schemes through comprehensive digital phenotyping using structured and unstructured data abstraction from the electronic health record or wearable monitoring technologies, and the optimization of treatment strategies, ranging from stroke prophylaxis to monitoring of antiarrhythmic drug (AAD) therapy. Although the clinical and population-wide impact of these tools continues to be elucidated, such transformative progress does not come without challenges, such as the concerns about adopting black box technologies, assessing input data quality for training such models, and the risk of perpetuating rather than alleviating health disparities. This review critically appraises the advances of machine learning related to the care of AF thus far, their potential future directions, and its potential limitations and challenges.

Heart failure (HF) and atrial fibrillation (AF) often coexist, being closely interrelated as the one increases the prevalence and incidence and worsens the prognosis of the other. Their frequent coexistence raises several challenges, including under-diagnosis of HF with preserved ejection fraction in AF and of AF in HF, characterization and diagnosis of atrial cardiomyopathy, target and impact of rate control therapy on outcomes, optimal rhythm control strategy in the era of catheter ablation, HF-related thromboembolic risk and management of anticoagulation in patients with comorbidities, such as chronic kidney disease or transient renal function worsening, coronary artery disease or acute coronary syndromes, valvular or structural heart disease interventions and cancer. In the present document, derived by an expert panel meeting, we sought to focus on the above challenging issues, outlining the existing evidence and identifying gaps in knowledge that need to be addressed.

BACKGROUND Catheter ablation (CA) continues to prove to be an intriguing therapeutic option for the management of atrial fibrillation (AF) especially in patients with heart failure with reduced ejection fraction (HFrEF). Recent data have suggested that CA may be a viable first-line strategy for these patients. STUDY QUESTION Is CA more effective in managing patients with AF with HFrEF compared to optimal medical treatment and anti-arrhythmic drugs? DATA SOURCES Randomized controlled trials (RCTs) comparing CA, medical treatment, or antiarrhythmic drugs to each other or a placebo group for the treatment of AF in HFrEF. We performed a comprehensive search in PubMed, Embase, and Cochrane library to identify relevant RCTs. STUDY DESIGN Our primary outcomes of interest were all-cause mortality, hospitalization for heart failure, and the percentage change in left ventricular ejection fraction. Also, we looked at functional outcomes such as Minnesota Living with Heart Failure Questionnaire and 6-minute walking distance. We used event rates for categorical variables and mean differences between the groups for the continuous variables. We used a frequentist approach employing a graph theory methodology to construct a network meta-analysis model. RESULTS We ended up with 17 RCTs with 5460 participants and 5 different treatments in our network meta-analysis. Compared to optimal medical therapy, CA was effective in reducing all-cause mortality odds ratio (OR) 0.44 (95% confidence interval, 0.27-0.74; P-value

Ischaemic stroke and systemic embolism are the major potentially preventable complications of atrial fibrillation (AF) leading to severe morbidity and mortality. Anticoagulation using vitamin K antagonists (VKA) or non-vitamin K oral anticoagulants (NOACs) is mandatory for stroke prevention in AF. Following approval of the four NOACs dabigatran, rivaroxaban, apixaban, and edoxaban, the use of VKA is declining steadily. Increasing age with thresholds of 65 and 75 years is a strong risk factor when determining annual stroke risk in AF patients. Current recommendations such as the “2016 Guidelines for the management of atrial fibrillation” of the European Society of Cardiology and the “2019 AHA/ACC/HRS Focused Update” by the American College of Cardiology, the American Heart Association, and the Heart Rhythm Society strengthen the importance of anticoagulation and detection of bleeding risks, of which older age is an important one. While patients aged ≥ 75 years are usually underrepresented in randomised clinical trials, they represent almost 40% of the trial populations in the large NOAC approval studies. Therefore, a sufficient amount of data is available to assess the efficacy and safety for this patient cohort in that specific indication. In this article, the evidence for stroke prevention in AF using either VKA or NOACs is summarised with a special focus on efficacy compared to bleeding risk in patients aged ≥ 75 years. Specifically, we used a model of increased weighing of intracranial bleeding to illustrate the potential benefit of NOACs over VKA in the elderly population. In brief, there are at least two tested strategies with apixaban and edoxaban which even confer an additional clinical net benefit compared with VKA. Furthermore, elderly subgroups of trials for combined antithrombotic treatment following percutaneous coronary interventions in anticoagulated patients are analysed.

Structured abstract Background The management of atrial fibrillation (AF) has changed with the introduction of direct anticoagulants (DOACs) and new techniques such as catheter ablation. An update collection of data from “real world” AF patients followed by cardiologists is useful to obtain information on both management, outcomes and guideline adherence in clinical practice. Methods Follow-up information on survival, embolic and bleeding events and hospital readmission, persistence of oral anticoagulant (OAC) therapy was collected in 84 centers participating to the BLITZ-AF study. Results Patients were followed for a median of 366 days (IQR: 356–378) and vital status was available for 2159 patients. Mortality was 9.2%. Heart failure was the most common cardiovascular cause of death (70%) followed by arrhythmias (6.7%), acute coronary syndrome (5.0%) and ischemic stroke (2.5%). During follow-up 18.1% of the patients were readmitted, mainly (81.3%) for cardiovascular causes. Patients on OAC were 83.4%, 9.1% were on antiplatelets and 7.5% did not receive antithrombotic therapy. The use of DOACs increased from 42.1% to 46.4% during the follow-up, OAC discontinuation occurred in 9.1%. AF recurrences occurred in 23.4% of the patients discharged in sinus rhythm. Rate control strategy was adopted in 55.9% and beta-blockers were the most used drugs (81.9%). Amiodarone (22%) and flecainide (9.7%) were the most frequent used antiahrrythmic drugs. Conclusions The follow-up of the BLITZ-AF study provide an up to date picture of the clinical course of patients with AF, who appear frequently affected by heart failure and severe comorbidities which might have led to the high mortality rate.

Background Free mobile applications (apps) that use photoplethysmography (PPG) waveforms may extend atrial fibrillation (AF) detection to underserved populations, but they have not been rigorously evaluated. Objective The purpose of this study was to systematically review and evaluate the quality, functionality, and adherence to self-management behaviors of existing mobile apps for AF. Methods We systematically searched 3 app stores for apps that were free, available in English, and intended for use by patients to detect and manage AF. A minimum of 2 reviewers evaluated (1) app quality, using the Mobile Application Rating Scale (MARS); (2) functionality using published criteria; and (3) features that support 4 self-management behaviors (including PPG waveform monitoring) identified using evidence-based guidelines. Interrater reliability between the reviewers was calculated. Results Of 12 included apps, 5 (42%) scored above average for quality (MARS score ≥3.0). App quality was highest for their ease of use, navigation, layout, and visual appeal (eg, functionality and aesthetics) and lowest for their behavioral change support and subjective impressions of quality. The most common app functionalities were capturing and graphically displaying user-entered data (n = 9 [75%]). Nearly all apps (n = 11 [92%]) supported PPG waveform monitoring, but only 2 (17%) supported all 4 self-management behaviors. Interrater reliability was high (0.75–0.83). Conclusion The reviewed apps had wide variability in quality, functionality, and adherence to self-management behaviors. Given the accessibility of these apps to underserved populations and the tremendous potential they hold for improving AF detection and management, high priority should be given to improving app quality and functionality.

PURPOSE OF REVIEW: Management of atrial fibrillation (AF) can be overwhelming with the amount of information and treatment options available today. This review discusses landmark and other clinically relevant trials published in the last 18 months. RECENT FINDINGS: There have been several recent key clinical trials and sub analyses in the field of atrial fibrillation. Early rhythm control with ablation or anti-arrhythmic medications has upended the previous practice of rate control for patients with atrial fibrillation. Vein of Marshall alcohol ablation in combination with endocardial mitral annular ablation and a hybrid epicardial/endocardial approach has shown promising results in the fight against persistent atrial fibrillation. Early ablation with cryoballoon therapy versus antiarrhythmic therapy gives further evidence for early ablation in patients with symptomatic paroxysmal atrial fibrillation. SUMMARY: The rapid development in technology and medications to treat atrial fibrillation, prevent stroke and improve quality of life for patients has created a vast amount of information for physicians to process. The present review will focus on the recent (within 2 years) clinical trials in atrial fibrillation and the impact they may have on your practice.

Introduction Diltiazem is commonly used for the management of atrial fibrillation (AFIB) with rapid ventricular rate (RVR) in the emergency department (ED). Conflicting studies comparing the efficacy of diltiazem have led to various dosing strategies. The objective of this study was to investigate diltiazem administration in a community ED and determine the effect of varying doses on heart rate (HR) control, systolic blood pressure (SBP) and diastolic blood pressure (DBP). Methods This is a retrospective, single-center study of adult patients treated with diltiazem for AFIB-RVR in the ED between January 1 and December 31, 2019. Inclusion criteria included pretreatment HR > 120 beats per minute (bpm). Patients were administered diltiazem at the discretion of the ED physician. Primary endpoint was time to achieve HR < 100 bpm after diltiazem. Secondary endpoints included mean weight-based dose of diltiazem, percentage of patients achieving HR < 100 bpm within 240 minutes of diltiazem, nadir SBP and nadir DBP. Results Ninety-nine patients were included in the study. Seventy-two percent of patients received ≤ 10 mg diltiazem bolus. Mean weight-based dose of diltiazem bolus was 0.13 mg/kg. Mean time to achieve HR < 100 bpm was 270 minutes for the entire cohort. Patients treated with ≥ 0.13 mg/kg diltiazem achieved an HR < 100 bpm at a mean time of 169 minutes compared to 318 minutes for < 0.13 mg/kg (p = 0.0107). HR control was achieved in 61% of patients who received ≥ 0.13 mg/kg compared to 36% of patients who received < 0.13 mg/kg diltiazem (p = 0.0213). No patients discontinued diltiazem for hypotension or bradycardia. The lowest recorded SBP and DBP within 240 minutes of diltiazem were 90 mmHg and 47 mmHg, respectively. There was no significant difference in the lowest SBP and DBP for patients who received < 0.13 mg/kg compared to ≥ 0.13 mg/mg diltiazem. Conclusion The majority of patients with AFIB RVR received a 10 mg non-weight-based diltiazem bolus dose in the ED. Diltiazem bolus dosing ≥ 0.13 mg/kg was associated with significantly improved times to achieve HR control compared to < 0.13 mg/kg and was not associated with hypotension or bradycardia.

Background Atrial fibrillation (AF) is the most common type of arrhythmia. The health burden of AF keeps increasing with the rising incidence of AF caused by the aging population and the high prevalence of unhealthy lifestyle. Pulmonary vein isolation (PVI) is the cornerstone of invasive rhythm control treatment in AF. Randomized controlled trials have shown superiority of an PVI strategy compared to conservative treatment. However, the best timing to perform a PVI to achieve the most optimal outcome is still unknown. Purpose To investigate whether the timing of performing PVI has consequences for the AF management in terms of medical cost, the number of repeated electrical cardioversion and hospitalisations and mortality. Methods In this monocentric retrospective observational study, all patients who underwent an electrical cardioversion and PVI between January 2012 and January 2020 were included using a hospital administrative data record. Follow-up data were collected up to a maximum of 67 months. Early PVI is defined as patients receiving a PVI after a first electrical cardioversion; late PVI is defined as patients receiving PVI after more than one electrical cardioversion. We compared the two groups for the mean medical cost, the number of repeated electrical cardioversions performed, any unplanned hospitalization associated with AF and mortality. Results A total of 407 patients were included in this analysis. Respectively, in the early versus the late PVI strategy groups, the mean age was 64.5 vs. 66.3 years (p=0.105) and the mean follow-up was 1630±843 vs. 2039±781 days (p Conclusions An early PVI tends to be superior to a late PVI strategy in the management of AF with less need for repeated electrical cardioversion and lower hospitalisation rate. Total medical cost and mortality rate were comparable in both approaches. Funding Acknowledgement Type of funding sources: None.

Aims Bleeding risk assessment is recommended in guidelines for the management of atrial fibrillation (AF). The HAS-BLED score was proposed prior to non-vitamin K antagonist oral anticoagulants (NOACs) and it has been suggested that the ORBIT score may be superior in predicting bleeds in NOAC users. We aimed to compare the HAS-BLED and ORBIT scores in contemporary AF patients treated with NOACs. Methods and results We analysed patients enrolled in the ESC-EHRA EORP-AF (EURObservational Research Programme in AF) General Long-Term Registry. HAS-BLED and ORBIT scores were computed based on original schemes. The primary outcome was the occurrence of major bleeding (MB). A total of 3018 patients (median age 70; 39.6% females) were included: median [interquartile range (IQR)] HAS-BLED and ORBIT scores were 1 [1–2] and 1 [0–2], respectively; 356 (11.8%) patients were at high risk for MB using HAS-BLED (≥3) and 123 (4.1%) using ORBIT (≥4). Overall, 60 (2.0%) MB events were recorded, with an incidence of 1.1 per 100 patient-years. Both HAS-BLED and ORBIT were associated with outcome, modestly predicting MB [area under the curve (AUC) 0.653, 95% confidence interval (CI) 0.593–0.714 and AUC 0.601, 95% CI 0.526–0.677, respectively]. Calibration plots showed that both scores were poorly calibrated, particularly the ORBIT score, which showed consistent poorer calibration. Time-dependent reclassification analysis showed a trend towards incorrect lower risk reclassification using ORBIT compared with HAS-BLED. Conclusion In this real-life contemporary cohort of AF patients treated with NOACs, the ORBIT score did not provide reclassification improvement, showing even poorer calibration compared with HAS-BLED. Our findings do not support the preferential use of ORBIT in NOAC-treated AF patients.

Stroke prevention and rate or rhythm control are crucial in the management of atrial fibrillation (AF). There is recent evidence for benefit of early rhythm control, yet rate control is the first choice in elderly patients. However, the efficacy and safety of rate and rhythm control in the elderly population remains largely unexplored. Therefore, we analyzed electronic health record data and investigated prescribing patterns and mortality of both strategies in elderly patients with AF. Data from patients with AF who were aged ≥75 years, used a pharmacological rate or rhythm control strategy, and visited Cardiology Centers of the Netherlands between 2007 and 2018 were extracted. Of the 1497 patients (54% female), 316 (21%) were prescribed rhythm control and 1181 (79%) rate control. Patients aged >85 years (OR: 2.28; 95% CI: 1.51-3.44, P< 0.001) and those with permanent AF (OR: 2.71; 95% CI: 1.67-4.41, P< 0.001) were more likely to receive rate control, whereas those with paroxysmal AF were less likely to receive rate control (OR: 0.42; 95% CI: 0.32-0.56, P< 0.001). After correction for relevant confounders, the mortality risk for patients using rhythm control and patients using rate control was similar (HR: 0.89; 95% CI: 0.70-1.12, P = 0.31). A more liberal approach towards prescribing a rhythm control strategy to the elderly patients with AF may be warranted and seems safe. Our data underscore the need for prospective studies to provide definite answers on efficacy and safety of rhythm control in elderly patients with AF.