A recent survey of 1147 patients with atrialfibrillation from eight high-income European countries suggested that the patients’ education level and knowledge are directly related to the use of antithrombotic treatment. 21 Overall, 54% of patients reported knowing that oral anticoagulation was associated with risk of bleeding.21 The awareness of oral anticoagulation-related risk of bleeding was lowest in patients without schooling (38%) and highest in those with a college or university education (57%). 21 This survey highlighted the potential opportunity to improve anticoagulation treatment in atrialfibrillation with education. Consequently, a European Heart Rhythm Association consensus docu- ment emphasised the need for patient education. 21,22 Additionally, physician decisions not to initiate oral anticoagulation therapy in eligible patients is one of the main barriers for the effective use of antithrombotic therapy in atrialfibrillation. 23 The need for frequent monitoring, medication costs, and lack of knowledge regarding the appropriate use of non-vitamin K antagonist oral anticoagulants were all shown to be related to unwillingness to initiate and maintain oral anticoagulation treatment in individual patients.23 Health-care providers require the tools necessary not only to identify high-risk patients who would benefit from anticoagulation therapy, but also to provide appropriate therapy given the in- creasing choices in anticoagulants. We designed a multifaceted and multilevel educational intervention to address these well known barriers.
rivaroxaban, compared with warfarin, and patients at high bleeding risk, defined as a Anticoagulation and Risk Factors in AtrialFibrillation score >5, were less likely to receive an NOAC. Patients were divided by level of payment into 3 categories, no/poor coverage (patients pay >80% of costs prescription), fair coverage (20%-80%), and good coverage (<20%). Patients with good benefits’ generosity were more likely to receive an NOAC. Because in Spain public health coverage is free and universal, the use of NOACS has become a financial challenge for the Spanish government and therefore the Ministry of Health and The Spanish Medicine Agency published a series of recommendations to regulate NOAC prescription. 16 In this sense, the VKA therapy remains the cornerstone of anticoagulant therapy in patients with AF and its use is recommended in patients’ naive to oral anticoagulation. The NOACs are recommended in specific clinical scenarios: (1) patients with contraindications to the use of VKA, hypersensitivity, or allergy; (2) patients with a history of intracranial hemorrhage; (3) patients with a history of stroke and high risk of bleeding (HAS-BLED >3 and leukoaraiosis grade III/IV or multiple cortical microbleedings); (4) embolic events in patients with VKA, despite good control of INR; (5) VKA-treated patients who have poor control of INR (time in therapeutic range <65% according to Rosendaal method 17 or < 60% as direct calculation, in the previous 6 months); and (6) patients with inability to access to the controls of INR. In our study, patients with history of major bleeding and intracranial hemorrhage were more frequently treated with NOACS, as recommended. Because of the design of the study, we don’t know which patients under treatment of NOCAS were previously treated with VKA and if the control of INR was in range or not, but in our experience, the main reason to switch from VKA to NOAC is a poor INR control. In our registry, 18 patients treated with VKA have a mean therapeutic time in range (TTR) calculated with Rosendaal method of 60.27% ± 24.48% and 63.77% ± 23.80% calculated with direct method, and 54% of patients have a poor anticoagulation control (defined as TTR <65%; Table 1), thus a large proportion of those patients might have indication of switching to NOAC.
5. Christophersen IE, Rienstra M, Roselli C, Yin X, Geelhoed B, Barnard J, Lin H, Arking DE, Smith AV, Albert CM, Chaffin M, Tucker NR, Li M, Klarin D, Bihlmeyer NA, Low SK, Weeke PE, Muller-Nurasyid M, Smith JG, Brody JA, Niemeijer MN, Dorr M, Trompet S, Huffman J, Gustafsson S, Schurmann C, Kleber ME, Lyytikainen LP, Seppala I, Malik R, Horimoto A, Perez M, Sinisalo J, Aeschbacher S, Theriault S, Yao J, Radmanesh F, Weiss S, Teumer A, Choi SH, Weng LC, Clauss S, Deo R, Rader DJ, Shah SH, Sun A, Hopewell JC, Debette S, Chauhan G, Yang Q, Worrall BB, Pare G, Kamatani Y, Hagemeijer YP, Verweij N, Siland JE, Kubo M, Smith JD, Van Wagoner DR, Bis JC, Perz S, Psaty BM, Ridker PM, Magnani JW, Harris TB, Launer LJ, Shoemaker MB, Padmanabhan S, Haessler J, Bartz TM, Waldenberger M, Lichtner P, Arendt M, Krieger JE, Kahonen M, Risch L, Mansur AJ, Peters A, Smith BH, Lind L, Scott SA, Lu Y, Bottinger EB, Hernesniemi J, Lindgren CM, Wong JA, Huang J, Eskola M, Morris AP, Ford I, Reiner AP, Delgado G, Chen LY, Chen YI, Sandhu RK, Boerwinkle E, Eisele L, Lannfelt L, Rost N, Anderson CD, Taylor KD, Campbell A, Magnusson PK, Porteous D, Hocking LJ, Vlachopoulou E, Pedersen NL, Nikus K, Orho- Melander M, Hamsten A, Heeringa J, Denny JC, Kriebel J, Darbar D, Newton-Cheh C, Shaffer C, Macfarlane PW, Heilmann-Heimbach S, Almgren P, Huang PL, Sotoodehnia N, Soliman EZ, Uitterlinden AG, Hofman A, Franco OH, Volker U, Jockel KH, Sinner MF, Lin HJ, Guo X, Dichgans M, Ingelsson E, Kooperberg C, Melander O, Loos RJF, Laurikka J, Conen D, Rosand J, van der Harst P, Lokki ML, Kathiresan S, Pereira A, Jukema JW, Hayward C, Rotter JI, Marz W, Lehtimaki T, Stricker BH, Chung MK, Felix SB, Gudnason V, Alonso A, Roden DM, Kaab S, Chasman DI, Heckbert SR, Benjamin EJ, Tanaka T, Lunetta KL, Lubitz SA, Ellinor PT (2017) Large-scale analyses of common and rare variants identify 12 new loci associated with atrialfibrillation. Nat Genet 49:946–952
Searches (with no restriction on publication date) of human-based studies written in English, Spanish or French were done in Pubmed, Science Direct, and Scopus using the terms “atrialfibrillation”, “physical activity”, “exercise”, “quality of life”, “exercise therapy” and “treatment” as well as combinations thereof. Review papers, meta- analyses and symposium/meeting publications were excluded.
Recently, the 2MACE score (2 points for metabolic syndrome and age ≥75, and 1 point for myocardial infarction [MI] or revascularization, congestive heart failure [ejection fraction ≤40%] and thromboembolism [stroke or transient ischemic attack]) has been described to stratify cardiovascular risk in patients with nonvalvular atrialfibrillation (AF). According to this clinical tool, patients with a score ≥3 (high risk) have a risk of almost 4-fold higher of having a cardiovascular adverse event. 1 Thus, this score may provide new information that would optimize the management and treatment of patients with AF, with important implications for clinical practice. In the present study, we investigated the incidence of nonembolic thrombotic adverse events in 2 “real-world” cohorts of patients with AF. In addition, we validated the 2MACE score as predictor of major adverse cardiovascular events (MACEs) in both populations, in comparison with the CHA 2 DS 2 -VASc score.
Since 2010, European and US guidelines on AF have been published almost yearly, reflecting the major changes in the management of patients with this condition. This whirlwind of changes is the result of the successive introduction of more discriminative embolism and bleeding risk indices, the key role of implantable cardiac devices in silent AF, novel oral anticoagulants (OAC) and new antiarrhythmic agents, and the development of ablation. Recently, nonvalvular atrialfibrillation (NVAF) has been defined as AF in the absence of rheumatic mitral stenosis, heart valve prosthesis, or mitral valve repair. 1 Clinical practice guidelines show general consensus in their recommendations, which reflect these major changes in overall management, and pharmacological and nonpharmacological decisions (such as whether to follow a rhythm or rate control strategy in initial NVAF management, and indications for classic and new antiarrhythmic agents). 11 However, these guidelines are not immediately applied in routine clinical practice, despite their strong clinical trial-based evidence and high class of recommendation.
Atrialfibrillation (AF), which is a family of cardiac diseases characterized by a rapid and unsynchronized contraction of the atria, is the most common cardiac arrhythmia. Indeed, AF has reached epidemic proportions , with one out of four people over 40 years old predicted to suffer from AF in the future . However, its underlying mechanisms are still not fully understood, and several theories for the initiation and maintenance of AF have been proposed [3, 4, 5]. One of the leading hypotheses (rotor theory) states that specific areas of the myocardium are responsible for AF initiation and mainte- nance. RF catheter ablation, where an RF catheter placed in- side the heart is used to ablate the areas causing AF, is increas-
Atrialfibrillation (AF) is the most common arrhythmia in Western countries and is associated with high mortality and morbidity. 1 and 2 It is the leading cause of embolic events and is also associated with episodes of heart failure, cognitive impairment, and decreased quality of life. 3, 4, 5 and 6 The most common embolic event is stroke, which is associated with severe disability and dependence, involving significant increases in costs and in the use of health care systems. 7 Identifying these patients is important because anticoagulation therapy is effective in preventing embolic events in patients at high risk. Study of the population prevalence of AF, using homogeneous criteria, provides valuable information for planning appropriate strategies for the prevention and treatment of this disease. In Spain, there is a lack of epidemiological data that would allow the prevalence rates of AF to be determined in the general population. In general, previous studies were conducted in groups of patients or in selected populations that were not representative of the Spanish general population, such as patients from specific areas not representative of the whole country, patients attending health centers or cardiology clinics, which introduced bias, or patients within narrow age ranges. 8, 9, 10 and 11
Radiofrequency catheter ablation has evolved into an effective treatment option for drug-resistant patients with atrialfibrillation. Electrical isolation of the pulmonary veins has become the standard ablation strategy mainly in patients with paroxysmal atrialfibrillation. However, the success rate of pulmonary veins isolation is about 50% in patients with persistent atrialfibrillation. Although different strategies to guide the electrophysiologist in ablation procedures have been proposed. Recent studies show that the generation of additional ablation lines guided ana- tomically or by fragmented complex electrograms mapping does not improve the success rate of the conventional pulmonary veins isolation procedure. In this review, we describe the limitations of current electrophysiological mapping methods, the new electrogram evaluation strategies and the signal processing methods that are proposed in the immediate future, to guide ablation procedures, particularly in patients with atrialfibrillation persistent.
vessel radius) ) higher blood viscosity will in- crease total blood resistance. No studies so far have been performed to determine the influence of increased blood resistance by higher viscosi- ty on the occurrence of atrialfibrillation. In this aspect should be mentioned, that the presence of left ventricular hypertrophy in hypertensive disease is not correlated so much with the level of arterial hypertension or with the duration of arterial hypertension, but is closely related with the level of blood viscosity in these patients (Fig. 3). 15 Blood viscosity has been found to be
The TTR has been explored in several controlled studies assessing VKA therapy, originally versus aspirin or placebo, and later in large comparative studies with DOAs. With the exception of the ROCKET-AF trial, mean TTR has remained above 60% in all the aforementioned trials (Table 3A in the supplementary material summarizes the most relevant trials of the last decade). Given the unique conditions in which controlled clinical trials are conducted, these TTR levels may be difficult to attain in daily practice. The TTR levels in patients from Argentina who participated in the ARISTOTLE (Apixaban for Reduction In STroke and Other ThromboemboLic Events in AtrialFibrillation), ROCKET-AF (Rivaroxaban
. K. Okumura, T. Komatsu, T. Yamashita, Y. Okuyama, M. Harada, Y. Konta, T. Hatayama, D. Horiuchi, E. Tsushima. Time in the therapeutic range during warfarin therapy in Japanese patients with non-valvular atrialfibrillation. — a multicenter study of its status and infuential factors. Circ. J., 75 (2011), pp. 2087–2094. . A. Rouaud, O. Hanon, A.-S. Boureau, G.G. Chapelet, L. de Decker. Comorbidities against quality control of VKA therapy in non-valvular atrialfibrillation: a French national cross-sectional study. PLoS One, 10 (2015), pp. 119–130.
Atrialfibrillation management is performed by various medical specialists, but anticoagulation control is usually managed by the general practitioner (GP) or haematologist and, in a smaller number of cases, by cardiologists or internists. To achieve a good control of the quality of anticoagulation requires experience and knowledge both by the doctor and the patient. Since 2010, we have seen annual updates of clinical practice guidelines (both European and American) containing new algorithms, use of thrombotic and bleeding risk scores, as well as the introduction of four nonvitamin K oral anticoagulants (NOACs), with a better safety profile. All these updates are useful, but their application in everyday clinical practice is not immediate. For that reason, the management of anticoagulation is not homogeneous among different professionals.
Atrialfibrillation is the most frequently encountered sustained arrhythmia in emergency departments. In Spain, it is becoming increasingly common. It is a serious condition that often affects elderly individuals who are at a high risk of stroke, who may have structural heart disease and associated comorbid conditions, and who usually present with acute symptoms associated with the arrhythmia. All of these factors have an important influence on treatment decisions. Since episodes of recent-onset atrialfibrillation are usually managed in the emergency department, it is vitally important that these departments implement appropriate treatment that increases the likelihood that sinus rhythm will be restored and that establishes prophylaxis for stroke as early as possible. This article contains a review of the methods of stroke prophylaxis used during the restoration of sinus rhythm, the aim of and strategies used for heart rate control, and the indications for, the factors influencing decisions on and the techniques used for restoring sinus rhythm, with particular emphasis on episodes of recent-onset atrialfibrillation.
The purpose of this section is to identify which patients with AF might benefit from specialist investigations or interventions, but not to compare or contrast them with one another. The most common reason for referral for specialist investigation or intervention is failed medical therapy due to antiarrhythmic drug intolerance or ineffectiveness. Secondly, those who may have an underlying electrophysiological problem, such as a pre-excitation syndrome due to an accessory pathway (eg Wolff–Parkinson–White syndrome) or those with focal AF, are commonly referred for pulmonary vein isolation. However, this procedure carries a small risk of pulmonary vein stenosis. Also, those with a family history of AF (familial AF) 336 may require specialist assessment. In addition, elderly patients may have sinus node disease that is associated with paroxysmal AF. Some 337 but not all 338 studies suggest a reduction in AF by atrial or physiological pacing. Pacemaker therapy in AF is also indicated for symptomatic low heart rates. Arrhythmia surgery, such as themaze operation, or less frequently, the corridor procedure, may be undertaken as a primary procedure – although uncommonly in the UK – or during associated cardiac surgery (eg mitral valve surgery). 339–341
According to all the statements aforementioned, we sought to select among pts with LSPAF: Firstly, does who theoretically involved the least degree of electrical atrial remodeling able to sustain SR after CV. Secondly, among these pts selected, to try to electrically stabilized the atrium with the highest degree of drug tolerance to sustained SR, including verapamil, in an attempt to lengthen the AERP to reverse the acute-rate dependent electrophysiological changes responsible for early AF recurrence within the first week after CV. 16-19, 30-33 In
Although the definition of nonvalvular atrialfibrillation (NVAF) varies, 1 and 2 it generally does not exclude patients with structural heart disease (SHD), such as certain valve diseases. However, there is limited information on the frequency of this association in Spain. The objective of this article was to report the prevalence and clinical profile of patients with SHD and well as the prevalence of heart failure in a broad Spanish nationwide sample of patients with NVAF.
We always need to put in perspective the risk and benefit of anticoagulating a patient with atrialfibrillation for preventing thromboembolism and major bleeding as well. This review outlines a rationale for clinical judgement to choose the best therapy.
Methods: a retrospective observational study was conducted in patients with atrialfibrillation treated at Hermanos Ameijeiras Hospital applying the risk scale for thromboembolism CHA2DS2-VASc. Descriptive statistics tests were applied. Results: out of 89 patients with atrialfibrillation, the mean age was 77.1 ± 9.5 years, there was a predominance of males (56.2 %). The risk factor most
Methods: 12 mongrel dogs (18-25 kg) underwent cervical vagal trunk stimulation at high-frequency (60 ms, 1-4V) to produce sinus arrest lasting >2 seconds,complete atrioventricular AV blocking or the sinus rate decreasing more than 50%. Left lateral thoracotomy was performed and the heart was exposed in a pericardial cradle. The HRA, LAA, PV-LAJ, LSPVm and LSPVd was locally stimulated (100 ms, 2-8V). ERP of HRA, LAA, PV-LAJ and within LSPV, ERP heterogeneity within LSPV and conduction between left superior pulmonary vein and left atria and atrialfibrillation inducing rate with vagal response was analyzed.