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Improved Atrial Fibrillation Outcomes Despite Rising Arrhythmia Prevalence

7 Jul, 15 | by Alistair Lindsay

Little is known about temporal trends in atrial fibrillation (AF) incidence, prevalence, and outcomes. Using the Framingham Heart Study, Schnabel and colleagues assessed AF incidence, prevalence, and outcomes over 50 years (202,417 person-years). Researchers drew on a cohort of 9,511 participants enrolled between 1958 and 2007 in which 1,544 incident AF cases (47% women) were identified. Over the study period, age-adjusted incidence increased threefold (3.7 to 13.4 new cases per 1000 person-years in men and from 2.5 to 8.6 new cases per 1000 person-years in women) and age-adjusted prevalence increased fourfold (20.4 to 96.2 cases per 1000 person-years in men and from 13.7 to 49.4 cases per 1000 person-years in women). more…

The SAFETY Clinical Trial: Intensive Outpatient Follow-up to Improve Outcomes after Hospitalization for Atrial Fibrillation

1 Feb, 15 | by Alistair Lindsay

The prevalence of atrial fibrillation (AF) is increasing with a concurrent rise in the number of hospitalizations for AF. The standard versus atrial fibrillation-specific management strategy (SAFETY) trial sought to test a nurse-led intervention following hospital discharge for chronic, non-valvular AF on patient outcomes of unplanned admission or all-cause death. Participants in the intervention arm received Holter monitoring and a home visit from a cardiac nurse within one to two weeks after discharge to tailor management of AF and comorbid disorders. After a median of 905 days of follow-up, 127 (76%) patients receiving the SAFETY intervention reached the primary endpoint compared to 137 (82%) patients receiving standard management (hazard ratio 0.97, 95% CI 0.76–1.23; p=0.85). more…

Left atrial appendage closure in atrial fibrillation – is a comparison against warfarin still meaningful?  

20 Dec, 14 | by Alistair Lindsay

The majority of patients with nonvalvular atrial fibrillation (AF) have an indication for anti-coagulation to reduce the risk of stroke. As the left atrial appendage (LAA) is thought to the be the predominant source of thromboembolic events in the setting of AF, LAA closure may provide an alternative to anti-coagulation for stroke risk reduction without the associated bleeding concerns of anti-coagulation. This multi-center, randomized, unblinded trial compared LAA closure to warfarin in patients with AF and at least one other stroke risk factor (i.e. CHADS2 scores ≥ 1).   Patients were followed for four years and the primary outcome was a composite of stroke, systemic embolism, and cardiovascular/unexplained death. In the intention to treat analysis for efficacy the LAA closure groups had 2.3 events per 100 patient-years compared to 3.8 events per 100 patient-years in the warfarin group (relative risk 0.60 favoring device; 95% credible interval, 0.41-1.05). The most frequent adverse event with the device was serious pericardial effusion and survival curves demonstrated an earlier risk of adverse events in the device group. more…

Warfarin for atrial fibrillation in patients with chronic kidney disease – does the thromboembolic benefit outweigh the bleeding risk?

8 Jun, 14 | by Alistair Lindsay

Chronic kidney disease (CKD) predisposes to high risks for both thrombo-embolism and bleeding. As a result, understanding the risk-benefit profile for use of anticoagulation therapies among CKD patients with atrial fibrillation is important to optimize patient outcomes. However, clinical trials evaluating efficacy and safety of anti-coagulants for atrial fibrillation generally exclude CKD patients and observational studies have had conflicting results. Accordingly, this prospective cohort study of 24,317 atrial fibrillation patients admitted with myocardial infarction in Sweden examined the association between warfarin therapy and patient outcomes by stage of CKD. Warfarin was prescribed in 21.8% patients and CKD (estimated glomerular filtration rate [eGFR] < 60 mL/min/1.73m2) was present in 51.7%. Compared with patients not treated with warfarin, the risk-adjusted composite outcome of death, myocardial infarction, or ischemic stroke was lower at 1 year of follow-up among patients treated with warfarin, regardless of CKD class. This reduction in thromboembolic events was not offset by an increased risk of bleeding events. more…

Weight reduction results in atrial fibrillation symptom improvement

2 Feb, 14 | by Alistair Lindsay

Obesity is known risk factor for atrial fibrillation (AF). However, the effect of weight reduction on AF symptom burden is unknown. In this study, 150 patients with symptomatic AF who were overweight or obese were randomized to a physician led weight loss program (intervention arm) or self-directed general lifestyle measures (control arm). All patients received intensive cardiometabolic risk factor management and were evaluated at 3 monthly intervals by blinded study personnel. Primary outcomes of interest were AF symptom burden and symptom severity evaluated using a validated tool to assess disease specific patient-reported health status. Secondary outcomes included holter-derived episodes of AF, left ventricular thickness and left atrial size on echocardiograms. more…

Apixaban shows safety in secondary analysis

2 Dec, 12 | by Alistair Lindsay

The decision to anticoagulate a patient with atrial fibrillation involves a balance between the risks of thromboembolism against those of haemorrhage, with both risks imperfectly predicted by even the best stratification scoring systems.  Although warfarin reduces the risk of stroke in patients with atrial fibrillation, its use remains limited by several limitations.  Apixaban is a novel direct factor Xa inhibitor, previously found to be superior to warfarin at prevention of stroke or systemic embolism in the ARISTOTLE (Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation) trial. more…

Fish Oils Don’t Decrease Post-Op AF

25 Nov, 12 | by Alistair Lindsay

Both clinical and experimental evidence have suggested an anti-arrhythmic effect of long-chain n-3 polyunsaturated fatty acids (n-3-PUFAs) in fish oil.  However, the effect of n-3-PUFAs on atrial arrhythmias such as postoperative atrial fibrillation (AF) remain uncertain.  The Omega-3 Fatty Acids for Prevention of Post-operative Atrial Fibrillation (OPERA) trial was designed to test whether perioperative n-3-PUFA supplementation could reduce postoperative AF. more…

Catheter ablation for paroxysmal AF

21 Nov, 12 | by Alistair Lindsay

Atrial fibrillation is the commonest cardiac arrhythmia. While a number of established drug therapies are often successful in achieving satisfactory control, more recently radiofrequency catheter ablation has emerged as an effective therapy for patients with paroxysmal AF.  However, the place of catheter ablation remains unclear with limited data comparing ablation with antiarrhythmic drug therapy as first-line treatment in patients. more…

Flec-SL: short- vs. long-term flecainide after AF cardioversion

5 Sep, 12 | by Alistair Lindsay

The goal of antiarrhythmic therapy following cardioversion for atrial fibrillation (AF) is to prevent further recurrences for as long as possible.  However, it is known that the atrial action potential normalises after 2-4 weeks of sinus rhythm, suggesting that drugs may not be essential in the long-term.  The goal of this study was to investigate whether short-term antiarrhythmic treatment following cardioversion for AF was non-inferior to long-term treatment. more…

Atrial Fibrillation: Women at higher stroke risk

4 Jun, 12 | by Alistair Lindsay

Patients with atrial fibrillation (AF) have a risk of stroke that is five times greater than that of the general population.  Moreover, it has previously been described that women with atrial fibrillation have a higher annual rate of stroke than men (3% vs. 1.6%).    The reasons for this remain unclear, although previous studies have suggested that women may be treated with warfarin less frequently than men.  Therefore the aim of this study was to compare the utilisation patterns of warfarin and the risk of subsequent stroke between older men and women with AF. more…

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