Cardioversion of persistent atrial fibrillation is associated with a 24-hour relapse gap: Observations from prolonged postcardioversion rhythm monitoring.

BACKGROUND: Many recurrences occur after electrical cardioversion (ECV) of atrial fibrillation (AF). Assessment of extent of remodeling and continuous prolonged rhythm monitoring might reveal actionable recurrence mechanisms. HYPOTHESIS: After ECV of AF specific patterns of arrhythmia recurrence can be distinguished. METHODS: All patients who underwent successful ECV due to persistent AF were included. Tissue velocity echocardiography during AF was performed before ECV to study atrial fibrillatory cycle length and fibrillatory velocity. After ECV, the heart rhythm of all patients was monitored 3 times daily during 4 weeks, and timing of recurrence was noted. RESULTS: In total, 50 patients (68% male) were included; mean age was 68 ± 9 years. Median duration of the current AF episode was 102 (range, 74-152) days. Twenty-one (42%) patients showed recurrence of persistent AF. No recurrences occurred during the first 24 hours. There were no differences in clinical characteristics between patients with or without recurrence of AF. However, patients with early recurrence of AF had significantly higher precardioversion wall-motion velocity compared with patients who remained in sinus rhythm (2.8 [1.6-3.6] vs 1.4 [0.9-3.3] cm/s; P = 0.017), whereas atrial fibrillatory cycle length did not differ. CONCLUSIONS: In this study on 50 patients successfully cardioverted for persistent AF, there was a relapse gap of ≥24 hours. This phenomenon has not been well appreciated before and offers an AF-free window of opportunity for electrocardiographically triggered cardiac imaging or complex electrophysiological procedures. Echocardiographic tissue velocity imaging may visualize atrial remodeling relevant to AF recurrence.

The influence of progression of atrial fibrillation on quality of life: a report from the Euro Heart Survey.

Aims: Progression of atrial fibrillation (AF) from paroxysmal to persistent forms is an active field of research. The influence of AF progression on health related quality of life (HRQoL) is currently unknown. We aimed to assess the influence of AF progression on HRQoL, and whether this association is mediated through symptoms, treatment, and major adverse events. Methods and results: In the Euro Heart Survey, 967 patients were included with paroxysmal AF who filled out EuroQoL-5D at baseline and at 1 year follow-up. Those who progressed (n = 132, 13.6%) developed more problems during follow-up than those who did not, on all EuroQoL-5D domains (increase in problems on mobility 20.5% vs. 11.4%; self-care 12.9% vs. 6.2%; usual activities 23.5% vs. 14.0%; pain/discomfort 20.5% vs. 13.7%; and anxiety/depression 22.7% vs. 15.7%; all P < 0.05), leading to a decrease in utility [baseline 0.744 ± 0.26, follow-up 0.674 ± 0.36; difference -0.07 (95% CI [-0.126,-0.013], P = 0.02)]. Multivariate analysis showed that the effect of progression on utility is mediated by a large effect of adverse events [stroke (-0.27 (95% CI [-0.43,-0.11]); P = 0.001], heart failure [-0.12 (95% CI [-0.20,-0.05]); P = 0.001], malignancy (-0.31 (95% CI [-0.56,-0.05]); P = 0.02] or implantation of an implantable cardiac defibrillator [-0.12 (95% CI [-0.23,-0.02]); P = 0.03)], as well as symptomatic AF [-0.04 (95% CI [-0.08,-0.01]); P = 0.008]. Conclusion: AF progression is associated with a decrease in HRQoL. However, multivariate analysis revealed that AF progression itself does not have a negative effect on HRQoL, but that this effect can be attributed to a minor effect of the associated symptoms and a major effect of associated adverse events.

Poor anticoagulation relates to extended access times for cardioversion and is associated with long-term major cardiac and cerebrovascular events.

BACKGROUND: Patients undergoing elective electrical cardioversion (ECV) for atrial fibrillation have a temporarily increased risk of thromboembolism. Current guidelines recommend adequate anticoagulation for ≥3 consecutive weeks precardioversion, i.e. consecutive INR values 2.0-3.0 in patients with vitamin K antagonists (VKA). We aimed to evaluate the occurrence and impact of subtherapeutic INRs precardioversion and to study factors associated with these unwanted fluctuations. METHODS: We recruited 346 consecutive patients undergoing elective ECV in the Maastricht University Medical Centre between 2008 and 2013. Predictors of subtherapeutic INR values were identified and incorporated into a logistic regression model. RESULTS: A subtherapeutic INR precardioversion occurred in 55.2% of patients. The only statistically significant predictor was VKA-naivety (Odds Ratio (OR) 4.78, 95% Confidence Interval (CI) 2.67-8.58, p<0.001). In patients with ≥1 subtherapeutic INR precardioversion, time from referral until cardioversion was 91.1±42.8days, compared to 41.7±26.6days (p<0.001) in patients without subtherapeutic INRs. No thromboembolic events occurred <30days after the ECV. Independent predictors for the combined endpoint of cardiovascular death, ischemic stroke and the need of blood transfusion (n=30, median follow-up of 374days) were coronary artery disease in the history (OR 3.35, 95%CI 1.54-7.25, p=0.002) and subtherapeutic INR precardioversion (OR 3.64, 95%CI 1.43-9.24, p=0.007). CONCLUSIONS: The use of VKA often results in subtherapeutic INRs precardioversion and is associated with a significant delay until cardioversion, especially in patients with recent initiation of VKA therapy. Furthermore, subtherapeutic INR levels prior to ECV are associated with the combined endpoint of cardiovascular death, ischemic stroke and the need of blood transfusion.

Systematic analysis of ECG predictors of sinus rhythm maintenance after electrical cardioversion for persistent atrial fibrillation.

BACKGROUND: Electrical cardioversion (ECV) is one of the rhythm control strategies in patients with persistent atrial fibrillation (AF). Unfortunately, recurrences of AF are common after ECV, which significantly limits the practical benefit of this treatment in patients with AF. OBJECTIVES: The objectives of this study were to identify noninvasive complexity or frequency parameters obtained from the surface electrocardiogram (ECG) to predict sinus rhythm (SR) maintenance after ECV and to compare these ECG parameters with clinical predictors. METHODS: We studied a wide variety of ECG-derived time- and frequency-domain AF complexity parameters in a prospective cohort of 502 patients with persistent AF referred for ECV. RESULTS: During 1-year follow-up, 161 patients (32%) maintained SR. The best clinical predictor of SR maintenance was antiarrhythmic drug (AAD) treatment. A model including clinical parameters predicted SR maintenance with a mean cross-validated area under the receiver operating characteristic curve (AUC) of 0.62 ± 0.05. The best single ECG parameter was the dominant frequency (DF) on lead V6. Combining several ECG parameters predicted SR maintenance with a mean AUC of 0.64 ± 0.06. Combining clinical and ECG parameters improved prediction to a mean AUC of 0.67 ± 0.05. Although the DF was affected by AAD treatment, excluding patients taking AADs did not significantly lower the predictive performance captured by the ECG. CONCLUSION: ECG-derived parameters predict SR maintenance during 1-year follow-up after ECV at least as good as known clinical predictors of rhythm outcome. The DF proved to be the most powerful ECG-derived predictor.

Maintenance of sinus rhythm after electrical cardioversion for recurrent atrial fibrillation following mitral valve surgery with or without associated radiofrequency ablation.

BACKGROUND: This study reports the outcomes of patients who underwent electrical cardioversion for atrial fibrillation recurrence following mitral valve surgery and associated radiofrequency ablation compared to those who did not undergo concomitant atrial fibrillation ablation. METHODS: The population consisted of 116 patients with persistent/long-standing persistent AF who underwent mitral valve surgery with (Group A, n=54) or without (Group B, n=62) associated radiofrequency ablation between January 2007 and January 2011 at three institutions and who subsequently underwent cardioversion for persistent atrial fibrillation within 12 months of their initial procedure. RESULTS: The mean follow-up duration was 30.7±9.4 months. Of the 104 patients with acute restoration of SR 42 (40.3%) had AF recurrence. The average time to recurrence after cardioversion was 7.3±4.2 days. Recurrence was significantly lower in patients undergoing ablation surgery (21.4%) than in those undergoing no ablation surgery (78.6%, p<0.001). Non-performed ablation procedure (p<0.001), time from surgery≥88 days and left atrial dimensions≥45.5 mm before cardioversion (both, p=0.005) were multivariable predictors of atrial fibrillation recurrence. In Group B the use of amiodarone was inversely correlated with recurrence of AF (p<0.001). This correlation was not significant (r=-0.02, p=0.85) in Group A. CONCLUSIONS: Electrical cardioversion for recurrent AF showed better results and stable recovery of sinus rhythm in patients undergoing concomitant surgical ablation during mitral valve surgery. This might be attributable to substrate modification caused by surgical lesions. Amiodarone improved the ECV-success rate only in patients with no associate ablation. Further larger randomized studies are necessary to confirm our findings.

The mechanical fibrillation pattern of the atrial myocardium is associated with acute and long-term success of electrical cardioversion in patients with persistent atrial fibrillation.

BACKGROUND: Electrophysiological studies demonstrate that a short atrial fibrillation cycle length (AFCL) is related with poor outcome of electrical cardioversion (ECV) of atrial fibrillation (AF). We found previously that the mechanical AFCL (AFCL-tvi) and atrial fibrillatory velocity (AFV-tvi) may be determined noninvasively using color tissue velocity imaging (TVI) and closely relates to the electrophysiological AFCL. OBJECTIVE: To evaluate the relation between AFCL-tvi, AFV-tvi, and success of ECV in patients with AF. METHODS: We prospectively studied 133 patients with persistent AF by performing echocardiography before ECV and measured the AFCL-tvi and AFV-tvi in the right atrium and left atrium. Recurrent AF was monitored. RESULTS: Nineteen (14%) patients had failure of ECV, 42 (32%) remained in sinus rhythm after 1-year follow-up, and 72 (54%) had a recurrence of persistent AF. Patients with immediate ECV failure had a lower median AFV-tvi measured in the right atrium than did patients with a successful ECV: 0.7 cm/s (0.2-1.0 cm/s) vs. 1.7 cm/s (0.9-2.8 cm/s) (P = .008). Patients with maintenance of sinus rhythm after 1 year had a longer AFCL-tvi measured in the left atrium than did patients with recurrence of AF (150 ms vs 137 ms; P = .017) and had a higher AFV-tvi in both atria (1.4 vs. 0.9 cm/s in the left atrium; P = .013 and 2.2 vs 1.4 cm/s in the right atrium; P = .011). Multivariate analyses showed that all atrial TVI parameters were independently associated with the maintenance of sinus rhythm after 1 year. CONCLUSION: Higher atrial fibrillatory wall velocities and longer AFCLs determined by echocardiography are associated with acute and long-term success of ECV.

Clinical correlates of echocardiographic tissue velocity imaging abnormalities of the left atrial wall during atrial fibrillation.

AIMS: In patients with atrial fibrillation (AF), echocardiographic tissue velocity imaging (TVI) enables assessment of electrical and structural remodelling by measuring, respectively, the AF cycle length (AFCL-TVI) and the atrial fibrillatory wall motion velocity (AFV-TVI). We investigated the clinical and echocardiographic correlates of atrial remodelling assessed by TVI. METHODS AND RESULTS: We studied 215 patients presenting with AF. In all patients, we measured the AFCL-TVI and the AFV-TVI in the left atrium. Standard baseline characteristics were recorded. We divided patients by median value of AFV-TVI and AFCL-TVI to evaluate the determinants of atrial remodelling. A low AFV-TVI was related with a longer median duration of the current AF episode, a higher prevalence of significant mitral regurgitation and a thicker left ventricle (LV). Multivariate analysis revealed that a low AFV-TVI was independently associated with a longer median duration of the current AF episode [OR 0.09 (95% CI 0.03-0.027); P < 0.001]. Univariately, a short AFCL-TVI was associated with a long median duration of the current AF episode, the use of anti-arrhythmic drugs, a lower LV ejection fraction (LVEF) and a smaller left atrial volume index (LAVI). Multivariate analysis revealed that LVEF [OR 1.48 (95% CI 1.09-2.01); P = 0.013] and LAVI [OR 1.37 (95% CI 1.08-1.74); P = 0.010] were independently associated with AFCL-TVI. CONCLUSION: This study investigated the clinical and echocardiographic correlates of atrial remodelling assessed by TVI. The AFV-TVI is reduced in patients with a long AF duration and who have mitral regurgitation. In addition, the AFCL is long if LAVI is high and LVEF preserved. Tissue velocity imaging parameters measured during AF may be helpful to characterize the degree of atrial remodelling and optimize treatment.

Tissue velocity imaging of the left atrium predicts response to flecainide in patients with acute atrial fibrillation.

BACKGROUND: Acute atrial fibrillation (AF) is often treated with the administration of intravenous flecainide; however, this treatment may not always be successful and is potentially hazardous. Previous studies suggest that electro-echocardiographic tissue velocity imaging (TVI) of the atrial wall may reflect atrial remodeling. OBJECTIVE: To study whether atrial TVI can be used to identify nonresponders of flecainide administered intravenously in patients with acute AF. METHODS: We used atrial TVI to measure atrial fibrillatory cycle length determined by using tissue velocity imaging (AFCL-TVI) and atrial fibrillatory wall motion velocity determined by using tissue velocity imaging (AFV-TVI) in the left atrium in 52 (55%) patients presenting with acute AF in the emergency department. These 2 parameters reflect electrical and structural remodeling, respectively. Standard baseline characteristics were recorded. RESULTS: Patients were predominantly men (76%) and 64 ± 11 years old. Thirty-six (69%) patients had successful cardioversion after flecainide infusion. There were no significant differences in baseline characteristics between responders and nonresponders. Patients with a successful cardioversion had a longer mean AFCL-TVI and higher median (interquartile range) AFV-TVI compared with patients with failed cardioversion: 172 ± 29 ms vs 137 ± 35 ms (P < .001) and 4.2 (3.3-6.2) cm/s vs 2.3 (1.9-3.5) cm/s (P = .001). CONCLUSIONS: Electro-echocardiographic atrial TVI measurement is a promising noninvasive tool for predicting outcome of pharmacological cardioversion. A short AFCL-TVI and a low AFV-TVI are related to failure of cardioversion of AF using flecainide.

Progression of atrial fibrillation in the REgistry on Cardiac rhythm disORDers assessing the control of Atrial Fibrillation cohort: clinical correlates and the effect of rhythm-control therapy.

INTRODUCTION: Paroxysmal atrial fibrillation (AF) may progress to persistent AF. We studied the clinical correlates and the effect of rhythm-control strategy on AF progression. METHODS: RecordAF was a worldwide prospective survey of AF management. Consecutive eligible patients with recent-onset AF were included and allocated to rate or rhythm control according to patient/physician choice. A total of 2,137 patients were followed up for 12 months. Atrial fibrillation progression was defined as a change from paroxysmal to persistent/permanent AF. RESULTS: Progression of AF occurred in 318 patients (15%) after 1 year. Patients with AF progression were older; had a higher diastolic blood pressure; and more often had a history of coronary artery disease, stroke or transient ischemic attack, hypertension, or heart failure. Patients treated with rhythm control were less likely to show progression than those treated only with rate control (164/1542 [11%] vs 154/595 [26%], P < .001). Multivariable analysis showed that history of heart failure (odds ratio [OR] 2.2, 95% CI 1.7-2.9, P < .0001), history of hypertension (OR 1.5, 95% CI 1.1-2.0, P = .01), and rate control rather than rhythm control (OR 3.2, 95% CI 2.5-4.1, P < .0001) were independent predictors of AF progression. The propensity score-adjusted OR of AF progression in patients with rate rather than rhythm control was 3.3 (95% CI 2.4-4.6, P < .0001). CONCLUSIONS: Although heart failure and hypertension are associated with AF progression, rhythm control is associated with lower risk of AF progression.

Characteristics, management and prognosis of elderly patients in the Euro Heart Survey on atrial fibrillation.

BACKGROUND AND AIMS: Atrial fibrillation (AF) is the most frequent sustained arrhythmia of elderly patients, in whom it determines an increase in morbidity and mortality. Aim of this study was to assess age-related differences in the characteristics, management and prognosis of patients with AF in European cardiology practices. METHODS: The Euro Heart Survey on AF was an observational study sponsored by the European Society of Cardiology. Patients were enrolled between 2003 and 2004 in 182 hospitals of 35 countries. For the purposes of this study, they were categorized into three age-groups: <65 (n=2124), 65-80 (n=2534) and >80 years (n=671). Follow-up was closed in 2005. RESULTS: Compared with general population estimates, patients >80 years were underrepresented in the Euro Heart Survey. The oldest patients were less likely to be enrolled by university or specialized centers, to receive extensive diagnostic testing, and to receive oral anticoagulation despite a worse stroke risk profile. Furthermore, the oldest patients less often received rhythm control therapy, even when presenting with palpitations and non-permanent AF. During 1 year follow-up, elderly patients more often suffered a myocardial infarction, new onset heart failure and major bleedings. They had higher all-cause and cardiovascular mortality. CONCLUSIONS: Elderly patients with AF are less often referred to the cardiologist and, based on current guidelines, are inadequately studied and treated, compared to younger counterparts. Education on evidence- based management and the design of randomized controlled trials specifically targeting the elderly, should improve the management and prognosis of this frail segment of the AF population.

Clinical and echocardiographic correlates of intra-atrial conduction delay.

AIMS: The total atrial conduction time (TACT) is an important electrophysiological parameter. We developed a new transthoracic echocardiographic tool (PA-TDI). The PA-TDI interval is a reflection of the TACT. In the present study, we evaluated the clinical and echocardiographic correlates of intra-atrial conduction delay. METHODS AND RESULTS: We studied 427 patients without class I anti-arrhythmic agents or amiodarone. All patients underwent an echocardiogram and the PA-TDI interval was measured. Patient characteristics were recorded. The mean PA-TDI was 157 ± 22 ms. Multivariate linear regression analysis revealed that atrial fibrillation (AF) in history (B = 9.7; 95%CI 5.7-13.8; P < 0.001), hypertension (B = 5.5; 95%CI 1.4-9.8; P = 0.01), clinically relevant valve disease (B = 5.7; 95%CI 0.5-10.8; P = 0.03), age (B = 5; 95%CI 3.3-6.6; P < 0.001), and body mass index (BMI; B = 2.6; 95%CI 0.3-4.9; P = 0.026) were independently associated with the PA-TDI interval. On the echocardiogram: the aortic diameter (B = 0.7; 95%CI 0.2-1.2; P = 0.009), left atrial dimension (B = 0.9; 95%CI 0.5-1.3; P < 0.001), mitral valve E-wave deceleration time (B = 0.1; 95%CI 0.1-0.1; P < 0.001), aortic incompetence (B = 13; 95%CI 3.3-22.6; P = 0.008), and mitral incompetence (B = 11; 95%CI 3.6-17.5; P < 0.003) were independently associated with the PA-TDI interval. CONCLUSION: This study is the largest to investigate the relation between the atrial conduction time, underlying heart diseases, and echocardiographic parameters. We found that the PA-TDI was independently prolonged in patients with a history of AF, hypertension, valve disease, higher age, and a higher BMI. Signs of diastolic dysfunction, valve incompetence, and enlarged atrium or aortic root on the echocardiogram were associated with a prolonged PA-TDI. This suggests that early and aggressive treatment of hypertension, diastolic dysfunction, and obesity could prevent intra-atrial conduction delay.

A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: the Euro Heart Survey.

OBJECTIVE: Despite extensive use of oral anticoagulation (OAC) in patients with atrial fibrillation (AF) and the increased bleeding risk associated with such OAC use, no handy quantification tool for assessing this risk exists. We aimed to develop a practical risk score to estimate the 1-year risk for major bleeding (intracranial, hospitalization, hemoglobin decrease > 2 g/L, and/or transfusion) in a cohort of real-world patients with AF. METHODS: Based on 3,978 patients in the Euro Heart Survey on AF with complete follow-up, all univariate bleeding risk factors in this cohort were used in a multivariate analysis along with historical bleeding risk factors. A new bleeding risk score termed HAS-BLED (Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile international normalized ratio, Elderly (> 65 years), Drugs/alcohol concomitantly) was calculated, incorporating risk factors from the derivation cohort. RESULTS: Fifty-three (1.5%) major bleeds occurred during 1-year follow-up. The annual bleeding rate increased with increasing risk factors. The predictive accuracy in the overall population using significant risk factors in the derivation cohort (C statistic 0.72) was consistent when applied in several subgroups. Application of the new bleeding risk score (HAS-BLED) gave similar C statistics except where patients were receiving antiplatelet agents alone or no antithrombotic therapy, with C statistics of 0.91 and 0.85, respectively. CONCLUSION: This simple, novel bleeding risk score (HAS-BLED) provides a practical tool to assess the individual bleeding risk of real-world patients with AF, potentially supporting clinical decision making regarding antithrombotic therapy in patients with AF.

The likelihood of decreasing strokes in atrial fibrillation patients by strict application of guidelines.

AIMS: Despite the known increased stroke risk associated with AF and the benefit of oral anticoagulation (OAC) in high-risk patients, still approximately 20% of all ischaemic strokes are atrial fibrillation (AF) related. We aimed to evaluate the frequency of inappropriate anticoagulation in all patients admitted with AF associated ischaemic stroke and calculate the theoretical number of preventable strokes in case of proper guideline adherence and assess secondary stroke prevention at discharge. METHODS AND RESULTS: In this cross-sectional study, all patients with ischaemic strokes admitted to our hospital during May 2003-August 2006 in whom the diagnosis AF was either known or established during hospital stay were identified. We studied if their admission and discharge antithrombotic therapy was in accordance with the published guidelines. Subsequently, we calculated the number of preventable strokes in case AF patients would have received adequate antithrombotic treatment on admission. On admission, in 51% of the OAC eligible known AF patients the drug was withheld. Improved antithrombotic guideline adherence potentially would have prevented 20 out of the 89 (22%) ischaemic strokes. At discharge at least 10% of the patients were still insufficiently protected against recurrent stroke. CONCLUSION: Many known AF patients admitted with ischaemic stroke lack adequate antithrombotic treatment on admission. Antithrombotic guideline adherence in these patients has the potential to prevent a substantial number strokes. Secondary stroke prevention at discharge is also suboptimal.

Progression from paroxysmal to persistent atrial fibrillation clinical correlates and prognosis.

OBJECTIVES: We investigated clinical correlates of atrial fibrillation (AF) progression and evaluated the prognosis of patients demonstrating AF progression in a large population. BACKGROUND: Progression of paroxysmal AF to more sustained forms is frequently seen. However, not all patients will progress to persistent AF. METHODS: We included 1,219 patients with paroxysmal AF who participated in the Euro Heart Survey on AF and had a known rhythm status at follow-up. Patients who experienced AF progression after 1 year of follow-up were identified. RESULTS: Progression of AF occurred in 178 (15%) patients. Multivariate analysis showed that heart failure, age, previous transient ischemic attack or stroke, chronic obstructive pulmonary disease, and hypertension were the only independent predictors of AF progression. Using the regression coefficient as a benchmark, we calculated the HATCH score. Nearly 50% of the patients with a HATCH score >5 progressed to persistent AF compared with only 6% of the patients with a HATCH score of 0. During follow-up, patients with AF progression were more often admitted to the hospital and had more major adverse cardiovascular events. CONCLUSIONS: A substantial number of patients progress to sustained AF within 1 year. The clinical outcome of these patients regarding hospital admissions and major adverse cardiovascular events was worse compared with patients demonstrating no AF progression. Factors known to cause atrial structural remodeling (age and underlying heart disease) were independent predictors of AF progression. The HATCH score may help to identify patients who are likely to progress to sustained forms of AF in the near future.

Atrial fibrillatory wall motion and degree of atrial remodeling in patients with atrial fibrillation: a tissue velocity imaging study.

INTRODUCTION: The atrial fibrillation cycle length (AFCL) and the intracardiac atrial electrogram morphology may be used to characterize atrial fibrillation (AF). However, assessment of these parameters requires an invasive electrophysiological study. We assessed clinical and electrophysiological correlates of noninvasive tissue velocity imaging (TVI) of the right and left atrial myocardial fibrillatory wall motion. METHODS AND RESULTS: We performed an electrophysiological study in 12 patients with AF referred for His bundle ablation. Using atrial electrograms, we determined the AFCL (AFCL-egm) and electrophysiological AF type. Simultaneously, transthoracic echocardiography was performed. We used the TVI traces to determine the cycle length of the atrial fibrillatory wall motion (AFCL-tvi) and atrial fibrillatory wall velocities (AFV-tvi). AFCL-tvi matched very well with AFCL-egm (r(2)= 0.98; P < 0.001), both in the left and right atrium. Patients with permanent AF had shorter AFCL-tvi (155 +/- 15 ms vs 216 +/- 23 ms; P < 0.001), higher AFCL-tvi variability, and lower AFV-tvi compared to patients with paroxysmal AF. Three electrophysiological AF types were found based on the morphology of the electrograms and these related to specific TVI patterns. CONCLUSION: TVI of the atrial fibrillatory wall motion may enhance noninvasive characterization of atrial remodeling in patients with atrial fibrillation.

Use and underuse of oral anticoagulation for stroke prevention in atrial fibrillation: old and new paradigms.

Atrial fibrillation (AF) is the most common sustained arrhythmia of the Western world. The increased ischemic stroke risk of the AF patient is one of the most important clinical issues to manage. Despite the well-known benefit of oral anticoagulation in high-risk AF patients, these drugs are widely underused in daily practice all over the world. We describe old and new paradigms of the use of oral anticoagulation. In the future, increased comprehensibility of stroke risk scores, development of a validated clinical bleed risk score, and new patient and physician user-friendly antithrombotic medication may contribute to improved adequate use of oral anticoagulation in AF patients.

Autonomic trigger patterns and anti-arrhythmic treatment of paroxysmal atrial fibrillation: data from the Euro Heart Survey.

AIMS: To investigate the clinical characteristics, management, and outcome of patients with paroxysmal atrial fibrillation (AF) associated with autonomic triggers. METHODS AND RESULTS: One thousand five hundred and seventeen patients with paroxysmal AF participated in the Euro Heart Survey on AF. We categorized patients according to trigger pattern as reported by the physician: adrenergic (AF associated with exercise, emotion or during daytime only and absence of vagal triggers), vagal (postprandial or night time only, without presence of adrenergic triggers) and mixed (combination of vagal and adrenergic triggers). Vagal AF was found in 91 patients (6%), adrenergic in 229 patients (15%) and mixed in 175 (12%) patients. Underlying heart disease was equally prevalent in the three groups. Among patients with vagal AF, 73% were treated with non-recommended drugs according to the guidelines. In vagal AF, non-recommended treatment was associated with a shift to persistent or permanent AF in 19% of the patients, compared with none in the group receiving recommended treatment (P = 0.06). CONCLUSION: This study is the first to address the issue of autonomic trigger patterns and AF in a large population. Autonomic trigger patterns were seen frequently in paroxysmal AF patients. Autonomic influences should be taken into consideration since non-recommended treatment may result in aggravation of vagal AF.