Factors associated with non-fatal heart failure and atrial fibrillation or flutter within the first 30 days post COPD exacerbation: a nested case-control study.

BACKGROUND: An immediate, temporal risk of heart failure and arrhythmias after a Chronic Obstructive Pulmonary Disease (COPD) exacerbation has been demonstrated, particularly in the first month post-exacerbation. However, the clinical profile of patients who develop heart failure (HF) or atrial fibrillation/flutter (AF) following exacerbation is unclear. Therefore we examined factors associated with people being hospitalized for HF or AF, respectively, following a COPD exacerbation. METHODS: We conducted two nested case-control studies, using primary care electronic healthcare records from the Clinical Practice Research Datalink Aurum linked to Hospital Episode Statistics, Office for National Statistics for mortality, and socioeconomic data (2014-2020). Cases had hospitalization for HF or AF within 30 days of a COPD exacerbation, with controls matched by GP practice (HF 2:1;AF 3:1). We used conditional logistic regression to explore demographic and clinical factors associated with HF and AF hospitalization. RESULTS: Odds of HF hospitalization (1,569 cases, 3,138 controls) increased with age, type II diabetes, obesity, HF and arrhythmia history, exacerbation severity (hospitalization), most cardiovascular medications, GOLD airflow obstruction, MRC dyspnea score, and chronic kidney disease. Strongest associations were for severe exacerbations (adjusted odds ratio (aOR)=6.25, 95%CI 5.10-7.66), prior HF (aOR=2.57, 95%CI 1.73-3.83), age≥80 years (aOR=2.41, 95%CI 1.88-3.09), and prior diuretics prescription (aOR=2.81, 95%CI 2.29-3.45). Odds of AF hospitalization (841 cases, 2,523 controls) increased with age, male sex, severe exacerbation, arrhythmia and pulmonary hypertension history and most cardiovascular medications. Strongest associations were for severe exacerbations (aOR=5.78, 95%CI 4.45-7.50), age≥80 years (aOR=3.15, 95%CI 2.26-4.40), arrhythmia (aOR=3.55, 95%CI 2.53-4.98), pulmonary hypertension (aOR=3.05, 95%CI 1.21-7.68), and prescription of anticoagulants (aOR=3.81, 95%CI 2.57-5.64), positive inotropes (aOR=2.29, 95%CI 1.41-3.74) and anti-arrhythmic drugs (aOR=2.14, 95%CI 1.10-4.15). CONCLUSIONS: Cardiopulmonary factors were associated with hospitalization for HF in the 30 days following a COPD exacerbation, while only cardiovascular-related factors and exacerbation severity were associated with AF hospitalization. Understanding factors will help target people for prevention.

Association Between Family History and Early-Onset Atrial Flutter Across Racial and Ethnic Groups.

BACKGROUND: Genetic and familial contributions to early-onset atrial fibrillation are described primarily in individuals of European ancestry. However, the role of racial and familial contributions in the pathogenesis of early-onset atrial flutter (EOAFL) is unclear. METHODS AND RESULTS: In this cross-sectional study, participants were enrolled prospectively from 2015 to 2021 in multiple academic centers with a diagnosis of atrial flutter (AFL) confirmed by ECG. EOAFL was defined as a diagnosis of AFL before age 66 years with no concomitant or previous diagnosis of atrial tachyarrhythmias. Family history was adjudicated through baseline questionnaires and direct family interviews about the diagnosis of atrial tachyarrhythmias, stroke, and cardiomyopathy. The primary exposure was a positive family history in first-degree relatives, and the primary outcome was the odds of EOAFL versus late-onset AFL. A total of 909 patients were enrolled. Participants with a positive family history of atrial tachyarrhythmias were younger, less likely to be of Black race, and more likely to have EOAFL. The adjusted odds ratio (OR) for EOAFL in those with a positive family history was 1.8 (95% CI, 1.1-3.0). There was an increased odds of EOAFL in those of Black race (OR, 2.1 [95% CI, 1.4-3.2]), alcohol use (OR, 1.6 [95% CI, 1.0-2.6]), and obstructive sleep apnea (OR, 1.9 [95% CI, 1.0-3.4]). Use of cardioselective ß blockers or calcium channel blockers before the diagnosis of AFL were associated with a lower odds of EOAFL (OR, 0.5 [95% CI, 0.2-0.9]). CONCLUSIONS: These findings suggest a potentially hereditary predisposition to EOAFL across race and ethnicity, warranting further study of the genetic contributions to AFL.

Use of apixaban in adults with congenital heart disease and atrial arrhythmias: The PROTECT-AR study.

BACKGROUND: Adults with congenital heart disease (ACHD) and atrial arrhythmias (AA) face an increased risk of thromboembolic events. Limited data exist on the use of non-vitamin K oral anticoagulants for thromboprophylaxis in ACHD. We aimed to assess the effectiveness and safety of apixaban in ACHD patients with AA. METHODS: PROTECT-AR (NCT03854149) was a prospective, multicenter, observational study conducted from 2019 to 2023. ACHD patients with atrial fibrillation, atrial flutter, or intra-atrial re-entrant tachycardia on routine apixaban treatment were included. The historical control group consisted of patients previously on vitamin K antagonist (VKA), who were analyzed prior to their transition to apixaban. The primary effectiveness endpoint was the composite of stroke or thromboembolism. The primary safety endpoint was major bleeding. RESULTS: The study enrolled 218 ACHD patients with AA on apixaban, of which 73 were previous VKA users. The analysis covered 527 patient-years of prospective exposure to apixaban and 169 patient-years of retrospective exposure to VKA. The annualized rate of stroke or thromboembolism was 0.6% in the apixaban group and 1.8% in the VKA group (absolute difference - 1.2%; upper limit of one-sided 95% confidence interval [CI] 0.9%, lower than the predefined non-inferiority margin of +1.8%, Pnon-inferiority < 0.001). The annualized rate of major bleeding was 1.5% in the apixaban group and 2.4% in the VKA group (hazard ratio 0.64; 95% CI 0.19-2.10, P = 0.48). CONCLUSION: In ACHD patients with AA, routine apixaban use exhibited a non-inferior rate of stroke or thromboembolism compared to historical VKA use, alongside a similar rate of major bleeding.

Electrophysiological cardiovascular MR: procedure-ready mesh model generation for interventional guidance based on non-selective excitation compressed sensing whole heart imaging.

Fully CMR-guided electrophysiological interventions (EP-CMR) have recently been introduced but data on the optimal CMR imaging protocol are scarce. This study determined the clinical utility of 3D non-selective whole heart steady-state free precession imaging using compressed SENSE (nsWHcs) for automatic segmentation of cardiac cavities as the basis for targeted catheter navigation during EP-CMR cavo-tricuspid isthmus ablation. Fourty-two consecutive patients with isthmus-dependent right atrial flutter underwent EP-CMR radiofrequency ablations. nsWHcs succeeded in all patients (nominal scan duration, 98 ± 10 s); automatic segmentation/generation of surface meshes of right-sided cavities exhibited short computation times (16 ± 3 s) with correct delineation of right atrium, right ventricle, tricuspid annulus and coronary sinus ostium in 100%, 100%, 100% and 95%, respectively. Point-by-point ablation adhered to the predefined isthmus line in 62% of patients (26/42); activation mapping confirmed complete bidirectional isthmus block (conduction time difference, 136 ± 28 ms). nsWHcs ensured automatic and reliable 3D segmentation of targeted endoluminal cavities, multiplanar reformatting and image fusion (e.g. activation time measurements) and represented the basis for precise real-time active catheter navigation during EP-CMR ablations of isthmus-dependent right atrial flutter. Hence, nsWHcs can be considered a key component in order to advance EP-CMR towards the ultimate goal of targeted substrate-based ablation procedures.

Peak frequency mapping of atypical atrial flutter.

INTRODUCTION: Peak frequency (PF) mapping is a novel method that may identify critical portions of myocardial substrate supporting reentry. The aim of this study was to describe and evaluate PF mapping combined with omnipolar voltage mapping in the identification of critical isthmuses of left atrial (LA) atypical flutters. METHODS AND RESULTS: LA omnipolar voltage and PF maps were generated in flutter using the Advisor HD-Grid catheter (Abbott) and EnSite Precision Mapping System (Abbott) in 12 patients. Normal voltage was defined as ≥0.5 mV, low-voltage as 0.1-0.5 mV, and scar as <0.1 mV. PF distributions were compared with ANOVA and post hoc Tukey analyses. The 1 cm radius from arrhythmia termination was compared to global myocardium with unpaired t-testing. The mean age was 65.8 ± 9.7 years and 50% of patients were female. Overall, 34 312 points were analyzed. Atypical flutters most frequently involved the mitral isthmus (58%) or anterior wall (25%). Mean PF varied significantly by myocardial voltage: normal (335.5 ± 115.0 Hz), low (274.6 ± 144.0 Hz), and scar (71.6 ± 140.5 Hz) (p < .0001 for all pairwise comparisons). All termination sites resided in low-voltage regions containing intermediate or high PF. Overall, mean voltage in the 1 cm radius from termination was significantly lower than the remaining myocardium (0.58 vs. 0.95 mV, p < .0001) and PF was significantly higher (326.4 vs. 245.1 Hz, p < .0001). CONCLUSION: Low-voltage, high-PF areas may be critical targets during catheter ablation of atypical atrial flutter.

Validation of a novel smartphone-based photoplethysmographic method for ambulatory heart rhythm diagnostics: the SMARTBEATS study.

AIMS: In the current guidelines, smartphone photoplethysmography (PPG) is not recommended for diagnosis of atrial fibrillation (AF), without a confirmatory electrocardiogram (ECG) recording. Previous validation studies have been performed under supervision in healthcare settings, with limited generalizability of the results. We aim to investigate the diagnostic performance of a smartphone-PPG method in a real-world setting, with ambulatory unsupervised smartphone-PPG recordings, compared with simultaneous ECG recordings and including patients with atrial flutter (AFL). METHODS AND RESULTS: Unselected patients undergoing direct current cardioversion for treatment of AF or AFL were asked to perform 1-min heart rhythm recordings post-treatment, at least twice daily for 30 days at home, using an iPhone 7 smartphone running the CORAI Heart Monitor PPG application simultaneously with a single-lead ECG recording (KardiaMobile). Photoplethysmography and ECG recordings were read independently by two experienced readers. In total, 280 patients recorded 18 005 simultaneous PPG and ECG recordings. Sufficient quality for diagnosis was seen in 96.9% (PPG) vs. 95.1% (ECG) of the recordings (P < 0.001). Manual reading of the PPG recordings, compared with manually interpreted ECG recordings, had a sensitivity, specificity, and overall accuracy of 97.7%, 99.4%, and 98.9% with AFL recordings included and 99.0%, 99.7%, and 99.5%, respectively, with AFL recordings excluded. CONCLUSION: A novel smartphone-PPG method can be used by patients unsupervised at home to achieve accurate heart rhythm diagnostics of AF and AFL with very high sensitivity and specificity. This smartphone-PPG device can be used as an independent heart rhythm diagnostic device following cardioversion, without the requirement of confirmation with ECG.

Sensitivity and specificity of handheld one lead ECG detecting atrial fibrillation in an outpatient clinic setting.

AIMS: To validate the sensitivity and specificity of the Zenicor One handheld ECG device for detection of atrial fibrillation in an outpatient clinical setting. METHODS AND RESULTS: Patients attending outpatient clinics at Danderyd Hospital (n = 220) were examined with one lead handheld ECG immediately after standard care 12­lead ECG recording. Twelve recordings were excluded (atrial flutter or pacing) or missing. The recordings were dichotomously categorized as "atrial fibrillation" or "not atrial fibrillation" by two senior cardiologists. In cases of diverging interpretations, a third senior cardiologist had the deciding vote. Sensitivity and specificity in diagnosing atrial fibrillation was calculated with 12­lead ECG as gold standard. Sensitivity and specificity for diagnosis of atrial fibrillation with one lead handheld ECG and 12­lead ECG as gold standard was 98% and 99% respectively. CONCLUSION: In a health-care outpatient setting, Zenicor One handheld ECG had high sensitivity and specificity for detection of atrial fibrillation when compared with 12­lead ECG.

Incidence and patterns of atrial fibrillation after catheter ablation of typical atrial flutter-the FLUTFIB study.

AIMS: In patients with atrial flutter (AFL), ablation of the cavotricuspid isthmus (CTI) is a highly effective procedure to prevent AFL recurrence, but atrial fibrillation (AF) may occur during follow-up. The presented FLUTFIB study was designed to identify the exact incidence, duration, timely occurrence, and associated symptoms of AF after CTI ablation using continuous cardiac monitoring via implantable loop recorders. METHODS AND RESULTS: One hundred patients with AFL without prior AF diagnosis were included after CTI ablation (mean age 69.7 ± 9.7 years, 18% female) and received an implantable loop recorder for AF detection. After a median follow-up of 24 months 77 patients (77%) were diagnosed with AF episodes. Median time to first AF occurrence was 180 (43-298) days. Episodes lasted longer than 1 h in most patients (45/77, 58%). Forty patients (52%) had AF-associated symptoms.Patients with and without AF development showed similar baseline characteristics and neither HATCH- nor CHA2DS2-VASc scores were predictive of future AF episodes. Oral anticoagulation (OAC) was stopped during FU in 32 patients (32%) and was re-initiated after AF detection in 15 patients (15%). No strokes or transient ischaemic attack episodes were observed during follow-up. CONCLUSION: This study represents the largest investigation using implantable loop recorders (ILRs) to detect AF after AFL ablation and shows a high incidence of AF episodes, most of them being asymptomatic and lasting longer than 1 h. In anticipation of trials determining the duration of AF episodes that should trigger OAC initiation, these results will help to guide anticoagulation management after CTI ablation.

A matching-adjusted indirect comparison of results from REDUCE and RESPECT-two randomized trials on patent foramen ovale closure devices to prevent recurrent cryptogenic stroke.

AIMS: Two randomized clinical trials, REDUCE and RESPECT, demonstrated that patent foramen ovale (PFO) closure in combination with antithrombotic therapy was more effective for the prevention of recurrent ischemic stroke compared with antithrombotic therapy alone. The aim of this study was to determine the relative efficacy and safety of the PFO closure devices used in REDUCE (HELEX and CARDIOFORM Septal Occluders) compared with the device used in RESPECT (Amplatzer PFO Occluder). METHODS: An unanchored matching-adjusted indirect comparison (MAIC) of the PFO closure arms of the REDUCE and RESPECT trials was performed using patient-level data from REDUCE weighted to match baseline characteristics from RESPECT. Comparisons of the following outcomes were made between the devices assessed in the trials: risk of recurrent ischemic stroke; recurrent ischemic stroke one year after randomization; any serious adverse event (SAE) related to the procedure or device; and atrial fibrillation or atrial flutter as an SAE related to the procedure or device. RESULTS: After conducting the MAIC, baseline characteristics were well-matched between the two trials. Compared to RESPECT, PFO closure using the devices from REDUCE resulted in a hazard ratio of 0.46 (95% confidence interval [CI] 0.15-1.43; p = 0.17) for the risk of recurrent stroke. For the recurrence of stroke after one year, SAE related to the procedure or device, and atrial fibrillation or atrial flutter as SAE related to the procedure or device, the MAIC resulted in a rate difference of -0.68 (95%CI -2.06 to 0.70; p = .34), -1.29 (95%CI -3.82 to 1.25; p = .32), and -0.19 (95%CI -1.16 to 0.78; p = .71), respectively. These findings were consistent across scenario analyses. CONCLUSIONS: This MAIC analysis found no statistically significant differences in efficacy and safety outcomes between PFO closure with the HELEX and CARDIOFORM Septal Occluders versus the Amplatzer PFO Occluder, as used in the REDUCE and RESPECT trials.

The individual efficacy and safety of medical devices used for patent foramen ovale (PFO) closure in patients with stroke of unknown origin has been demonstrated in two independent trials: REDUCE (using the HELEX Septal Occluder and the CARDIOFORM Septal Occluder) and RESPECT (using the Amplatzer PFO Occluder). In the absence of a direct head-to-head trial for these devices, indirect treatment comparisons offer an alternative to assess their relative efficacy and safety. This study used a matching-adjusted indirect comparison to demonstrate that there were no significant differences between the devices used for PFO closure in the REDUCE and RESPECT trials in terms of safety outcomes.

Predicting Adverse Outcomes Following Catheter Ablation Treatment for Atrial Flutter/Fibrillation.

BACKGROUND & AIM: To develop prognostic survival models for predicting adverse outcomes after catheter ablation treatment for non-valvular atrial fibrillation (AF) and/or atrial flutter (AFL). METHODS: We used a linked dataset including hospital administrative data, prescription medicine claims, emergency department presentations, and death registrations of patients in New South Wales, Australia. The cohort included patients who received catheter ablation for AF and/or AFL. Traditional and deep survival models were trained to predict major bleeding events and a composite of heart failure, stroke, cardiac arrest, and death. RESULTS: Out of a total of 3,285 patients in the cohort, 177 (5.3%) experienced the composite outcome-heart failure, stroke, cardiac arrest, death-and 167 (5.1%) experienced major bleeding events after catheter ablation treatment. Models predicting the composite outcome had high-risk discrimination accuracy, with the best model having a concordance index >0.79 at the evaluated time horizons. Models for predicting major bleeding events had poor risk discrimination performance, with all models having a concordance index <0.66. The most impactful features for the models predicting higher risk were comorbidities indicative of poor health, older age, and therapies commonly used in sicker patients to treat heart failure and AF and AFL. DISCUSSION: Diagnosis and medication history did not contain sufficient information for precise risk prediction of experiencing major bleeding events. Predicting the composite outcome yielded promising results, but future research is needed to validate the usefulness of these models in clinical practice. CONCLUSIONS: Machine learning models for predicting the composite outcome have the potential to enable clinicians to identify and manage high-risk patients following catheter ablation for AF and AFL proactively.

When a little flutter gets a bit too exciting .

A middle-aged man with no previous cardiac history was admitted to the hospital being treated for thigh cellulitis, during his stay he developed palpitations and tachycardia which on initial ECG showed atrial flutter with a 2:1 AV block and evidence of an accessory pathway. He was subsequently given AV nodal blocking agents in the form of beta-blockers (bisoprolol) to slow his heart rate down; unfortunately, this led to hemodynamic instability due to 1:1 conduction of the atrial flutter down the accessory pathway. This case report demonstrates the importance of recognising pre-excitation on an ECG and the potential adverse effect of administering AV nodal blockade.

Posttransplant atrial fibrillation: Evidence of early posttransplant recipient-to-donor atrioatrial connections.

INTRODUCTION: Atrial fibrillation and atrial flutter originating from the donor s heart is a commonly reported complication post heart transplant. Atrial tachyarrhythmia originating from the recipient s heart, propagated through recipient-to-donor connections, is rare with only few cases reported in the literature; most reported cases from our review occur years post-transplant. CASE: A 47-year-old male presented with atrial tachycardia 6 months post heart transplant. Electrophysiologic study demonstrated atrial fibrillation originating from native heart and propagated through atrio-atrial connections to the donor heart. This arrhythmia was successfully terminated with radiofrequency ablation. CONCLUSION: Atrio-atrial connection between recipient and donor can form as early as a few months post heart transplant. Radiofrequency ablation appears to be an effective treatment for atrial fibrillation propagated through donor-to-recipient connections.

Safety and Efficacy of Combining Left Atrial Appendage Occlusion With Another Cardiac Procedure.

BACKGROUND: Clinical outcomes of left atrial appendage occlusion (LAAO) combined with other cardiac procedures have not been previously examined. OBJECTIVES: This study sought to evaluate the safety and efficacy of combining LAAO with other cardiac procedures vs isolated LAAO. METHODS: We conducted a retrospective cohort study using the 2016 to 2020 National Inpatient Sample database to compare patients undergoing LAAO combined with another cardiac procedure vs isolated LAAO. Outcomes included risk-adjusted major adverse cardiovascular events (MACEs), in-hospital mortality, major complications, length of stay (LOS), and total costs. RESULTS: The total cohort included 88,910 weighted encounters, of which 1,225 (1.4%) involved concomitant cardiac procedures. After risk adjustment, patients in the concomitant procedure group had similar odds of MACEs (adjusted OR: 1.82; 95% CI: 0.94-2.74); in-hospital mortality; and complications including stroke, acute kidney injury, major bleeding, blood transfusion, and vascular injury. They also had similar LOS (1 day vs 1 day; P = 0.32) and higher costs ($44,723 vs $32,364; P < 0.01) compared with isolated LAAO but shorter LOS (1 day vs 2 days; P < 0.01) and lower costs ($51,552 vs $63,170; P = 0.04) compared with LAAO with sequential procedures. In subgroup analyses, concomitant atrial fibrillation/atrial flutter ablation had higher adjusted odds of heart block (P < 0.01), and concomitant transcatheter aortic valve replacement had higher adjusted odds of stroke (P = 0.02) and vascular injury (P < 0.01). CONCLUSIONS: In this retrospective observational study, combining LAAO with another cardiac intervention appeared to be associated with similar MACEs and LOS. However, certain complications appeared to be more frequent, and the cost was higher with combined procedures.

Dissecting the associations of KCNH2 genetic polymorphisms with various types of cardiac arrhythmias.

BACKGROUND: Cardiac arrhythmia, a common cardiovascular disease, is closely related to genetic polymorphisms. However, the associations between polymorphisms in KCNH2 and various arrhythmias remain inadequately explored. METHODS: Guided by the assumption that KCNH2 genetic polymorphisms significantly contribute to the development of arrhythmias, we thoroughly explored the associations between 85 KCNH2 genetic variations and 16 cardiac arrhythmias in a sample obtained from the UK Biobank (UKBB, N = 307,473). The illnesses documented in the electronic medical records of the sample were mapped to a phecode system for a more accurate representation of distinct phenotypes. Survival analysis was used to test the effect of KCNH2 variants on arrhythmia incidence, and a phenotype-wide association study (PheWAS) was performed to investigate the effect of KCNH2 polymorphisms on 102 traits, including physical measurements, biomarkers, and hematological indicators. RESULTS: Novel associations of variants rs2269001 and rs7789585 in KCNH2 with paroxysmal tachycardia (PT) and atrial fibrillation/flutter (AF/AFL), respectively, were identified. Moreover, with an increase in the number of minor alleles of these two variants, the incidence rates of PT and AF/AFL decreased. In addition, the PheWAS results suggested that these two single nucleotide polymorphisms were associated with multiple parameters in physical measurements and neutrophil percentage. CONCLUSION: The multiple novel associations observed in this study illustrate the importance of KCNH2 genetic variations in the pathogenesis of arrhythmia.

Atrial flutter complicating acute respiratory distress syndrome (ARDS): A rare case report.

RATIONALE: This case report addresses a unique instance of atrial flutter complicating acute respiratory distress syndrome (ARDS), contributing a novel addition to the medical literature. The co-occurrence of these conditions sheds light on a rare clinical scenario that requires careful consideration. PATIENT CONCERNS: The patient exhibited symptoms of pronounced dyspnea, tachypnea, and hypoxemia. Clinical assessment revealed irregular heart rhythms, notably atrial flutter, alongside characteristic signs of ARDS, including bilateral pulmonary infiltrates and reduced lung compliance. DIAGNOSES AND INTERVENTIONS: After a comprehensive evaluation, the patient was diagnosed with atrial flutter complicating ARDS. Therapeutic measures encompassed antiarrhythmic agents, mechanical ventilation, and targeted ARDS management protocols. The intricate interplay between cardiac and respiratory factors necessitated a multidisciplinary approach. OUTCOMES: Throughout treatment, the patient's respiratory distress gradually improved. Control of the atrial flutter was achieved, and oxygenation levels were restored within acceptable limits. This successful outcome underscores the significance of a well-coordinated treatment strategy in addressing complex cases like this. LESSONS: This case highlights the importance of recognizing and managing the intricate relationship between cardiac arrhythmias such as atrial flutter and respiratory complications like ARDS. The successful management of this patient underscores the value of multidisciplinary collaboration and tailored therapeutic interventions. Practitioners should remain vigilant for such rare complications and consider this case a reminder of the potential complexities that can arise in critical care scenarios.

Cardiovascular Disease: Atrial Fibrillation and Atrial Flutter.

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia in adults, with lifetime rates of 21% to 33%. There are numerous risk factors, including older age, hypertension, coronary disease, obstructive sleep apnea, diabetes, and others. Patients engaging in lifelong high-endurance exercise also have increased risk. Some organizations recommend screening; others do not. However, many patients identify AF themselves using mobile cardiac monitoring devices, some of which accurately detect the arrhythmia. Patients with AF with hemodynamic instability are treated with immediate synchronized cardioversion. Treatment options for stable patients include scheduled cardioversion, rhythm control with pharmacotherapy, catheter ablation, and rate control with pharmacotherapy. Catheter ablation is increasingly used as first-line therapy, with up to 80% of patients remaining AF-free after one or two ablation treatments, an outcome superior to that with pharmacotherapy. Patients with AF should receive anticoagulation based on the CHA2DS2-VASc (Congestive heart failure, Hypertension, Age 75 years or older [doubled], Diabetes, prior Stroke or transient ischemic attack or thromboembolism [doubled], Vascular disease, Age 65 to 74 years, Sex category) score, and also before and immediately after ablation or cardioversion. It is uncertain whether long-term anticoagulation is needed after successful ablation. Atrial flutter (AFL) is the second most common sustained supraventricular arrhythmia. Patients with AFL are at risk of developing AF, and many recommendations for managing AFL are similar to those for AF. The preferred management for AFL is catheter ablation, with success rates exceeding 90%.