Prospective multicentric validation of a novel prediction model for paroxysmal atrial fibrillation.

BACKGROUND: The early recognition of paroxysmal atrial fibrillation (pAF) is a major clinical challenge for preventing thromboembolic events. In this prospective and multicentric study we evaluated prediction scores for the presence of pAF, calculated from non-invasive medical history and echocardiographic parameters, in patients with unknown AF status. METHODS: The 12-parameter score with parameters age, LA diameter, aortic root diameter, LV,ESD, TDI A', heart frequency, sleep apnea, hyperlipidemia, type II diabetes, smoker, ß-blocker, catheter ablation, and the 4-parameter score with parameters age, LA diameter, aortic root diameter and TDI A' were tested. Presence of pAF was verified by continuous electrocardiogram (ECG) monitoring for up to 21 days in 305 patients. RESULTS: The 12-parameter score correctly predicted pAF in all 34 patients, in which pAF was newly detected by ECG monitoring. The 12- and 4-parameter scores showed sensitivities of 100% and 82% (95%-CI 65%, 93%), specificities of 75% (95%-CI 70%, 80%) and 67% (95%-CI 61%, 73%), and areas under the receiver operating characteristic (ROC) curves of 0.84 (95%-CI 0.80, 0.88) and 0.81 (95%-CI 0.74, 0.87). Furthermore, properties of AF episodes and durations of ECG monitoring necessary to detect pAF were analysed. CONCLUSIONS: The prediction scores adequately detected pAF using variables readily available during routine cardiac assessment and echocardiography. The model scores, denoted as ECHO-AF scores, represent simple, highly sensitive and non-invasive tools for detecting pAF that can be easily implemented in the clinical practice and might serve as screening test to initiate further diagnostic investigations for validating the presence of pAF. Prospective validation of a novel prediction model for paroxysmal atrial fibrillation based on echocardiography and medical history parameters by long-term Holter ECG.

Paroxysmal Supraventricular Tachycardia in Wolff-Parkinson-White Syndrome in a Newborn-Case Report and Mini-Review.

Wolff-Parkinson-White (WPW) syndrome is a rare abnormal condition frequently associated with paroxysmal supraventricular tachycardia (PSVT) and is described as an arrhythmia under the form of increased heartbeat. Currently, there are various possible treatments going from medicines such as adenosine and beta-blockers to cardioversion. The unknown causes of this condition together with the different responses to treatment in each patient make it difficult to establish the best therapeutic approach. In this context, in the current paper, we were interested in reporting the therapeutic options and their efficiency in the case of associated heart or inflammatory conditions in a 13-day-old patient.

Bloqueo ventriculoauricular repetitivo durante una taquicardia por reentrada intranodular / Repetitive ventriculoatrial block during nodal reentrant tachycardia

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Clozapine-related Paroxysmal Supraventricular Tachycardia: a Case Report.

Clozapine is considered to be more effective than other antipsychotic drugs for treating treatmentresistant schizophrenia. However, side effects of clozapine include agranulocytosis and, less commonly, cardiovascular disease, which is occasionally fatal. We describe a 56-year-old woman who developed clozapine-related paroxysmal supraventricular tachycardia during clozapine dose titration and had a recurrence despite being treated with verapamil. For treatment-resistant schizophrenia, a slow titration of the clozapine dose is necessary, and potential cardiac side-effects should be monitored.

Association of Burden of Atrial Fibrillation With Risk of Ischemic Stroke in Adults With Paroxysmal Atrial Fibrillation: The KP-RHYTHM Study.

Importance: Atrial fibrillation is a potent risk factor for stroke, but whether the burden of atrial fibrillation in patients with paroxysmal atrial fibrillation independently influences the risk of thromboembolism remains controversial. Objective: To determine if the burden of atrial fibrillation characterized using noninvasive, continuous ambulatory monitoring is associated with the risk of ischemic stroke or arterial thromboembolism in adults with paroxysmal atrial fibrillation. Design, Setting, and Participants: This retrospective cohort study conducted from October 2011 and October 2016 at 2 large integrated health care delivery systems used an extended continuous cardiac monitoring system to identify adults who were found to have paroxysmal atrial fibrillation on 14-day continuous ambulatory electrocardiographic monitoring. Exposures: The burden of atrial fibrillation was defined as the percentage of analyzable wear time in atrial fibrillation or flutter during the up to 14-day monitoring period. Main Outcomes and Measures: Ischemic stroke and other arterial thromboembolic events occurring while patients were not taking anticoagulation were identified through November 2016 using electronic medical records and were validated by manual review. We evaluated the association of the burden of atrial fibrillation with thromboembolism while not taking anticoagulation after adjusting for the Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) or CHA2DS2-VASc stroke risk scores. Results: Among 1965 adults with paroxysmal atrial fibrillation, the mean (SD) age was 69 (11.8) years, 880 (45%) were women, 496 (25%) were persons of color, the median ATRIA stroke risk score was 4 (interquartile range [IQR], 2-7), and the median CHA2DS2-VASc score was 3 (IQR, 1-4). The median burden of atrial fibrillation was 4.4% (IQR ,1.1%-17.23%). Patients with a higher burden of atrial fibrillation were less likely to be women or of Hispanic ethnicity, but had more prior cardioversion attempts compared with those who had a lower burden. After adjusting for either ATRIA or CHA2DS2-VASc stroke risk scores, the highest tertile of atrial fibrillation burden (≥11.4%) was associated with a more than 3-fold higher adjusted rate of thromboembolism while not taking anticoagulants (adjusted hazard ratios, 3.13 [95% CI, 1.50-6.56] and 3.16 [95% CI, 1.51-6.62], respectively) compared with the combined lower 2 tertiles of atrial fibrillation burden. Results were consistent across demographic and clinical subgroups. Conclusions and Relevance: A greater burden of atrial fibrillation is associated with a higher risk of ischemic stroke independent of known stroke risk factors in adults with paroxysmal atrial fibrillation.

Atrial fibrillation decision support tool: Population perspective.

BACKGROUND: Appropriate thromboprophylaxis for patients with atrial fibrillation or atrial flutter (AF) remains a national challenge. The recent availability of direct oral anticoagulants (DOACs) with comparable efficacy and improved safety compared with warfarin alters the balance between risk factors for stroke and benefit of anticoagulation. Our objective was to examine the impact of DOACs as an alternative to warfarin on the net benefit of oral anticoagulant therapy (OAT) in a real-world population of AF patients. METHODS: This is a retrospective cohort study of patients with paroxysmal or persistent nonvalvular AF. We updated an Atrial Fibrillation Decision Support Tool (AFDST) to include DOACs as treatment options. The tool generates patient-specific recommendations based upon individual patient risk factor profiles for stroke and major bleeding using quality-adjusted life-years (QALYs) calculated for each treatment strategy by a decision analytic model. The setting included inpatient and ambulatory sites in an academic health center in the midwestern United States. The study involved 5,121 adults with nonvalvular AF seen for any ambulatory visit or inpatient hospitalization over the 1-year period (January through December 2016). Outcome measure was net clinical benefit in QALYs. RESULTS: When DOACs are a therapeutic option, the AFDST recommends OAT for 4,134 (81%) patients and no antithrombotic therapy or aspirin for 489 (9%). A strong recommendation for OAT could not be made in 498 (10%) patients. When warfarin is the only option, OAT is recommended for 3,228 (63%) patients and no antithrombotic therapy or aspirin for 973 (19%). A strong recommendation for OAT could not be made in 920 (18%) patients. In total, 1,508 QALYs could be gained if treatment were changed to that recommended by the AFDST. CONCLUSIONS: Availability of DOACs increases the proportion of patients for whom oral anticoagulation therapy is recommended in a real-world cohort of AF patients and increased projected QALYs by more than 1,500 when all patients are receiving thromboprophylaxis as recommended by the AFDST compared with current treatment.

[Regulatory adaptive status in determining the effectiveness of bisoprololum and sotalolum in patients with hypertensive disease and paroxysmal supraventricular tachycardia].

AIM: To determine efficacy of bisoprolol and sotalol treatments in patients with paroxysmal supraventricular tachycardia (SVT) and essential hypertension (EH) considering effects of these treatments on the regulatory adaptive status (RAS). MATERIALS AND METHODS: The study included 49 patients with paroxysmal SVT associated with stage II-III EH randomized to two groups of either bisoprolol (6.9±2.2 mg/day, n=25) or sotalol (162.5±46.2 mg/day, n=24) treatment. Lisinopril (14.5±3.9 and 14.3±4.7 mg/day) and, if indicated, atorvastatin (15.4±3.8 mg/day, n=9 and 16.0±4.8 mg/day, n=10), and acetylsalicylic acid (91.5±14.7 mg/day, n=12 and 94.1±16.5 mg/day, n=14) were administered as a part of combination therapy. Quantitative evaluation of RAS (cardiorespiratory synchronism test), EchoCG, triplex scanning of brachiocephalic arteries, treadmill test, 6-min walk test, 24-h BP and ECG monitoring, and subjective assessment of the quality of life were performed at baseline and after 6 months of therapy. RESULTS: Both regimens of the combination drug therapy comparably improved the structural and functional status of the heart, increased exercise tolerance, effectively suppressed SVT paroxysms, and improved the quality of life. In this process, sotalol reduced RAS to a lesser extent that bisoprolol. CONCLUSION: In patients with paroxysmal SVT associated with stage II-III EH, the sotalol treatment as a part of the combination therapy may be preferable due to fewer adverse effects on RAS compared to bisoprolol.

Respuesta al ECG de noviembre de 2017 / Response to ECG, November 2017

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[Multicenter investigation of the correlation between supraventricular tachycardia and tachycardia-induced cardiomyopathy in children].

Objective: This study aimed to investigate the correlation between supraventricular tachycardia (SVT) and tachycardia-induced cardiomyopathy(TIC) in children and assess the risk factors for the development of TIC. Method: One hundred and eighty-three patients were recruited in four hospitals of Beijing diagnosed as SVT were divided into two groups depending on whether or not complicated with TIC. The age, gender, tachycardia type, ventricular rate during tachycardia, frequency of tachycardia episodes and duration of tachycardia were compared between the two groups and risk factors associated with TIC were analyzed. Statistical analyses were performed using t test, Mann-Whitney U and χ(2) test. Result: Totally 183 patients were included in this study (paroxysmal supraventricular tachycardia, PSVT, n=149; atrial tachycardia, AT, n=34). The incidence of TIC was 13.1%. There was significant difference regarding the incidence of TIC between children with AT and children with PSVT (26.5% vs. 10.1%, χ(2)=6.537, P=0.011). The percentage of AT in patients with TIC was significantly higher than patients without TIC (37.5% vs. 15.7%, χ(2)=6.537, P=0.011). Patients with TIC had a higher frequency of tachycardia episodes(2.5(1.0-4.8) beats/year vs 4.0(1.0-10.0) beats/year, Z=-2.223, P=0.026)and longer duration of tachycardia(11.0(1.1-36.0) h vs 2.5(1.0-12.0) h, Z=-2.154, P=0.031)compared with patients without TIC. Multivariate predictors of TIC was longer duration of tachycardia (OR=2.041, P=0.028). Conclusion: TIC occurs in 13.1% of children with SVT. The incidence of TIC in children with AT is higher than in children with PSVT. Risk factor for the development of TIC is longer duration of tachycardia.

One symptom, two arrhythmias: the rare and the even rarer.

BACKGROUND: Wolff-Parkinson-White (WPW) syndrome and idiopathic left ventricular tachycardia (ILVT) are rare and up to now the coexistence of both entities has rarely been reported. In patients with ventricular preexcitation the underlying mechanism of paroxysmal tachycardia most likely is atrioventricular reentrant tachycardia (AVRT). However, without ECG documentation of the tachycardia diagnosis of the underlying mechanism cannot be made due to similar clinical presentation of AVRT and ILVT. CASE PRESENTATION: We report a case of a two-staged occurrence of two rare arrhythmias in a young adult, who was admitted to our hospital twice within 6 months because of paroxysmal tachycardia. WPW syndrome and ILVT as underlying arrhythmias have been diagnosed and were ablated successfully. CONCLUSIONS: This case highlights the diagnostic defiance of rare tachycardia entities and the paramount importance of ECG documentation and analysis of all available tachycardia ECGs.

Necrotising enterocolitis after supraventricular tachycardia: an unusual precursor to a common problem.

Supraventricular tachycardia (SVT) is the most common neonatal arrhythmia. Necrotising enterocolitis (NEC) is a disease with multifactorial aetiology, most common in preterm infants. There are three previous case reports in the literature of NEC following neonatal SVT. We present two cases of late preterm infants with NEC, characterised by pneumatosis on abdominal X-ray and ultrasound, following recurrent SVT without haemodynamic instability. The infants were successfully treated with antibiotic therapy and bowel rest.

High molecular weight fibroblast growth factor-2 as a promising prognostic biomarker to predict the occurrence of heart failure in atrial fibrillation patients.

Heart failure (HF) has a significant effect on the prognosis of the patients with atrial fibrillation (AF), and also it is an important risk factor for overall mortality. High molecular weight fibroblast growth factor-2 (Hi-FGF-2) is emerging as a prognostic marker with HF and AF. The aim of this study was to prove that Hi-FGF-2 would predict occurrence of HF in the patients with AF. Subjects diagnosed with paroxysmal AF (Group paAF), persistent AF (Group peAF) and sinus rhythm (Group SR) were enrolled in the study. Serum Hi-FGF-2 concentration was measured by ELISA at baseline. Multivariable logistic models and receiver operating characteristic (ROC) curve analysis were established to predict the prognosis of AF subjects. 260 patients were enrolled in the study: 104 (40.0%) admitted for sinus rhythm (Group SR) and 156 (60.0%) with AF (Group paAF and Group peAF). The Hi-FGF-2 levels were much lower in the Group SR (58.2 ± 27.1 ng/L) than in the Group AF. Furthermore, the Group peAF (84.3 ± 34.1 ng/L) had higher Hi-FGF-2 levels than the Group paAF (72.9 ± 35.8 ng/L). Serum Hi-FGF-2 levels were classified into trisection in the multivariable logistic model (T1 < 57.3 ng/L, 57.3 < T2 < 86.5 ng/L, and T3 > 86.5 ng/L). Hi-FGF-2 showed good predictive ability for new-onset HF in the patients with AF. The occurrence of HF was associated significantly with increased tertile of serum Hi-FGF-2 levels (T2: OR 5.922, 95% CI 1.109-31.626, P = 0.037 and T3: OR 8.262, 95% CI 1.735-39.343, P = 0.008). ROC curve analysis showed that the area under curves for Hi-FGF-2 were 0.720 (P < 0.0001). Hi-FGF-2 has a significant meaning in AF subjects. Further to this, higher circulating Hi-FGF-2 was highly related to persistent AF, and Hi-FGF-2 may be an independent risk factor of occurrence HF in AF subjects.

Paradoxical Embolism in a Girl with Atrial Septal Defect After Paroxysmal Supraventricular Tachycardia Ablation.

Paradoxical embolism is a kind of important pathogenesis of cardiocerebrovascular diseases. In our case, radiofrequency current catheter ablation was accomplished successfully in a 15-year-old girl who had been experiencing supraventricular tachycardia for 6 months. She presented with abrupt onset of left hemiplegia and loss of consciousness on the first postoperative day. An urgent cerebral computed tomography showed a hyperdense right middle cerebral artery. Transthoracic echocardiogram examination revealed an atrial septal defect (ASD), with the diameter measuring 39 mm. The case highly suggests that the issue of ASD should be resolved by either closed or prompt anticoagulant therapy, especially for patients who are planned to receive catheter manipulation.

The treatment of paroxysmal atrial fibrillation in UK primary care.

OBJECTIVE: To determine whether patients with paroxysmal atrial fibrillation (AF) are less likely to be treated with anticoagulants than patients with persistent/permanent AF and to investigate trends in treatment between 2000 and 2015. UK and European guidelines recommend that anticoagulants are offered to all patients with AF at increased risk of stroke, irrespective of AF type. METHODS: Sixteen sequential cross-sectional analyses from 2000 to 2015 were carried out with index dates on 1st of May each year. The data source was primary care data from 648 practices across the UK contributing to The Health Improvement Network database. All patients with a diagnosis of AF aged ≥35 years and registered for at least 1 year were included. The main outcome measure was prescription of anticoagulant medication. RESULTS: The proportion of patients with AF with a diagnosis of paroxysmal AF increased from 7.4% (95% CI 7.0 to 7.8) in 2000 to 14.0% (95% CI 13.7 to 14.3) in 2015. Among patients with a CHADS2 score of ≥1, between 2000 and 2015 the proportion prescribed anticoagulants increased from 18.8% (95% CI 16.4 to 21.4) to 56.2% (95% CI 55.0 to 57.3) and from 34.2% (95% CI 33.3 to 35.0) to 69.4% (95% CI 68.9 to 69.8) in patients with paroxysmal and other (persistent/permanent) AF, respectively; RR for treatment of patients with paroxysmal AF compared with patients with other AF increased from 0.48 (95% CI 0.42 to 0.55) to 0.76 (95% CI 0.74 to 0.77). Adjusting for age, sex, Townsend score and presence or absence of contraindications had little effect on the results. CONCLUSIONS: In 2000, eligible patients with paroxysmal AF were half as likely to be treated with anticoagulants as patients with other AF; this has improved over time, but in 2015, eligible patients with paroxysmal AF were still around 20% less likely to be prescribed anticoagulant medication.

Clinical characteristics of atrial fibrillation-related cardioembolic stroke in patients aged 80 years or older.

AIM: Atrial fibrillation (AF)-related cardioembolic stroke is a serious problem in the aging society. The present study examined the clinical characteristics and outcomes of AF-related cardioembolic stroke in patients aged ≥80 years. METHODS: Between September 2011 and April 2014, consecutive patients with ischemic stroke and AF were retrospectively extracted from the multicenter database. Clinical characteristics were compared between patients aged ≥80 years and <80 years. Multivariate cox proportional hazard models were used to estimate hazard ratios and 95% confidential intervals on 90-day mortality for age of ≥80 years. RESULTS: A total of 253 patients aged ≥80 years (87 men, 86.4 ± 5.0 years) and 196 patients aged <80 years (134 men, 70.4 ± 7.1 years) were included. Patients aged ≥80 years were more frequently female, and more likely to have higher premorbid modified Rankin Scale score (mRS), lower body mass index, previous history of stroke, prior antiplatelet therapy, congestive heart failure, and persistent AF. Patients aged ≥80 years had higher initial National Institutes of Health Stroke Scale score and were more likely to have occlusion of the cervicocephalic arteries, but less likely to receive thrombolysis. Patients aged ≥80 years had a higher mRS and mortality after 3 months. Age of ≥80 years was a significant predictor of 90-day mortality after adjustment for sex (hazard ratio 2.20, 95% confidential interval 1.25-4.09), but was no longer significant after further adjustment for other clinical characteristics and stroke severity. CONCLUSIONS: In AF-related cardioembolic stroke, patients aged ≥80 years had different clinical characteristics and poorer outcome compared with patients aged <80 years. Geriatr Gerontol Int 2017; 17: 708-713.

Electrocardiographic and Echocardiographic predictors of paroxysmal atrial fibrillation detected after ischemic stroke.

BACKGROUND: Detection of atrial fibrillation after ischemic stroke is challenging due to its paroxysmal nature. We aimed to assess predictors of paroxysmal atrial fibrillation using non-invasive surface ECG and transthoracic echocardiography to select candidates for atrial fibrillation screening. METHODS: Ischemic stroke patients without documented atrial fibrillation (n = 110, 67 ± 10 years, 40 female) and a control group of age- and gender-matched patients with history of paroxysmal atrial fibrillation prior to stroke (n = 55, 67 ± 10 years, 19 female) comprised the study sample. Using non-invasive ECG monitoring for three weeks, short episodes of paroxysmal atrial fibrillation were detected in 24 of 110 patients (22 %). The standard 12-lead ECG with sinus rhythm at stroke onset was digitally processed and analyzed. Transthoracic echocardiography data were reviewed for these patients. RESULTS: Atrial fibrillation history was independently associated with P terminal force in lead V 1 > 40 mm*ms (OR 4.04 95 % CI 1.34-12.14, p = 0.013) and left atrial volume index (OR 1.08 95 % CI 1.03-1.13, p = 0.002; for LAVI > 40 mL/m2 OR 6.40 95 % CL 1.47-27.91, p = 0.013). Among patients without atrial fibrillation history, no ECG characteristics were predictive of atrial fibrillation detected after stroke. Left atrial volume index remained an independent predictor of atrial fibrillation detected after stroke (OR 1.09 95 % CI 1.02-1.16, p = 0.017). A cutoff of <40 mL/m2 had an 84 % negative predictive value for ruling out atrial fibrillation on ambulatory monitoring with a sensitivity of 50 % and a specificity of 86 %. CONCLUSION: In a post hoc analysis, left atrial dilatation assessed by left atrial volume index independently predicted atrial fibrillation after stroke in patients without prior atrial fibrillation history, while the other clinical or ECG markers were not predictive of atrial fibrillation detected early after ischemic stroke. TRIAL REGISTRATION: This study is a post hoc analysis from the prospective case-control study registered in December 2011, ClinicalTrials.gov ID: NCT01325545 .

Left ventricular stiffness estimated by diastolic wall strain is associated with paroxysmal atrial fibrillation in structurally normal hearts.

BACKGROUND: Left ventricular (LV) diastolic dysfunction depends on an impaired relaxation and stiffness. Abnormal LV relaxation contributes to the development of atrial fibrillation (AF), but the role of LV stiffness in AF remains unclear. HYPOTHESIS: Diastolic wall strain (DWS), a load-independent, noninvasive direct measure of LV stiffness, correlates with prevalent AF. METHODS: This study included 328 consecutive subjects with structurally normal hearts: 164 paroxysmal AF patients and 164 age- and sex-matched (1:1) controls. We calculated the DWS from the M-mode echocardiographic measurements of the LV posterior wall thickness at end-systole and end-diastole during sinus rhythm. RESULTS: The DWS was lower in the AF patients (0.35 ± 0.07) than in the controls (0.41 ± 0.06; P < 0.001). After adjusting for the risk factors of AF using a conditional logistic regression analysis, a history of hypertension, plasma brain-type natriuretic peptide level, and DWS were independently associated with AF prevalence, whereas body mass index, LV mass index, left atrial volume, and any conventional indices of the diastolic function were not. A low DWS (<0.380) was the strongest indicator of AF (odds ratio: 6.22, 95% confidence interval: 3.08-14.2, P < 0.001). CONCLUSIONS: Increased LV stiffness estimated by DWS was a strong determinant of the prevalence of AF. LV stiffness may play a role in the pathogenesis of paroxysmal AF in structurally normal hearts.