Trends and outcomes of combined percutaneous (TAVI+PCI) and surgical approach (SAVR+CABG) for patients with aortic valve and coronary artery disease: A National Readmission Database (NRD) analysis.

BACKGROUND: In patients with severe aortic stenosis (AS) and concomitant severe coronary artery disease (CAD), the relative merits of a combined percutaneous (transcatheter aortic valve implantation [TAVI] and percutaneous coronary intervention [PCI]] versus surgical approach (surgical aortic valve replacement [SAVR] and coronary artery bypass graft [CABG]) remain unknown. AIMS: To determine the utility of combined percutaneous versus surgical approaches in patients with severe AS and CAD. METHODS: The National Readmission Database (NRD) (2015-2019) was queried to identify all cases of TAVI+PCI and SAVR+CABG. The adjusted odds ratios (aOR) of mortality, stroke, and its composite (major adverse cardiovascular events [MACE]) were calculated using a propensity-score matched (PSM) analysis. RESULTS: A total of 89,314 (5358 TAVI+PCI, 83,956 SAVR+CABG) patients were included in the crude analysis. There was a gradual increase in the utilization of TAVI+PCI from 2016 to 2019 by 2%-4% per year. Using PSM, a subset of 11,361 (5358 TAVI+PCI, 6003 SAVR+CABG) patients with a balanced set of demographics and baseline comorbidities was selected. During index hospitalization, the adjusted odds of MACE (aOR 0.72, 95% confidence interval [CI] 0.62-0.83), and all-cause mortality (aOR 0.68, 95% CI 0.57-0.81) were significantly lower in patients undergoing TAVI+PCI compared with SAVR+CABG. However, patients undergoing TAVI+PCI had a higher incidence of MACE (aOR 1.40, 95% CI 1.05-1.87), and mortality (aOR 1.75, 95% CI 1.22-2.50) at 30-days. The risk of index-admission (aOR 0.82, 95% CI 0.62-1.09) and 30-day (aOR 0.88, 95% CI 0.51-1.51) stroke was similar between the two groups. CONCLUSION: In selected patients with severe AS and concomitant CAD, a combined percutaneous approach (TAVR+PCI) compared with SAVR+CABG may confer a lower risk of MACE and mortality during index admission but a higher incidence of 30-day complications.

Septal Myectomy or Alcohol Ablation for Hypertrophic Cardiomyopathy: A Nationwide Inpatient Sample (NIS) Database Analysis.

BACKGROUND: Comparison of the real-world cohort on the relative safety of alcohol septal ablation (ASA) vs. septal myectomy (SM) for the management of hypertrophic cardiomyopathy (HCM) has been lacking. METHODS: The National Inpatient Sample (NIS) (2012-2019) was used to select all cases of HCM. The safety of ASA vs. SM was compared using a one:many propensity score matched (PSM) analysis. Adjusted odds ratios (aOR) for mortality and other in-hospital complications were computed. RESULTS: A total of 6208 HCM patients (ASA 3106 vs. SM 3102) were included using a PSM analysis. Post-procedural bleeding (aOR 0.18, 95 % CI 0.11-0.32, p < 0.0001) and the need for an intra-aortic balloon pump (aOR 0.51, 95 % CI, 0.28-0.96, p = 0.037) were significantly lower while permanent pacemaker (PPM) implantation was significantly higher in ASA group as compared with SM group (aOR 1.72, 95 % CI, 1.43-2.06, p < 0.0001). The total in-hospital mean adjusted cost and length of stay were also significantly lower in the ASA group. However, there were no significant differences in adjusted odds of all-cause mortality (aOR 0.91, 95 % CI 0.62-1.33, p = 0.61), stroke (aOR 0.91, 95 % CI, 0.59-1.4, p = 0.66), and major bleeding (aOR 1.0, 95 % CI 7.8-1.29, p = 0.99) between the two comparison groups. CONCLUSION: In patients with hypertrophic cardiomyopathy, alcohol septal ablation appears to be an acceptable alternative to septal myectomy due to a lower risk of post-procedural bleeding and the need for an intra-aortic balloon pump. However, ASA confers a higher risk of PPM placement.

Trends and Outcomes of Transcatheter Aortic Valve Implantation in Patients With Peripheral Arterial Disease: Insights From the National Readmissions Database.

Due to shared risk factors, many patients with severe aortic stenosis (AS) also have concomitant peripheral arterial disease (PAD). The readmission rates and long term clinical outcomes of these patients following transcatheter aortic valve implantation (TAVI) in a large sample has not been well defined. The National Readmissions Database (NRD) (2015-2019) was used to identify patients undergoing TAVI. TAVI in patients with PAD was compared with those without PAD using a propensity score matched (PSM) analysis to obtain adjusted odds ratios (aOR) with 95% confidence intervals (CI) of net adverse clinical events (NACE), and its components. A total of 189,216 patients were identified, of which 14,925 patients (7386 with PAD, 7539 without PAD) were selected for adjusted analysis. Using PSM, patients with PAD undergoing TAVI had significantly higher in-hospital adjusted odds of NACE (aOR 1.60, 95% CI 1.36-1.88), and mortality (aOR 4.10, 95% CI 2.88-5.83). However, rates of other in-hospital peri procedural complications (stroke, major bleeding, paravalvular leak, cardiogenic shock) were not significantly different. There was no significant difference in the incidence of NACE, mortality, or other complications between the 2 groups at 30- and 180 days follow-up. Patients with PAD undergoing TAVI have an increased risk of mortality and NACE during the periprocedural period. However, following discharge, there was no statistically significant difference in 30 days and 6 month outcomes of TAVI in this population compared to those without significant PAD.

Risk Stratification for Transcatheter Aortic Valve Replacement.

Risk assessment models developed from administrative and clinical databases are used for clinical decision making. Since these models are derived from a database, they have an inherent limitation of being as good as the data they are derived from. Many of these models under or overestimate certain clinical outcomes particularly mortality in certain group of patients. Undeniably, there is significant variability in all these models on account of patient population studied, the statistical analysis used to develop the model and the period during which these models were developed. This review aims to shed light on development and application of risk assessment models for cardiac surgery with special emphasis on risk stratification in severe aortic stenosis to select patients for transcatheter aortic valve replacement.

Culprit Vessel Only Versus Multivessel Percutaneous Coronary Intervention in Acute Myocardial Infarction with Cardiogenic Shock: A Systematic Review and Meta-Analysis.

BACKGROUND: Previous studies comparing outcomes between culprit vessel only percutaneous coronary intervention (CV-PCI) versus multivessel percutaneous coronary intervention (MV-PCI) in patients with cardiogenic shock in the setting of acute myocardial infarction have shown conflicting results. This meta-analysis investigates the optimal approach for management of these patients considering recently published data. METHODS: Electronic databases including MEDLINE, ClinicalTrials.gov and the Cochrane Library were searched for all clinical studies published until May 1, 2018, which compared outcomes in patients presenting with acute myocardial infarction and cardiogenic shock. Studies comparing CV-PCI versus MV-PCI in patients with multivessel coronary artery disease were screened for inclusion in final analysis. The primary end point was in-hospital/30 day mortality. Secondary endpoints included long term (>6 months) mortality, renal failure requiring renal replacement therapy, stroke, bleeding, and recurrent myocardial infarction. Odds ratio (OR) with 95% of confidence interval (CI) were computed and p values <0.05 were considered significant. RESULTS: Patient who underwent CV-PCI had significantly lower short-term mortality (in-hospital or 30-day mortality) (OR: 0.73, CI: 0.61-0.87, p = 0.0005), and lower odds of severe renal failure requiring renal replacement therapy (OR: 0.76, CI: 0.59-0.98, p = 0.03). There was no statistically significant difference in long-term mortality, stroke, bleeding, and recurrent myocardial infarction between two groups. CONCLUSION: This meta-analysis showed lower short-term mortality and decreased odds of renal failure requiring renal replacement therapy with CV-PCI compared to MV-PCI. However, subgroup analysis including studies exclusively assessing STEMI patients revealed no statistically significant difference in outcomes. Further randomized trials are needed to confirm these findings and evaluate long term results.

Percutaneous Closure of Patent Foramen Ovale in Patients with Cryptogenic Stroke - An Updated Comprehensive Meta-Analysis.

BACKGROUND: The ideal treatment strategy for patients with cryptogenic stroke and patent foramen ovale (PFO) is not yet clear. Previous randomized controlled trials (RCTs) comparing transcatheter PFO closure with medical therapy in patients with cryptogenic stroke to prevent recurrent ischemic stroke showed mixed results. This meta-analysis aims to compare rates of recurrent stroke, transient ischemic attack (TIA) and all-cause mortality with PFO closure and medical therapy vs. medical therapy alone. METHODS: PubMed and the Cochrane Center Register of Controlled Trials were searched for studies published through June 2018, comparing PFO closure plus medical therapy versus medical therapy alone. Six RCTs (n = 3750) comparing PFO closure with medical therapy were included in the analysis. End points were recurrent stroke, TIA and all-cause mortality. The odds ratios (OR) with 95% confidence interval (CI) were computed and p < 0.05 was considered as a level of significance. RESULTS: A total of 1889 patients were assigned to PFO closure plus medical therapy and 1861 patients were assigned to medical therapy only. Risk of recurrent stroke was significantly lower in the PFO closure plus medical therapy group compared to medical therapy alone. (OR 0.47, 95% CI 0.33-0.67, p < 0.0001). Rate of TIA was similar between the two groups (OR 0.76, 95% CI 0.52-1.14), p = 0.18). There was no difference in all-cause mortality between two groups (OR 0.73, CI 0.33-1.58, p = 0.42). Patients undergoing PFO closure were more likely to develop transient atrial fibrillation than medical therapy alone (OR: 5.85; CI: 3.06-11.18, p ≤0.0001) whereas the risk of bleeding was similar between the groups (OR: 0.93; CI: 0.55-1.57, p = 0.78). CONCLUSIONS: The results of this meta-analysis suggest that transcatheter closure of PFO plus medical therapy is superior to medical therapy alone for the prevention of recurrent cryptogenic stroke. However, PFO closure in these patients has not been shown to reduce the risk of recurrent TIA or all-cause mortality. There is a higher rate of transient atrial fibrillation post PFO closure device placement, the long-term effects of which have yet to be studied.

Rate and predictors of electrical failure in non-recalled defibrillator leads.

BACKGROUND: Implantable cardioverter defibrillator (ICD) leads are considered as the 'weakest link' in defibrillator systems due to FDA recalls and advisories involving popular lead models from major manufacturers. The rate of electrical failure of ICD leads not implicated in a recall is however not well determined. METHODS: Medical records of patients implanted with ICDs at hospitals of the University of Pittsburgh Medical Center between 2002 and 2014 were analyzed. Leads were classified as having electrically failed if removed or replaced for reasons other than infection or heart transplantation. Patients were followed to endpoint of death or electrical lead failure. RESULTS: 2410 consecutive ICD recipients (mean age 66 ±â€¯13 years, women 22%, single/dual/biventricular-ICD 20%/44%/36%) were included. During a mean follow-up of 3.9 ±â€¯3.3 years, 1272 patients (53%) died, 55 patients (2.3%) had ICD lead electrical failure, and 1052 (44%) patients were alive with functional leads at the time of last follow-up. Patients with failed leads had higher BMI (p = 0.07), better functional status (p = 0.04), higher serum creatinine (p = 0.004), wider QRS complex (p = 0.01), higher number of implanted leads (p = 0.06) and were more likely to have ischemic cardiomyopathy (p = 0.03). After adjusting for these variables in a binary logistic regression model, only a lower BMI, presence of non-ischemic cardiomyopathy, and a better functional status remained independently predictive of electrical failure. CONCLUSIONS: Only 2.3% of non-recalled ICD leads experience electrical failure (annual failure rate of 0.6%). A higher patient functional status, lower BMI, and non-ischemic etiology of cardiomyopathy are independently associated with higher rates of ICD lead failure.

A Rare Case of Complete Fragmentation of Pacemaker Lead after a High-Velocity Theme Park Ride.

Pacemaker lead fracture is one of the most common causes of pacemaker malfunction and is most frequently associated with weight lifting or chest trauma. These patients usually present with symptoms of dizziness, syncope, chest discomfort, and palpitations or less commonly with extracardiac symptoms. Diagnosis is made by ECG and careful review of chest imaging such as chest X-ray or fluoroscopy. Treatment involves placement of a new lead with or without extraction of the fractured lead. We present an interesting case of complete severance of the tip of a dual-chamber pacemaker's atrial lead after a high-velocity theme park ride. In our case, the fracture occurred during amusement park rides and went undiagnosed until the patient presented for routine pacemaker evaluation. This case indicates that extreme physical forces in the absence of direct trauma, such as during amusement park rides, may result in lead fractures and patients with pacemakers should be cautioned regarding such activities.

Takotsubo Cardiomyopathy Mimicking Stent Thrombosis After Percutaneous Coronary Intervention.

Takotsubo cardiomyopathy, also known as "broken heart syndrome," is a transient left ventricular dysfunction associated with stress (usually emotional) induced myocardial injury and stunning. It often presents as myocardial infarction on surface electrocardiogram (EKG). Diagnosis is made by coronary angiography, which rules out coronary artery disease and shows pathognomonic apical ballooning. In this article, we present a case of a 72-year-old woman who initially presented with an ST segment elevation myocardial infarction on EKG. Coronary angiography showed severe left anterior descending artery and diagonal lesions requiring percutaneous coronary intervention. Post-percutaneous coronary intervention, EKG changes resolved. The next day, the patient developed recurrent chest pain and her EKG showed diffuse T-wave inversion in precordial leads with reemerging ST segment elevations concerning for stent thrombosis. The patient underwent repeat emergent coronary angiography, which showed patent stents and findings consistent with takotsubo cardiomyopathy.

Antithrombotic Therapy in Nonvalvular Atrial Fibrillation: Consensus and Challenges.

Atrial fibrillation (AF) is associated with high risk of systemic thromboembolism leading to significant morbidity and mortality. Warfarin, previously the mainstay for stroke prevention in AF, requires close monitoring because of multiple food and drug interactions. In recent years, food and drug administration has approved several direct oral anticoagulants (DOACs) for use in patients with nonvalvular AF. These agents have not been studied in patients with valvular AF who are at an even higher risk of systemic thromboembolism. DOACs do not require frequent blood testing or changes in dosage except when renal function deteriorates, however, the lack of established antidotes for many of these agents remains a challenge. Also, currently there is no head-to-head comparison between these agents to guide clinical choice. This article discusses the advantages and disadvantages of currently approved oral antithrombotics in nonvalvular AF, with a special emphasis on the DOACs and their individual characteristics.

A Case of a Reversible Neurologic Adverse Reaction to Apixaban Confirmed by Re-Challenge.

Post-marketing reporting of adverse drug events is essential for new medications, as pre-FDA approval studies lack sufficient subject numbers to detect signals for rare events. Prescriptions for the novel oral anticoagulant factor Xa inhibitors (rivaroxaban, apixaban, edoxaban) have equaled or exceeded those for vitamin K antagonists in many clinical settings requiring chronic anticoagulation, and those of injectable heparins for deep vein thrombosis prophylaxis. We report the case of a 60-year-old woman followed for permanent atrial fibrillation who was prescribed apixaban. She rapidly developed worsening neurologic symptoms of imbalance and non-vertiginous dizziness preventing her from walking, headache, diplopia, and confusion/disorientation. Her symptoms began to resolve after stopping the drug, with return to baseline function within 72 h. Unbeknownst to her cardiology care team, the patient chose to re-challenge herself with apixaban at the same dose, producing identical symptoms and again total symptom resolution within 24 h of drug discontinuation. When seen by her physician, her physical examination was unchanged from her pre-treatment baseline. Symptoms did not recur when switched to rivaroxaban therapy.

Usefulness of the CHA2DS2-VASc Score to Predict Mortality in Defibrillator Recipients.

The CHA2DS2-VASC score is a well-validated stratification tool that predicts the risk of thromboembolism and stroke in patients with nonvalvular atrial fibrillation. Several studies have examined its application as a predictor of mortality in clinical applications other than atrial fibrillation. However, there are current no studies examining its use as an outcome prediction tool in a population of patients with implantable cardiac defibrillators (ICDs). In this study, we examined data from 2,258 patients who underwent ICD device implantation at the hospitals of the University of Pittsburgh Medical Center from February 2002 to April 2014 (median follow-up 5.1 years) and examined the impact of their CHA2DS2-VASC score at the time of device implantation on all-cause mortality. Survival curves based on CHA2DS2-VASC scores were generated using the Kaplan-Meier method and were adjusted for unbalanced covariates using the Cox proportional hazards model. The mean CHA2DS2-VASC score was 3.15 ± 1.52 (range 1 to 8, mode 3). The CHA2DS2-VASC score predicted all-cause mortality in a significant and dose-dependent fashion. Analyzing the population by quartiles revealed increasing all-cause mortality from Q1 to Q4 (p <0.001). Using a Cox multivariate model adjusting for ejection fraction, BMI, serum creatinine, hemoglobin level, and QRS width, the CHA2DS2-VASC score remained a strong predictor of all-cause mortality (hazard ratio 1.26 per 1-point increase, 95% confidence interval 1.20 to 1.32). In conclusion, the CHA2DS2-VASC score is a simple tool that highly predicts all-cause mortality in patients with ICD.

Predictors and outcomes of lead extraction requiring a bailout femoral approach: Data from 2 high-volume centers.

BACKGROUND: Lead extraction (LE) infrequently requires the use of the "bailout" femoral approach. Predictors and outcomes of femoral extraction are not well characterized. OBJECTIVE: The aim of this study was to determine the predictors of need for femoral LE and its outcomes. METHODS: Consecutive patients who underwent LE at our centers were identified. Baseline demographic characteristics, procedural outcomes, and clinical outcomes were ascertained by medical record review. Patients were stratified into 2 groups on the basis of the need for femoral extraction. RESULTS: A total of 1080 patients underwent LE, of whom 50 (4.63%) required femoral extraction. Patients requiring femoral extraction were more likely to have leads with longer dwell time (9.5 ± 6.0 years vs 5.7 ± 4.3 years; P < .001), to have more leads extracted per procedure (2.0 ± 1.0 vs 1.7 ± 0.9; P = .003), and to have infection as an indication for extraction (72% vs 37.2%; P < .001). Procedural and clinical success was lower in the femoral extraction group than in the nonfemoral group (58% and 76% vs 94.7% and 97.9 %, respectively; P < .001). Major periprocedural complications (0% vs 1.3%; P = 1.0) and periprocedural mortality (0% vs 0.8%; P = 1.0) were similar between the 2 groups. CONCLUSION: In this study, femoral extraction was needed in ~5% of LEs. Longer lead dwell time, higher number of leads extracted per procedure, and the presence of infection predicted the need for femoral extraction. Procedural success of femoral extraction was low, highlighting the fact that this approach is mostly used as a bailout strategy and thus selects for more challenging cases.

Comparative effectiveness of antiarrhythmic drugs for rhythm control of atrial fibrillation.

INTRODUCTION: Although there are many different antiarrhythmic drugs (AADs) approved for rhythm management of atrial fibrillation (AF), little comparative effectiveness data exist to guide drug selection. METHODS: We followed 5952 consecutive AF patients who were prescribed amiodarone (N=2266), dronedarone (N=488), dofetilide (N=539), sotalol (N=1718), or class 1C agents (N=941) to the primary end point of AF recurrence. RESULTS: Median follow-up time was 18.2 months (range 0.1-101.6 months). Patients who were prescribed amiodarone had the highest, while patients on class 1C agents had the lowest baseline CHA2DS2-VASc score, Charlson comorbidity index, and burden of comorbid illnesses including coronary artery disease, congestive heart failure, diabetes mellitus, hyperlipidemia, chronic obstructive lung disease, chronic kidney disease, or cancer (p<0.05 for all comparisons). After adjusting for baseline characteristics, using dronedarone as benchmark, amiodarone [hazard ratio (HR) 0.58, p<0.001], class 1C agents (HR 0.70, p<0.001), and sotalol (HR 0.79, p=0.008), but not dofetilide (HR 0.87, p=0.178) were associated with less AF recurrence. In addition, compared to dronedarone, amiodarone and class 1C agents were associated with lower rates of admissions for AF (HR 0.55, p<0.001 for amiodarone; HR 0.71, p=0.021 for class 1C agents) and all-cause mortality was lowest in patients treated with class 1C agents (HR 0.42, p=0.018). The risk of stroke was similar among all groups. CONCLUSION: Compared with dronedarone, amiodarone, class 1C agents, and sotalol are more effective for rhythm control, while dofetilide had similar efficacy. These findings have important implications for clinical practice.

Mortality risk of long-term amiodarone therapy for atrial fibrillation patients without structural heart disease.

BACKGROUND: Amiodarone is often prescribed in the management of atrial fibrillation (AF) but is known to cause significant end-organ toxicities. In this study, we examined the impact of amiodarone on all-cause mortality in AF patients with structurally normal hearts. METHODS: We performed a retrospective cohort analysis of all AF patients with structurally normal hearts who were prescribed antiarrhythmic drugs (AAD) for rhythm control of AF at our institution from 2006 to 2013 (n = 2,077). Baseline differences between the amiodarone (AMIO: n = 403) and other AADs (NON-AMIO: n = 1,674) groups were corrected for using propensity score matching. RESULTS: Amiodarone use as first-line therapy decreased significantly with a higher degree of prescriber specialization in arrhythmia management (31%, 22%, and 9% for primary care physicians, general cardiologists and cardiac electrophysiologists, respectively, p < 0.001). After propensity score matching, baseline comorbidities were balanced between the AMIO and NON-AMIO groups. Over a median follow-up of 28.2 months (range 6.0-100.9 months), amiodarone was associated with increased all-cause (HR 2.41, p = 0.012) and non-cardiac (HR 3.55, p = 0.008) mortality, but not cardiac mortality. AF recurrence and cardiac hospitalizations were similar between the two study groups. CONCLUSIONS: Amiodarone treatment of AF is associated with increased mortality in patients without structural heart disease and therefore should be avoided or only used as a second-line therapy, when other AF therapies fail. Adherence to guideline recommendations in the management of AF patients impacts clinical outcome.

Risk of Stroke and Death in Atrial Fibrillation by Type of Anticoagulation: A Propensity-Matched Analysis.

BACKGROUND: We examined the effect of novel oral anticoagulants (NOACs) compared to warfarin on the risk of death or stroke in atrial fibrillation (AF) patients in every day clinical practice. METHODS: We examined a cohort of 2,836 AF patients, of whom 2,253 were prescribed warfarin and 583 were prescribed an NOAC. Patients with glomerular filtration rate < 30 mg/mL or history of significant valvular heart disease were excluded. Patients were followed to primary end points of death or stroke. Propensity matching was used to adjust for differences in baseline characteristics between the groups. RESULTS: Compared to patients in the NOAC group, patients on warfarin had more comorbidities and higher CHADS2 and CHA2 DS2 -VASc scores (1.7 vs 1.3 for CHADS2 , 2.8 vs 2.2 for CHA2 DS2 -VASc, P < 0.0001 for both). After adjusting for differences in baseline characteristics, NOAC use was associated with significant reduction in all-cause mortality compared to warfarin (hazard ratio [HR] = 0.47, 95% confidence interval [CI; 0.3-0.8], P = 0.006) but not stroke, over a median follow-up of 42.5 months. The difference in mortality persisted after propensity score matching (HR = 0.51, 95% CI [0.28-0.93], P = 0.03). CONCLUSIONS: Compared to warfarin, NOAC use is associated with decreased all-cause mortality but not stroke risk. These data from real-life clinical practice add to existing evidence for decreased mortality among patients prescribed NOACs compared to warfarin.

Patient outcomes according to adherence to treatment guidelines for rhythm control of atrial fibrillation.

BACKGROUND: Although guidelines for antiarrhythmic drug therapy in atrial fibrillation (AF) were published in 2006, it remains uncertain whether adherence to these guidelines affects patient outcomes. METHODS AND RESULTS: We retrospectively evaluated the records of 5976 consecutive AF patients who were prescribed at least 1 antiarrhythmic drug between 2006 and 2013. Patients with 1 or more prescribed antiarrhythmic drugs that did not comply with guideline recommendations comprised the non-guideline-directed group (=2920); the remainder constituted the guideline-directed group (=3056). Time to events was assessed using the survival analysis method and adjusted for covariates using Cox regression. Rates of adherence to the guidelines increased significantly with a higher degree of prescriber specialization in arrhythmias (49%, 55%, and 60% for primary care physicians, general cardiologists, and cardiac electrophysiologists, respectively, P=0.001) for the first prescribed antiarrhythmic drug. Compared to the non-guideline-directed group, the guideline-directed group had higher rates of heart failure, but lower baseline CHADS2-VASc scores (P<0.001) and lower rates of coronary artery disease, valvular disease, hypertension, hyperlipidemia, pulmonary disease, and renal insufficiency (P<0.05 for all). During 45 ± 26 months follow-up, the guideline-directed group had a lower risk of AF recurrence (hazard ratio=0.86, 95% CI=0.80 to 0.93), fewer hospital admissions for AF (hazard ratio=0.87, 95% CI=0.79 to 0.97), and fewer procedures for recurrent AF, including electrical cardioversion, pacemaker implantation, and atrioventricular nodal ablation (P<0.01 for all). The mortality and stroke risks were similar between the groups. CONCLUSIONS: Adherence to published guidelines in the antiarrhythmic management of AF is associated with improved patient outcomes.