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1.
Combination of ablation and left atrial appendage closure as "One-stop" procedure in the treatment of atrial fibrillation: Current status and future perspective.
He, B, Jiang, LS, Hao, ZY, Wang, H, Miao, YT
Pacing and clinical electrophysiology : PACE. 2021;(7):1259-1266
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Abstract
Atrial fibrillation (AF), the most common arrhythmia, is a major cause of stroke and systemic embolism. Left atrial appendage closure (LAAC) has been proved to be noninferior to traditional Vitamin K antagonists (VKAs) as well as novel oral anticoagulants (NOACs), which is becoming an important alternative to prevent stroke in non-valvular AF. Catheter-based AF ablation (CA) is recommended to be a standard of care in patients with AF refractory to drug therapy due to a better rhythm control and improvement of life quality than antiarrhythmic drugs. Theoretically, the one-stop combination with LAAC and CA tends to bring more benefits in patients with AF, as it not only relieves symptoms, but also reduces the risk of stroke significantly. However, several important questions still need to be considered in the combination procedure although quite a few attempts have already been made in clinical practice. This review provides a comprehensive update on the concept, technique, perioperative management, benefits and other critical issues of the "one-stop" procedure.
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Treatment strategies for new onset atrial fibrillation in patients treated on an intensive care unit: a systematic scoping review.
Drikite, L, Bedford, JP, O'Bryan, L, Petrinic, T, Rajappan, K, Doidge, J, Harrison, DA, Rowan, KM, Mouncey, PR, Young, D, et al
Critical care (London, England). 2021;(1):257
Abstract
BACKGROUND New-onset atrial fibrillation (NOAF) in patients treated on an intensive care unit (ICU) is common and associated with significant morbidity and mortality. We undertook a systematic scoping review to summarise comparative evidence to inform NOAF management for patients admitted to ICU. METHODS We searched MEDLINE, EMBASE, CINAHL, Web of Science, OpenGrey, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects, ISRCTN, ClinicalTrials.gov, EU Clinical Trials register, additional WHO ICTRP trial databases, and NIHR Clinical Trials Gateway in March 2019. We included studies evaluating treatment or prevention strategies for NOAF or acute anticoagulation in general medical, surgical or mixed adult ICUs. We extracted study details, population characteristics, intervention and comparator(s), methods addressing confounding, results, and recommendations for future research onto study-specific forms. RESULTS Of 3,651 citations, 42 articles were eligible: 25 primary studies, 12 review articles and 5 surveys/opinion papers. Definitions of NOAF varied between NOAF lasting 30 s to NOAF lasting > 24 h. Only one comparative study investigated effects of anticoagulation. Evidence from small RCTs suggests calcium channel blockers (CCBs) result in slower rhythm control than beta blockers (1 study), and more cardiovascular instability than amiodarone (1 study). Evidence from 4 non-randomised studies suggests beta blocker and amiodarone therapy may be equivalent in respect to rhythm control. Beta blockers may be associated with improved survival compared to amiodarone, CCBs, and digoxin, though supporting evidence is subject to confounding. Currently, the limited evidence does not support therapeutic anticoagulation during ICU admission. CONCLUSIONS From the limited evidence available beta blockers or amiodarone may be superior to CCBs as first line therapy in undifferentiated patients in ICU. The little evidence available does not support therapeutic anticoagulation for NOAF whilst patients are critically ill. Consensus definitions for NOAF, rate and rhythm control are needed.
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Double or Triple Antithrombotic Treatment in Atrial Fibrillation Patients with Acute Myocardial Infarction Undergoing Percutaneous Coronary Intervention.
Benetou, DR, Varlamos, C, Mpahara, A, Alexopoulos, D
American journal of cardiovascular drugs : drugs, devices, and other interventions. 2021;(1):11-20
Abstract
Patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) have traditionally received triple antithrombotic therapy (TAT) consisting of aspirin and a P2Y12 inhibitor plus an oral anticoagulant (OAC) to reduce atherothrombotic events, even though this strategy is associated with a high risk of severe bleeding. Recent trials have indicated that dual antithrombotic therapy (DAT), consisting of a P2Y12 inhibitor plus an OAC, may be superior to TAT in terms of bleeding risk; however, the trade-off regarding ischemic complications may be questionable. Patients who have had a myocardial infarction (MI) before undergoing PCI warrant special consideration because of the accompanying high ischemic risk, including stent thrombosis, which might be exacerbated by an aspirin-free strategy such as DAT. In particular, in the acute phase of ST-segment elevation MI (STEMI), the highly prothrombotic milieu may necessitate initial TAT, though durations may vary, making a tailored antithrombotic regimen for this high-risk subset of patients a fairly challenging and difficult scenario for clinicians. Since patients with MI, especially STEMI, are underrepresented in randomized trials, data regarding the optimal antithrombotic treatment in such patients are sparse. This review aims to analyze the outcomes of different antithrombotic regimens in patients with MI and AF undergoing PCI, define the role of DAT versus TAT regarding safety and efficacy outcomes, and address controversial issues and future perspectives.
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4.
Stroke prevention strategies in high-risk patients with atrial fibrillation.
Kotalczyk, A, Mazurek, M, Kalarus, Z, Potpara, TS, Lip, GYH
Nature reviews. Cardiology. 2021;(4):276-290
Abstract
Effective stroke prevention with oral anticoagulation (OAC) is the cornerstone of the management of patients with atrial fibrillation. The use of OAC reduces the risk of stroke and death. For most patients with atrial fibrillation without moderate or severe mitral valve stenosis or prosthetic mechanical heart valves, treatment options include vitamin K antagonists, such as warfarin, and non-vitamin K antagonist oral anticoagulants (NOACs). Although most guidelines generally recommend NOACs as the first-line OAC, caution is required in some groups of patients with atrial fibrillation at high risk of stroke and bleeding who have been under-represented or not studied in the randomized clinical trials on NOACs for stroke prevention. In addition to OAC, non-pharmacological, percutaneous therapies, including left atrial appendage occlusion, for stroke prevention have emerged, sometimes used in combination with catheter ablation for the treatment of the atrial fibrillation. High-risk groups of patients with atrial fibrillation include patients with end-stage renal failure (including those receiving dialysis), extremely old patients (such as those aged >80 years with multiple risk factors for bleeding), patients with dementia or those living in a long-term care home, patients with previous intracranial bleeding or recent acute bleeding (such as gastrointestinal bleeding), patients with acute ischaemic stroke and patients with an intracardiac thrombus. This Review provides an overview of stroke prevention strategies, including left atrial appendage occlusion, in patients with atrial fibrillation at high risk of stroke and bleeding.
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5.
Antithrombotic Therapy in Patients With Atrial Fibrillation Treated With Oral Anticoagulation Undergoing Percutaneous Coronary Intervention: A North American Perspective: 2021 Update.
Angiolillo, DJ, Bhatt, DL, Cannon, CP, Eikelboom, JW, Gibson, CM, Goodman, SG, Granger, CB, Holmes, DR, Lopes, RD, Mehran, R, et al
Circulation. 2021;(6):583-596
Abstract
A growing number of patients undergoing percutaneous coronary intervention (PCI) with stent implantation also have atrial fibrillation. This poses challenges for their optimal antithrombotic management because patients with atrial fibrillation undergoing PCI require oral anticoagulation for the prevention of cardiac thromboembolism and dual antiplatelet therapy for the prevention of coronary thrombotic complications. The combination of oral anticoagulation and dual antiplatelet therapy substantially increases the risk of bleeding. Over the last decade, a series of North American Consensus Statements on the Management of Antithrombotic Therapy in Patients with Atrial Fibrillation Undergoing Percutaneous Coronary Intervention have been reported. Since the last update in 2018, several pivotal clinical trials in the field have been published. This document provides a focused updated of the 2018 recommendations. The group recommends that in patients with atrial fibrillation undergoing PCI, a non-vitamin K antagonist oral anticoagulant is the oral anticoagulation of choice. Dual antiplatelet therapy with aspirin and a P2Y12 inhibitor should be given to all patients during the peri-PCI period (during inpatient stay, until time of discharge, up to 1 week after PCI, at the discretion of the treating physician), after which the default strategy is to stop aspirin and continue treatment with a P2Y12 inhibitor, preferably clopidogrel, in combination with a non-vitamin K antagonist oral anticoagulant (ie, double therapy). In patients at increased thrombotic risk who have an acceptable risk of bleeding, it is reasonable to continue aspirin (ie, triple therapy) for up to 1 month. Double therapy should be given for 6 to 12 months with the actual duration depending on the ischemic and bleeding risk profile of the patient, after which patients should discontinue antiplatelet therapy and receive oral anticoagulation alone.
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6.
Management of Atrial Fibrillation in 2021: An Updated Comparison of the Current CCS/CHRS, ESC, and AHA/ACC/HRS Guidelines.
Cheung, CC, Nattel, S, Macle, L, Andrade, JG
The Canadian journal of cardiology. 2021;(10):1607-1618
Abstract
Given its complexity, the management of atrial fibrillation (AF) has relied increasingly on expert guideline recommendations; however, discrepancies between these professional societies can lead to confusion among practicing clinicians. This article compares the recommendations in the 2019 American Heart Association (AHA)/American College of Cardiology (ACC)/Heart Rhythm Society (HRS), the 2020 European Society of Cardiology (ESC), and the 2020 Canadian Cardiovascular Society/Canadian Heart Rhythm Society (CCS/CHRS) AF guidelines. Although many of the recommendations are fundamentally similar, there are important differences among guidelines; specifically, key differences are present in (1) definitions and classification of AF; (2) the role of opportunistic AF detection; (3) symptom and quality-of-life evaluation; (4) stroke-risk stratification and the indication for oral anticoagulation (OAC) therapy; (5) the role of aspirin in prevention of stroke for patients with AF; (6) the antithrombotic regimens employed in the context of coronary artery disease; (7) the role of OAC, and specifically non-vitamin K direct-acting oral anticoagulants (DOACs), in patients with chronic and end-stage renal disease; (8) the target heart rate for patients treated with a rate-control strategy, along with the medications recommended to achieve the heart-rate target; and (9) the role of catheter ablation as first-line therapy or in patients with heart failure. These differences highlight areas of continuing clinical uncertainty in which there are important needs and opportunities for future investigative work.
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7.
Challenges of treatment adherence with direct oral anticoagulants in pandemic.
Dittrich, T, Polymeris, A, De Marchis, GM
Current opinion in neurology. 2021;(1):38-44
Abstract
PURPOSE OF REVIEW Direct oral anticoagulants (DOAC) are crucial for the prevention of thromboembolic events in patients with nonvalvular atrial fibrillation. Drug adherence by the patient but also adherence to guidelines by the physician are suboptimal. This review highlights aspects of DOAC treatment during the coronavirus disease 2019 (COVID-19) pandemic and selected challenging scenarios. RECENT FINDINGS For patients with a newly diagnosed indication for oral anticoagulation, a new interim clinical guidance recommends starting DOAC instead of vitamin K antagonists if DOAC are not contraindicated. The goal is to reduce the potential exposure of patients to severe acute respiratory syndrome coronavirus during the routine coagulation monitoring visits. As COVID-19 can lead to kidney failure, we discuss the challenges of DOAC dosing in kidney failures. Finally, we discuss two common challenges - when to start a DOAC after an ischemic stroke linked to atrial fibrillation, and whether cerebral microbleeds, including their count, are per se a contraindication to DOAC. SUMMARY There are still open challenges regarding DOAC treatment on the patient and physician side, both related and unrelated to the pandemic.
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8.
Effect of non-vitamin-K oral anticoagulants on stroke severity compared to warfarin: a meta-analysis of randomized controlled trials.
Costello, M, Murphy, R, Judge, C, Ruttledge, S, Gorey, S, Loughlin, E, Hughes, D, Nolan, A, O'Donnell, MJ, Canavan, M
European journal of neurology. 2020;(3):413-418
Abstract
BACKGROUND AND PURPOSE In addition to lowering stroke risk, warfarin use is also associated with reduced stroke severity in patients with atrial fibrillation and acute ischaemic stroke. It was sought to determine whether the effect of non-vitamin-K oral anticoagulants (NOACs), compared to warfarin, differed by stroke severity. METHODS Phase III randomized controlled trials with participants who were randomized to receive NOACs or warfarin for stroke prevention in the setting of non-valvular atrial fibrillation were identified. Stroke was classified into two categories, fatal or disabling stroke and non-disabling stroke, and meta-analyses were completed for both outcomes and for comparative case fatality of stroke amongst trials. RESULTS Five randomized controlled trials met our inclusion criteria. In clinical trials evaluating the NOACs usually prescribed in clinical practice (four trials), acute stroke was reported in 1403 (1.86%) participants, 787 (1.04%) in the NOAC group [386 (0.51%) fatal or disabling, 401 (0.53%) non-disabling] and 616 (0.82%) in the warfarin group [367 (0.49%) fatal or disabling, 249 (0.33%) non-disabling]. On meta-analysis NOACs were significantly superior to warfarin for fatal or disabling stroke (odds ratio [OR] 0.77; 95% confidence interval [CI] 0.66-0.89, I2 = 21%) and non-disabling stroke (OR 0.85; 95% CI 0.73-0.98, I2 = 2%). The case fatality of stroke was no different between groups (OR 0.90, 95% CI 0.75-1.13, I2 = 0%), but the point estimate favoured NOACs. CONCLUSION In phase III trials of NOACs, for prevention of stroke in atrial fibrillation, NOACs are associated with a lower risk of both fatal/disabling and non-disabling stroke compared to warfarin.
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Non-vitamin K antagonist oral anticoagulants (NOACs) in cancer patients with atrial fibrillation.
Undas, A, Drabik, L
Anatolian journal of cardiology. 2020;(1):10-18
Abstract
Non-vitamin K antagonist oral anticoagulants (NOACs), or direct oral anticoagulants have not been tested in randomized trials conducted in patients with atrial fibrillation (AF), who had malignant disease. However, their use in cancer patients increases and real-life evidence for their effectiveness and safety in this vulnerable subset of patients is growing. The challenges of the use of NOACs in cancer patients with AF and the current expert opinions on this subject have been summarized in this review article.
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10.
Atrial Fibrillation and Heart Failure With Preserved Ejection Fraction in Patients With Nonalcoholic Fatty Liver Disease.
Packer, M
The American journal of medicine. 2020;(2):170-177
Abstract
The most common causes of chronic liver disease in the developed world-nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH)-are the hepatic manifestations of an insulin-resistant state that is linked to visceral adiposity and systemic inflammation. NAFLD and NASH lead to an expansion of epicardial adipose tissue and the release of proinflammatory adipocytokines that cause microcirculatory dysfunction and fibrosis of the adjoining myocardium, resulting in atrial fibrillation as well as heart failure with a preserved ejection fraction (HFpEF). Inflammatory changes in the left atrium lead to electroanatomical remodeling; thus, NAFLD and NASH markedly increase the risk of atrial fibrillation. Simultaneously, patients with NAFLD or NASH commonly show diastolic dysfunction or latent HFpEF. Interventions include 1) weight loss by caloric restriction, bariatric surgery, or intensive exercise, and 2) drugs that ameliorate fat-mediated inflammation in both the liver and heart (eg, statins, metformin, sodium-glucose cotransporter 2 inhibitors, glucagon-like peptide-1 receptor agonists, and pioglitazone). Patients with NAFLD or NASH commonly have an inflammation-related atrial and ventricular myopathy, which may contribute to symptoms and long-term outcomes.