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Blood lipid levels and recurrence of atrial fibrillation after radiofrequency catheter ablation: a prospective study.
Shang, Y, Chen, N, Wang, Q, Zhuo, C, Zhao, J, Lv, N, Huang, Y
Journal of interventional cardiac electrophysiology : an international journal of arrhythmias and pacing. 2020;(2):221-231
Abstract
PURPOSE The relation between dyslipidemia and atrial fibrillation (AF) development remains controversial. We conducted a prospective study to investigate the association of lipids with the risk of recurrence of AF after radiofrequency catheter ablation (RFCA). METHODS This study enrolled 287 consecutive patients who underwent initial circumferential pulmonary vein ablation (CPVA). Fasting levels of total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), and triglycerides (TG) were measured at baseline before ablation. Patients were classified according to lipid quartiles. AF recurrence was confirmed by 48-h electrocardiograms at follow-up visits. RESULTS A total of 71 patients (24.7%) experienced AF recurrence during 3 to 12 months after ablation. By univariate Cox regression survival analysis, TC (HR, 0.63; 95%CI, 0.48-0.82), LDL-C (HR, 0.61; 95%CI, 0.44-0.84), non-paroxysmal AF type (HR, 2.56; 95%CI, 1.52-4.21), and left atrial diameter (HR, 2.18; 95%CI, 1.46-3.24) were significantly associated with AF recurrence. By multivariate Cox regression survival analysis, lower quartiles of TC (HR, 3.66; 95%CI, 1.56-8.56) and LDL-C (HR, 2.28; 95%CI 1.09-4.77) were associated with higher risk of AF recurrence compared with the highest quartiles. After adjustment by sex, lower TC (HR, 11.70; 95%CI, 2.79-49.13) and LDL-C (HR, 11.00; 95%CI, 2.77-43.72) levels were associated with the recurrence of AF in women, but not in men. HDL-C and TG levels showed no association with AF recurrence in both genders. CONCLUSIONS TC and LDL-C levels were negatively correlated with AF recurrence after RFCA in women. HDL-C and TG were not independently associated with AF recurrence in both genders.
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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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Daily Supplementation of L-Glutamine in Atrial Fibrillation Patients: The Effect on Heat Shock Proteins and Metabolites.
Starreveld, R, Ramos, KS, Muskens, AJQM, Brundel, BJJM, de Groot, NMS
Cells. 2020;(7)
Abstract
Pharmaco-therapeutic strategies of atrial fibrillation (AF) are moderately effective and do not prevent AF onset and progression. Therefore, there is an urgent need to develop novel therapies. Previous studies revealed heat shock protein (HSP)-inducing compounds to mitigate AF onset and progression. Such an HSP inducing compound is L-glutamine. In the current study we investigate the effect of L-glutamine supplementation on serum HSP27 and HSP70 levels and metabolite levels in patients with AF patients (n = 21). Hereto, HSP27 and HSP70 levels were determined by ELISAs and metabolites with LC-mass spectrometry. HSP27 levels significantly decreased after 3-months of L-glutamine supplementation [540.39 (250.97-1315.63) to 380.69 (185.68-915.03), p = 0.004] and normalized to baseline levels after 6-months of L-glutamine supplementation [634.96 (139.57-3103.61), p < 0.001]. For HSP70, levels decreased after 3-months of L-glutamine supplementation [548.86 (31.50-1564.51) to 353.65 (110.58-752.50), p = 0.045] and remained low after 6-months of L-glutamine supplementation [309.30 (118.29-1744.19), p = 0.517]. Patients with high HSP27 levels at baseline showed normalization of several metabolites related to the carbohydrates, nucleotides, amino acids, vitamins and cofactors metabolic pathways after 3-months L-glutamine supplementation. In conclusion, L-glutamine supplementation reduces the serum levels of HSP27 and HSP70 within 3-months and normalizes metabolite levels. This knowledge may fuel future clinical studies on L-glutamine to improve cardioprotective effects that may attenuate AF episodes.
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Deleterious cardiovascular effect of exosome in digitalis-treated decompensated congestive heart failure.
Fu, JL, Yu, Q, Li, MD, Hu, CM, Shi, G
Journal of biochemical and molecular toxicology. 2020;(5):e22462
Abstract
Heart failure (HF) is a medical condition inability of the heart to pump sufficient blood to meet the metabolic demand of the body to take place. The number of hospitalized patients with cardiovascular diseases is estimated to be more than 1 million each year, of which 80% to 90% of patients ultimately progress to decompensated HF. Digitalis glycosides exert modest inotropic actions when administered to patients with decompensated HF. Although its efficacy in patients with HF and atrial fibrillation is clear, its value in patients with HF and sinus rhythm has often been questioned. A series of recent studies have cast serious doubt on the benefit of digoxin when added to contemporary HF treatment. We are hypothesizing the role and mechanism of exosome and its biological constituents responsible for worsening the disease state and mortality in decompensated HF patients on digitalis.
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A Structured Literature Review and International Consensus Validation of FORTA Labels of Oral Anticoagulants for Long-Term Treatment of Atrial Fibrillation in Older Patients (OAC-FORTA 2019).
Pazan, F, Collins, R, Gil, VM, Hanon, O, Hardt, R, Hoffmeister, M, Monteiro, P, Quinn, TJ, Ropers, D, Sergi, G, et al
Drugs & aging. 2020;(7):539-548
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Abstract
INTRODUCTION Evidence regarding safety and efficacy of oral anticoagulants for the treatment of atrial fibrillation (AFib) in older adults has been assessed regarding the age appropriateness of oral anticoagulants (OAC) according to the FORTA (Fit fOR The Aged) classification (OAC-FORTA). Three years after its first version (OAC-FORTA 2016), an update was initiated to create OAC-FORTA 2019. METHODS A structured review of randomized controlled clinical trials and summaries of individual product characteristics was performed to detect newly emerged evidence on oral anticoagulants in older patients with AFib. This review was used by an interdisciplinary panel of European experts (N = 10) in a Delphi process to label OACs according to FORTA. RESULTS A total of 202 records were identified and 11 studies finally included. We found four new trials providing relevant data on efficacy and safety of warfarin, apixaban, dabigatran or rivaroxaban in older patients with AFib. In the majority of studies comparing the non-vitamin-K oral anticoagulants (NOACs) with warfarin, NOACs were superior to warfarin regarding at least one relevant clinical endpoint. The mean consensus coefficient significantly increased from 0.867 (OAC-FORTA 2016) to 0.931 (p < 0.05) and the proposed FORTA classes were confirmed in all cases during the first round (consensus coefficient > 0.8). Warfarin, dabigatran, edoxaban and rivaroxaban were assigned to the FORTA B label, acenocoumarol, fluindione and phenprocoumon were labeled FORTA C and only apixaban was rated as FORTA A. CONCLUSION OAC-FORTA 2019 confirms that AFib can be successfully treated with positively labeled antithrombotics at advanced age.
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Thromboembolism and bleeding risk in atrial fibrillation ablation with uninterrupted anticoagulation between new oral anticoagulants and vitamin K antagonists: insights from an updated meta-analysis.
Liu, XH, Gao, XF, Chen, CF, Chen, B, Xu, YZ
Journal of thrombosis and thrombolysis. 2020;(1):201-210
Abstract
Cumulative reports comparing the efficacy and safety outcomes between uninterrupted NOACs and vitamin K antagonists (VKA) in AF ablation had been freshly published. This meta-analysis aimed at offering a more comprehensive evaluation between these two anticoagulants in uninterrupted strategy. We searched in PUBMED, EMBASE, and Cochrane Library (inception to June 10, 2019) for eligible studies. Fixed-effects model was preferred in pooled analysis if I2 < 50%. Publication bias was also evaluated. A total of 23 studies involving 12,725 individuals were analyzed in this literature. There were no difference between uninterrupted NOACs and VKA groups in incidence of Stroke/TIA (RR 0.98, 95% CI 0.54-1.77, P = 0.93, I2 = 0%), silent cerebral embolism (RR 1.09, 95% CI 0.82-1.43, P = 0.56, I2 = 0%), minor bleeding complication (RR 0.97, 95% CI 0.83-1.14, P = 0.73, I2 = 0%), cardiac tamponade (RR 0.95, 95% CI 0.63-1.42, P = 0.80, I2 = 0%). Uninterrupted NOACs was associated with significantly lower major bleeding incidence (RR 0.67, 95% CI 0.49-0.92, P = 0.01, I2 = 0%), pericardial effusion (RR 0.75, 95% CI 0.56-1.00, P = 0.048, I2 = 9%). In sub-analysis, no difference was found in all sub-analyses for Stroke/TIA while significant major bleeding risk reduction in uninterrupted NOACs was identified in the subgroup of CHA2DS2-VASc score ≥ 2 and target activated clotting time (ACT) > 300 s. In conclusions, uninterrupted NOACs was more effective than uninterrupted VKA in reducing major bleeding and pericardial effusion risk without increasing thromboembolism risk, and the benefits of uninterrupted NOACs on major bleeding complication could be more pronounced if CHA2DS2-VASc score ≥ 2 or target ACT > 300 s.
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Educational Impact on Apixaban Adherence in Atrial Fibrillation (the AEGEAN STUDY): A Randomized Clinical Trial.
Montalescot, G, Brotons, C, Cosyns, B, Crijns, HJ, D'Angelo, A, Drouet, L, Eberli, F, Lane, DA, Besse, B, Chan, A, et al
American journal of cardiovascular drugs : drugs, devices, and other interventions. 2020;(1):61-71
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Abstract
INTRODUCTION Adherence to non-vitamin-K oral anticoagulants (NOACs) may be lower than to vitamin K antagonists because NOACs do not require routine monitoring. OBJECTIVE We assessed the impact of an educational program on adherence and persistence with apixaban in patients with non-valvular atrial fibrillation (NVAF). METHODS Patients with NVAF eligible for NOACs with one or more stroke risk factor (prior stroke/transient ischemic attack, age ≥ 75 years, hypertension, diabetes, or symptomatic heart failure) were randomized (1:1) to standard of care (SOC) or SOC with additional educational (information booklet, reminder tools, virtual clinic access). The primary outcome was adherence to apixaban (2.5 or 5 mg twice daily) at 24 weeks. Patients receiving the educational program were re-randomized (1:1) to continue the program for 24 further weeks or to switch to secondary SOC. Implementation adherence and persistence were reassessed at 48 weeks. RESULTS In total, 1162 patients were randomized (SOC, 583; educational program, 579). Mean implementation adherence ± standard deviation (SD) at 24 weeks was 91.6% ± 17.1 for SOC and 91.9% ± 16.1 for the educational program arm; results did not differ significantly between groups at any time-point. At 48 weeks, implementation adherence was 90.4% ± 18.0, 90.1% ± 18.6, and 89.3% ± 18.1 for continued educational program, SOC, and secondary SOC, respectively; and corresponding persistence was 86.1% (95% confidence interval [CI] 81.3-89.7), 85.2% (95% CI 81.5-88.2), and 87.8% (95% CI 83.4-91.1). Serious adverse events were similar across groups. CONCLUSION High implementation adherence and persistence with apixaban were observed in patients with NVAF receiving apixaban. The educational program did not show additional benefits. CLINICAL TRIAL REGISTRATION This study is registered at ClinicalTrials.gov [NCT01884350].
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Emergency Department Management of Recent-Onset Atrial Fibrillation.
Weant, KA, Matuskowitz, AJ, Gregory, H, Caporossi, J, Hall, GA
Advanced emergency nursing journal. 2020;(3):176-185
Abstract
Atrial fibrillation (AF) is the most common tachyarrhythmia managed in the emergency department (ED). Visits to the ED for a presentation of AF have been increasing in recent years, with an admission rate that exceeds 60% in the United States and contributes substantially to health care costs. Recent-onset AF-defined as symptom onset less than 48 hr-is a common ED presentation for which rate control or acute electrical or pharmacological cardioversion may be appropriate treatment modalities depending on patient-specific circumstances. The focus of this review is to discuss the current recommendations regarding the management of recent-onset nonvalvular AF in the ED, discuss medication administration considerations, and identify implementation strategies in the ED to optimize throughput and reduce hospital admissions.
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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.
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Oral anticoagulants and risk of acute liver injury in patients with nonvalvular atrial fibrillation: a propensity-weighted nationwide cohort study.
Maura, G, Bardou, M, Billionnet, C, Weill, A, Drouin, J, Neumann, A
Scientific reports. 2020;(1):11624
Abstract
Insufficient real-world data on acute liver injury (ALI) risk associated with oral anticoagulants (OACs) exist in patients with nonvalvular atrial fibrillation (NVAF). Using the French national healthcare databases, a propensity-weighted nationwide cohort study was performed in NVAF patients initiating OACs from 2011 to 2016, considering separately those (1) with no prior liver disease (PLD) as main population, (2) with PLD, (3) with a history of chronic alcoholism. A Cox proportional hazards model was used to estimate the hazard ratio with 95% confidence interval (HR [95% CI]) of serious ALI (hospitalised ALI or liver transplantation) during the first year of treatment, for each non-vitamin K antagonist (VKA) oral anticoagulant (NOAC: dabigatran, rivaroxaban, apixaban) versus VKA. In patients with no PLD (N = 434,015), only rivaroxaban new users were at increased risk of serious ALI compared to VKA initiation (adjusted HR: 1.41 [1.05-1.91]). In patients with chronic alcoholism history (N = 13,173), only those initiating dabigatran were at increased risk of serious ALI compared to VKA (2.88 [1.74-4.76]) but an ancillary outcome suggested that differential clinical follow-up between groups might partly explain this association. In conclusion, this study does not suggest an increase of the 1-year risk of ALI in NOAC versus VKA patients with AF.