Background There are two approaches to the treatment of atrial fibrillation: one is cardioversion and treatment with antiarrhythmic drugs to maintain sinus rhythm, and the other is the use of rate-controlling drugs, allowing atrial fibrillation to persist. In both approaches, the use of anticoagulant drugs is recommended. Methods We conducted a randomized, multicenter comparison of these two treatment strategies in patients with atrial fibrillation and a high risk of stroke or death. The primary end point was overall mortality. Results A total of 4060 patients (mean [+/-SD] age, 69.7+/-9.0 years) were enrolled in the study; 70.8 percent had a history of hypertension, and 38.2 percent had coronary artery disease. Of the 3311 patients with echocardiograms, the left atrium was enlarged in 64.7 percent and left ventricular function was depressed in 26.0 percent. There were 356 deaths among the patients assigned to rhythm-control therapy and 310 deaths among those assigned to rate-control therapy (mortality at five years, 23.8 percent and 21.3 percent, respectively; hazard ratio, 1.15 [95 percent confidence interval, 0.99 to 1.34]; P=0.08). More patients in the rhythm-control group than in the rate-control group were hospitalized, and there were more adverse drug effects in the rhythm-control group as well. In both groups, the majority of strokes occurred after warfarin had been stopped or when the international normalized ratio was subtherapeutic. Conclusions Management of atrial fibrillation with the rhythm-control strategy offers no survival advantage over the rate-control strategy, and there are potential advantages, such as a lower risk of adverse drug effects, with the rate-control strategy. Anticoagulation should be continued in this group of high-risk patients.

A comparison of rate control and rhythm control in patients with atrial fibrillation.

https://www.onlinelibrary.wiley.com/doi/pdf/10.1016/j.ejheart.2008.08.005

ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2008: the Task Force for the diagnosis and treatment of acute and chronic heart failure 2008 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association of the ESC (HFA) and endorsed by the European Society of Intensive Care Medicine (ESICM).

Guidelines and Expert Consensus Documents summarize and evaluate all currently available evidence on a particular issue with the aim of assisting physicians and other healthcare providers in selecting the best management strategies for a typical patient, suffering from a given condition, taking into account the impact on outcome, as well as the risk–benefit ratio of particular diagnostic or therapeutic means. Guidelines are no substitutes for textbooks. The legal implications of medical guidelines have been discussed previously.

A great number of Guidelines and Expert Consensus Documents have been issued in recent years by the European Society of Cardiology (ESC) as well as by other societies and organizations. Because of the impact on clinical practice, quality criteria for development of guidelines have been established in order to make all decisions transparent to the user. The recommendations for formulating and issuing ESC Guidelines and Expert Consensus Documents can be found on the ESC Web Site in the guidelines section (www.escardio.org).

In brief, experts in the field are selected and undertake a comprehensive review of the published evidence for management and/or prevention of a given condition. A critical evaluation of diagnostic and therapeutic procedures is performed, including assessment of the risk–benefit ratio. Estimates of expected health outcomes for larger societies are included, where data exist. The level of evidence and the strength of recommendation of particular treatment options are weighed and graded according to pre-defined scales, as outlined in Tables 1 and 2 .

View this table:

Table 1 
Classes of recommendations



View this table:

Table 2 
Levels of evidence



The experts of the writing panels have provided disclosure statements of all relationships they may have which might be perceived as real or potential sources of conflicts of interest. These disclosure forms are kept on file at the European Heart House, headquarters of the ESC. Any changes in conflict of interest that arise …

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ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2008

Authors/Task Force Members: Kenneth Dickstein (Chairperson) (Norway)*, Alain Cohen-Solal (France), Gerasimos Filippatos (Greece), John J.V. McMurray (UK), Piotr Ponikowski (Poland), Philip Alexander Poole-Wilson (UK), Anna Strömberg (Sweden), Dirk J. van Veldhuisen (The Netherlands), Dan Atar (Norway), Arno W. Hoes (The Netherlands), Andre Keren (Israel), Alexandre Mebazaa (France), Markku Nieminen (Finland), Silvia Giuliana Priori (Italy), Karl Swedberg (Sweden)

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Esc guidelines for the diagnosis and treatment of acute and chronic heart failure 2008

BACKGROUND Mortality from coronary heart disease in the United States has decreased substantially in recent decades. We conducted a study to determine how much of this decrease could be explained by the use of medical and surgical treatments as opposed to changes in cardiovascular risk factors. METHODS We applied a previously validated statistical model, IMPACT, to data on the use and effectiveness of specific cardiac treatments and on changes in risk factors between 1980 and 2000 among U.S. adults 25 to 84 years old. The difference between the observed and expected number of deaths from coronary heart disease in 2000 was distributed among the treatments and risk factors included in the analyses. RESULTS From 1980 through 2000, the age-adjusted death rate for coronary heart disease fell from 542.9 to 266.8 deaths per 100,000 population among men and from 263.3 to 134.4 deaths per 100,000 population among women, resulting in 341,745 fewer deaths from coronary heart disease in 2000. Approximately 47% of this decrease was attributed to treatments, including secondary preventive therapies after myocardial infarction or revascularization (11%), initial treatments for acute myocardial infarction or unstable angina (10%), treatments for heart failure (9%), revascularization for chronic angina (5%), and other therapies (12%). Approximately 44% was attributed to changes in risk factors, including reductions in total cholesterol (24%), systolic blood pressure (20%), smoking prevalence (12%), and physical inactivity (5%), although these reductions were partially offset by increases in the body-mass index and the prevalence of diabetes, which accounted for an increased number of deaths (8% and 10%, respectively). CONCLUSIONS Approximately half the decline in U.S. deaths from coronary heart disease from 1980 through 2000 may be attributable to reductions in major risk factors and approximately half to evidence-based medical therapies.

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Explaining the Decrease in U.S. Deaths from Coronary Disease, 1980–2000

Trends in case-fatality in 22 968 patients admitted for the first time with atrial fibrillation in Scotland, 1986–1995

Objective: To examine the long-term outcome of patients evaluated in a rapid assessment chest pain clinic (RACPC): are “low-risk” patients safely reassured? Design: Retrospective cohort study Setting: Staff grade-led RACPC in an urban teaching hospital Participants: 3378 patients (51% male), attending the RACPC between April 1996 and February 2000 Main outcome measures: Death, coronary mortality, morbidity and revascularisation over a median follow-up of 6 years Coronary standardised mortality ratio (SMR) Results: 2036 (603%) patients were categorised as “low risk”, 957 (283%) as having “stable coronary artery disease” and 214 (63%) as being an “acute coronary syndrome” During the study, 36% of patients in the low risk category, 119% in the stable coronary artery disease category and 246% in the acute coronary syndrome category died from coronary artery disease or had a myocardial infarction 55%, 182% and 184%, respectively, died from any cause Compared to the local population (coronary SMR  = 100), our “low risk/non-coronary chest pain” cohort had a coronary SMR of 51 (95% CI 31 to 83), the “stable coronary artery disease” cohort 240 (187 to 308) and the “acute coronary syndrome” cohort 780 (509 to 1196) Conclusion: The RACPC was effective at triaging patients with chest pain Patients identified as at “low risk” were unlikely to have an adverse coronary outcome and were appropriately reassured

https://heart.bmj.com/content/heartjnl/94/5/628.full.pdf

Long-term outcome of low-risk patients attending a rapid-assessment chest pain clinic

The authors investigated the possibility of an association between oral polio vaccine (OPV) and intussusception by linking Scottish vaccination and hospitalization data sets and performing self-controlled case series analysis. The issue was important because rotavirus vaccine, another live oral virus vaccine, was withdrawn from the market in 1999 after studies showed a strong association with intussusception. OPV was recommended for all infants in the United Kingdom at ages 2, 3, and 4 months until 2004, when new combination vaccines containing inactivated poliovirus were introduced. Analysis was carried out for 466 intussusception cases occurring in 1987-1999 for which linked records on OPV vaccination were available. Six possible risk periods for intussusception, ranging from 3 days after vaccination to 41 days after vaccination, were examined, with separate analysis for each of the three OPV doses and also for data on all three doses combined. Of the 24 possible risk periods examined, the relative incidence of intussusception after vaccination was unchanged for 18, significantly decreased for five, and significantly increased for only one. The authors conclude that overall, there is no evidence for an association between OPV and intussusception, even when each dose is considered separately.

/pdf/oral-polio-vaccine-and-intussusception-a-data-linkage-study-3p7fo5isp4.pdf

Oral polio vaccine and intussusception: a data linkage study using records for vaccination and hospitalization.

No study has described the burden to a health service of the complete spectrum of possible acute coronary syndromes (ACS). The objective of this study was to describe the changing burden of suspected ACS on the hospital sector of the National Health Service in Scotland over the period 1990–2000.

The record linkage system for discharges from Scottish hospitals and deaths has been described previously.1 We identified all emergency hospitalisations of patients ⩾ 18 years old in Scotland between January 1990 and December 2000 where acute myocardial infarction (AMI; International classification of diseases , (ICD), ninth revision, code 410, ICD-10 I21, 22), angina (ICD-9 411, 413, ICD-10 I20, I249), or chest pain (ICD-9 786.5, ICD-10 R07) was coded as the principal diagnosis on discharge. Numbers and age and sex specific rates of discharges (and patients discharged), length of stay, revascularisation procedures, and deaths were studied. We used linear regression to examine trends in population hospitalisation rates, hospitalisation numbers, and …

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Hospital burden of suspected acute coronary syndromes: recent trends

Improvements in coronary revascularisation techniques and an increase in the use of percutaneous interventions1 have led to a rise in the number of coronary artery bypass grafting operations in older patients with more severe cardiac disease and worse comorbidity and who have previously undergone revascularisation procedures. 2 3 Advances in surgical and anaesthetic techniques have prevented a worsening risk profile from being translated into an increase in perioperative deaths. 2 3 The aim of our study was to examine time trends in major outcomes up to two years after coronary artery bypass grafting.

We used the Scottish morbidity record (SMR1) system to identify all operations for coronary artery bypass grafting performed in Scottish NHS hospitals from 1981 to 1996. We excluded operations that included other procedures. Information was obtained on age, sex, urgency of the operation, and Carstairs …

https://www.bmj.com/content/bmj/324/7331/201.1.full.pdf

Alan Finlayson

Papers

Trends in case-fatality in 22 968 patients admitted for the first time with atrial fibrillation in Scotland, 1986–1995

Long-term outcome of low-risk patients attending a rapid-assessment chest pain clinic

Oral polio vaccine and intussusception: a data linkage study using records for vaccination and hospitalization.

Hospital burden of suspected acute coronary syndromes: recent trends

Time trends in survival and readmission following coronary artery bypass grafting in Scotland, 1981-96: retrospective observational study