Prospective randomized comparison of antiarrhythmic therapy versus first-line radiofrequency ablation in patients with atrial flutter.

Objective: To assess variables associated with the occurrence of atrial fibrillation (AF) and the relation of AF with short- and long-term outcomes and with other in-hospital complications in patients with acute coronary syndromes (ACS) with and without ST-segment elevation. Design: Pooled database of 120 566 patients with ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation (NSTE) ACS enrolled in 10 clinical trials. Multivariable logistic regression and Cox proportional hazards modelling were used to identify factors associated with AF and its relation with clinical outcomes. Setting: ACS complicated by AF. Patients: 120 566 patients with STEMI and NSTE-ACS in 10 clinical trials. Interventions: None evaluated. Main outcome measure: Short- and long-term mortality. Results: Occurrence of AF was 7.5% in the overall population (STEMI 8.0% (n = 84 161); NSTE-ACS = 6.4% (n = 36 405)). Seven-day mortality was higher for patients with AF (5.1%) than for those without (1.6%). After adjusting for confounders, association of AF with 7-day mortality was present in STEMI (hazards ratio (HR) = 1.65; 95% CI 1.44 to 1.90) and NSTE-ACS (HR = 2.30; 95% CI 1.83 to 2.90; p interaction = 0.015). Risk of long-term mortality (day 8 to 1 year) was also higher in STEMI (HR = 2.37; 95% CI 1.79 to 3.15) and NSTE-ACS (HR = 1.67; 95% CI 1.41 to 1.99). AF had a larger impact in NSTE-ACS on risk of short-term mortality (p Conclusions: AF is more common in patients with STEMI. An association of AF with short- and long-term mortality among patients with STEMI and NSTE-ACS was found. Understanding these findings may lead to better care of patients with this common arrhythmia.

https://heart.bmj.com/content/heartjnl/94/7/867.full.pdf

Short- and long-term outcomes following atrial fibrillation in patients with acute coronary syndromes with or without ST-segment elevation

Background—The occurrence of atrial fibrillation after ablation of type I atrial flutter remains an important clinical problem. To gain further insight into the pathogenesis and significance of postablation atrial fibrillation, we examined the time to onset, determinants, and clinical course of atrial fibrillation after ablation of type I flutter in a large patient cohort. Methods and Results—Of 110 consecutive patients with ablation of type I atrial flutter, atrial fibrillation was documented in 28 (25%) during a mean follow-up of 20.1±9.2 months (cumulative probability of 12% at 1 month, 23% at 1 year, and 30% at 2 years). Among 17 clinical and procedural variables, only a history of spontaneous atrial fibrillation (relative risk 3.9, 95% confidence intervals 1.8 to 8.8, P=0.001) and left ventricular ejection fraction <50% (relative risk 3.8, 95% confidence intervals 1.7 to 8.5, P=0.001) were significant and independent predictors of subsequent atrial fibrillation. The presence of both these characteris...

Atrial Fibrillation After Radiofrequency Ablation of Type I Atrial Flutter: Time to Onset, Determinants, and Clinical Course

Background Several studies have shown that patients undergoing cardioversion of atrial fibrillation have a high prevalence of of atrial thrombus and spontaneous echo contrast and frequently develop atrial stunning after restoration of sinus rhythm. These findings are strongly associated with increased risk of embolism in these patients. However, little is known about the prevalence of these markers of thromboembolism in patients undergoing cardioversion of atrial flutter. Methods and Results We performed transesophageal echocardiography in 47 consecutive, nonanticoagulated patients scheduled for elective cardioversion of atrial flutter. In patients who underwent successful cardioversion, mitral inflow velocity was recorded by transthoracic pulsed Doppler examination immediately after restoration of sinus rhythm. All patients were men (mean age, 65±10 years). Mean duration of flutter was 4±9 weeks. Atrial thrombus and/or spontaneous echo contrast were found in 16 patients (34%). Left atrial thrombus was se...

Prevalence of thrombus, spontaneous echo contrast, and atrial stunning in patients undergoing cardioversion of atrial flutter. A prospective study using transesophageal echocardiography

Atrial fibrillation (AF) is a frequent complication after acute myocardial infarction (AMI) that has been associated with increased in-hospital and long-term mortality rates in the prethrombolytic and thrombolytic eras. Current therapies, including percutaneous coronary intervention (PCI), are effective in reducing mortality in patients with AMI. However, little is known concerning the incidence and prognostic significance of AF in patients with AMI who are treated with PCI. We evaluated 2,475 consecutive patients with AMI who underwent PCI within 24 hours after onset and who were enrolled in the Osaka Acute Coronary Insufficiency Study. Patients were categorized into 2 groups according to the presence of AF or atrial flutter. The incidence of AF was 12.0%. Patients with AF were older, were in higher Killip classes, had higher rates of previous myocardial infarction and previous cerebrovascular disease, had systolic blood pressure of or =100 beats/min, multivessel disease, and had poorer reperfusion of the infarct-related artery than those without AF. Patients with AF had higher in-hospital (16.0% vs 6.7%, p <0.001) and 1-year (18.9% vs 7.9%, p <0.001) mortality than those without AF. Multivariate Cox regression analysis revealed that AF was an independent predictor of 1-year mortality (hazard ratio 1.64, 95% confidence interval 1.05 to 2.55) but was not a predictor of in-hospital mortality. AF is a common complication in patients with AMI who are treated with PCI and independently influences 1-year mortality.

Prognostic significance of atrial fibrillation/atrial flutter in patients with acute myocardial infarction treated with percutaneous coronary intervention.

The Alternation between Atrial Flutter and Atrial Fibrillation

A patient with previous actual atrial flutter had what appeared to be atrial flutter seen on Holter monitoring during treatment with a transcutaneous electrical nerve stimulation (TENS) unit. This proved to be artifact caused by the unit rather than a true arrhythmia. The artifact was reproduced in a normal volunteer by application of a TENS unit.

Teresa Mitchell

Papers

The Alternation between Atrial Flutter and Atrial Fibrillation

Pseudoatrial flutter: artifact simulating atrial flutter caused by a transcutaneous electrical nerve stimulator (TENS).