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Showing papers in "Europace in 2010"


Journal ArticleDOI
01 Oct 2010-Europace
TL;DR: Guidelines summarize and evaluate all currently available evidence on a particular issue with the aim of assisting physicians in selecting the best management strategy for an individual 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.
Abstract: Guidelines summarize and evaluate all currently available evidence on a particular issue with the aim of assisting physicians in selecting the best management strategy for an individual 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 large number of Guidelines 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 can be found on the ESC Web Site (http://www.escardio.org/knowledge/guidelines/rules). 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 that 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 during the writing period must be notified to the ESC. The Task Force report received its entire financial support from …

3,749 citations


Journal ArticleDOI
01 Nov 2010-Europace
TL;DR: In this paper, a focused update on the use of devices in heart failure is presented, which is the first publication of its kind from the Committee for Practice Guidelines (CPG).
Abstract: AF : atrial fibrillation AV : atrio-ventricular CPG : Committee for Practice Guidelines CRT : cardiac resynchronization therapy CRT-P : CRT with pacemaker function CRT-D : CRT with defibrillator function CTX : cardiac transplantation CV : cardiovascular EHRA : European Heart Rhythm Association ESC : European Society of Cardiology HF : heart failure HFA : Heart Failure Association Hosp : hospitalization ICD : implantable cardioverter defibrillator LBBB : left bundle branch block LV : left ventricular LVAD : left ventricular assist device LVEDD : left ventricular end-diastolic diameter LVEF : left ventricular ejection fraction LVESi : left ventricular stroke volume index LVESV : left ventricular end-systolic volume 6MWT : 6 min walk test NA : not applicable NIH : National Institutes of Health NS : not significant NYHA : New York Heart Association OMT : optimal medical therapy pVO2 : peak oxygen consumption QoL : quality of life RBBB : right bundle branch block RCT : randomized clinical trial SR : sinus rhythm VE/CO2 : ventilation/carbon dioxide ratio The Committee for Practice Guidelines (CPG) of the European Society of Cardiology recognizes that new evidence from clinical research trials may impact on current recommendations. The current heart failure (HF) guidelines1 were published in 2008 and the cardiac pacing guidelines in 2007.2 In order to keep these guidelines up to date, it would be appropriate to modify the recommendations and levels of evidence according to the most recent clinical trial evidence. This Focused Update on the use of devices in heart failure 2010 is the first publication of its kind from the CPG. Practice Guideline recommendations should represent evidence-based medicine. Traditionally, these recommendations are based on the outcomes in the cohort of patients described by the inclusion criteria in the protocols of randomized clinical trials (RCTs). More recently, based on the fact that the characteristics of the patients actually included in a trial may differ substantially from the eligibility criteria, Guideline Task Force members frequently favour restricting the applicability of these recommendations to the clinical profile and outcomes of the enrolled cohort, representing a more accurate interpretation of the evidence provided by a trial's result. In contrast to previous guidelines, this focused update considers the characteristics of the patients included in the trials and contains several examples. In MADIT-CRT, although the protocol permitted inclusion of patients in both New York Heart Association (NYHA) I and II function class, only 15% of the patients included in this trial were classified as NYHA I, many of whom had been previously symptomatic. Similarly, although the inclusion criteria permitted randomization of patients with a QRS width of ≥130 m, the favourable effect on the primary endpoint was limited to patients with a QRS width of ≥150 ms, a prospective, pre-specified cut-off. The text accompanying these recommendations explains and justifies the decisions to …

578 citations


Journal ArticleDOI
01 Oct 2010-Europace
TL;DR: The ultimate judgement regarding this procedure must be made by the patient after careful communication about the deactivation's consequences, respecting his/her autonomy and clarifying that he/she has a legal and ethical right to refuse it.
Abstract: The purpose of this Consensus Statement is to focus on implantable cardioverter-defibrillator (ICD) deactivation in patients with irreversible or terminal illness. This statement summarizes the opinions of the Task Force members, convened by the European Heart Rhythm Association (EHRA) and the Heart Rhythm Society (HRS), based on ethical and legal principles, as well as their own clinical, scientific, and technical experience. It is directed to all healthcare professionals who treat patients with implanted ICDs, nearing end of life, in order to improve the patient dying process. This statement is not intended to recommend or promote device deactivation. Rather, the ultimate judgement regarding this procedure must be made by the patient (or in special conditions by his/her legal representative) after careful communication about the deactivation's consequences, respecting his/her autonomy and clarifying that he/she has a legal and ethical right to refuse it. Obviously, the physician asked to deactivate the ICD and the industry representative asked to assist can conscientiously object to and refuse to perform device deactivation.

351 citations


Journal ArticleDOI
01 Mar 2010-Europace
TL;DR: The findings suggest that device-assisted lead extraction is a high-risk procedure and that serious complications including death may not be mitigated by emergency surgery, however, skilled standby cardiothoracic surgery is essential when performing pacemaker and ICD lead extractions.
Abstract: Aims An estimated 10 000–15 000 pacemaker and implantable cardioverter–defibrillator (ICD) leads are extracted annually worldwide using specialized tools that disrupt encapsulating fibrous tissue. Additional information is needed regarding the safety of the devices that have been approved for lead extraction. The aim of this study was to determine whether complications due to device-assisted lead extraction might be more hazardous than published data suggest, and whether procedural safety precautions are effective. Methods and results We searched the US Food and Drug Administration's (FDA) Manufacturers and User Defined Experience (MAUDE) database from 1995 to 2008 using the search terms ‘lead extraction and death’ and ‘lead extraction and injury’. Additional product specific searches were performed for the terms ‘death’ and ‘injury’. Between 1995 and 2008, 57 deaths and 48 serious cardiovascular injuries associated with device-assisted lead extraction were reported to the FDA. Owing to underreporting, the FDA database does not contain all adverse events that occurred during this period. Of the 105 events, 27 deaths and 13 injuries occurred in 2007–2008. During these 2 years, 23 deaths were linked with excimer laser or mechanical dilator sheath extractions. The majority of deaths and injuries involved ICD leads, and most were caused by lacerations of the right atrium, superior vena cava, or innominate vein. Overall, 62 patients underwent emergency surgical repair of myocardial perforations and venous lacerations and 35 (56%) survived. Conclusion These findings suggest that device-assisted lead extraction is a high-risk procedure and that serious complications including death may not be mitigated by emergency surgery. However, skilled standby cardiothoracic surgery is essential when performing pacemaker and ICD lead extractions. Although the incidence of these complications is unknown, the results of our study imply that device-assisted lead extractions should be performed by highly qualified physicians and their teams in specialized centres.

255 citations


Journal ArticleDOI
01 Jun 2010-Europace
TL;DR: This study supports the use of genetic testing as a new diagnostic tool in ARVC/D and also suggests a prognostic impact, as the severity of the disease appears different according to the underlying gene or the presence of multiple mutations.
Abstract: AIMS: Five desmosomal genes have been recently implicated in arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) but the clinical impact of genetics remains poorly understood. We wanted to address the potential impact of genotyping. METHODS AND RESULTS: Direct sequencing of the five genes (JUP, DSP, PKP2, DSG2, and DSC2) was performed in 135 unrelated patients with ARVD/C. We identified 41 different disease-causing mutations, including 28 novel ones, in 62 patients (46%). In addition, a genetic variant of unknown significance was identified in nine additional patients (7%). Distribution of genes was 31% (PKP2), 10% (DSG2), 4.5% (DSP), 1.5% (DSC2), and 0% (JUP). The presence of desmosomal mutations was not associated with familial context but was associated with young age, symptoms, electrical substrate, and extensive structural damage. When compared with other genes, DSG2 mutations were associated with more frequent left ventricular involvement (P = 0.006). Finally, complex genetic status with multiple mutations was identified in 4% of patients and was associated with more frequent sudden death (P = 0.047). CONCLUSION: This study supports the use of genetic testing as a new diagnostic tool in ARVC/D and also suggests a prognostic impact, as the severity of the disease appears different according to the underlying gene or the presence of multiple mutations.

219 citations


Journal ArticleDOI
01 Mar 2010-Europace
TL;DR: A systematic review of recommended 'major' and 'possible' clinical risk markers for sudden cardiac death in hypertrophic cardiomyopathy in HCM provides sound evidence for the use of the six major risk factors for SCD in the risk stratification of HCM patients.
Abstract: We performed a systematic literature review of recommended 'major' and 'possible' clinical risk markers for sudden cardiac death (SCD) in hypertrophic cardiomyopathy (HCM). We searched the Medline, Embase and Cochrane databases for articles published between 1971 and 2007. We included English language reports on HCM patients containing follow-up data on the endpoint (sudden) cardiac death using survival analysis. Analysis was undertaken using the quality of reporting of meta-analyses (QUORUM) statement checklist. The quality was checked using a quality assessment form from the Cochrane Collaboration. Thirty studies met inclusion criteria and passed quality assessment. The use of the six major risk factors (previous cardiac arrest or sustained ventricular tachycardia, non-sustained ventricular tachycardia, extreme left ventricular hypertrophy, unexplained syncope, abnormal blood pressure response, and family history of sudden death) in risk stratification for SCD as recommended by international guidelines was supported by the literature. In addition, left ventricular outflow tract obstruction seems associated with a higher risk of SCD. Our systematic review provides sound evidence for the use of the six major risk factors for SCD in the risk stratification of HCM patients. Left ventricular outflow tract obstruction could be included in the overall risk profile of patients with a marked left ventricular outflow gradient under basal conditions.

161 citations


Journal ArticleDOI
01 Nov 2010-Europace
TL;DR: There is strong evidence for the beneficial effect of ICD-only therapy on the survival of patients with ischaemic or non-ischaemic heart disease, with a left ventricular ejection fraction ≤35%, if they are 40 days from myocardial infarction and ≥3 months from a coronary revascularization procedure.
Abstract: Aims: Much controversy exists concerning the efficacy of primary prophylactic implantable cardioverter-defibrillators (ICDs) in patients with low ejection fraction due to coronary artery disease (CAD) or dilated cardiomyopathy (DCM). This is also related to the bias created by function improving interventions added to ICD therapy, e.g. resynchronization therapy. The aim was to investigate the efficacy of ICD-only therapy in primary prevention in patients with CAD or DCM.Methods and results: Public domain databases, MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials, were searched from 1980 to 2009 for randomized clinical trials of ICD vs. conventional therapy. Two investigators independently abstracted the data. Pooled estimates were calculated using both fixed-effects and random-effects models. Eight trials were included in the final analysis (5343 patients). Implantable cardioverter-defibrillators significantly reduced the arrhythmic mortality [relative risk (RR): 0.40; 95 confidence interval (CI): 0.27-0.67] and all-cause mortality (RR: 0.73; 95 CI: 0.64-0.82). Regardless of aetiology of heart disease, ICD benefit was similar for CAD (RR: 0.67; 95 CI: 0.51-0.88) vs. DCM (RR: 0.74; 95 CI: 0.59-0.93).Conclusions: The results of this meta-analysis provide strong evidence for the beneficial effect of ICD-only therapy on the survival of patients with ischaemic or non-ischaemic heart disease, with a left ventricular ejection fraction ≤35, if they are 40 days from myocardial infarction and ≥3 months from a coronary revascularization procedure.

159 citations


Journal ArticleDOI
01 Jan 2010-Europace
TL;DR: Cardiac device infection is a rare complication, with significant morbidity and mortality, and complete hardware removal with appropriate duration of antimicrobial therapy results in the best outcomes for patients.
Abstract: Aims To describe the incidence and management of cardiac device infection. Infection is a serious, potentially fatal complication of device implantation. The numbers of device implants and infections are rising. Optimal care of device infection is not well defined. Methods and results We retrospectively identified cases of device infection at our institution between 2000 and 2007 by multiple source record review, and active surveillance. Device infection was related to demographics, clinical, and procedural characteristics. Descriptive analysis was performed. From 2000 to 2007, a total of 2029 permanent pacemakers and 1076 biventricular/implantable cardioverter–defibrillators (ICDs) or ICDs were implanted. Thirty-nine cases of confirmed device infections were identified—27 pacemaker and 12 bivent/ICD or ICD infections, giving an infection rate of 1.25%. Median time from implant or revision to presentation was 150 days (range 2915 days, IQR25% 35–IQR75% 731). Ninety percent of patients presented with generator-site infections. The most common organism was methicillin-sensitive Staphylococcus aureus (30.8%), followed by coagulase negative Staphylococcus (20.5%). Complete device extraction occurred in 82%. Of these, none had relapse, and mortality was 7.4% ( n = 2/27). With partial removal or conservative therapy ( n = 13), relapse occurred in 67% ( n = 8/12), with mortality of 8.4% ( n = 1/12). Median duration of antibiotics was 42 days (range 47 days, IQR25% 28–IQR75% 42 days). Re-implantation of a new device occurred in 54%, at a median of 28 days (range 73 days, IQR25% 8.5–IQR75% 35 days). Methicillin-Resistant Staphylococcus Aureus infection predicted mortality ( P < 0.004, RR 37, 95% CI 5.3–250). Median follow-up was 36 months. Conclusion Cardiac device infection is a rare complication, with significant morbidity and mortality. Complete hardware removal with appropriate duration of antimicrobial therapy results in the best outcomes for patients.

154 citations


Journal ArticleDOI
01 Feb 2010-Europace
TL;DR: In patients' cohort, a single catheter ablation procedure based on CPVA using steerable sheath for catheter navigation resulted in a 1 year success rate of 75.7% and among those patients who are at high risk for recurrence after CPVA other ablation endpoints rather than completion of predefined lesions might be necessary to increase the success rate.
Abstract: AIMS Identifying suitable candidates for circumferential left atrial pulmonary vein ablation (CPVA). CPVA is widely used as an ablation strategy in patients with atrial fibrillation (AF). Understanding the predictors of long-term success of single catheter ablation procedure of AF based on CPVA can help to identify those patients who have a high risk of recurrence based on this approach. METHODS AND RESULTS In this retrospective analysis 674 consecutive patients (464 male, mean age 57.3 +/- 10.8 years) with AF (84.8%, paroxysmal) treated with CPVA ablation between May 2005 and August 2007 using a manually controlled steerable sheath (Agilis((R)) St. Jude Medical Inc., St. Paul, MN, USA), were included. The endpoint of the ablation was the completion of predefined lesions (CPVA for paroxysmal, and CPVA+mitral isthmus and roof line ablation for persistent AF). Seven day Holter recordings were done immediately, 3, 6, and 12 month after ablation. AF longer than 30 s was considered as recurrence. The success was defined as lack of recurrence during 7-day Holter recordings done 3, 6, and 12 months after ablation. Early recurrence was defined as recurrence during the first 7-day Holter recording immediately after ablation. Forty-five and 20.8% of the patients received antiarrhythmic medications for the first 3 and 6 months after ablation procedure, respectively. After 6 months all antiarrhythmics were discontinued. About 51.5% experienced early recurrence. Twelve months success rate was 75.7% (paroxysmal: 75.7%, persistent: 75.0%, P = 1.0). Using multivariate analysis left atrial (LA) diameter > or =50 mm was the predictor of early recurrence {Hazard Ratio (HR) [95% confidence interval (CI)] = 5.1 (2.0-12.9)}. LA Diameter > or =50 mm [HR (95% CI) = 4.6 (2.6-9.1)]; early recurrence [HR (95% CI) = 4.3 (2.0-9.1)]; and arterial hypertension [HR (95% CI) = 4.6 (2.6-9.1)] were predictors of late recurrence. CONCLUSION In our patients' cohort, a single catheter ablation procedure based on CPVA using steerable sheath for catheter navigation resulted in a 1 year success rate of 75.7% [without (91.0%) and with (58.6%) early recurrence, respectively, P = 0.0001]. Among those patients who are at high risk for recurrence after CPVA other ablation endpoints rather than completion of predefined lesions might be necessary to increase the success rate.

144 citations


Journal ArticleDOI
01 Feb 2010-Europace
TL;DR: Atrial arrhythmia-free survival was similar in patients with paroxysmal or persistent AF, with and without antiarrhythmic drugs during the follow-up, who underwent electrophysiologically guided pulmonary vein (PV) isolation or anatomical PV ablation.
Abstract: Aims In the last decade, several approaches to ablating triggers and substrates of atrial fibrillation (AF) have been developed. However, most studies have reported data only on short- or medium-term follow-up. The aim of this study was to investigate whether the 1-year efficacy of catheter ablation for AF is predictive of long-term clinical success. Methods and results Between February 2001 and October 2003, 229 consecutive patients affected by drug-refractory paroxysmal or persistent AF underwent a single radiofrequency catheter ablation procedure (anatomical approach in 146 patients and electrophysiologically guided approach in 83 patients). Of these patients, 177 (mean age 59.1 +/- 10.5 years, 57.6% with paroxysmal AF) were free from any atrial arrhythmia recurrence after 12 months. These 177 patients were subsequently followed up for at least another 24 months, by means of electrocardiogram and 24 h Holter monitoring. After a mean follow-up of 49.7 +/- 13.3 months (range 36-83 months), 58.2% of the patients were free from any atrial arrhythmia recurrence (39.5% without antiarrhythmic drugs). The actuarial atrial arrhythmia recurrence rate was 13.0% at 2 years, 21.8% at 3 years, 35.0% at 4 years, 46.8% at 5 years, and 54.6% at 6 years. Atrial arrhythmia-free survival was similar in patients with paroxysmal or persistent AF, with and without antiarrhythmic drugs during the follow-up, who underwent electrophysiologically guided pulmonary vein (PV) isolation or anatomical PV ablation. Conclusion Even patients in whom catheter ablation prevents AF recurrence for 1 year should not be considered 'cured', since >40% of them will suffer AF recurrence over a long-term clinical follow-up.

141 citations


Journal ArticleDOI
01 Feb 2010-Europace
TL;DR: The various types of animal models used for AF research are discussed, the principle mechanisms governing atrial arrhythmias in each model are reviewed, and some guidelines for model selection for various purposes are provided.
Abstract: Atrial fibrillation (AF) is the most common arrhythmia in clinical practice. A variety of animal models have been used to study the pathophysiology of AF, including molecular basis, ion-current determinants, anatomical features, and macroscopic mechanisms. In addition, animal models play a key role in the development of new therapeutic approaches, whether drug-based, molecular therapeutics, or device-related. This article discusses the various types of animal models that have been used for AF research, reviews the principle mechanisms governing atrial arrhythmias in each model, and provides some guidelines for model selection for various purposes.

Journal ArticleDOI
01 Apr 2010-Europace
TL;DR: In some patients, permanent HBP may be an alternative to right ventricular apical pacing and this paper presents the experience with permanent His-bundle pacing.
Abstract: Aims Right ventricular apical pacing can have deleterious effects and the His bundle has been widely reported to be an alternative site. This paper presents our experience with permanent His-bundle pacing (HBP). Methods and results Patients referred for pacemaker implants (regardless of block type) were screened to determine if temporary HBP corrected conduction dysfunctions (threshold ≤2.5 V for 1 ms) and provided infra-Hisian 1:1 conduction of at least 120 s/m. Of the 182 patients selected, HBP corrected conduction dysfunctions in 133 (73%) patients, 42 (32%) of whom were rejected for the permanent procedure due to high thresholds. His-bundle lead implantation was attempted in the remaining 91 patients and was successful in 59 (65% of all attempts, 44% of all possible cases). Conclusion In some patients, permanent HBP may be an alternative to right ventricular apical pacing.

Journal ArticleDOI
01 Mar 2010-Europace
TL;DR: RFCA was successful in restoring long-term sinus rhythm and improving symptomatic status in most HCM patients with refractory AF, including the subset with proven sarcomere gene mutations, although redo procedures were often necessary.
Abstract: Aims In patients with hypertrophic cardiomyopathy (HCM) and atrial fibrillation (AF), radiofrequency catheter ablation (RFCA) represents a promising option. However, the predictors of RFCA efficacy remain largely unknown. We assessed the outcome of a multicentre HCM cohort following RFCA for symptomatic AF refractory to medical therapy. Methods and results Sixty-one patients (age 54 ± 13 years; time from AF onset 5.7 ± 5.5 years) with paroxysmal ( n = 35; 57%), recent persistent ( n = 15; 25%), or long-standing persistent AF ( n = 11; 18%) were enrolled. A scheme with pulmonary vein isolation plus linear lesions was employed. Of the 61 patients, 32 (52%) required redo procedures. Antiarrhythmic therapy was maintained in 22 (54%). At the end of a 29 ± 16 months follow-up, 41 patients (67%) were in sinus rhythm, including 17 of the 19 patients aged ≤50 years, with marked improvement in New York Heart Association (NYHA) functional class (1.2 ± 0.5 vs. 1.9 ± 0.7 at baseline; P < 0.001). In the remaining 20 patients (33%), with AF recurrence, there was less marked, but still significant, improvement following RFCA (NYHA class 1.8 ± 0.7 vs. 2.3 ± 0.7 at baseline; P = 0.002). Independent predictors of AF recurrence were increased left atrium volume [hazard ratio (HR) per unit increase 1.009, 95% confidence interval (CI) 1.001–1.018; P = 0.037] and NYHA functional class (HR 2.24, 95% CI 1.16–4.35; P = 0.016). Among 11 genotyped HCM patients (6 with MYBPC3, 2 with MYH7, 1 with MYL2 and 2 with multiple mutations), RFCA success rate was comparable with that of the overall cohort ( n = 8; 73%). Conclusion RFCA was successful in restoring long-term sinus rhythm and improving symptomatic status in most HCM patients with refractory AF, including the subset with proven sarcomere gene mutations, although redo procedures were often necessary. Younger HCM patients with small atrial size and mild symptoms proved to be the best RFCA candidates, likely due to lesser degrees of atrial remodelling.

Journal ArticleDOI
01 Aug 2010-Europace
TL;DR: In patients with AF ablation, the presence of severe OSA is an independent predictor of arrhythmia recurrence, and the effect of OSA on the outcome ofAF ablation is clarified.
Abstract: Aims Atrial fibrillation (AF) ablation efficacy varies according to patients' clinical characteristics Although the association of obstructive sleep apnoea (OSA) and AF is well established, data on AF ablation efficacy in OSA are scarce The aim of this study was to clarify the effect of OSA on the outcome of AF ablation Methods and results A series of 174 consecutive patients without polysomnography submitted to circumferential pulmonary vein ablation were included in the study All patients were assessed by Berlin Questionnaire (BQ) and underwent an echocardiogram and a clinical evaluation Patients with a high BQ score, indicating high risk for OSA, participated in a sleep study Diagnoses were classified according to the apnoea–hypoapnoea index (AHI) as mild (AHI < 10/h), non-severe (AHI < 30/h), or severe (AHI ≥ 30/h) OSA Follow-up consisted of outpatient visits and 24 or 48 h Holter monitoring at 1, 4, and 7 months, and every 6 months thereafter Any episode of AF or left atrial (LA) flutter was considered recurrence Fifty-one (293%) patients had high BQ scores The sleep study showed that 17 (98%) and 25 (144%) of these patients had non-severe and severe OSA, respectively One-year arrhythmia-free probability after a single ablation procedure was 485% in patients with low risk for OSA (low BQ score or AHI < 10/h), 304% in the non-severe OSA group (10 < AHI < 30/h) and 143% in the severe OSA group (AHI ≥ 30) Anteroposterior LA diameter [hazard ratio (HR) = 1046, 95% confidence interval (CI): 1005–1089; P = 0029] and severe OSA (HR = 1870, 95% CI: 1106–3161; P = 0019) were the independent predictors of arrhythmia recurrence Conclusion In patients with AF ablation, the presence of severe OSA is an independent predictor for AF ablation failure

Journal ArticleDOI
01 Mar 2010-Europace
TL;DR: There is no evidence for a beneficial effect of treatment with n-3 PUFA on the occurrence of POAF in patients undergoing open heart surgery.
Abstract: Aims To examine the effect of n -3 polyunsaturated fatty acid (PUFA) treatment on the incidence of post-operative atrial fibrillation (POAF). Methods and results A prospective, randomized, double-blinded, placebo-controlled trial was conducted in patients admitted for coronary artery bypass grafting and/or valvular repair surgery. The patients received either n -3 PUFA capsules, containing a daily dose of 1240 mg eicosapentaenoic acid and 1000 mg docosahexaenoic acid, or olive oil capsules for 5–7 days prior to surgery and post-operatively until hospital discharge. The endpoint was POAF, defined as an episode detected by continuous electrocardiographic monitoring, lasting >5 min. A total of 170 patients were enrolled in the study, and 168 patients underwent surgery. Their median age was 67 (range 43–82) years, and 79.2% were males. There was no difference in baseline characteristics between the n -3 PUFA group ( n = 83) and the placebo group ( n = 85), and the incidence of POAF was 54.2 and 54.1% ( P = 0.99), respectively. Factors associated with POAF included advanced age, peak post-operative C-reactive protein level, valvular surgery, lower body mass index, and non-smoking, but n -3 PUFA concentration in plasma lipids was not associated with POAF. Conclusion There is no evidence for a beneficial effect of treatment with n -3 PUFA on the occurrence of POAF in patients undergoing open heart surgery.

Journal ArticleDOI
01 Aug 2010-Europace
TL;DR: It seems unlikely that adequate equity of access to this potentially lifesaving treatment will be provided until adequate registries, audits, and gap analyses are undertaken throughout Europe.
Abstract: The correct rate of implantation for implantable cardioverter defibrillator (ICD) and CRT-D devices is not known, but practice surveys suggest persistent under-utilization of these treatments on both sides of the Atlantic. Although recent clinical trial results and the implementation of current guidelines appear to have encouraged a growth of the rate of implantation in most countries, there remains a remarkable trans-Atlantic difference which has not changed much for more than 10 years. For every European ICD implant, there are four implants in the USA after adjustment for the size of the populations. Since very large variations in the implantation rates also occur between and within European Countries, an opportunity is afforded to explore the possible cause of these differences. It seems very unlikely to be explained simply by guideline discrepancies, financial constraints, or differences in disease prevalence. Instead, it is more likely to be attributable to a relative paucity of electrophysiologists, and their associated resources. In turn, the failure to establish effective educational programmes, screening, and referral pathways contributes to far fewer patients. It seems unlikely that adequate equity of access to this potentially lifesaving treatment will be provided until adequate registries, audits, and gap analyses are undertaken throughout Europe.

Journal ArticleDOI
01 Aug 2010-Europace
TL;DR: In this paper, the authors compared the Carto-Merge mapping system with the electroanatomical map to compare the outcome of atrial fibrillation (AF) ablation either after one procedure or after two procedures.
Abstract: Aims To compare in a randomized and prospective fashion the outcome of atrial fibrillation (AF) ablation either after one procedure or after two procedures using the Carto-XP vs. the Carto-Merge mapping system in two different AF populations. Methods and results Two hundred and ninety-nine patients with paroxysmal and persistent AF were enrolled in the study. One hundred and fifty patients with paroxysmal or persistent AF were randomly assigned to the Carto-Merge group and 149 patients to the Carto-XP group. The Carto-Merge patients underwent magnetic resonance imaging (MRI) of left atrium (LA) the day before the ablation. The ablation scheme included electrical disconnection of the pulmonary veins plus linear lesions. In the Carto-Merge patients, the three-dimensional MRI of the LA reconstruction merged with the electroanatomical map, and in the Carto-XP patients, the electroanatomical map guided the procedure. Considering the overall population with paroxysmal AF, 54% maintained sinus rhythm (SR), whereas in the persistent AF population, SR was present in 43% of the patients at the 12-month follow-up. In patients with paroxysmal AF, 52% in the Carto-XP group and 55% in the Carto-Merge group maintained SR without drugs. Procedure durations and exposure to X-ray in the Carto-XP group were 94.6 ± 17.5 and 40.4 ± 13.5 min, respectively. In the Carto-Merge group, duration and X-ray exposure were 89 ± 41.6 and 22.1 ± 11.4 min, respectively. Considering the patients with persistent AF at the12-month follow-up, 44% in the Carto-XP group and 42% in the Carto-Merge group maintained SR without drugs. Procedure durations and X-ray exposure in the Carto-XP group were 102.9 ± 22.9 and 58 ± 8.7 min, respectively. In the Carto-Merge group, both duration and X-ray exposure were 114.4 ± 50.9 and 28.8 ± 14.3 min, respectively. Conclusion Image integration using Carto-Merge in patients undergoing catheter ablation for paroxysmal and persistent AF does not significantly improve the clinical outcome, but shortens the X-ray exposure.

Journal ArticleDOI
01 May 2010-Europace
TL;DR: A high level of acceptance and satisfaction after 1-year remote control by HM was detected by the five-point scale HoMASQ, which showed a good internal reliability.
Abstract: Aims To evaluate patients’ acceptance and satisfaction of the Home Monitoring (HM) remote control system after 1 year of follow-up by a self-made questionnaire (HM Acceptance and Satisfaction Questionnaire, HoMASQ) specifically designed for this purpose. Methods and results The HoMASQ contains 12 items designed to investigate five different aspects strictly connected to patient's acceptance and satisfaction of remote monitoring: (i) relationship with their healthcare provider, (ii) easy of use of HM technology, (iii) related psychological aspects, (iv) implications on general health, and (v) overall satisfaction. Each item was rated on a five-point scale: from 0 to 4 with favourable responses score ≥2. The theoretical maximum total score (the highest detected acceptance and satisfaction level) was 48. The HoMASQ was given to 119 patients followed by HM during the 1-year follow-up visit. Ninety-nine percent of all the administered questionnaire items were answered. The mean total score was 40.8 ± 5.4 with a mean percentage of favourable answers of 96.3 ± 18.8% (CI 95.2 − 97.2%). The mean scores for each of the five areas of the HoMASQ were: 3.0 ± 0.9 for relationship, 3.4 ± 0.6 for easy of use, 3.4 ± 0.9 for psychological aspects, and 3.4 ± 0.8 for clinical implication and overall satisfaction. Cronbach's alpha for reliability of the HoMASQ was 0.73. Conclusion A high level of acceptance and satisfaction after 1-year remote control by HM was detected by the five-point scale HoMASQ, which showed a good internal reliability.

Journal ArticleDOI
01 Mar 2010-Europace
TL;DR: Ganglionated plexi ablation in chronic AF results in long-term maintenance of sinus rhythm in 38.2% of cases and repeat procedures with circumferential isolation of all PV offer a success rate of 59.6% over a follow-up of 16 +/- 7 months.
Abstract: Aims To study the potential efficacy of ganglionated plexi (GP) ablation in the setting of longstanding persistent atrial fibrillation (AF). Methods and results Anatomic ablation at the areas of GP in the left atrium was performed in 89 patients with symptomatic, drug-refractory, persistent AF (71 men, 56 +/- 7 years of age). In 29 patients, a second procedure by means of circumferential pulmonary vein (PV) isolation was performed, and 5 of them were subjected to a third circumferential ablation. At 16 +/- 7 months after the final ablation procedure, 53 (59.6%) of the 89 patients were in sinus rhythm in the absence of antiarrhythmic drug therapy, 5 (5.6%) patients had permanent AF, and 31 (34.8%) patients had paroxysmal AF. The long-term success rate for patients who underwent a single ablation procedure with only GP ablation was 38.2% over a follow-up of 24 +/- 3 months. Independent predictors of later arrhythmia recurrences were left atrial diameter [HR 1.039 (1.00-1.07), P = 0.028] and duration of AF prior to ablation [HR 1.116 (1.02-1.22), P = 0.008]. Conclusion Ganglionated plexi ablation in chronic AF results in long-term maintenance of sinus rhythm in 38.2% of cases. Repeat procedures with circumferential isolation of all PV offer a success rate of 59.6% over a follow-up of 16 +/- 7 months.

Journal ArticleDOI
01 Feb 2010-Europace
TL;DR: The T(peak)-T(end) interval and T( peak)-T (end)/QT ratio were associated with VT/VF inducibility in BS, and the utility of T( Peak-T( end)/ QT ratio as a new marker of arrhythmogenesis in BS requires further studies, including a large number of patients.
Abstract: Aims The present study investigated whether several ECG markers of ventricular repolarization are associated with ventricular tachycardia/fibrillation (VT/VF) inducibility in subjects with type 1 ECG pattern of Brugada syndrome (BS). Methods and results The clinical data of 23 individuals (19 males, age 42.69 ± 14.63) with spontaneous ( n = 10) or drug-induced ( n = 13) type 1 ECG pattern of BS who underwent programmed ventricular stimulation were analysed. Sustained VT/VF was induced in 17 subjects (74%) and was significantly associated with the presence of spontaneous type 1 ECG of BS ( P = 0.012). Among the studied ECG repolarization markers, subjects with inducible VT/VF displayed an increased T peak– T end interval in leads V2 (88.82 ± 15.70 vs. 78.33 ± 4.08 ms, P = 0.02) and V6 (76.33 ± 10.08 vs. 66.66 ± 5.16 ms, P = 0.04) and a greater T peak– T end/QT ratio in lead V6 (0.214 ± 0.028 vs. 0.180 ± 0.014, P = 0.009) compared with those without arrhythmias. Ventricular tachycardia/fibrillation inducibility was not associated with arrhythmic events during a mean follow-up period of 4.61 ± 2.14 years ( P = 0.739). Conclusion The T peak– T end interval and T peak– T end/QT ratio were associated with VT/VF inducibility in BS. The utility of T peak– T end/QT ratio as a new marker of arrhythmogenesis in BS requires further studies, including a large number of patients.

Journal ArticleDOI
01 Jan 2010-Europace
TL;DR: This study shows a high incidence of silent micro-embolic events after PV ablation, and CAD, left ventricular dilatation, and hypertrophy were potential predictors of this complication.
Abstract: Aims Left atrial catheter ablation of the pulmonary veins (PV) has evolved as an important therapeutic option for the treatment of atrial fibrillation (AF). We aimed to investigate the incidence and predictors of silent cerebral embolism associated with PV catheter ablation, detected by diffusion-weighted magnetic resonance imaging (DW-MRI). Methods and results We performed a prospective analysis of 53 consecutive patients with persistent or paroxysmal AF that underwent PV ablation and post-procedural cerebral MRI 1 day after lasso catheter-guided ostial PV ablation. Patients were analysed for possible demographical, medical, echocardiographical, and procedural predictors of embolic events. A mean of 3.5 ± 0.5 PVs were ablated per patient. In six patients, DW-MRI depicted new clinically silent microembolism after PV ablation (11%). The number of ineffective medical antiarrhythmic agents prior to ablation procedure was significantly higher in the embolism group (3.3 ± 0.5 vs. 2.2 ± 1.4, P = 0.014). Coronary heart disease (CAD) was more frequent in patients with cerebral embolisms (33 vs. 2%, P = 0.031); left ventricular volume (130 ± 12 vs. 103 ± 26 mL, P = 0.002), and septal wall thickness (13.0 ± 1.4 vs. 7.9 ± 4.8 mm, P = 0.025) were significantly increased. Conclusion This study shows a high incidence of silent micro-embolic events after PV ablation. CAD, left ventricular dilatation, and hypertrophy were potential predictors of this complication.

Journal ArticleDOI
01 May 2010-Europace
TL;DR: A comprehensive international patient and professional information and support programme on AF is needed to improve management and consequently health outcomes.
Abstract: Aims Atrial fibrillation (AF) is not always perceived as a serious health threat, but is the most common sustained arrhythmia, with a major impact on morbidity, mortality, and patient quality of life (QoL). A survey was undertaken to examine the level of understanding, perception, and attitudes of the cardiovascular risks associated with AF. Methods and results The AF AWARE group (an international coalition of organizations with an interest in AF) conducted an international quantitative survey in 11 countries in 2009, to investigate patients' ( n = 825) and cardiologists' ( n = 810) perceptions of AF, preferences for communicating information on AF and burden of AF. Both patients and physicians considered AF life-threatening (55 and 43%, respectively). Physicians were more concerned about the risk of stroke and hospitalizations than patients, whereas patients were most concerned about death risk. One in four patients felt unable to explain AF and >33% were worried or fearful about their disease. Many physicians (51%) wanted more patient information with >60% viewing available information as poor/difficult to find. Hospital specialists and GPs were identified as key information sources for patients. Most patients (83%) reported symptoms, yet 75% claimed to be satisfied with AF therapies. Atrial fibrillation patients, often with associated diseases, made an average of nine visits per year to their doctors, who consider AF difficult and time consuming to manage. Patients and physicians rated the QoL impact of AF as moderate to high. Conclusions A comprehensive international patient and professional information and support programme on AF is needed to improve management and consequently health outcomes.

Journal ArticleDOI
01 Jan 2010-Europace
TL;DR: Circumferential pulmonary vein ablation was as effective in AF secondary to endurance sport practice as in other aetiologies of AF.
Abstract: Aims Long-term endurance sport practice has been increasingly recognized as a risk factor for lone atrial fibrillation (AF). However, data on the outcome of circumferential pulmonary vein ablation (CPVA) in endurance athletes are scarce. The aim of the study was to evaluate the efficacy of CPVA in AF secondary to endurance sport practice. Methods and results Patients submitted to CPVA answered a questionnaire about lifetime history of endurance sport practice. Endurance athletes were defined as those who engaged in >3 h per week of high-intensity exercise for at least the 10 years immediately preceding their AF diagnosis. A series of 182 consecutive patients was included (51 ± 11 years, 65% with paroxysmal AF, 81% men, 42 ± 6 mm mean left atrial diameter); 107 (59%) patients had lone AF, and 42 of them (23% of the study population) were classified as endurance athletes (lone AF sport group). Freedom from arrhythmia after a single CPVA was similar in the lone AF sport group compared with the remaining patients ( P = 0.446). Left atrial size and long-standing AF were the only independent predictors for arrhythmia recurrence after ablation. Conclusion Circumferential pulmonary vein ablation was as effective in AF secondary to endurance sport practice as in other aetiologies of AF.

Journal ArticleDOI
01 Feb 2010-Europace
TL;DR: This large-scale real-life patient cohort of primary stationary pacemaker implantation showed that gender has an impact onto pacemaker implants, with less favourable outcomes for women.
Abstract: Aims The aim of the study was to evaluate the effects of patient gender onto primary pacemaker implantation, evaluating the database of the Institute of Quality Assurance Hessen in the federal state of Hessen, Germany. Methods and results The database of the obligatory external quality control program for the years 2003–2006 was evaluated retrospectively. In 72 centres, 17 826 patients undergoing stationary primary pacemaker implantation have been registered. Male patients had more AV blocks when compared with women and less sick sinus syndrome and atrial fibrillation with bradycardia. In patients being 80 years and older, men received significantly more dual-chamber devices than women for the indications: AV block and sick sinus syndrome. In women, atrial pacing thresholds were significantly higher and P-wave amplitudes were significantly lower. Women had, independent from age or pacing system implanted, significantly more acute complications than men, with significant differences for pneumothorax and pocket haematoma. Conclusion This large-scale real-life patient cohort of primary stationary pacemaker implantation showed that gender has an impact onto pacemaker implantation, with less favourable outcomes for women.

Journal ArticleDOI
01 Dec 2010-Europace
TL;DR: This expert consensus aims to provide guidance for the management of patients receiving one or multiple shocks from an ICD, and expresses the view of a multidisciplinary group of experts in the fields of general adult cardiology, ICD treatment, invasive electrophysiology, and psychosomatic medicine.
Abstract: AF : Atrial fibrillation ATP : Antitachycardia pacing CRT : Cardiac resynchronization therapy EHRA : European Heart Rhythm Association ES : Electrical storm HRS : Heart Rhythm Society ICD : Implantable cardiac defibrillator SCD : Sudden cardiac death SSRI : Selective serotonin receptor inhibitor VF : Ventricular fibrillation VT : Ventricular tachycardia This expert consensus aims to provide guidance for the management of patients receiving one or multiple shocks from an ICD. The document expresses the view of a multidisciplinary group of experts in the fields of general adult cardiology, ICD treatment, invasive electrophysiology, and psychosomatic medicine. A variety of clinical settings, including emergency medicine, general cardiology, and interventional electrophysiology, are addressed as well as the different groups of clinicians involved in the care of these patients. To cover different levels of expertise in ICD treatment, it is intended to provide comprehensive information ranging from a basic explanation of how an ICD works to specialist advice for device programming. Almost 30 years after the first human implants, ICD therapy has become the treatment of choice in patients at risk of developing malignant ventricular arrhythmias.1,2 Accordingly, the number of patients implanted with an ICD has increased substantially over the past decade,3 mainly as a consequence of the expansion of ICD indications into the field of primary prevention of SCD in patients with decreased left ventricular function. In 2008, ∼120 000 patients received an ICD worldwide.3 As a result of the growing number of ICD patients, ICD-related problems are increasingly encountered and patients with one or multiple shocks are to day frequently seen at emergency departments, hospital wards, or ICD clinics. Therefore, personnel working in these environments should have specific knowledge concerning the management of ICD-related problems. Table 1 summarizes the most common causes of ICD shocks. Trials reported appropriate therapies in 17–64% of patients, whereas inappropriate shocks, most often caused by supraventricular tachycardia, occurred in 10–24%.4 Among patients enrolled in primary prevention ICD trials, women experienced less appropriate ICD interventions than men.5 Modern device algorithms facilitate effective termination of VT without shock delivery by ATP, discrimination …

Journal ArticleDOI
01 Aug 2010-Europace
TL;DR: In this paper, the authors identify electrocardiographic (ECG) and further predictors for atrioventricular (AV) block with a need for pacemaker implantation after transcatheter aortic valve implantation (TAVI).
Abstract: The objective of this study was to identify electrocardiographic (ECG) and further predictors for atrioventricular (AV) block with a need for pacemaker (PM) implantation after transcatheter aortic valve implantation (TAVI). Pre- and post-procedural ECGs of patients with severe aortic stenosis and ongoing TAVI were investigated in a prospective study. From 50 consecutive patients enrolled in the study (mean age 80 +/- 6 years, 46% men), 17 (34%) experienced an AV block with subsequent requirement of a permanent PM [16 of 36 (44.4%) with CoreValve System and 1 of 14 (7.1%) with Edwards Sapiens System]. In patients with right bundle branch block (RBBB), PM implantation had to be performed more frequently [6 of 6 (100%) with CoreValve System and none with Edwards Sapiens System], P = 0.005. An AV block (Mobitz II second degree and third degree) occurred mostly within the first 24 h (range: Days 0-13) after the index procedure. No recovery of AV conduction with a change in PM indication occurred in a mean follow-up time of 13 +/- 6 days. Our data demonstrate that patients with pre-operative RBBB and those receiving CoreValve prosthesis are at a significantly higher risk for PM implantation after TAVI. Therefore, patients with the presence of RBBB before TAVI may be at lower risk for PM implantation using the Edwards Sapiens System.

Journal ArticleDOI
01 Jul 2010-Europace
TL;DR: In patients presenting for AF ablation, LA thrombus is only seen in those with clinical risk factors, and toE is indicated in this group but may be unnecessary in patients withoutclinical risk factors.
Abstract: Aims The exact role of transoesphageal echo (TOE) prior to atrial fibrillation (AF) ablation remains unclear. This study examines the incidence and predictors of left atrial (LA) thrombus in patients undergoing AF ablation. Methods and results Patients were treated with warfarin for at least 4 weeks prior to ablation. This was substituted with therapeutic dalteparin 3 days before the procedure. All patients underwent TOE to exclude LA thrombus. Six clinical risk factors for thrombus were defined, known to be risk factors for stroke in AF: age >75, diabetes, hypertension, valve disease, prior stroke, or transient ischaemic attack and cardiomyopathy. A total of 635 procedures were performed. The incidence of thrombus was 12/635 (1.9%) despite therapeutic anti-coagulation. Patients with thrombus had larger LA diameter, mean 50.6 ± 6.2 mm vs. 44.2 ± 7.6 ( P = 0.006). In univariate analysis, persistent AF [odds ratio (OR) = 10.4 with 95% CI 1.8–19.1], hypertension [OR = 11.7 with 95% CI 2.5–54.1], age >75 (OR = 4.5 with 95% CI 1.2–17.2), and cardiomyopathy (OR 5.9 with 95% CI 1.8–19.1) were significantly associated with thrombus. In multivariate analysis, hypertension (OR = 14.2 with 95% CI 2.6–77.5), age >75 (OR = 8.1, 95% CI 1.5–44.9), and cardiomyopathy (OR = 10.5 with 95% CI 2.6–77.5) were independently associated with thrombus. There was no thrombus in patients without clinical risk factors. Conclusion In patients presenting for AF ablation, LA thrombus is only seen in those with clinical risk factors. TOE is indicated in this group but may be unnecessary in patients without clinical risk factors.

Journal ArticleDOI
01 Jan 2010-Europace
TL;DR: It is shown that short-term implantation-related complications of contemporary device therapy are still frequent, occur much more frequently by trainees than by cardiologists, require a large number of additional surgical procedures, and substantially prolong the hospital stay.
Abstract: Aims The aim of this study was to evaluate the current short-term (<3 months) complication rate related to cardiac rhythm management (CRM) device implantations. Methods and results We analysed data of the complications related to all CRM device implantations during 1 year (2006) in a tertiary referral university hospital. In 567 device implantations, pacing system upgrade procedures, or lead revisions, 78 complications occurred in 69 (12.2%) patients. Lead dislodgement, pocket haematoma or bleeding, pneumothorax, and infection were the most common accounting for >80% of all complications. The complication rate was more than twice as high in bradycardia pacemaker (PM) implantations performed by cardiology trainees (17.4%) than by experienced cardiologists (7.7%, P = 0.001). When performed by experienced cardiologists, the complication rate was not higher in implantations of more complex devices compared with that of bradycardia PMs. Fifty-two of the 69 patients needed additional surgical procedures. Altogether, the complications required 504 additional treatment days in hospital. Conclusion In conclusion, our retrospective 1-year single-centre survey shows that short-term implantation-related complications of contemporary device therapy are still frequent, occur much more frequently by trainees than by cardiologists, require a large number of additional surgical procedures, and substantially prolong the hospital stay.

Journal ArticleDOI
01 Jan 2010-Europace
TL;DR: In this paper, the authors present a prospective study of 941 consecutive patients referred to the Syncope Units of nine general hospitals from 15 March 2008 to 15 September 2008, where a median of 15 patients per month were examined in each unit, but the five older units had a two-fold higher volume of activity than the four newer ones (instituted < 1 year before): 23 vs. 12, P = 0.02.
Abstract: Aims Although an organizational model for syncope management facilities was proposed in the 2004 guidelines of the European Society of Cardiology (ESC), its implementation in clinical practice and its effectiveness are largely unknown. Methods and results This prospective study enrolled 941 consecutive patients referred to the Syncope Units of nine general hospitals from 15 March 2008 to 15 September 2008. A median of 15 patients per month were examined in each unit, but the five older units had a two-fold higher volume of activity than the four newer ones (instituted <1 year before): 23 vs. 12, P = 0.02. These figures give an estimated volume of 163 and 60 patients per 100 000 inhabitants per year, respectively. Referrals: 60% from out-of-hospital services, 11% immediate and 13% delayed referrals from the Emergency Department, and 16% hospitalized patients. A diagnosis was established on initial evaluation in 191 (21%) patients and early by means of 2.9 ± 1.6 tests in 541 (61%) patients. A likely reflex cause was established in 67%, orthostatic hypotension in 4%, cardiac in 6% and non-syncopal in 5% of the cases. The cause of syncope remained unexplained in 159 (18%) patients, despite a mean of 3.5 ± 1.8 tests per patient. These latter patients were older, more frequently had structural heart disease or electrocardiographic abnormalities, unpredictable onset of syncope due to the lack of prodromes, and higher OESIL and EGSIS risk scores than the other groups of patients. The mean costs of diagnostic evaluation was €209 per outpatient and €1073 per inpatient. The median cost of hospital stay was €2990 per patient. Conclusion We documented the current practice of syncope management in specialized facilities that have adopted the management model proposed by the ESC. The results are useful for those who wish to replicate this model in other hospitals. Syncope remains unexplained during in-hospital evaluation in more complex cases at higher risk.

Journal ArticleDOI
01 Apr 2010-Europace
TL;DR: Clinical presentation of AF in Cameroon is much more severe than in developed countries, and death and stroke rate at 1 year are very high in Cameroon possibly because of a lower use of OAC, and a higher prevalence of rheumatic mitral disease and of more severe co-morbidities.
Abstract: Aims The purpose of this prospective study was to characterize the clinical profile of patients with atrial fibrillation (AF) in the urban population of a sub-Saharan African country and to assess how successfully current guidelines are applied in that context. Methods and results This prospective study involved 10 cardiologists in Cameroon. Enrolment started on 1 June 2006 and ended on 30 June 2007. Consecutive patients were included if they were >18 years and AF was documented on an ECG during the index office visit. In this survey, 172 patients were enrolled (75 males and 97 females; mean age 65.8 +/- 13 years). The prevalence of paroxysmal, persistent, and permanent AF was 22.7, 21.5, and 55.8%, respectively. Underlying cardiac disorders, present in 156/172 patients (90.7%), included hypertensive heart disease (47.7%), valvular heart disease (25.6%), dilated cardiomyopathy (15.7%), and coronary artery disease (6%). A rate-control strategy was chosen in 83.7% of patients (144 of 172) and drugs most commonly used were digoxin and amiodarone. The mean CHADS(2) score was 1.9 +/- 1.1 and 158 of 172 patients (91.9%) had a CHADS(2) score > or =1. Among patients with an indication for oral anticoagulation (OAC), only 34.2% (54 of 158) actually received it. During a follow-up of 318 +/- 124 days, 26 of 88 patients died (29.5%), essentially from a cardiovascular cause (15 of 26). Ten patients (16.1%) had a non-lethal embolic stroke and 23 (26.1%) had symptoms of severe congestive heart failure. Conclusion Clinical presentation of AF in Cameroon is much more severe than in developed countries. A rate-control strategy is predominant in Cameroon and OAC is prescribed in only 34.2% of eligible patients, despite a high CHADS(2) score at inclusion. Death and stroke rate at 1 year are very high in Cameroon possibly because of a lower use of OAC, and a higher prevalence of rheumatic mitral disease and of more severe co-morbidities.