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Trends in Cardiovascular Medicine Apr 2023In contrast to current guidelines and earlier trials, recent studies demonstrated superiority of rhythm- over rate-control and challenged the strategy of "rate versus... (Review)
Review
In contrast to current guidelines and earlier trials, recent studies demonstrated superiority of rhythm- over rate-control and challenged the strategy of "rate versus rhythm" therapy in patients with atrial fibrillation. These newer studies have started to shift the use of rhythm-control therapy from the symptom-driven therapy of current guidelines to a risk-reducing strategy aimed at restoring and maintaining sinus rhythm. This review discusses recent data and presents an overview on the current discourse: The concept of early rhythm control seems attractive. Patients with rhythm control may undergo less atrial remodeling compared to those with rate control. In addition, in EAST-AFNET 4 an outcome-reducing effect of rhythm control was achieved by delivering therapy with relatively few complications early after the initial AF diagnosis. Successful rhythm control therapy and most likely reduced AF burden, estimated by the presence of sinus rhythm at 12 months after randomization, explained most of the reduction in cardiovascular outcomes achieved by rhythm control. However, it is too early to call for early rhythm control for all AF patients. Rhythm control may raise concerns regarding the generalizability of trial results in routine practice involving important questions on the definition of "early" and "successful", and the relevant issue of antiarrhythmic drugs versus catheter ablation. Further information is required to select patients who will benefit from an early ablative or non-ablative rhythm management.
PubMed: 37054762
DOI: 10.1016/j.tcm.2023.04.001 -
European Heart Journal Oct 2022
Topics: Humans; Atrial Fibrillation; Secondary Prevention
PubMed: 36036652
DOI: 10.1093/eurheartj/ehac490 -
Scientific Reports Feb 2020Arrhythmia constitutes a problem with the rate or rhythm of the heartbeat, and an early diagnosis is essential for the timely inception of successful treatment. We have...
Arrhythmia constitutes a problem with the rate or rhythm of the heartbeat, and an early diagnosis is essential for the timely inception of successful treatment. We have jointly optimized the entire multi-stage arrhythmia classification scheme based on 12-lead surface ECGs that attains the accuracy performance level of professional cardiologists. The new approach is comprised of a three-step noise reduction stage, a novel feature extraction method and an optimal classification model with finely tuned hyperparameters. We carried out an exhaustive study comparing thousands of competing classification algorithms that were trained on our proprietary, large and expertly labeled dataset consisting of 12-lead ECGs from 40,258 patients with four arrhythmia classes: atrial fibrillation, general supraventricular tachycardia, sinus bradycardia and sinus rhythm including sinus irregularity rhythm. Our results show that the optimal approach consisted of Low Band Pass filter, Robust LOESS, Non Local Means smoothing, a proprietary feature extraction method based on percentiles of the empirical distribution of ratios of interval lengths and magnitudes of peaks and valleys, and Extreme Gradient Boosting Tree classifier, achieved an F-Score of 0.988 on patients without additional cardiac conditions. The same noise reduction and feature extraction methods combined with Gradient Boosting Tree classifier achieved an F-Score of 0.97 on patients with additional cardiac conditions. Our method achieved the highest classification accuracy (average 10-fold cross-validation F-Score of 0.992) using an external validation data, MIT-BIH arrhythmia database. The proposed optimal multi-stage arrhythmia classification approach can dramatically benefit automatic ECG data analysis by providing cardiologist level accuracy and robust compatibility with various ECG data sources.
Topics: Aged; Aged, 80 and over; Algorithms; Arrhythmia, Sinus; Arrhythmias, Cardiac; Atrial Fibrillation; Databases as Topic; Electrocardiography; Female; Humans; Male; Middle Aged; Models, Cardiovascular
PubMed: 32076033
DOI: 10.1038/s41598-020-59821-7 -
Cardiovascular Journal of AfricaThe restoration and maintenance of sinus rhythm is a desirable strategy for many patients with atrial fibrillation (AF) since it has been associated with improvement in... (Review)
Review
The restoration and maintenance of sinus rhythm is a desirable strategy for many patients with atrial fibrillation (AF) since it has been associated with improvement in symptoms and a better quality of life. Sinus rhythm can be achieved by pharmacological or electrical cardioversion or after catheter ablation of AF. Despite high rates of successful cardioversion, AF recurrence remains a major challenge. Anti-arrhythmic drug therapy currently plays a significant role in maintaining sinus rhythm after cardioversion. Amiodarone is the most commonly prescribed anti-arrhythmic drug for patients with AF. This is due to its particular electrophysiological properties and superior anti-arrhythmic effects in comparison with other anti-arrhythmic drugs. Understanding the cardiac electrophysiology and arrhythmogenesis mechanisms may result in identification of new targets for anti-arrhythmic therapy. The aim of this article was to review amiodarone's clinical pharmacology and evaluate evidence supporting amiodarone for treatment and prevention of AF recurrence after cardioversion.
Topics: Amiodarone; Anti-Arrhythmia Agents; Atrial Fibrillation; Electric Countershock; Humans; Quality of Life; Recurrence; Treatment Outcome
PubMed: 33496719
DOI: 10.5830/CVJA-2020-060 -
The Egyptian Heart Journal : (EHJ) :... Nov 2023Electroconvulsive therapy (ECT) is a therapy used to treat refractory mental health conditions, ranging from depression to catatonia, and it has gained renewed... (Review)
Review
BACKGROUND
Electroconvulsive therapy (ECT) is a therapy used to treat refractory mental health conditions, ranging from depression to catatonia, and it has gained renewed prominence in practice and the literature of late. Given that ECT involves the application of direct current to the body, there exists a risk of a change in cardiac rhythm during therapy. When atrial fibrillation is induced, ECT carries a potential risk of stroke. These risks have not been previously analyzed or summarized in the literature to allow physicians to make educated decisions about periprocedural risk and anticoagulation needs.
METHODS
To better describe this risk, the authors reviewed PubMed for articles that described the post-ECT cardioversion of AF to sinus rhythm, new development of AF post-ECT, and new stroke after either rhythm change.
RESULTS
Included were 14 studies describing 19 unique patients. Most patients had no rhythm change during at least one of many ECT sessions. Five patients converted from AF to sinus rhythm during at least one session, while AF followed ECT in seventeen patients during at least one ECT session. Four patients experienced both ECT-related cardioversion from AF to sinus rhythm as well as conversion from sinus rhythm to AF. Although no patients with a rhythm change experienced a stroke, one unanticoagulated patient who remained in AF developed a stroke post-ECT.
CONCLUSIONS
Electroconvulsive therapy is demonstrated to be associated with rhythm changes-from atrial fibrillation to sinus rhythm as well as from sinus rhythm to atrial fibrillation. Thus, stroke risk during and after ECT remains a possibility. The anticoagulation of patients with AF who undergo ECT should be based on individual stroke risk factors, using validated stroke risk models, rather than prescribed routinely.
PubMed: 38010438
DOI: 10.1186/s43044-023-00409-7 -
Cells Nov 2021Rhythm disturbances are life-threatening cardiovascular diseases, accounting for many deaths annually worldwide. Abnormal electrical activity might arise in a... (Review)
Review
Rhythm disturbances are life-threatening cardiovascular diseases, accounting for many deaths annually worldwide. Abnormal electrical activity might arise in a structurally normal heart in response to specific triggers or as a consequence of cardiac tissue alterations, in both cases with catastrophic consequences on heart global functioning. Preclinical modeling by recapitulating human pathophysiology of rhythm disturbances is fundamental to increase the comprehension of these diseases and propose effective strategies for their prevention, diagnosis, and clinical management. In silico, in vivo, and in vitro models found variable application to dissect many congenital and acquired rhythm disturbances. In the copious list of rhythm disturbances, diseases of the conduction system, as sick sinus syndrome, Brugada syndrome, and atrial fibrillation, have found extensive preclinical modeling. In addition, the electrical remodeling as a result of other cardiovascular diseases has also been investigated in models of hypertrophic cardiomyopathy, cardiac fibrosis, as well as arrhythmias induced by other non-cardiac pathologies, stress, and drug cardiotoxicity. This review aims to offer a critical overview on the effective ability of in silico bioinformatic tools, in vivo animal studies, in vitro models to provide insights on human heart rhythm pathophysiology in case of sick sinus syndrome, Brugada syndrome, and atrial fibrillation and advance their safe and successful translation into the cardiology arena.
Topics: Animals; Atrial Fibrillation; Brugada Syndrome; Disease Models, Animal; Heart Rate; Humans; Multifactorial Inheritance; Sick Sinus Syndrome
PubMed: 34831398
DOI: 10.3390/cells10113175 -
A comparison of medical therapy and ablation for atrial fibrillation in patients with heart failure.Expert Review of Cardiovascular Therapy Mar 2022Atrial fibrillation and heart failure frequently co-exist and the combination is associated with a worse prognosis than either condition alone. A number of... (Review)
Review
INTRODUCTION
Atrial fibrillation and heart failure frequently co-exist and the combination is associated with a worse prognosis than either condition alone. A number of pharmacological agents and invasive procedures have been shown to benefit this complex patient group.
OBJECTIVE
In this review, we compare different therapeutic approaches to atrial fibrillation and heart failure, including pharmacotherapy, left atrial catheter ablation and pace-and-ablate.
EXPERT OPINION
Left atrial catheter ablation is an efficacious option for restoring sinus rhythm and is most likely to provide benefit to those in whom durable sinus rhythm can be expected, and whose life expectancy is not significantly reduced by other pathologies or advanced age. A pace-and-ablate approach, particularly with physiological pacing, may provide more benefit to those with low chance of maintaining sinus rhythm. Both invasive options generally outperform pharmacotherapy, although it is important to individualize the approach for each patient through shared decision-making.
Topics: Atrial Fibrillation; Catheter Ablation; Heart Failure; Humans
PubMed: 35255780
DOI: 10.1080/14779072.2022.2050695 -
Arrhythmia & Electrophysiology Review Apr 2022Progression of AF is accompanied by structural and electrical remodelling, resulting in complex electrical conduction disorders. This is defined as electropathology and... (Review)
Review
Progression of AF is accompanied by structural and electrical remodelling, resulting in complex electrical conduction disorders. This is defined as electropathology and it increases with the progression of AF. The severity of electropathology, thus, defines the stage of AF and is a major determinant of effectiveness of AF therapy. As specific features of AF-related electropathology are still unknown, it is essential to first quantify the electrophysiological properties of atrial tissue and then to examine the inter- and intra-individual variation during normal sinus rhythm. Comparison of these parameters between patients with and without a history of AF unravels quantified electrophysiological features that are specific to AF patients. This can help to identify patients at risk for early onset or progression of AF. This review summarises current knowledge on quantified features of atrial electrophysiological properties during sinus rhythm and discusses its relevance in identifying AF-related electropathology.
PubMed: 35846426
DOI: 10.15420/aer.2022.03 -
Heart Rhythm Apr 2024Sinus rhythm activation time is useful to assess infarct border zone substrate.
BACKGROUND
Sinus rhythm activation time is useful to assess infarct border zone substrate.
OBJECTIVE
We sought to further investigate sinus activation in ventricular tachycardia (VT).
METHODS
Canine postinfarction data were analyzed retrospectively. In each experiment, an infarct was created in the left ventricular wall by left anterior descending coronary artery ligation. At 3 to 5 days after ligation, 196-312 bipolar electrograms were recorded from the anterior left ventricular epicardium overlapping the infarct border zone. Sustained monomorphic VT was induced by premature electrical stimulation in 50 experiments and was noninducible in 43 experiments. Acquired sinus rhythm and VT electrograms were marked for electrical activation time, and activation maps of representative sinus rhythm and VT cycles were constructed. The sinus rhythm activation signature was defined as the cumulative number of multielectrode recording sites that had activated per time epoch, and its derivative was used to predict VT inducibility and to define the sinus rhythm slow/late activation sequence.
RESULTS
Plotting mean activation signature derivative, a best cutoff value was useful to separate experiments with reentrant VT inducibility (sensitivity, 42/50) vs noninducibility (specificity, 39/43), with an accuracy of 81 of 93. For the 50 experiments with inducible VT, recording sites overlying a segment of isochrone encompassing the sinus rhythm slow/late activation sequence spanned the VT isthmus location in 32 cases (64%), partially spanned it in 15 cases (30%), but did not span it in 3 cases (6%).
CONCLUSION
The sinus rhythm activation signature derivative is assistive to differentiate substrate supporting reentrant VT inducibility vs noninducibility and to identify slow/late activation for targeting isthmus location.
PubMed: 38677360
DOI: 10.1016/j.hrthm.2024.04.082