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Postepy W Kardiologii Interwencyjnej =... 2017Numerous epidemiologic studies have investigated the link between nonalcoholic fatty liver disease (NAFLD) and long-term atrial fibrillation (AF) risk, but the results...
INTRODUCTION
Numerous epidemiologic studies have investigated the link between nonalcoholic fatty liver disease (NAFLD) and long-term atrial fibrillation (AF) risk, but the results are surprisingly conflicting.
AIM
Therefore, we systematically reviewed all published studies assessing the risk of AF in patients with NAFLD and conducted a meta-analysis.
MATERIAL AND METHODS
We performed a literature search using PubMed, EMBASE and Cochrane Library databases in February 2017 with no restrictions. Two cohort studies and two cross-sectional studies were identified, involving a total of 5150 subjects (NAFLD: 1655; controls: 3495) in this meta-analysis. Data from selected studies were extracted and a meta-analysis was performed using a random effects model.
RESULTS
Nonalcoholic fatty liver disease patients had a significantly higher risk of AF compared to controls (relative risk (RR): 2.61; 95% confidence interval (CI): 1.34-5.06, = 0.00; = 52.5%, = 0.097). In a further analysis stratified by presence of type 2 diabetes, the increased risk was present predominantly in patients with type 2 diabetes (RR = 5.10; 95% CI: 2.43-10.7, < 0.001; = 0, = 0.958). However, subjects without type 2 diabetes were at slightly increased risk of AF but the relative risk did not reach statistical significance (RR = 1.68; 95% CI: 0.99-2.82, = 0.05; = 0, = 0.461).
CONCLUSIONS
Our meta-analysis suggested that ultrasound-diagnosed NAFLD patients have a significantly higher risk for AF after adjustment for numerous important clinical risk factors for AF. These results need to be confirmed in large prospective studies.
PubMed: 29056998
DOI: 10.5114/aic.2017.70198 -
The Cochrane Database of Systematic... Aug 2016People with atrial fibrillation (AF) often undergo cardiac surgery for other underlying reasons and are frequently offered concomitant AF surgery to reduce the frequency... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
People with atrial fibrillation (AF) often undergo cardiac surgery for other underlying reasons and are frequently offered concomitant AF surgery to reduce the frequency of short- and long-term AF and improve short- and long-term outcomes.
OBJECTIVES
To assess the effects of concomitant AF surgery among people with AF who are undergoing cardiac surgery on short-term and long-term (12 months or greater) health-related outcomes, health-related quality of life, and costs.
SEARCH METHODS
Starting from the year when the first "maze" AF surgery was reported (1987), we searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library (March 2016), MEDLINE Ovid (March 2016), Embase Ovid (March 2016), Web of Science (March 2016), the Database of Abstracts of Reviews of Effects (DARE, April 2015), and Health Technology Assessment Database (HTA, March 2016). We searched trial registers in April 2016. We used no language restrictions.
SELECTION CRITERIA
We included randomised controlled trials evaluating the effect of any concomitant AF surgery compared with no AF surgery among adults with preoperative AF, regardless of symptoms, who were undergoing cardiac surgery for another indication.
DATA COLLECTION AND ANALYSIS
Two review authors independently selected studies and extracted data. We evaluated the risk of bias using the Cochrane 'Risk of bias' tool. We included outcome data on all-cause and cardiovascular-specific mortality, freedom from atrial fibrillation, flutter, or tachycardia off antiarrhythmic medications, as measured by patient electrocardiographic monitoring greater than three months after the procedure, procedural safety, 30-day rehospitalisation, need for post-discharge direct current cardioversion, health-related quality of life, and direct costs. We calculated risk ratios (RR) for dichotomous data with 95% confidence intervals (CI) using a fixed-effect model when heterogeneity was low (I² ≤ 50%) and random-effects model when heterogeneity was high (I² > 50%). We evaluated the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework to create a 'Summary of findings' table.
MAIN RESULTS
We found 34 reports of 22 trials (1899 participants) with five additional ongoing studies and three studies awaiting classification. All included studies were assessed as having high risk of bias across at least one domain. The effect of concomitant AF surgery on all-cause mortality was uncertain when compared with no concomitant AF surgery (7.0% versus 6.6%, RR 1.14, 95% CI 0.81 to 1.59, I² = 0%, 20 trials, 1829 participants, low-quality evidence), but the intervention increased freedom from atrial fibrillation, atrial flutter, or atrial tachycardia off antiarrhythmic medications > three months (51.0% versus 24.1%, RR 2.04, 95% CI 1.63 to 2.55, I² = 0%, eight trials, 649 participants, moderate-quality evidence). The effect of concomitant AF surgery on 30-day mortality was uncertain (2.3% versus 3.1%, RR 1.25 95% CI 0.71 to 2.20, I² = 0%, 18 trials, 1566 participants, low-quality evidence), but the intervention increased the risk of permanent pacemaker implantation (6.0% versus 4.1%, RR 1.69, 95% CI 1.12 to 2.54, I² = 0%, 18 trials, 1726 participants, moderate-quality evidence). Investigator-defined adverse events, including but limited to, need for surgical re-exploration or mediastinitis, were not routinely reported but were not different between the two groups (other adverse events: 24.8% versus 23.6%, RR 1.07, 95% CI 0.85 to 1.34, I² = 45%, nine trials, 858 participants), but the quality of this evidence was very low.
AUTHORS' CONCLUSIONS
For patients with AF undergoing cardiac surgery, there is moderate-quality evidence that concomitant AF surgery approximately doubles the risk of freedom from atrial fibrillation, atrial flutter, or atrial tachycardia off anti-arrhythmic drugs while increasing the risk of permanent pacemaker implantation. The effects on mortality are uncertain. Future, high-quality and adequately powered trials will likely affect the confidence on the effect estimates of AF surgery on clinical outcomes.
Topics: Anti-Arrhythmia Agents; Atrial Fibrillation; Atrial Flutter; Cardiac Surgical Procedures; Cause of Death; Humans; Pacemaker, Artificial; Randomized Controlled Trials as Topic; Tachycardia
PubMed: 27551927
DOI: 10.1002/14651858.CD011814.pub2 -
Journal of Intensive Care 2015Atrial fibrillation (AF) is a common arrhythmia in the ICU. The aim of this review is to summarize relevant information on new-onset AF in non-cardiac critical illness...
BACKGROUND
Atrial fibrillation (AF) is a common arrhythmia in the ICU. The aim of this review is to summarize relevant information on new-onset AF in non-cardiac critical illness with respect to epidemiology, prevention, and treatment.
METHODS
We conducted a PubMed search in June 2014 and included studies describing the epidemiology, prevention, and treatment of new-onset AF and atrial flutter during ICU stay in non-cardiac adult patients. Selected studies were divided into the three categories according to the extracted information. The methodological quality of selected studies was described according to the Grading of Recommendations Assessment, Development and Evaluation system.
RESULTS
We identified 1,132 citations, and after full-text-level selection, we included 10 studies on etiology/outcome and five studies on treatment. There was no study related to prevention. Overall quality of evidence was mostly low or very low due to their observational study designs, small sample sizes, flawed diagnosis of new-onset AF, and the absence of mortality evaluation. The incidence of new-onset AF varied from 4.5% to 15.0%, excluding exceptional cases (e.g., septic shock). Severity scores of patients with new-onset AF were higher than those without new-onset AF in eight studies, in four of which the difference was statistically significant. Five studies reported risk factors for new-onset AF, all of which used multivariate analyses to extract risk factors. Multiple risk factors are reported, e.g., advanced age, the white race, severity scores, organ failures, and sepsis. Hospital mortality in new-onset AF patients was higher than that of patients without AF in all studies, four of which found statistical significance. Among the five studies on treatment, only one study was randomized controlled, and various interventions were studied.
CONCLUSIONS
New-onset AF occurred in 5%-15% of the non-cardiac critically ill patients. Patients with new-onset AF had poor outcomes compared with those without AF. Despite the high incidence of new-onset AF in the general ICU population, currently available information for AF, especially for management (prevention, treatment, and anticoagulation), is quite limited. Further research is needed to improve our understanding of new-onset AF in critically ill patients.
PubMed: 25914828
DOI: 10.1186/s40560-015-0085-4 -
Critical Care (London, England) Dec 2014Critically ill patients with sepsis are prone to develop cardiac dysrhythmias, most commonly atrial fibrillation (AF). Systemic inflammation, circulating stress... (Review)
Review
INTRODUCTION
Critically ill patients with sepsis are prone to develop cardiac dysrhythmias, most commonly atrial fibrillation (AF). Systemic inflammation, circulating stress hormones, autonomic dysfunction, and volume shifts are all possible triggers for AF in this setting. We conducted a systematic review to describe the incidence, risk factors and outcomes of new-onset AF in patients with sepsis.
METHODS
MEDLINE, EMBASE and Web Of Science were searched for studies reporting the incidence of new-onset AF, atrial flutter or supraventricular tachycardia in patients with sepsis admitted to an intensive care unit, excluding studies that primarily focused on postcardiotomy patients. Studies were assessed for methodological quality using the GRADE system. Risk factors were considered to have a high level of evidence if they were reported in ≥ 2 studies using multivariable analyses at a P value <0.05. Subsequently, the strength of association was classified as strong, moderate or weak, based on the reported odds ratios.
RESULTS
Eleven studies were included. Overall quality was low to moderate. The weighted mean incidence of new-onset AF was 8% (range 0 to 14%), 10% (4 to 23%) and 23% (6 to 46%) in critically ill patients with sepsis, severe sepsis and septic shock, respectively. Independent risk factors with a high level of evidence included advanced age (weak strength of association), white race (moderate association), presence of a respiratory tract infection (weak association), organ failure (moderate association), and pulmonary artery catheter use (moderate association). Protective factors were a history of diabetes mellitus (weak association) and the presence of a urinary tract infection (weak association). New-onset AF was associated with increased short-term mortality in five studies (crude relative effect estimates ranging from 1.96 to 3.32; adjusted effects 1.07 to 3.28). Three studies reported a significantly increased length of stay in the ICU (weighted mean difference 9 days, range 5 to 13 days), whereas an increased risk of ischemic stroke was reported in the single study that looked at this outcome.
CONCLUSIONS
New-onset AF is a common consequence of sepsis and is independently associated with poor outcome. Early risk stratification of patients may allow for pharmacological interventions to prevent this complication.
Topics: Atrial Fibrillation; Humans; Incidence; Intensive Care Units; Risk Factors; Sepsis; Treatment Outcome
PubMed: 25498795
DOI: 10.1186/s13054-014-0688-5 -
Academic Emergency Medicine : Official... Jul 2014Electrical cardioversion is commonly used to treat patients with atrial fibrillation and atrial flutter to restore normal sinus rhythm. There has been considerable... (Review)
Review
OBJECTIVES
Electrical cardioversion is commonly used to treat patients with atrial fibrillation and atrial flutter to restore normal sinus rhythm. There has been considerable debate as to whether the electrode placement affects the efficacy of electrical cardioversion. The objective of this study was to examine the effectiveness of anteroposterior (A-P) versus anterolateral (A-L) electrode placement to restore normal sinus rhythm.
METHODS
A search of eight electronic databases, including Medline, EMBASE, CINAHL, and Cochrane was completed. Grey literature (hand-searching, Google, and SCOPUS) searching was also conducted. Studies were included if they were controlled clinical trials comparing the effectiveness of A-P versus A-L pad placement to restore normal sinus rhythm in adult patients with atrial fibrillation and flutter. Two independent reviewers judged study relevance, inclusion, and quality (e.g., risk of bias). Individual and pooled statistics were calculated as relative risks (RRs) with 95% confidence intervals (CIs) using a random-effects model, and heterogeneity (I(2) ) was reported.
RESULTS
From 788 citations, 13 studies were included; seven involved monophasic, five involved biphasic, and one analyzed both waveform devices. The included studies tended to report cumulative success rates to restoring normal sinus rhythm after one to five sequential shocks of increasing energy; the number of shocks and energy used differed among studies. The risk of bias of the studies was "unclear." After the first shock, pad placement was not associated with an increased likelihood of restoring normal sinus rhythm (RR = 0.88; 95% CI = 0.73 to 1.06); however, heterogeneity was high (I(2) = 63%). Subgroup comparisons revealed that the A-L position was more effective (RR = 0.77; 95% CI = 0.59 to 1.00) at restoring normal sinus rhythm when using biphasic shocks (comparison p = 0.04). Overall, the pooled results failed to identify a difference between A-P and A-L pad placement in restoring normal sinus rhythm at any time (RR = 1.00; 95% CI = 0.95 to 1.05); however, heterogeneity was high (I(2) = 61%). No significant subgroup differences were found. Side effects were reported in only three studies.
CONCLUSIONS
The published literature is restricted to persistent atrial fibrillation and atrial flutter, pad placement varied, and energy levels used were lower than currently recommended; however, the accumulated evidence suggests that electrical pad placement is not a critically important factor in successful cardioversion in atrial fibrillation and flutter (AF/AFL). A trial is urgently needed in recent-onset atrial fibrillation and atrial flutter patients using biphasic devices and high energy levels to resolve the debate.
Topics: Adult; Anti-Arrhythmia Agents; Atrial Fibrillation; Atrial Flutter; Combined Modality Therapy; Electric Countershock; Female; Humans; Male; Premedication
PubMed: 25117151
DOI: 10.1111/acem.12407 -
Journal of Atrial Fibrillation 2013The aim of this systematic literature review and meta-analyses was to explore the relationship between physical activity and risk of new-onset atrial fibrillation (AF)... (Review)
Review
The aim of this systematic literature review and meta-analyses was to explore the relationship between physical activity and risk of new-onset atrial fibrillation (AF) or flutter (AFlu). The search revealed 10 published studies that were eligible for three different meta-analyses. A meta-analysis of six case-control studies showed that risk of AF increased more than 5-fold in athletes compared to non-athletic controls, OR=5.3 [(3.6, 7.9; 95% confidence interval (CI)], p<0.0001. A second meta-analysis of three case-control studies showed a significantly higher prevalence of athletes among AF populations compared to their healthy controls, OR=4.7 (3.1-6.9; 95% CI), p<0.0001. A third meta-analysis of three prospective large-scale long-term studies showed that moderate/high habitual physical activity was associated with significantly reduced risk of AF compared with none or very low intensity physical activity OR=0.89(0.83, 0.96; 95% CI), p=002 Long-term vigorous physical training or lack of physical activity both are associated with increased risk of AF, while habitual moderate physical activity may be associated with reduced risk. Further large-scale prospective randomized controlled studies particularly in athletes are needed to further confirm these findings.
PubMed: 28496815
DOI: 10.4022/jafib.789 -
The Journal of Thoracic and... May 2011Our objectives were to evaluate short- and long-term mortality associated with new-onset atrial fibrillation after coronary artery bypass grafting and to identify... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVES
Our objectives were to evaluate short- and long-term mortality associated with new-onset atrial fibrillation after coronary artery bypass grafting and to identify preoperative and intraoperative patient characteristics associated with new-onset atrial fibrillation.
METHODS
Three independent investigators comprehensively reviewed the literature using Medline from 1960, Web of Science from 1980, and Scopus from 1960. All searches were done through December 2009. Selected cohort studies were used to evaluate associations between new-onset atrial fibrillation after coronary artery bypass grafting or coronary bypass plus valve and short-term mortality (defined as 30-day or in-hospital mortality) and long-term mortality (defined as mortality ≥ 6 months). We excluded studies involving atrial flutter, off-pump coronary bypass, and isolated valve surgery. Heterogeneity among studies was accounted for by meta-analysis with random-effects models.
RESULTS
Eleven studies (n = 40,112) met our inclusion criteria. New-onset atrial fibrillation was associated with higher short-term mortality (3.6% vs 1.9%; odds ratio [OR], 2.29; 95% confidence interval [CI], 1.74-3.01; P < .00001; heterogeneity of effects, P = .002). Mortality risks at 1 year and 4 years were 2.56 (95% CI, 2.14-3.08) and 2.19 (95% CI, 1.97-2.45; P < .0001), respectively. Older age, lower ejection fraction, history of hypertension, heart failure, prior stroke, peripheral arterial disease, and longer cardiopulmonary bypass and aortic clamp times were associated with new-onset atrial fibrillation. Preoperative use of ß-blockers reduced occurrence of new-onset atrial fibrillation (OR, 0.94 [95% CI, 0.88-1.01; P = .08]), whereas angiotensin-converting enzyme inhibitors increased it (OR, 1.20 [95% CI, 1.11-1.29], P < .00001).
CONCLUSIONS
New-onset atrial fibrillation after coronary artery bypass grafting appears to increase short- and long-term mortality. Preoperative use of ß-blockers, avoidance of angiotensin-converting enzyme inhibitors, and shorter cardiopulmonary bypass and aortic clamp times potentially reduce occurrence of new-onset atrial fibrillation.
Topics: Adrenergic beta-Antagonists; Aged; Angiotensin-Converting Enzyme Inhibitors; Aorta; Atrial Fibrillation; Cardiopulmonary Bypass; Chi-Square Distribution; Constriction; Coronary Artery Bypass; Female; Humans; Male; Middle Aged; Odds Ratio; Risk Assessment; Risk Factors; Time Factors
PubMed: 21247589
DOI: 10.1016/j.jtcvs.2010.10.040 -
Health Technology Assessment... Oct 2010This paper presents a summary of the evidence review group (ERG) report on the clinical effectiveness and cost-effectiveness of dronedarone for the treatment of atrial... (Review)
Review
This paper presents a summary of the evidence review group (ERG) report on the clinical effectiveness and cost-effectiveness of dronedarone for the treatment of atrial fibrillation (AF) or atrial flutter based upon a review of the manufacturer's submission to the National Institute for Health and Clinical Excellence (NICE) as part of the single technology appraisal process. The population considered in the submission were adult clinically stable patients with a recent history of or current non-permanent AF. Comparators were the current available anti-arrhythmic drugs: class 1c agents (flecainide and propafenone), sotalol and amiodarone. Outcomes were AF recurrence, all-cause mortality, stroke, treatment discontinuations (due to any cause or due to adverse events) and serious adverse events. The main evidence came from four phase III randomised controlled trials, direct and indirect meta-analyses from a systematic review, and a synthesis of the direct and indirect evidence using a mixed-treatment comparison. Overall, the results from the different synthesis approaches showed that the odds of AF recurrence appeared statistically significantly lower with dronedarone and other anti-arrhythmic drugs than with non-active control, and that the odds of AF recurrence are statistically significantly higher for dronedarone than for amiodarone. However, the results for outcomes of all-cause mortality, stroke and treatment discontinuations and serious adverse events were all uncertain. A discrete event simulation model was used to evaluate dronedarone versus antiarrhythmic drugs and standard therapy alone. The incremental cost-effectiveness ratio of dronedarone was relatively robust and less than 20,000 pounds per quality-adjusted life-year. Exploratory work undertaken by the ERG identified that the main drivers of cost-effectiveness were the benefits assigned to dronedarone for all-cause mortality and stroke. Dronedarone is not cost-effective relative to its comparators when the only effect of treatment is a reduction in AF recurrences. In conclusion, uncertainties remain in the clinical effectiveness and cost-effectiveness of dronedarone. In particular, the clinical evidence for the major drivers of cost-effectiveness (all-cause mortality and stroke), and consequently the additional benefits attributed in the economic model to dronedarone compared to other anti-arrhythmic drugs are highly uncertain. The final guidance, issued by NICE on 25 August 2010, states that: Dronedarone is recommended as an option for the treatment of non-permanent atrial fibrillation only in people: whose atrial fibrillation is not controlled by first-line therapy (usually including beta-blockers), that is, as a second-line treatment option, and who have at least one of the following cardiovascular risk factors: - hypertension requiring drugs of at least two different classes, diabetes mellitus, previous transient ischaemic attack, stroke or systemic embolism, left atrial diameter of 50 mm or greater, left ventricular ejection fraction less than 40% (noting that the summary of product characteristics [SPC] does not recommend dronedarone for people with left ventricular ejection fraction less than 35% because of limited experience of using it in this group) or age 70 years or older, and who do not have unstable New York Heart Association (NYHA) class III or IV heart failure. Furthermore, 'People who do not meet the criteria above who are currently receiving dronedarone should have the option to continue treatment until they and their clinicians consider it appropriate to stop'.
Topics: Adult; Aged; Aged, 80 and over; Amiodarone; Anti-Arrhythmia Agents; Atrial Fibrillation; Atrial Flutter; Clinical Trials, Phase III as Topic; Cost-Benefit Analysis; Dronedarone; Humans; Middle Aged; Randomized Controlled Trials as Topic
PubMed: 21047492
DOI: 10.3310/hta14suppl2/08 -
Health Technology Assessment... Nov 2008To determine the safety, clinical effectiveness and cost-effectiveness of radio frequency catheter ablation (RCFA) for the curative treatment of atrial fibrillation (AF)... (Comparative Study)
Comparative Study Meta-Analysis Review
OBJECTIVES
To determine the safety, clinical effectiveness and cost-effectiveness of radio frequency catheter ablation (RCFA) for the curative treatment of atrial fibrillation (AF) and typical atrial flutter.
DATA SOURCES
For the systematic reviews of clinical studies 25 bibliographic databases and internet sources were searched in July 2006, with subsequent update searches for controlled trials conducted in April 2007. For the review of cost-effectiveness a broad range of studies was considered, including economic evaluations conducted alongside trials, modelling studies and analyses of administrative databases.
REVIEW METHODS
Systematic reviews of clinical studies and economic evaluations of catheter ablation for AF and typical atrial flutter were conducted. The quality of the included studies was assessed using standard methods. A decision model was developed to evaluate a strategy of RFCA compared with long-term antiarrhythmic drug (AAD) treatment alone in adults with paroxysmal AF. This was used to estimate the cost-effectiveness of RFCA in terms of cost per quality-adjusted life-year (QALY) under a range of assumptions. Decision uncertainty associated with this analysis was presented and used to inform future research priorities using the value of information analysis.
RESULTS
A total of 4858 studies were retrieved for the review of clinical effectiveness. Of these, eight controlled studies and 53 case series of AF were included. Two controlled studies and 23 case series of typical atrial flutter were included. For atrial fibrillation, freedom from arrhythmia at 12 months in case series ranged from 28% to 85.3% with a weighted mean of 76%. Three RCTs suggested that RFCA is more effective than long-term AAD therapy in patients with drug-refractory paroxysmal AF. Single RCTs also suggested superiority of RFCA over electrical cardioversion followed by long-term AAD therapy and of RFCA plus AAD therapy over AAD maintenance therapy alone in drug-refractory patients. The available RCTs provided insufficient evidence to determine the effectiveness of RFCA beyond 12 months or in patients with persistent or permanent AF. Adverse events and complications were generally rare. Mortality rates were low in both RCTs and case series. Cardiac tamponade and pulmonary vein stenosis were the most frequently recorded complications. For atrial flutter, freedom from arrhythmia at 12 months in case series ranged from 85% to 92% with a weighted mean of 88%. Neither of the atrial flutter RCTs reported freedom from arrhythmia at 12 months. One RCT found a statistically significant benefit favouring ablation over AADs in terms of freedom from arrhythmia at a mean follow-up of 22 months. A second RCT reported a more modest effect favouring ablation in terms of freedom from atrial flutter at follow-up in older patients (mean age 78 years) after their first episode of flutter. In the atrial flutter case series, mortality was rare and the most frequent complications were atrioventricular block and haematomas. Complications in the RCTs were similar, except for those events likely to have been caused by AAD therapy (e.g. thyroid dysfunction). The review of cost-effectiveness evidence found one relevant study, which from a UK NHS perspective had a number of important limitations. The base-case analysis in the decision model demonstrated that if the quality of life benefits of RFCA are maintained over the remaining lifetime of the patient then the cost-effectiveness of RFCA appears clear. These findings were robust over a wide range of alternative assumptions, being between 7763 and 7910 pounds per additional QALY with very little uncertainty. If the quality of life benefits of RFCA are assumed to be maintained for no more than 5 years, cost-effectiveness of RFCA is dependent on a number of factors. Estimates of cost-effectiveness that explored the influence of these factors ranged from 23,000 to 38,000 pounds per QALY.
CONCLUSIONS
RFCA is a relatively safe and efficacious procedure for the therapeutic treatment of AF and typical atrial flutter. There is some randomised evidence to suggest that RFCA is superior to AADs in patients with drug-refractory paroxysmal AF in terms of freedom from arrhythmia at 12 months. RFCA appears to be cost-effective if the observed quality of life benefits are assumed to continue over a patient's lifetime. However, there remain uncertainties around longer-term effects of the intervention and the extent to which published effectiveness findings can be generalised to 'typical' UK practice. All catheter ablation procedures for the treatment of AF or atrial flutter undertaken in the UK should be recorded prospectively and centrally and measures to increase compliance in recording RFCA procedures may be needed. This would be of particular value in establishing the long-term benefits of RFCA and the true incidence and impact of any complications. Collection of appropriate quality of life data within any such registry would also be of value to future clinical and cost-effectiveness research in this area. Any planned multicentre RCTs comparing RFCA against best medical therapy for the treatment of AF and/or atrial flutter should be conducted among 'non-pioneering' centres using the techniques and equipment typically employed in UK practice and should measure relevant outcomes.
Topics: Adult; Anti-Arrhythmia Agents; Atrial Fibrillation; Atrial Flutter; Catheter Ablation; Cost-Benefit Analysis; Databases, Bibliographic; Humans; Quality-Adjusted Life Years; Safety; Technology Assessment, Biomedical; Treatment Outcome; United Kingdom
PubMed: 19036232
DOI: 10.3310/hta12340 -
WITHDRAWN: Anticoagulants or antiplatelet therapy for non-rheumatic atrial fibrillation and flutter.The Cochrane Database of Systematic... Jul 2007Atrial fibrillation (AF) carries a high risk of stroke and other thromboembolic events. Appropriate use of drugs to prevent thromboembolism in patients with AF involves... (Review)
Review
BACKGROUND
Atrial fibrillation (AF) carries a high risk of stroke and other thromboembolic events. Appropriate use of drugs to prevent thromboembolism in patients with AF involves comparing the patient's risk of stroke to the risk of hemorrhage from medication use.
OBJECTIVES
To quantify risk of stroke, major hemorrhage and death from using medications that have been rigorously evaluated for prevention of thromboembolism in AF.
SEARCH STRATEGY
Articles were identified through the Cochrane Collaboration's CENTRAL database and MEDLINE until December 1999.
SELECTION CRITERIA
Included Randomized controlled trials of drugs to prevent thromboembolism in adults with non-postoperative AF. Excluded RCTS of patients with rheumatic valvular disease.
DATA COLLECTION AND ANALYSIS
Data were abstracted by two reviewers. Odds ratios from all qualitatively similar studies were combined, with weighting by study size, to yield aggregate odds ratios for stroke, major hemorrhage, and death for each drug.
MAIN RESULTS
Fourteen articles were included in this review. Warfarin was more efficacious than placebo for primary stroke prevention {aggregate odds ratio (OR) of stroke=0.30 [95% Confidence Interval (C.I.) 0.19,0.48]}, with moderate evidence of more major bleeding { OR= 1.90 [95% C.I. 0.89,4.04].}. Aspirin was inconclusively more efficacious than placebo for stroke prevention {OR=0.68 [95% C.I. 0.29,1.57]}, with inconclusive evidence regarding more major bleeds {OR=0.81[95% C.I. 0.37,1.78]}. For primary prevention, assuming a baseline risk of 45 strokes per 1000 patient-years, warfarin could prevent 30 strokes at the expense of only 6 additional major bleeds. Aspirin could prevent 17 strokes, without increasing major hemorrhage. In direct comparison, there was moderate evidence for fewer strokes among patients on warfarin than on aspirin {aggregate OR=0.64[95% C.I. 0.43,0.96]}, with only suggestive evidence for more major hemorrhage {OR =1.58 [95% C.I. 0.76,3.27]}. However, in younger patients, with a mean age of 65 years, the absolute reduction in stroke rate with warfarin compared to aspirin was low (5.5 per 1000 person-years) compared to an older group (15 per 1000 person-years). Low-dose warfarin or low-dose warfarin with aspirin was less efficacious for stroke prevention than adjusted-dose warfarin.
AUTHORS' CONCLUSIONS
The evidence strongly supports warfarin in AF for patients at average or greater risk of stroke, although clearly there is a risk of hemorrhage. Although not definitively supported by the evidence, aspirin may prove to be useful for stroke prevention in sub-groups with a low risk of stroke, with less risk of hemorrhage than with warfarin. Further studies are needed of low- molecular weight heparin and aspirin in lower risk patients.
Topics: Anticoagulants; Atrial Fibrillation; Atrial Flutter; Confidence Intervals; Hemorrhage; Humans; Odds Ratio; Platelet Aggregation Inhibitors; Randomized Controlled Trials as Topic; Stroke; Thromboembolism
PubMed: 17636690
DOI: 10.1002/14651858.CD001938.pub2