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Despite being a rare phenomenon, pericardial hydatid cysts present unique diagnostic challenges and require a multimodality imaging as well as a multidisciplinary approach for a curative management. The authors here present a case of a middle aged man who was referred to them for management of new onset atrial flutter with mitral regurgitation.
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Aleteo Atrial , Equinococosis , Insuficiencia de la Válvula Mitral , Humanos , Masculino , Aleteo Atrial/complicaciones , Aleteo Atrial/diagnóstico , Equinococosis/complicaciones , Equinococosis/diagnóstico , Insuficiencia de la Válvula Mitral/diagnóstico , Insuficiencia de la Válvula Mitral/etiología , Insuficiencia de la Válvula Mitral/complicaciones , Persona de Mediana Edad , Diagnóstico Diferencial , Pericardio/diagnóstico por imagen , Ecocardiografía/métodos , Quiste Mediastínico/complicaciones , Quiste Mediastínico/diagnóstico , Quiste Mediastínico/diagnóstico por imagenRESUMEN
BACKGROUND: Direct oral anticoagulants are the standard of care for stroke prevention in eligible patients with atrial fibrillation and atrial flutter; however, bleeding remains a significant concern, limiting their use. Milvexian is an oral Factor XIa inhibitor that may offer similar anticoagulant efficacy with less bleeding risk. METHODS: LIBREXIA AF (NCT05757869) is a global phase III, randomized, double-blind, parallel-group, event-driven trial to compare milvexian with apixaban in participants with atrial fibrillation or atrial flutter. Participants are randomly assigned to milvexian 100 mg or apixaban (5 mg or 2.5 mg per label indication) twice daily. The primary efficacy objective is to evaluate if milvexian is noninferior to apixaban for the prevention of stroke and systemic embolism. The principal safety objective is to evaluate if milvexian is superior to apixaban in reducing the endpoint of International Society of Thrombosis and Hemostasis (ISTH) major bleeding events and the composite endpoint of ISTH major and clinically relevant nonmajor (CRNM) bleeding events. In total, 15,500 participants from approximately 1,000 sites in over 30 countries are planned to be enrolled. They will be followed until both 430 primary efficacy outcome events and 530 principal safety events are observed, which is estimated to take approximately 4 years. CONCLUSION: The LIBREXIA AF study will determine the efficacy and safety of the oral Factor XIa inhibitor milvexian compared with apixaban in participants with either atrial fibrillation or atrial flutter. TRIAL REGISTRATION: ClinicalTrials.gov NCT05757869.
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Fibrilación Atrial , Inhibidores del Factor Xa , Pirazoles , Piridonas , Accidente Cerebrovascular , Humanos , Fibrilación Atrial/complicaciones , Fibrilación Atrial/tratamiento farmacológico , Pirazoles/uso terapéutico , Pirazoles/administración & dosificación , Piridonas/uso terapéutico , Piridonas/administración & dosificación , Piridonas/efectos adversos , Método Doble Ciego , Accidente Cerebrovascular/prevención & control , Accidente Cerebrovascular/etiología , Masculino , Femenino , Inhibidores del Factor Xa/uso terapéutico , Inhibidores del Factor Xa/administración & dosificación , Aleteo Atrial/complicaciones , Hemorragia/inducido químicamente , Persona de Mediana Edad , Anciano , Factor XIa/antagonistas & inhibidores , Anticoagulantes/uso terapéutico , Anticoagulantes/administración & dosificación , Anticoagulantes/efectos adversosAsunto(s)
Antiarrítmicos , Aleteo Atrial , Electrocardiografía , Taquicardia Ventricular , Verapamilo , Humanos , Antiarrítmicos/uso terapéutico , Aleteo Atrial/complicaciones , Aleteo Atrial/tratamiento farmacológico , Aleteo Atrial/fisiopatología , Informes de Casos como Asunto , Ablación por Catéter , Taquicardia Ventricular/complicaciones , Taquicardia Ventricular/tratamiento farmacológico , Taquicardia Ventricular/fisiopatología , Verapamilo/uso terapéuticoRESUMEN
OBJECTIVES: The objectives of this study are to study the risk of developing cardiac arrhythmia and its subtypes over time in patients with systemic sclerosis (SSc), to assess potential risk factors for arrhythmia in SSc and to explore whether arrhythmia is associated with mortality. METHODS: We used nationwide Swedish registers to identify patients with incident SSc 2004-2019 and matched general population comparators (1:10). The primary outcome was incident arrhythmia. Follow-up started at the date of SSc diagnosis and ended at the primary outcome, death, emigration or 31 December 2019. We estimated the incidence of arrhythmia overall and stratified by subtype and explored the relative risk in relation to time since diagnosis using flexible parametric models. We used Cox regression to study risk factors for arrhythmia and the association of arrhythmia with mortality. RESULTS: We identified 1565 patients and 16 009 comparators. The overall incidence of arrhythmia was 255 (95% CI 221 to 295) and 119 (95% CI 112 to 127) per 10 000 person years in patients with SSc and comparators, respectively, corresponding to an IRR of 2.1 (95% CI 1.8 to 2.5). The greatest hazard difference between patients with SSc compared with the comparators was seen in the first year of follow-up (HR for arrhythmia 3.0; 95% CI 2.3 to 3.8). Atrial fibrillation and flutter were the most common arrhythmia subtypes. Male sex, index age and pulmonary arterial hypertension were significant risk factors for arrhythmia in SSc. Incident arrhythmia was significantly associated with mortality (HR 2.2; 95% CI 1.6 to 3.0). CONCLUSION: SSc is associated with higher incidence of cardiac arrhythmia compared with general population. Arrhythmia seems to be an early manifestation of SSc and is associated with higher mortality.
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Arritmias Cardíacas , Sistema de Registros , Esclerodermia Sistémica , Humanos , Esclerodermia Sistémica/mortalidad , Esclerodermia Sistémica/complicaciones , Esclerodermia Sistémica/epidemiología , Suecia/epidemiología , Masculino , Femenino , Persona de Mediana Edad , Incidencia , Factores de Riesgo , Arritmias Cardíacas/epidemiología , Arritmias Cardíacas/mortalidad , Arritmias Cardíacas/complicaciones , Arritmias Cardíacas/etiología , Anciano , Adulto , Modelos de Riesgos Proporcionales , Aleteo Atrial/epidemiología , Aleteo Atrial/complicaciones , Aleteo Atrial/mortalidadRESUMEN
We present a case of a young man with a new-onset supraventricular arrhythmia accompanied by polyuria and natriuresis with subsequent renal salt-wasting causing hypovolemic hyponatremia. Resolution of the electrolyte imbalance occurred only after successful atrial flutter ablation.
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Hiponatremia , Humanos , Masculino , Hiponatremia/etiología , Adulto , Ablación por Catéter , Aleteo Atrial/etiología , Aleteo Atrial/complicaciones , Taquicardia Supraventricular/etiología , Taquicardia Supraventricular/complicaciones , Poliuria/etiología , Enfermedades Renales/complicacionesRESUMEN
RATIONALE: This case report addresses a unique instance of atrial flutter complicating acute respiratory distress syndrome (ARDS), contributing a novel addition to the medical literature. The co-occurrence of these conditions sheds light on a rare clinical scenario that requires careful consideration. PATIENT CONCERNS: The patient exhibited symptoms of pronounced dyspnea, tachypnea, and hypoxemia. Clinical assessment revealed irregular heart rhythms, notably atrial flutter, alongside characteristic signs of ARDS, including bilateral pulmonary infiltrates and reduced lung compliance. DIAGNOSES AND INTERVENTIONS: After a comprehensive evaluation, the patient was diagnosed with atrial flutter complicating ARDS. Therapeutic measures encompassed antiarrhythmic agents, mechanical ventilation, and targeted ARDS management protocols. The intricate interplay between cardiac and respiratory factors necessitated a multidisciplinary approach. OUTCOMES: Throughout treatment, the patient's respiratory distress gradually improved. Control of the atrial flutter was achieved, and oxygenation levels were restored within acceptable limits. This successful outcome underscores the significance of a well-coordinated treatment strategy in addressing complex cases like this. LESSONS: This case highlights the importance of recognizing and managing the intricate relationship between cardiac arrhythmias such as atrial flutter and respiratory complications like ARDS. The successful management of this patient underscores the value of multidisciplinary collaboration and tailored therapeutic interventions. Practitioners should remain vigilant for such rare complications and consider this case a reminder of the potential complexities that can arise in critical care scenarios.
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Aleteo Atrial , Síndrome de Dificultad Respiratoria , Humanos , Aleteo Atrial/complicaciones , Aleteo Atrial/terapia , Arritmias Cardíacas , Síndrome de Dificultad Respiratoria/complicaciones , Síndrome de Dificultad Respiratoria/terapia , Corazón , Antiarrítmicos , DisneaRESUMEN
BACKGROUND: Atrial fibrillation (AF) and/or atrial flutter (AFL) with rapid ventricular response (RVR) is a condition that often requires urgent treatment. Although guidelines have recommendations regarding chronic rate control therapy, recommendations on the best choice for acute heart rate (HR) control in RVR are unclear. METHODS: A systematic search across multiple databases was performed for studies evaluating the outcome of HR control (defined as HR less than 110 bpm and/or 20% decrease from baseline HR). Included studies evaluated AF and/or AFL with RVR in a hospital setting, with direct comparison between intravenous (IV) diltiazem and metoprolol and excluded cardiac surgery and catheter ablation patients. Hypotension (defined as systolic blood pressure less than 90 mmHg) was measured as a secondary outcome. Two authors performed full-text article review and extracted data, with a third author mediating disagreements. Random effects models utilizing inverse variance weighting were used to calculate odds ratios (OR) and 95% confidence intervals (CI). Heterogeneity was assessed using the I2 test. RESULTS: A total of 563 unique titles were identified through the systematic search, of which 16 studies (7 randomized and 9 observational) were included. In our primary analysis of HR control by study type, IV diltiazem was found to be more effective than IV metoprolol for HR control in randomized trials (OR 4.75, 95% CI 2.50-9.04 with I2 = 14%); however, this was not found for observational studies (OR 1.26, 95% CI 0.89-1.80 with I2 = 55%). In an analysis of observational studies, there were no significant differences between the two drugs in odds of hypotension (OR 1.12, 95% CI 0.51-2.45 with I2 = 18%). CONCLUSION: While there was a trend toward improved HR control with IV diltiazem compared with IV metoprolol in randomized trials, this was not seen in observational studies, and there was no observed difference in hypotension between the two drugs.
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Fibrilación Atrial , Aleteo Atrial , Hipotensión , Humanos , Diltiazem/uso terapéutico , Fibrilación Atrial/complicaciones , Metoprolol/uso terapéutico , Aleteo Atrial/tratamiento farmacológico , Aleteo Atrial/complicaciones , Hipotensión/tratamiento farmacológico , Estudios Observacionales como AsuntoRESUMEN
BACKGROUND: In arrhythmogenic right ventricular cardiomyopathy (ARVC), risk of atrial arrhythmias (AAs) persists after ventricular tachycardia (VT) ablation. OBJECTIVE: The purpose of this study was to determine the type, prevalence, outcome, and risk correlates of AA in ARVC in patients undergoing VT ablation. METHODS: Prospectively collected procedural and clinical data on ARVC patients undergoing VT ablation were analyzed. Risk score for typical atrial flutter was determined from univariate logistic regression analysis. RESULTS: Of 119 consecutive patients with ARVC and VT ablation, 40 (34%) had AA: atrial fibrillation (AF) in 31, typical isthmus-dependent atrial flutter (AFL) in 27, and atrial tachycardia/atypical flutter (AT) in 10. Seventeen patients (43%) with AA experienced inappropriate defibrillator therapy, with 15 patients experiencing shocks. Ablation was performed for typical AFL in 21 (53%), AT in 5 (13%), and pulmonary vein isolation for AF in 4 (10%) patients and prevented AA in 78% and all AFL during additional mean follow-up of 65 months. Risk score for typical flutter included age >40 years (1 point), ≥moderate right ventricular dysfunction (2 points), ≥moderate tricuspid regurgitation (2 points), ≥moderate right atrial dilation (2 points), and right ventricular volume >250 cc (3points), with score >4 identifying 50% prevalence of typical flutter. CONCLUSION: AAs are common in patients with ARVC and VT, can result in inappropriate implantable cardioverter-defibrillator shocks, and typically are controlled with atrial ablation. A risk score can be used to identify patients at high risk for typical AFL who may be considered for isthmus ablation at the time of VT ablation.
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Displasia Ventricular Derecha Arritmogénica , Fibrilación Atrial , Aleteo Atrial , Ablación por Catéter , Taquicardia Supraventricular , Taquicardia Ventricular , Humanos , Adulto , Aleteo Atrial/complicaciones , Aleteo Atrial/diagnóstico , Displasia Ventricular Derecha Arritmogénica/complicaciones , Displasia Ventricular Derecha Arritmogénica/diagnóstico , Taquicardia Ventricular/diagnóstico , Taquicardia Ventricular/epidemiología , Taquicardia Ventricular/etiología , Taquicardia Supraventricular/cirugía , Complicaciones Posoperatorias/etiología , Ablación por Catéter/efectos adversos , Resultado del TratamientoRESUMEN
Tachycardia-induced cardiomyopathy is defined as a reversible left ventricular (LV) systolic dysfunction (SeD) resulting from a sustained fast heart rate. LV remodeling in patients with severe LV dysfunction at diagnosis remains poorly understood. In this retrospective cohort study, we described LV remodeling in 50 patients who underwent atrial flutter ablation. These patients were divided into severe LV SeD (LV ejection fraction [EF] ≤30%) and LV nonsevere SeD (LVEF 31% to 50%) at baseline. All continuous variables are expressed as median and interquartile range. LVEF was 18% (13 to 25) and 38% (34 to 41) in the SeD (n = 29) and LV nonsevere SeD (n = 21) groups, respectively. At baseline, patients with SeD had higher LV end-diastolic diameter (56 [54 to 59] vs 49 mm [47 to 52], p <0.01), LV end-systolic diameter (48 [43 to 51] vs 36 mm [34 to 41], p <0.01), LV end-diastolic volume (71 [64 to 85] vs 56 ml/m2 [46 to 68], p <0.01), LV end-systolic volume (56 [53 to 70] vs 36 ml/m2 [27 to 42], p <0.01), and lower tricuspid annular plane systolic excursion (12 [10 to 13] vs 16 mm [13 to 19], p <0.01). At last follow-up, LVEF was not statistically significantly different between groups. However, LV end-systolic diameter (36 [34 to 39] vs 32 mm [32 to 34], p = 0.01) and LV end-systolic volume (29 [26 to 35] vs 25 ml/m2 [20 to 29], p = 0.02) remained larger in the SeD group. Seven patients (14%), all from the SeD group, had a LVEF ≤35% 2 months after rhythm control, and reverse remodeling was observed up to 9 months. In conclusion, more than half of patients with tachycardia-induced cardiomyopathy and atrial flutter had LVEF ≤30% at baseline. LVEF recovery and LV remodeling were observed beyond 2 months, highlighting the importance of rhythm control and early guideline-directed medical therapy in these patients.
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Aleteo Atrial , Cardiomiopatías , Ablación por Catéter , Disfunción Ventricular Izquierda , Humanos , Aleteo Atrial/complicaciones , Aleteo Atrial/cirugía , Estudios Retrospectivos , Cardiomiopatías/complicaciones , Disfunción Ventricular Izquierda/etiología , Función Ventricular Izquierda , Volumen Sistólico , Taquicardia , Remodelación Ventricular/fisiologíaRESUMEN
INTRODUCTION: Acute cardiac tamponade is a rare event during any type of interventional or surgical procedure. It can occur during electrophysiology procedures due to radiofrequency ablation, lead or catheter manipulation, transseptal puncture, laser lead extractions, or left atrial appendage occlusion device positioning. Cardiac tamponade is difficult to study in a prospective manner, and case reports and case series are important contributions to understanding the best options for patient care. An 87-year-old Caucasian male patient breathing spontaneously developed acute tamponade during an atrial flutter ablation. Pericardial drain insertion was difficult, and hypotension failed to respond to epinephrine boluses. The patient became hypoxemic and hypercarbic, requiring intubation. Unexpectedly, the blood pressure markedly increased postintubation and remained in a normal range until the pericardium was drained. CONCLUSION: Spontaneous ventilation is considered important to maintain venous return to the right heart during cardiac tamponade. However, spontaneous ventilation reduces venous return to the left heart and worsens the paradoxical pulse in tamponade. Intravenous vasopressors are thought to be ineffective during cardiac tamponade. Our patient maintained pulmonary blood flow as indicated by end-tidal carbon dioxide measurements but had no measurable systemic blood pressure during spontaneous ventilation. Our case demonstrates that tracheal intubation and positive pressure ventilation can transiently improve left heart venous return, systemic perfusion, and drug delivery to the systemic circulation.
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Aleteo Atrial , Taponamiento Cardíaco , Ablación por Catéter , Anciano de 80 o más Años , Humanos , Masculino , Aleteo Atrial/cirugía , Aleteo Atrial/complicaciones , Taponamiento Cardíaco/etiología , Taponamiento Cardíaco/cirugía , Ablación por Catéter/efectos adversos , Ablación por Catéter/métodos , Hemodinámica/fisiología , Respiración con Presión Positiva , Estudios ProspectivosRESUMEN
BACKGROUND: Our study hypothesized that an intelligent gradient boosting machine (GBM) model can predict cerebrovascular events and all-cause mortality in mitral stenosis (MS) with atrial flutter (AFL) by recognizing comorbidities, electrocardiographic and echocardiographic parameters. METHODS: The machine learning model was used as a statistical analyzer in recognizing the key risk factors and high-risk features with either outcome of cerebrovascular events or mortality. RESULTS: A total of 2184 patients with their chart data and imaging studies were included and the GBM analysis demonstrated mitral valve area (MVA), right ventricular systolic pressure, pulmonary artery pressure (PAP), left ventricular ejection fraction (LVEF), New York Heart Association (NYHA) class, and surgery as the most significant predictors of transient ischemic attack (TIA/stroke). MVA, PAP, LVEF, creatinine, hemoglobin, and diastolic blood pressure were predictors for all-cause mortality. CONCLUSION: The GBM model assimilates clinical data from all diagnostic modalities and significantly improves risk prediction performance and identification of key variables for the outcome of MS with AFL.
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Aleteo Atrial , Estenosis de la Válvula Mitral , Accidente Cerebrovascular , Humanos , Estenosis de la Válvula Mitral/complicaciones , Estenosis de la Válvula Mitral/diagnóstico por imagen , Aleteo Atrial/complicaciones , Función Ventricular Izquierda , Volumen Sistólico , Electrocardiografía , Accidente Cerebrovascular/complicacionesRESUMEN
OBJECTIVES: Comparison of the danish comorbidity index for acute myocardial infarction (DANCAMI), the charlson comorbidity index (CCI), the elixhauser comorbidity index (ECI), and the CHA2DS2-VASc score to predict ischemic stroke, cardiovascular mortality, and all-cause mortality after atrial fibrillation/flutter. MATERIALS AND METHODS: A population-based cohort study of all Danish patients with incident atrial fibrillation/flutter during 2000-2020 (n=361,901). C-Statistics were used to evaluate the discriminatory performance for predicting 1 and 5-year risks of the outcomes for a baseline model (including age and sex) +/- the individual indices. RESULTS: For the DANCAMI, the 5-year risk did not increase with comorbidity burden for ischemic stroke (5.9% for low vs. 5.6% for severe) but did increase for cardiovascular mortality (10% for low vs. 16% for severe) and all-cause mortality (33% for low vs. 61% for severe). C-Statistics for predicting 5-year ischemic stroke risk were similar for all models (0.64). C-Statistics for predicting 5-year cardiovascular mortality risk were also similar for the baseline (0.76), the DANCAMI (0.77), the CCI (0.76), the ECI (0.76), and the CHA2DS2-VASc (0.76) models. C-Statistics for predicting 5-year all-cause mortality risk were lower for the baseline (0.71) and the CHA2DS2-VASc (0.71) models than for the DANCAMI (0.75), the CCI (0.74), and the ECI (0.74) models. The 1-year C-Statistics were comparable. CONCLUSION: The DANCAMI predicted ischemic stroke and cardiovascular mortality risks similar to the CCI, the ECI, and the CHA2DS2-VASc. The DANCAMI predicted all-cause mortality risk similar to the CCI and the ECI, but better than the baseline and the CHA2DS2-VASc.
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Fibrilación Atrial , Aleteo Atrial , Accidente Cerebrovascular Isquémico , Infarto del Miocardio , Accidente Cerebrovascular , Humanos , Fibrilación Atrial/complicaciones , Accidente Cerebrovascular/etiología , Accidente Cerebrovascular Isquémico/complicaciones , Estudios de Cohortes , Medición de Riesgo , Infarto del Miocardio/complicaciones , Aleteo Atrial/complicaciones , Factores de RiesgoRESUMEN
BACKGROUND: Fetal atrial flutter (AF), accounting for 30% of all fetal tachyarrhythmias, predominantly (over 80%) manifests as a 2:1 atrioventricular conduction. Swift referral and timely intervention become imperative in instances of severe persistent arrhythmia. CASE PRESENTATION: We discuss the case of a 32-year-old multiparous Chinese woman, at 30+2 weeks of gestation, wherein an ultrasonographic examination revealed persistent fetal AF (atrial rate ranging from 219 to 445 beats/min and ventricular rate from 219 to 228 beats/min, with a 2:1 or 1:1 down transmission) and minor ascites. Despite the maternal ingestion of digoxin and sotalol, the fetal heart rhythm remained uncorrected. Following this, at 32+3 weeks of gestation, an intramuscular injection of cedilanid, guided by ultrasound, was administered to the fetus. Postoperatively, the fetal ventricular rate demonstrated a decline after 6 days, and the ascites resolved. Subsequently, at 33+3 weeks, a cesarean section was necessitated due to maternal intolerance to the medication, resulting in the delivery of the infant. Remarkably, the infant's cardiac rhythm spontaneously converted to sinus rhythm within 5 min of birth. A follow-up conducted 1 year postpartum revealed no recurrence of AF. CONCLUSIONS: This case illustrates that in the event of transplacental drug treatment failure, intrauterine therapeutic intervention should be considered. Moreover, it highlights the encouraging prognosis associated with fetal AF, as the cardiac rhythm spontaneously reverted to sinus rhythm postbirth in this instance.
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Aleteo Atrial , Enfermedades Fetales , Embarazo , Humanos , Femenino , Adulto , Aleteo Atrial/tratamiento farmacológico , Aleteo Atrial/complicaciones , Aleteo Atrial/diagnóstico , Antiarrítmicos/uso terapéutico , Cesárea , Ascitis/complicaciones , Ascitis/tratamiento farmacológico , Enfermedades Fetales/tratamiento farmacológico , Arritmias Cardíacas/complicaciones , Arritmias Cardíacas/tratamiento farmacológico , FetoRESUMEN
BACKGROUND: Atrial flutter with 1:1 conduction to the ventricles is a dangerous cardiac arrhythmia. Contemporary guidelines recommend atrioventricular nodal blocking agents should be co-administered with class 1C anti-arrhythmics, as prophylaxis against 1:1 flutter. No guidance is provided on the type or strength of atrioventricular nodal blockade required, and in practice, these agents are frequently prescribed at low dose, or even omitted, due to their side effect profile. CASE PRESENTATION: A 62 year old Caucasian man with a history of paroxysmal atrial fibrillation treated with flecainide, presented with atrial flutter with 1:1 conduction to the ventricles and was cardioverted. Diltiazem was added to prevent this complication and he again presented with atrial flutter with 1:1 conduction to the ventricles, despite prophylaxis with coadministration of diltiazem. CONCLUSIONS: This case report demonstrates failure of diltiazem to prevent 1:1 flutter in a patient chronically treated with flecainide for paroxysmal atrial fibrillation.
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Fibrilación Atrial , Aleteo Atrial , Bloqueo Atrioventricular , Masculino , Humanos , Persona de Mediana Edad , Diltiazem/uso terapéutico , Aleteo Atrial/tratamiento farmacológico , Aleteo Atrial/complicaciones , Flecainida/uso terapéutico , Fibrilación Atrial/tratamiento farmacológico , Fibrilación Atrial/complicaciones , Electrocardiografía , Antiarrítmicos/uso terapéutico , Bloqueo Atrioventricular/inducido químicamente , Bloqueo Atrioventricular/complicaciones , Bloqueo Atrioventricular/tratamiento farmacológicoRESUMEN
BACKGROUND: Interatrial block (IAB) is associated with thromboembolism and atrial arrhythmias. However, prior studies included small patient cohorts so it remains unclear whether IAB predicts adverse outcomes particularly in context of atrial fibrillation (AF)/atrial flutter (AFL). OBJECTIVES: This study sought to determine whether IAB portends increased stroke risk in a large cohort in the presence or absence of AFAF/AFL. METHODS: We performed a 5-center retrospective analysis of 4,837,989 electrocardiograms (ECGs) from 1,228,291 patients. IAB was defined as P-wave duration ≥120 ms in leads II, III, or aVF. Measurements were extracted as .XML files. After excluding patients with prior AF/AFL, 1,825,958 ECGs from 458,994 patients remained. Outcomes were analyzed using restricted mean survival time analysis and restricted mean time lost. RESULTS: There were 86,317 patients with IAB and 355,032 patients without IAB. IAB prevalence in the cohort was 19.6% and was most common in Black (26.1%), White (20.9%), and Hispanic (18.5%) patients and least prevalent in Native Americans (9.2%). IAB was independently associated with increased stroke probability (restricted mean time lost ratio coefficient [RMTLRC]: 1.43; 95% CI: 1.35-1.51; tau = 1,895), mortality (RMTLRC: 1.14; 95% CI: 1.07-1.21; tau = 1,924), heart failure (RMTLRC: 1.94; 95% CI: 1.83-2.04; tau = 1,921), systemic thromboembolism (RMTLRC: 1.62; 95% CI: 1.53-1.71; tau = 1,897), and incident AF/AFL (RMTLRC: 1.16; 95% CI: 1.10-1.22; tau = 1,888). IAB was not associated with stroke in patients with pre-existing AF/AFL. CONCLUSIONS: IAB is independently associated with stroke in patients with no history of AF/AFL even after adjustment for incident AF/AFL and CHA2DS2-VASc score. Patients are at increased risk of stroke even when AF/AFL is not identified.
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Fibrilación Atrial , Aleteo Atrial , Accidente Cerebrovascular , Tromboembolia , Humanos , Fibrilación Atrial/complicaciones , Fibrilación Atrial/epidemiología , Bloqueo Interauricular/complicaciones , Bloqueo Interauricular/epidemiología , Estudios Retrospectivos , Electrocardiografía , Accidente Cerebrovascular/epidemiología , Accidente Cerebrovascular/etiología , Aleteo Atrial/complicaciones , Aleteo Atrial/epidemiología , Tromboembolia/epidemiología , Tromboembolia/etiologíaRESUMEN
INTRODUCTION: Atrial fibrillation/flutter (AF) is common among patients with pulmonary hypertension (PH) and is associated with poor clinical outcomes. AF has been shown to occur more commonly among patients with postcapillary PH, although AF also occurs among patients with precapillary PH. The goal of this study was to evaluate the independent impact of PH hemodynamic phenotype on incident AF among patients with PH. METHODS: We retrospectively identified 262 consecutive patients, without a prior diagnosis of atrial arrhythmias, seen at the PH clinic at Mayo Clinic, Florida, between 1997 and 2017, who had right heart catheterization and echocardiography performed, with follow-up for outcomes through 2021. Kaplan-Meier analysis and Cox-proportional hazards regression modeling were used to evaluate the independent effect of PH hemodynamic phenotype on incident AF. RESULTS: Our study population was classified into two broad PH hemodynamic groups: precapillary (64.9%) and postcapillary (35.1%). The median age was 59.5 years (Q1: 48.4, Q3: 68.4), and 72% were female. In crude models, postcapillary PH was significantly associated with incident AF (HR 2.17, 95% CI: 1.26-3.74, p = 0.005). This association was lost following multivariable adjustment, whereas left atrial volume index remained independently associated with incident AF (aHR 1.30, 95% CI: 1.09-1.54, p = 0.003). CONCLUSION: We found PH hemodynamic phenotype was not significantly associated with incident AF in our patient sample; however, echocardiographic evidence of left atrial remodeling appeared to have a greater impact on AF development. Larger studies are needed to validate these findings and identify potential modifiable risk factors for AF in this population.
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Fibrilación Atrial , Aleteo Atrial , Hipertensión Pulmonar , Humanos , Femenino , Masculino , Fibrilación Atrial/complicaciones , Fibrilación Atrial/epidemiología , Fibrilación Atrial/diagnóstico , Hipertensión Pulmonar/epidemiología , Hipertensión Pulmonar/complicaciones , Estudios Retrospectivos , Atrios Cardíacos , Factores de Riesgo , Aleteo Atrial/complicaciones , HemodinámicaRESUMEN
OBJECTIVE: Atrial fibrillation/flutter (AF/AFL) accounts for high rates of ED presentations and hospital admissions. There is increasing evidence to suggest that delaying cardioversion for acute uncomplicated AF is safe, and that many patients will spontaneously revert to sinus rhythm (SR). We conducted a before-and-after evaluation of AF/AFL management after a change in ED pathway using a conservative 'rate-and-wait' approach, incorporating next working day outpatient clinic follow-up and delayed cardioversion if required. METHODS: We performed a before-and-after retrospective cohort study examining outcomes for patients who presented to the ED in Christchurch, New Zealand, with acute uncomplicated AF/AFL in the 1-year period before and after the implementation of a new conservative management pathway. RESULTS: A total of 360 patients were included in the study (182 'Pre-pathway' vs 178 'Post-Pathway'). Compared to the pre-pathway cohort, those managed under the new pathway had an 81.2% reduction in ED cardioversions (n = 32 vs n = 6), and 50.7% reduction in all cardioversions (n = 65 vs n = 32). There was a 31.6% reduction in admissions from ED (n = 54 vs n = 79). ED length of stay (3.9 h vs 3.8 h, net difference -0.1 h, 95% confidence interval [CI] -0.6 to 0.3), 1-year ED AF representation (32.4% vs 26.4%, net difference -6.0% [95% CI -16.0% to 3.9%]), 1-year ED ischaemic stroke presentation (2.2% in both groups) and 7-day all-cause mortality rates (hazard ratio 1.05 [95% CI 0.6 to 1.9]) were all similar. CONCLUSIONS: Using a conservative 'rate-and-wait' strategy with early follow-up for patients presenting to ED with AF/AFL can safely reduce unnecessary cardioversions and avoidable hospitalisations.
Asunto(s)
Fibrilación Atrial , Aleteo Atrial , Isquemia Encefálica , Accidente Cerebrovascular , Humanos , Fibrilación Atrial/tratamiento farmacológico , Cardioversión Eléctrica , Antiarrítmicos/uso terapéutico , Estudios Retrospectivos , Isquemia Encefálica/inducido químicamente , Isquemia Encefálica/complicaciones , Isquemia Encefálica/tratamiento farmacológico , Accidente Cerebrovascular/complicaciones , Hospitalización , Aleteo Atrial/inducido químicamente , Aleteo Atrial/complicaciones , Aleteo Atrial/tratamiento farmacológico , Servicio de Urgencia en Hospital , Resultado del TratamientoRESUMEN
CONTEXT: Although iodine-induced hyperthyroidism is a potential consequence of iodinated radiologic contrast administration, its association with long-term cardiovascular outcomes has not been previously studied. OBJECTIVE: To investigate the relationships between hyperthyroidism observed after iodine contrast administration and incident atrial fibrillation/flutter. METHODS: Retrospective cohort study of the U.S. Veterans Health Administration (1998-2021) of patients age ≥18 years with a normal baseline serum thyrotropin (TSH) concentration, subsequent TSH <1 year, and receipt of iodine contrast <60 days before the subsequent TSH. Cox proportional hazards regression was employed to ascertain the adjusted hazard ratio (HR) with 95% CI of incident atrial fibrillation/flutter following iodine-induced hyperthyroidism, compared with iodine-induced euthyroidism. RESULTS: Iodine-induced hyperthyroidism was observed in 2500 (5.6%) of 44 607 Veterans (mean ± SD age, 60.9 ± 14.1 years; 88% men) and atrial fibrillation/flutter in 10.4% over a median follow-up of 3.7 years (interquartile range 1.9-7.4). Adjusted for sociodemographic and cardiovascular risk factors, iodine-induced hyperthyroidism was associated with an increased risk of atrial fibrillation/flutter compared with those who remained euthyroid after iodine exposure (adjusted HR 1.19, 95% CI 1.06-1.33). Females were at greater risk for incident atrial fibrillation/flutter than males (females, HR 1.81, 95% CI 1.12-2.92; males, HR 1.15, 95% CI 1.03-1.30; P for interaction = .04). CONCLUSION: Hyperthyroidism following a high iodine load was associated with an increased risk of incident atrial fibrillation/flutter, particularly among females. The observed sex-based differences should be confirmed in a more sex-diverse study sample, and the cost-benefit analysis of long-term monitoring for cardiac arrhythmias following iodine-induced hyperthyroidism should be evaluated.
Asunto(s)
Fibrilación Atrial , Aleteo Atrial , Hipertiroidismo , Yodo , Masculino , Femenino , Humanos , Persona de Mediana Edad , Anciano , Adolescente , Fibrilación Atrial/inducido químicamente , Fibrilación Atrial/epidemiología , Estudios Retrospectivos , Hipertiroidismo/inducido químicamente , Hipertiroidismo/epidemiología , Hipertiroidismo/complicaciones , Aleteo Atrial/etiología , Aleteo Atrial/complicaciones , Yodo/efectos adversos , Tirotropina , Factores de RiesgoRESUMEN
BACKGROUND: Management of adults with atrial fibrillation (AF) or atrial flutter in the emergency department (ED) includes rate reduction, cardioversion, and stroke prevention. Different approaches to these components of care may lead to variation in frequency of hospitalization and stroke prevention actions, with significant implications for patient experience, cost of care, and risk of complications. Standardization using evidence-based recommendations could reduce variation in management, preventable hospitalizations, and stroke risk. METHODS: We describe the rationale for our ED-based AF treatment recommendations. We also describe the development of an electronic clinical decision support system (CDSS) to deliver these recommendations to emergency physicians at the point of care. We implemented the CDSS at three pilot sites to assess feasibility and solicit user feedback. We will evaluate the impact of the CDSS on hospitalization and stroke prevention actions using a stepped-wedge cluster randomized pragmatic clinical trial across 13 community EDs in Northern California. DISCUSSION: We hypothesize that the CDSS intervention will reduce hospitalization of adults with isolated AF or atrial flutter presenting to the ED and increase anticoagulation prescription in eligible patients at the time of ED discharge and within 30 days. If our hypotheses are confirmed, the treatment protocol and CDSS could be recommended to other EDs to improve management of adults with AF or atrial flutter. TRIAL REGISTRATION: ClinicalTrials.gov NCT05009225 . Registered on 17 August 2021.
Asunto(s)
Fibrilación Atrial , Aleteo Atrial , Sistemas de Apoyo a Decisiones Clínicas , Accidente Cerebrovascular , Adulto , Humanos , Anticoagulantes/uso terapéutico , Fibrilación Atrial/complicaciones , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/terapia , Aleteo Atrial/diagnóstico , Aleteo Atrial/terapia , Aleteo Atrial/complicaciones , Servicio de Urgencia en Hospital , Ensayos Clínicos Controlados Aleatorios como Asunto , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/prevención & control , Ensayos Clínicos Pragmáticos como AsuntoRESUMEN
BACKGROUND: China bears the biggest atrial fibrillation (AF) burden in the world. However, little is known about the incidence and predictors of AF. This study aimed to investigate the current incidence of AF and its electrocardiographic (ECG) predictors in general community individuals aged over 60 years in China. METHODS: This was a prospective cohort study, recruiting subjects who were aged over 60 years and underwent annual health checkups from April to July 2015 in four community health centers in Songjiang District, Shanghai, China. The subjects were then followed up from 2015 to 2019 annually. Data on sociodemographic characteristics, medical history, and the resting 12-lead ECG were collected. Kaplan-Meier curve was used for showing the trends in AF incidence and calculating the predictors of AF. Associations of ECG abnormalities and AF incidence were examined using Cox proportional hazard models. RESULTS: This study recruited 18,738 subjects, and 351 (1.87%) developed AF. The overall incidence rate of AF was 5.2/1000 person-years during an observation period of 67,704 person-years. Multivariable Cox regression analysis indicated age (hazard ratio [HR], 1.07; 95% confidence interval [CI]: 1.06-1.09; Pâ<â0.001), male (HR, 1.30; 95% CI: 1.05-1.62; Pâ=â0.018), a history of hypertension (HR, 1.55; 95% CI: 1.23-1.95; Pâ<â0.001), a history of cardiac diseases (HR, 3.23; 95% CI: 2.34-4.45; Pâ<â0.001), atrial premature complex (APC) (HR, 2.82; 95% CI: 2.17-3.68; Pâ<â0.001), atrial flutter (HR, 18.68; 95% CI: 7.37-47.31; Pâ<â0.001), junctional premature complex (JPC) (HR, 3.57; 95% CI: 1.59-8.02; Pâ=â0.002), junctional rhythm (HR, 18.24; 95% CI: 5.83-57.07; Pâ<â0.001), ventricular premature complex (VPC) (HR, 1.76; 95% CI: 1.13-2.75, Pâ=â0.012), short PR interval (HR, 5.49; 95% CI: 1.36-22.19; Pâ=â0.017), right atrial enlargement (HR, 6.22; 95% CI: 1.54-25.14; Pâ=â0.010), and pacing rhythm (HR, 3.99; 95% CI: 1.57-10.14; Pâ=â0.004) were independently associated with the incidence of AF. CONCLUSIONS: The present incidence of AF was 5.2/1000 person-years in the studied population aged over 60 years in China. Among various ECG abnormalities, only APC, atrial flutter, JPC, junctional rhythm, short PR interval, VPC, right atrial enlargement, and pacing rhythm were independently associated with AF incidence.