Rhythm control in atrial fibrillation:assessing risks, benefits and outcome

Atrial fibrillation (AF) is the most common cardiac arrhythmia in the world with a prevalence of 2-4%. This percentage is expected to increase in the coming years due to the increase in risk factors associated with AF, the increase of the average age of the population and due to earlier detection of AF. Treatments focused on stopping AF and restoring and maintaining the normal sinus rhythm are called ‘rhythm-control strategies’. These treatments are mainly applied to treat the symptoms of AF. Despite the development of many rhythm-control strategies during the last 50+ years, rhythm-control remains challenging and there is still no golden standard among these various strategies in achieving and maintaining sinus rhythm, as AF keeps coming back especially in cases of long episodes of AF and in patients with multiple underlying comorbidities. Additionally, every patient is different and it remains difficult to decide which patient should undergo these rhythm-control strategies because it is not easy to predict who can be treated successfully with each of these strategies. That is why the choice for AF treatment is often based on a shared-decision with the patient after discussing the benefits and risks of each rhythm-control strategy. It is also important to remember that treating a patient with AF is more than trying to ‘clean up’ AF on the ECG. Treating the underlying risk factors and associated comorbidities in AF patients is essential to achieve the best possible outcome for these patients

Disasters and Disaster Medicine

The rate of disaster occurrence has increased greatly in the recent decades in both natural and man-made ones. There are more hurricanes and other natural disasters occurring now than a century ago. In addition, there is marked increase in the terrorist attacks on cities and civilians in both conventional weapons and in chemical and biological ones. The increase in the rate of disasters obliges medical society to pay more and more attention to the disaster response. There are attempts to make the subject of disaster as an independent specialty of medicine because it has unique focus in managing cases and it involves dealing with several issues other than direct medical treatment of patients

Update on management of atrial fibrillation in heart failure:a focus on ablation

Atrial fibrillation is increasingly encountered in patients with heart failure. Both diseases have seen tremendous rises in incidence in recent years. In general, the treatment of atrial fibrillation is focused on relieving patients from atrial fibrillation-related symptoms and risk reduction for thromboembolism and the occurrence or worsening of heart failure. Symptomatic relief may be accomplished by either (non-)pharmacological rate or rhythm control in combination with optimal therapy of underlying cardiovascular morbidities and risk factors. Atrial fibrillation ablation has been performed in patients without overt heart failure successfully for many years. However, in recent years, attempts have been made for patients with heart failure as well. In this review, we discuss the current literature describing the treatment of atrial fibrillation in heart failure. We highlight the early rate versus rhythm control studies, the importance of addressing underlying conditions and treatment of risk factors. A critical evaluation will be performed of the catheter ablation studies that have been performed so far in light of larger (post-hoc) ablation studies. Furthermore, we will hypothesise the role of patient selection as next step in optimising outcome for patient with atrial fibrillation and heart failure

Role of Primary Health Care System in Response to a Major Incident: Challenges and Actions

There is obvious increase in world population and in term of number of major incidents (MI) all over the world, there is a need for faster and wider responses. To achieve this aim and keep losses to the minimum, we need to optimize our methods and protocols of the response to decrease the losses, pain, and suffering of people and losses of infrastructures, belongings, and the country’s future. Primary health care (PHC) system, which is present in all residency gatherings in cities and towns, provides suitable potential for this improvement. This role has been formulated in 1978 in Alma-Ata meeting, which changes the scope of service of primary health care system to take responsibility of the community in addition to patients’ care. The involvement of the primary health care in response to major incidents shows good results, and there is a need to strengthen the major incidents’ response plan in the primary health care to provide better response and help to all populations especially the vulnerable ones

Access to Emergency Healthcare

Access to emergency services is essential for the health and well-being of people. The World Health Organization (WHO) made it a human right for everybody to have access to emergency care and it is an ethical obligation for governments to provide this service for the whole population. In recent years, the overcrowding in emergency departments has become a prominent issue that needs proper solutions. There have been several attempts resolving this ongoing issue. One of those is the patients’ distribution according to the severity level of their chief complaint, since more than half of the urgent cases are of low acuity and can be managed in less equipped facilities. Primary healthcare centers are perfectly suited to look after a significant proportion of cases for many reasons such as their scope of service, their wider geographical distribution, and are a more cost-effective resource for such cases than the use of higher acuity facilities. In Qatar, we have been implementing such model of patient distribution to release the burden on emergency departments since 1999. In this chapter we are proposing a full protocol to distribute emergency patients involving the ambulance service, primary healthcare centers, and emergency departments. Cooperation of all these services with the help of higher authorities and media is expected to show great improvements in patient care and better crowd control in emergency departments

Systematic review of the safety of medication use in inpatient, outpatient and primary care settings in the Gulf Cooperation Council countries

Background Errors in medication use are a patient safety concern globally, with different regions reporting differing error rates, causes of errors and proposed solutions. The objectives of this review were to identify, summarise, review and evaluate published studies on medication errors, drug related problems and adverse drug events in the Gulf Cooperation Council (GCC) countries. Methods A systematic review was carried out using six databases, searching for literature published between January 1990 and August 2016. Research articles focussing on medication errors, drug related problems or adverse drug events within different healthcare settings in the GCC were included. Results Of 2094 records screened, 54 studies met our inclusion criteria. Kuwait was the only GCC country with no studies included. Prescribing errors were reported to be as high as 91% of a sample of primary care prescriptions analysed in one study. Of drug-related admissions evaluated in the emergency department the most common reason was patient non-compliance. In the inpatient care setting, a study of review of patient charts and medication orders identified prescribing errors in 7% of medication orders, another reported prescribing errors present in 56% of medication orders. The majority of drug related problems identified in inpatient paediatric wards were judged to be preventable. Adverse drug events were reported to occur in 8.5–16.9 per 100 admissions with up to 30% judged preventable, with occurrence being highest in the intensive care unit. Dosing errors were common in inpatient, outpatient and primary care settings. Omission of the administered dose as well as omission of prescribed medication at medication reconciliation were common. Studies of pharmacists’ interventions in clinical practice reported a varying level of acceptance, ranging from 53% to 98% of pharmacists’ recommendations. Conclusions Studies of medication errors, drug related problems and adverse drug events are increasing in the GCC. However, variation in methods, definitions and denominators preclude calculation of an overall error rate. Research with more robust methodologies and longer follow up periods is now required.Peer reviewe

First-line treatment of persistent and long-standing persistent atrial fibrillation with single-stage hybrid ablation:a 2-year follow-up study

AIMS: This study evaluates the efficacy and safety of first-line single-stage hybrid ablation of (long-standing) persistent atrial fibrillation (AF), over a follow-up period of 2 years, and provides additional information on arrhythmia recurrences and electrophysiological findings at repeat ablation. METHODS AND RESULTS: This is a prospective cohort study that included 49 patients (65% persistent AF; 35% long-standing persistent AF) who underwent hybrid ablation as first-line ablation treatment (no previous endocardial ablation). Patients were relatively young (57.0 ± 8.5 years) and predominantly male (89.8%). Median CHA2DS2-VASc score was 1.0 (0.5; 2.0) and mean left atrium volume index was 43.7 ± 10.9 mL/m2. Efficacy was assessed by 12-lead electrocardiography and 72-h Holter monitoring after 3, 6, 12, and 24 months. Recurrence was defined as AF/atrial flutter (AFL)/tachycardia (AT) recorded by electrocardiography or Holter monitoring lasting >30 s during 2-year follow-up. At 2-year follow-up, single and multiple procedure success rates were 67% and 82%, respectively. Two (4%) patients experienced a major complication (bleeding) requiring intervention following hybrid ablation. Among the 16 (33%) patients who experienced an AF/AFL/AT recurrence, 13 (81%) were ATs/AFLs and only 3 (19%) were AF. Repeat ablation was performed in 10 (20%) patients and resulted in sinus rhythm in 7 (70%) at 2-year follow-up. CONCLUSION: First-line single-stage hybrid AF ablation is an effective treatment strategy for patients with persistent and long-standing persistent AF with an acceptable rate of major complications. Recurrences are predominantly AFL/AT that can be successfully ablated percutaneously. Hybrid ablation seems a feasible approach for first-line ablation of (long-standing) persistent AF

Obesity is associated with impaired long-term success of pulmonary vein isolation:A plea for risk factor management before ablation

Aims: Obesity is an increasing health problem and is an important risk factor for the development of atrial fibrillation (AF). We investigated the association of body mass index (BMI) on the safety and long-term efficacy of pulmonary vein isolation (PVI) for drug-refractory AF. Methods: 414 consecutive patients who underwent transcatheter PVI for AF between 2003 and 2013 were included. Successful PVI was defined as absence of atrial arrhythmia on Holter monitoring or ECG, without and with antiarrhythmic drugs during follow-up. Obesity was defined as BMI≥30 kg/m². Results: Mean age was 56±10 years, 316 (76%) were male, 311 (75%) had paroxysmal AF and 111 (27%) were obese. After a mean follow-up of 46±32 months (1590 patient-years), freedom from atrial arrhythmia and antiarrhythmic drugs was significantly lower in patients with obesity compared with non-obese patients (30% vs 46%, respectively, P=0.005, log-rank 0.016). With antiarrhythmic drugs, freedom from atrial arrhythmia was 56% vs 68% (P=0.036). No differences in minor and major adverse events were observed between patients with obesity and non-obese patients (major 6% vs 3%, P=0.105, and minor 5% vs 5%, P=0.512). Sensitivity analyses demonstrated that BMI (as continuous variable) was associated with PVI outcome (HR 1.08, 95% CI 1.02 to 1.14, P=0.012). Conclusion: Obesity is associated with reduced efficacy of PVI for drug-refractory AF. No relation between obesity and adverse events was found

Identifying patients with atrial fibrillation recurrences after two pulmonary vein isolation procedures

INTRODUCTION: Pulmonary vein isolation (PVI) is an important treatment for atrial fibrillation (AF). However, many patients need more than one procedure to maintain long-term sinus rhythm. Even after two PVIs some may suffer from AF recurrences. We aimed to identify characteristics of patients who fail after two PVI procedures. METHODS AND RESULTS: We included 557 consecutive patients undergoing a first PVI procedure with a second-generation 28 mm cryoballoon. Follow-up procedures were performed using radiofrequency ablation targeting reconnected PVs only. Recurrent AF was defined as any episode of AF lasting >30 s on ECG or 24 hour Holter monitoring performed at 3, 6 and 12 months post procedure. Mean age was 59.1±10.2 years, 383 (68.8%) were male, 448 (80.4%) had paroxysmal AF and the most common underlying condition was hypertension (36.6%). A total of 140/557 (25.1%) patients underwent redo procedure with PVI only. Of these patients 45 (32.4%) had recurrence of AF. These patients were comparable regarding age and sex to those in sinus rhythm after one or two procedures. Multivariate logistic regression showed that non-paroxysmal AF (OR 1.08 (95% CI 1.01 to 1.15), estimated glomerular filtration rate (OR 0.96, 95% CI 0.94 to 0.99), bundle branch block (OR 4.17, 95% CI 1.38 to 12.58), heart failure (OR 4.17, 95% CI 1.38 to 12.58) and Left Atrium Volume Index (OR 1.04, 95% CI 1.01 to 1.08) were associated with AF recurrence after two PVIs. The area under the curve for the identified risk factors was 0.74. CONCLUSIONS: Using a PVI-only approach, recurrence of AF after two AF ablation procedures is associated with more advanced underlying disease and persistent types of AF