Perspectives on the modern management of non-valvular atrial fi brillation

Atrial fi brillation is the most common clinical arrhythmia. The mainstay in the prevention of atrial fi brillation related stroke is oral anticoagulation. The 2 most important aspects in the management of patients with atrial fi brillation, is therefore risk stratifi cation for stroke and risk assessment for bleeding. Assessment of risk factors is in fact a dynamic process. In appropriate patients, novel anticoagulants are safe and better tolerated, and may be considered as an alternative to warfarin. In patients who are truly intolerant of, or where an absolute contra-indication to anticoagulationexists, occlusion of the left atrial appendage may be considered. Patients are to be carefully counselled with regards this therapy as currently, questions surrounding its safety and long-term effi ciency remain unanswered. This is an area of on-going research and further evidenceis awaited. Catheter ablation of atrial fi brillation is a highly effective therapy to achieve freedom of recurrent arrhythmia and relief from symptomatic atrial fi brillation. Recent systematic reviews demonstrate a low incidence of periprocedural complications with regards catheter ablation of atrial fi brillation, with acute complication rates having decreased signifi cantly in recent years. This may be attributed to increasing experience andimproved catheter technology

Cardiac monitoring in memory clinics: national survey of UK practice

Aims and method People diagnosed with dementia are often started on acetylcholinesterase inhibitors (AChEIs). As AChEIs can be associated with cardiac side-effects, an electrocardiogram (ECG) is sometimes requested before treatment. Previous work has suggested there is little consensus as to when or how ECGs should be obtained. This can create inconsistent practice, with patient safety, economic and practical repercussions. We surveyed 305 UK memory clinic practitioners about prescribing practice. Results More than 84% of respondents completed a pulse and cardiac history before prescribing AChEIs. Opinion was divided as to who should fund and conduct ECGs. It was believed that obtaining an ECG causes patients inconvenience and delays treatment. Despite regularly interpreting ECGs, 76% of respondents did not update this clinical skill regularly. Clinical implications The variation in practice observed has service-level and patient implications and raises potential patient safety concerns. Implementing national guidelines or seeking novel ways of conducting cardiac monitoring could help standardise practice

Assessment of atrial fibrosis for the rhythm control of atrial fibrillation

Rhythm control of atrial fibrillation (AF) remains challenging, with modest long-term success rates. Atrial fibrosis has been associated with AF, but the clinical utility of assessment of this fibrosis has yet to be fully elucidated. In this paper we review the current state of understanding of the pathophysiology of atrial fibrosis in AF, and its impact upon the instigation and propagation of the arrhythmia. Fibrosis causes an increase in volume of dysfunctional extracellular matrix, and is associated with cellular alterations such as hypertrophy, apoptosis and membrane dysfunction within the atrial myocardium. In turn, these cause pathological alterations to atrial conduction, such as increased anisotropy, conduction block and re-entry, which can lead to AF. We review current methods of assessing atrial fibrosis and their impact upon the prediction of success of interventional rhythm control strategies such as ablation and cardioversion. We focus particularly on circulating biomarkers of fibrosis and scar formation; their role in the fibrotic process, and their value in the prediction of rhythm control success. We also review imaging and invasive electrocardiographic mapping techniques that may identify fibrosis, and again assess their potential predictive value. In this area there exist many unanswered questions, but further work will help to refine techniques to reliably identify and treat those patients who are most likely to benefit from rhythm control treatment strategies

Left atrial voltage, circulating biomarkers of fibrosis, and atrial fibrillation ablation. A prospective cohort study.

Aims To test the ability of four circulating biomarkers of fibrosis, and of low left atrial voltage, to predict recurrence of atrial fibrillation after catheter ablation. Background Circulating biomarkers potentially may be used to improve patient selection for atrial fibrillation ablation. Low voltage areas in the left atrium predict arrhythmia recurrence when mapped in sinus rhythm. This study tested type III procollagen N terminal peptide (PIIINP), galectin-3 (gal-3), fibroblast growth factor 23 (FGF-23), and type I collagen C terminal telopeptide (ICTP), and whether low voltage areas in the left atrium predicted atrial fibrillation recurrence, irrespective of the rhythm during mapping. Methods 92 atrial fibrillation ablation patients were studied. Biomarker levels in peripheral and intra-cardiac blood were measured with enzyme-linked immunosorbent assay. Low voltage (<0.5mV) was expressed as a proportion of the mapped left atrial surface area. Follow-up was one year. The primary endpoint was recurrence of arrhythmia. The secondary endpoint was a composite of recurrence despite two procedures, or after one procedure if no second procedure was undertaken. Results The biomarkers were not predictive of either endpoint. After multivariate Cox regression analysis, high proportion of low voltage area in the left atrium was found to predict the primary endpoint in sinus rhythm mapping (hazard ratio 4.323, 95% confidence interval 1.337–13.982, p = 0.014) and atrial fibrillation mapping (hazard ratio 5.195, 95% confidence interval 1.032–26.141, p = 0.046). This effect was also apparent for the secondary endpoint. Conclusion The studied biomarkers do not predict arrhythmia recurrence after catheter ablation. Left atrial voltage is an independent predictor of recurrence, whether the left atrium is mapped in atrial fibrillation or sinus rhythm

The Changing Landscape for Stroke\ua0Prevention in AF: Findings From the GLORIA-AF Registry Phase 2

Background GLORIA-AF (Global Registry on Long-Term Oral Antithrombotic Treatment in Patients with Atrial Fibrillation) is a prospective, global registry program describing antithrombotic treatment patterns in patients with newly diagnosed nonvalvular atrial fibrillation at risk of stroke. Phase 2 began when dabigatran, the first non\u2013vitamin K antagonist oral anticoagulant (NOAC), became available. Objectives This study sought to describe phase 2 baseline data and compare these with the pre-NOAC era collected during phase&nbsp;1. Methods During phase 2, 15,641 consenting patients were enrolled (November 2011 to December 2014); 15,092 were eligible. This pre-specified cross-sectional analysis describes eligible patients\u2019 baseline characteristics. Atrial fibrillation&nbsp;disease characteristics, medical outcomes, and concomitant diseases and medications were collected. Data were analyzed using descriptive statistics. Results Of the total patients, 45.5% were female; median age was 71 (interquartile range: 64, 78) years. Patients were from Europe (47.1%), North America (22.5%), Asia (20.3%), Latin America (6.0%), and the Middle East/Africa (4.0%). Most had high stroke risk (CHA2DS2-VASc [Congestive heart failure, Hypertension, Age&nbsp; 6575 years, Diabetes mellitus, previous Stroke, Vascular disease, Age 65 to 74 years, Sex category] score&nbsp; 652; 86.1%); 13.9% had moderate risk (CHA2DS2-VASc&nbsp;= 1). Overall, 79.9% received oral anticoagulants, of whom 47.6% received NOAC and 32.3% vitamin K antagonists (VKA); 12.1% received antiplatelet agents; 7.8% received no antithrombotic treatment. For comparison, the proportion of phase 1 patients (of N&nbsp;= 1,063 all eligible) prescribed VKA was 32.8%, acetylsalicylic acid 41.7%, and no therapy 20.2%. In Europe in phase 2, treatment with NOAC was more common than VKA (52.3% and 37.8%, respectively); 6.0% of patients received antiplatelet treatment; and 3.8% received no antithrombotic treatment. In North America, 52.1%, 26.2%, and 14.0% of patients received NOAC, VKA, and antiplatelet drugs, respectively; 7.5% received no antithrombotic treatment. NOAC use was less common in Asia (27.7%), where 27.5% of patients received VKA, 25.0% antiplatelet drugs, and 19.8% no antithrombotic treatment. Conclusions The baseline data from GLORIA-AF phase 2 demonstrate that in newly diagnosed nonvalvular atrial fibrillation patients, NOAC have been highly adopted into practice, becoming more frequently prescribed than VKA in&nbsp;Europe and North America. Worldwide, however, a large proportion of patients remain undertreated, particularly in&nbsp;Asia&nbsp;and North America. (Global Registry on Long-Term Oral Antithrombotic Treatment in Patients With Atrial Fibrillation [GLORIA-AF]; NCT01468701

The assessment of circulating matrix metalloproteinases and their inhibitors in health and cardiovascular disease

The thesis objective was to define the variance of circulating MMP-9, TIMP-1 & -2 in healthy controls (HC), and study these in hypertension, diabetes, stable coronary (CAD) and peripheral arterial disease (PAD), in particular the effect of the treatment; the link to coronary collateralisation, inflammation and diastolic dysfunction. In HC, I found no gender differences or diurnal variation in MMP/TIMPs except MMP-9 being lower in the Far Eastern cohort.  TIMP-1 & -2 declined with aging and rose with acute exercise.  Patients with hypertension had higher MMP-9 and TIMP-1 compared to HC; MMP-9 correlated with cardiovascular risk scores.  MMP-9 fell whereas TIMP-1 rose with anti-hypertensive therapy.  In diabetic patients, MMP-9, TIMP-1 & -2 were higher compared to HC, but only TIMP-1 fell with treatment.  TIMP-1 correlated with echocardiographic indices of impaired diastolic relaxation in diabetes and hypertension.  In gestational hypertension MMP-9 was lower and TIMP-1 & -2 higher compared to normotensive pregnant controls. In CAD and PAD MMP-9 and TIMP-1 were raised compared to HC (TIMP-2 also elevated in CAD).  In CAD, women had higher MMP-9 and a trend towards lower MMP-9 in patients with collaterals was seen.  White cell count correlated with MMP-9. In PAD, MMP-9 and TIMP-1 tracked disease severity.  Neutrophil MMP-9 was elevated in CAD and systolic dysfunction. There is a difference in circulating MMP-9, TIMP-1 & -2 in patients with CVD compared to HC.  I have shown a link between tissue structure and inflammation and these measures, which are potential markers of tissue turnover and prognosis.EThOS - Electronic Theses Online ServiceGBUnited Kingdo

The State of Cardiac Electrophysiology in Africa: Ongoing Efforts and Future Directions

Rapid urbanization has increased noncommu- nicable diseases exponentially in Africa with cardiovascular disorders playing a dominant role. The diagnosis of cardiac arrhythmias has there- fore become common in daily practice in many African centers where electrocardiograph (ECG) machines are available

Coronary Guidewires in Temporary Cardiac Pacing and Assessment of Myocardial Viability: Current Perspectives and Future Directions

Intracoronary guidewires used in percutaneous coronary intervention can also be configured to provide temporary ventricular pacing. Trans coronary electrophysiological parameters recorded by employing coronary guidewires may have a potential role in assessing myocardial viability and could provide a means to make an immediate on-table decision about revascularisation. To date, some small studies have demonstrated the safety of this technique in temporary cardiac pacing, but further research is required to refine this approach and establish its clinical utility in myocardial viability assessment. In this review we discuss the potential role of trans coronary electrophysiology in the assessment of myocardial viability