CLINICAL STUDIES
Stroke with intermittent atrial fibrillation: incidence and predictors during aspirin therapy
Robert G. Hart, MDa,
Lesly A. Pearce, MS ,
Robert M. Rothbart, MD, FACC ,
John H. McAnulty, MD, FACC ,
Richard W. Asinger, MD, FACC||,
Jonathan L. Halperin, MD, FACC¶ for the Stroke Prevention in Atrial Fibrillation Investigators
a University of Texas Health Science Center, San Antonio, Texas, USA
Axio Research Corporation, Seattle, Washington, USA
LeBauer Cardiology Associates, Greensboro, North Carolina, USA
Oregon Health Sciences University, Portland, Oregon, USA
|| Hennepin County Medical Center, Minneapolis, Minnesota, USA
¶ Mt. Sinai Medical Center, New York, New York, USA
Manuscript received March 4, 1999;
revised manuscript received July 8, 1999,
accepted September 10, 1999.
Reprint requests and correspondence: Dr. Robert G. Hart, Department of Medicine (Neurology), University of Texas HSC, 7703 Floyd Curl Drive, San Antonio, Texas 78284
HartR{at}uthscsa.edu
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Abstract
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OBJECTIVE
This study was performed to characterize the risk of stroke in elderly patients with recurrent intermittent atrial fibrillation (AF).
BACKGROUND
Although intermittent AF is common, relatively little is known about the attendant risk of stroke.
METHODS
A longitudinal cohort study was performed comparing 460 participants with intermittent AF with 1,552 with sustained AF treated with aspirin in the Stroke Prevention in Atrial Fibrillation studies and followed for a mean of two years. Independent risk factors for ischemic stroke were identified by multivariate analysis.
RESULTS
Patients with intermittent AF were, on average, younger (66 vs. 70 years, p < 0.001), were more often women (37% vs. 26% p < 0.001) and less often had heart failure (11% vs. 21%, p < 0.001) than those with sustained AF. The annualized rate of ischemic stroke was similar for those with intermittent (3.2%) and sustained AF (3.3%). In patients with intermittent AF, independent predictors of ischemic stroke were advancing age (relative risk [RR] = 2.1 per decade, p < 0.001), hypertension (RR = 3.4, p = 0.003) and prior stroke (RR = 4.1, p = 0.01). Of those with intermittent AF predicted to be high risk (24%), the observed stroke rate was 7.8% per year (95% confidence interval 4.5 to 14).
CONCLUSIONS
In this large cohort of AF patients given aspirin, those with intermittent AF had stroke rates similar to patients with sustained AF and similar stroke risk factors. Many elderly patients with recurrent intermittent AF have substantial rates of stroke and likely benefit from anticoagulation. High-risk patients with intermittent AF can be identified using the same clinical criteria that apply to patients with sustained AF.
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Abbreviations and Acronyms
| | AF | = atrial fibrillation | | CI | = confidence interval | | INR | = international normalized ratio | | RR | = relative risk | | SPAF | = Stroke Prevention in Atrial Fibrillation | | TIA | = transient ischemic attack |
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In about 25% of elderly people who have atrial fibrillation (AF), the dysrhythmia is intermittent, spontaneously arising and remitting with highly variable frequency, duration and symptoms (1–6). Stroke rates and risk factors are less well characterized in patients with intermittent (paroxysmal) AF as compared with those with sustained (constant) AF (7–9). Patients with intermittent AF are typically younger and have less associated cardiovascular disease versus those with sustained AF. While it is commonly held that patients with intermittent AF have a lower risk of stroke than those with sustained AF (1,10,11), the pattern of AF has not emerged as an independent predictor of stroke in multivariate analyses of elderly cohorts with this dysrhythmia (12–17). Regarding selection of antithrombotic prophylaxis, it is not known whether risk factors used to stratify stroke risk in AF patients apply specifically to those with intermittent AF.
We analyzed stroke rates and predictors of stroke among 460 participants with intermittent AF given aspirin in the Stroke Prevention in Atrial Fibrillation (SPAF) I-III studies and compared them with participants with sustained AF.
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Methods
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Participants in the SPAF I, II and III clinical trials (1987 to 1997) assigned to aspirin (325 mg/day) or to a combination of aspirin plus inefficacious fixed-dose warfarin in the SPAF III trial were considered in this analysis. The design, participant features and main results of these trials have been reported (18–23); these were carried out in compliance with local regulations governing human research. In brief, participants were adults with documented sustained or recurrent AF without mitral stenosis or prosthetic cardiac valves recruited from inpatient and outpatient facilities at two dozen clinical sites. Those under age 60 years without associated cardiovascular disease ("lone AF") and heavy alcohol users precluding safe anticoagulation were not eligible. Participants in the SPAF III trial assigned aspirin plus fixed, low-dose warfarin were included if the international normalized ratio (INR) did not exceed 1.4 during follow-up (mean achieved INR = 1.1, n = 290), because INRs below 1.5 offer minimal protection against ischemic stroke in patients with AF (18,24,25).
Atrial fibrillation was categorized as intermittent if sinus rhythm was documented within 12 months before study entry for SPAF I and II participants and within three months for SPAF III subjects. Diagnosis of intermittent AF required at least two electrocardiogram (ECG)-documented episodes before entry, no reversible cause of AF (e.g., thyrotoxicosis, pneumonia) and no iatrogenic cardioversion unless AF recurred before entry. For this analysis, those classified as intermittent AF with AF on the entry ECG and no subsequent documentation of sinus rhythm during the next six months were reclassified as sustained AF (n = 86; 16% of those initially classified as intermittent). When ischemic stroke occurred within the first six months after entry, the pattern of AF was classified based on observations before the stroke. Participants undergoing therapeutic cardioversion during the initial six months using drugs (n = 31) or countershock (n = 22) were included in the main analysis, except as otherwise specified. Hypertension was diagnosed if blood pressure exceeded either 160 mm Hg systolic or 90 mm Hg diastolic on repeated observations over six months or if chronic antihypertensive medication was required.
Patients were followed in clinic every three to six months to assess compliance and detect strokes. Stroke events were verified and categorized as cardioembolic, noncardioembolic or of uncertain cause by a central events committee unaware of treatment using a clinical classification scheme (26). A risk stratification scheme previously derived from this cohort by multivariate analysis was used to compare predictors of thromboembolism in patients with intermittent versus sustained AF (15).
Baseline characteristics of the intermittent versus sustained AF groups were compared using the Student t test for continuous variables and the chi-square test for categorical variables. The age-adjusted relative risk (RR) for stroke associated with a characteristic was estimated using a Cox proportional hazards model after first including the variable age. Differences in age-adjusted RRs between the intermittent and sustained AF patients were evaluated by fitting the model, adjusting for age, pattern of AF and factor of interest, and then testing significance of the interaction term for pattern of AF and factor of interest. Independent predictors of stroke were identified by a combination of forward and backward stepwise modeling techniques (Cox proportional hazards model). Statistical significance in each of these cases was assessed using the likelihood ratio statistic. Stroke rates were expressed per patient-year of observation, with 95% confidence intervals (CIs) determined from the Poisson distribution. Rates were compared between groups using a Poisson regression model. Analyses were done using SPSS and EGRET statistical software. All tests were two sided; statistical significance was accepted at the 95% confidence level (p < 0.05).
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Results
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Among 2,012 SPAF participants receiving aspirin or aspirin plus inefficacious doses of warfarin, AF was classified as intermittent in 460 (23%). Those with intermittent AF (mean age 66 years) were, on average, four years younger than those with sustained AF (p < 0.001), were more often women (p < 0.001) and had lower frequencies of heart failure and peripheral arterial disease (Table 1). During the initial six months of observation, 72% of SPAF III participants with intermittent AF had recurrent AF based on symptoms or rhythm tracings (comparable data not available for SPAF I and II).
During a mean follow-up of two years, the observed rate of ischemic stroke (n = 27) was 3.2% per year (95% CI 2.2 to 4.6) among those with intermittent AF compared with 3.3% per year (95% CI 2.7 to 4.0) for those with sustained AF. The exclusion of patients in whom cardioversion was attempted (4% of intermittent and 2% of sustained AF patients) did not alter the observed stroke rates.
Factors associated with ischemic stroke in patients with intermittent AF by univariate analysis were age (p < 0.001), hypertension (age-adjusted, p = 0.002), prior stroke or transient ischemic attack (TIA) (age-adjusted, p = 0.007) and peripheral arterial disease (age-adjusted, p = 0.002) (Table 2). Based on age-adjusted univariate analysis, systolic blood pressure >160 was more strongly associated with subsequent stroke in patients with sustained than intermittent AF (p = 0.06), while peripheral arterial disease was more closely related to stroke in patients with intermittent than sustained AF (p = 0.02). Age (p < 0.001), hypertension (p = 0.003) and prior stroke or TIA (p = 0.01) were the strongest predictors of ischemic stroke in patients with intermittent AF by multivariate analysis; these factors were also predictive among those with sustained AF (Table 3).
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Table 2 Factors Associated With Ischemic Stroke in Intermittent Versus Sustained AF: Age-adjusted Relative Risks*
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Applying the risk stratification scheme previously derived from the entire cohort, those with intermittent AF were more frequently classified as low risk than were those with sustained AF (p = 0.004, linear association), although differences were small (Table 4 , Fig. 1). This scheme successfully stratified participants with intermittent AF based on observed stroke rates (Table 4, Fig. 2 ; p < 0.001). About one-fourth of those with intermittent AF had high-risk features, and in these patients the rate of ischemic stroke was 7.8% per year (95% CI 4.5 to 14). Considering each category of predicted stroke risk by this scheme, there were no significant differences in observed stroke rates between those with intermittent and sustained AF (Table 4).
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Figure 1 Distribution according to predicted stroke risk using the SPAF Exploratory Analysis Criteria for patients with intermittent (n = 460) versus sustained (n = 1552) atrial fibrillation.
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Discussion
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In this large cohort of patients treated with aspirin, intermittent AF was associated with stroke rates comparable with sustained AF. Predictors of ischemic stroke were also similar, and a single risk stratification scheme predicted stroke for patients with either pattern of AF. Nearly one-fourth of the cohort with intermittent AF was classified as high-risk, and their rate of ischemic stroke was substantial during treatment with aspirin.
Our results are at odds with studies reporting lower rates of stroke in patients with intermittent rather than sustained AF (1,3,10) and in line with case series showing no differences in stroke between recurrent intermittent and sustained AF (9,17,27). Patients younger than 60 years old with "lone" AF and those with a single documented episode of AF were not eligible for participation. Hence, our cohort differs importantly from those in which young patients with "lone" or isolated episodes were prevalent (3,4,9). The mean age of our cohort was similar to that of patients with intermittent AF seen in clinical practice (5,7,9). Previous studies also have identified concomitant hypertension (7,30) and age (7,9) as predictors of stroke in intermittent AF.
Treatment with adjusted-dose warfarin appears to reduce stroke similarly for patients with either intermittent or sustained AF, although data are limited. Among high-risk paticipants in the SPAF III trial categorized as intermittent AF, those given adjusted-dose warfarin had significantly (p = 0.01) fewer strokes (0 strokes/91 participants) than those given aspirin and low, inefficacious doses of warfarin (6 strokes/80 participants) (Pearce LA for the SPAF Investigators, personal communication).
Study limitations.
Participants in the SPAF clinical trials were recruited mainly from in-patient, hospital-based populations and may not be representative of those with intermittent AF in the general population. Furthermore, our findings may not apply to younger, healthier and less symptomatic outpatients with intermittent AF. The risk of cardioembolic stroke associated with intermittent AF is likely to be related to the frequency and duration of paroxysms. The frequency and duration of episodes of AF were not accurately ascertained in this study, and stroke could not be reliably correlated with recurrence of the dysrhythmia or with conversion to sustained AF during follow-up (28). All participants in our study were given aspirin, which decreases ischemic stroke by about 20% in patients with AF (29).
Conclusions.
Elderly people with recurrent intermittent AF in this cohort had rates of ischemic stroke comparable with those with sustained AF and shared risk factors for stroke. The risk of stroke varies widely among those with intermittent AF as it does for sustained AF, and our results suggest that stroke risk can be stratified using the same clinical features irrespective of the pattern of AF. Additional studies correlating the frequency and duration of paroxysms with stroke rates are needed. Selection of antithrombotic therapy to prevent stroke should be based on the estimated risk of thromboembolism both for patients with intermittent and sustained AF. Patients with intermittent AF and additional stroke risk factors have high rates of stroke and likely benefit from anticoagulation for stroke prevention.
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Footnotes
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This work was supported by a grant (R01 NS 24-224) from the Division of Stroke and Trauma, National Institute of Neurological Disorders and Stroke, Bethesda, MD.
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References
|
|---|
1. Kannell WB, Abbott RD, Savage DD, McNamara P. Coronary heart disease and atrial fibrillation: The Framingham Study. Am Heart J. 1983;106:389–396[CrossRef][Medline]
2. Takahashi N, Seki A, Imataka K, Fujii J. Clinical features of paroxysmal atrial fibrillation: an observation of 94 patients. Jpn Heart J. 1981;22:143–148[Medline]
3. Phillips SJ, Whisnant JP, O’Fallon WM, Frye RL. Prevalence of cardiovascular disease and diabetes mellitus in residents of Rochester, Minnesota. Mayo Clin Proc. 1990;65:344–357[Medline]
4. Gajewski J, Singer RB. Mortality in an insured population with atrial fibrillation. J Am Med Assoc. 1981;245:1540–1544[Abstract/Free Full Text]
5. Lip GYH, Golding D, Nazir M, et al. A survey of atrial fibrillation in general practice: the West Birmingham Atrial Fibrillation Project. Br J Gen Prac. 1997;47:285–289[Medline]
6. O’Connell JE, Gray CS. Atrial fibrillation and stroke prevention in the community. Age Aging. 1996;25:307–309[Abstract/Free Full Text]
7. Corbalan R, Arriagada D, Braun S, et al. Risk factors for systemic embolism in patients with paroxysmal atrial fibrillation. Am Heart J. 1992;124:149–153[CrossRef][Medline]
8. Petersen P, Godtfredsen J. Embolic complications in paroxysmal atrial fibrillation. Stroke. 1986;17:622–626[Abstract/Free Full Text]
9. Nakajima K, Ichinose M. Ischemic stroke in elderly patients with paroxysmal atrial fibrillation. Jpn J Geriatrics. 1996;33:273–277
10. Treseder AS, Sastey BSD, Thomas TPL, et al. Atrial fibrillation and stroke in elderly hospitalized patients. Age Aging. 1986;15:89–92[Abstract/Free Full Text]
11. Petersen P. Thromboembolic complications in atrial fibrillation. Stroke. 1990;21:4–13[Abstract/Free Full Text]
12. Stroke Prevention in Atrial Fibrillation Investigators. Predictors of thromboembolism in atrial fibrillation: I. Clinical features of patients at risk. Ann Intern Med. 1992;116:1–5[Abstract/Free Full Text]
13. Atrial Fibrillation Investigators. Risk factors for stroke and efficacy of antithrombotic therapy in atrial fibrillation: analysis of pooled data from five randomized clinical trials. Arch Intern Med. 1994;154:1949–1957
14. Stroke Prevention in Atrial Fibrillation Investigators. Risk factors for thromboembolism during aspirin therapy in patients with atrial fibrillation: The Stroke Prevention in Atrial Fibrillation Study. J Stroke Cerebrovasc Dis. 1995;5:147–157
15. Hart RG, Pearce LA, McBride R, et al. Predictors of ischemic stroke during aspirin therapy in atrial fibrillation: exploratory analyses of 2012 participants in the SPAF I-III clinical trials. Stroke. 1999;30:1223–1229[Abstract/Free Full Text]
16. Moulton AW, Singer DE, Haas JS. Risk factors for stroke in patients with nonrheumatic atrial fibrillation. A case-control study. Am J Med. 1991;91:156–161[CrossRef][Medline]
17. Cabin HS, Clubb KS, Hall C, et al. Risk for systemic embolization of atrial fibrillation without mitral stenosis. Am J Cardiol. 1990;65:1112–1116[CrossRef][Medline]
18. Stroke Prevention in Atrial Fibrillation Investigators. Adjusted-dose warfarin versus low-intensity, fixed-dose warfarin plus aspirin for high-risk patients with atrial fibrillation: The Stroke Prevention in Atrial Fibrillation III randomised clinical trial. Lancet. 1996;348:633–638[CrossRef][Medline]
19. Stroke Prevention in Atrial Fibrillation Investigators. Prospective identification of patients with nonvalvular atrial fibrillation at low-risk of stroke during treatment with aspirin. JAMA. 1998;279:1273–1277[Abstract/Free Full Text]
20. Stroke Prevention in Atrial Fibrillation Investigators. The Stroke Prevention in Atrial Fibrillation Study: final results. Circulation. 1991;84:527–539[Abstract/Free Full Text]
21. Stroke Prevention in Atrial Fibrillation Investigators. Warfarin vs. aspirin for prevention of thromboembolism in atrial fibrillation: Stroke Prevention in Atrial Fibrillation II Study. Lancet. 1994;343:687–691[CrossRef][Medline]
22. Stroke Prevention in Atrial Fibrillation Investigators. Warfarin compared to aspirin for prevention of arterial thromboembolism in atrial fibrillation: design and patient characteristics of the SPAF II Study. Cerebrovasc Dis. 1992;2:332–341[CrossRef]
23. Stroke Prevention in Atrial Fibrillation Investigators. The Stroke Prevention in Atrial Fibrillation III study: rationale, design and patient features. J Stroke Cerebrovas Dis. 1997;5:341–353
24. Hylek EM, Skates SJ, Sheehan MA, Singer DE. An analysis of the lowest effective intensity of prophylactic anticoagulation for patients with nonrheumatic atrial fibrillation. N Engl J Med. 1996;335:540–546[Abstract/Free Full Text]
25. Hart RG. Intensity of anticoagulation to prevent stroke in patients with atrial fibrillation. Ann Intern Med. 1998;128:408[Free Full Text]
26. Miller VT, Rothrock JF, Pearce LA, et al. Ischemic stroke in patients with atrial fibrillation: effect of aspirin according to stroke mechanism. Neurology. 1993;43:32–36[Abstract/Free Full Text]
27. Roy D, Marchand E, Ganne P, et al. Usefulness of anticoagulant therapy in the prevention of embolic complications of atrial fibrillation. Am Heart J. 1986;112:1039–1043[CrossRef][Medline]
28. Flaker GC, Fletcher KA, Rothbart RM, et al. Clinical and echocardiographic features of intermittent atrial fibrillation that predict recurrent atrial fibrillation. Am J Cardiol. 1995;76:355–358[CrossRef][Medline]
29. Hart RG, Benavente O, McBride R, Pearce LA. Antithrombotic therapy to prevent stroke in patients with atrial fibrillation: a meta-analysis. Ann Intern Med. 1999;131:492–501[Abstract/Free Full Text]
30. Whisnant JP, Wiebers DO, O’Fallon WM, et al. A population-based model of risk factors for ischemic stroke. Neurology. 1996;47:1420–1428[Abstract/Free Full Text]
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|
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|
|
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|
|
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e61 - e61.
[Full Text]
[PDF]
|
|
|
|
|
|
|
N. L. Glazer, S. Dublin, N. L. Smith, B. French, L. A. Jackson, J. B. Hrachovec, D. S. Siscovick, B. M. Psaty, and S. R. Heckbert
Newly Detected Atrial Fibrillation and Compliance With Antithrombotic Guidelines
Arch Intern Med,
February 12, 2007;
167(3):
246 - 252.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
W. Rosamond, K. Flegal, G. Friday, K. Furie, A. Go, K. Greenlund, N. Haase, M. Ho, V. Howard, B. Kissela, et al.
Heart Disease and Stroke Statistics--2007 Update: A Report From the American Heart Association Statistics Committee and Stroke Statistics Subcommittee
Circulation,
February 6, 2007;
115(5):
e69 - e171.
[Full Text]
[PDF]
|
|
|
|
|
|
|
L Kalra, G Y H Lip, and on behalf of the Guideline Development Group for t
Antithrombotic treatment in atrial fibrillation
Heart,
January 1, 2007;
93(1):
39 - 44.
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. Nieuwlaat, A. Capucci, G. Y.H. Lip, S. B. Olsson, M. H. Prins, F. H. Nieman, J. Lopez-Sendon, P. E. Vardas, E. Aliot, M. Santini, et al.
Antithrombotic treatment in real-life atrial fibrillation patients: a report from the Euro Heart Survey on Atrial Fibrillation
Eur. Heart J.,
December 2, 2006;
27(24):
3018 - 3026.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
S. Monte, A. Macchia, F. Pellegrini, M. Romero, V. Lepore, A. D'Ettorre, M. Saugo, L. Tavazzi, and G. Tognoni
Antithrombotic treatment is strongly underused despite reducing overall mortality among high-risk elderly patients hospitalized with atrial fibrillation
Eur. Heart J.,
September 2, 2006;
27(18):
2217 - 2223.
[Abstract]
[Full Text]
[PDF]
|
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Writing Committee Members, V. Fuster, L. E. Ryden, D. S. Cannom, H. J. Crijns, A. B. Curtis, K. A. Ellenbogen, J. L. Halperin, J.-Y. Le Heuzey, G. N. Kay, et al.
ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: full text: A report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation) Developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society
Europace,
September 1, 2006;
8(9):
651 - 745.
[Full Text]
[PDF]
|
|
|
|
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V. Fuster, L. E. Ryden, D. S. Cannom, H. J. Crijns, A. B. Curtis, K. A. Ellenbogen, J. L. Halperin, J.-Y. Le Heuzey, G. N. Kay, J. E. Lowe, et al.
ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation--Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation) Developed in Collaboration With the European Heart Rhythm Association and the Heart Rhythm Society
J. Am. Coll. Cardiol.,
August 15, 2006;
48(4):
854 - 906.
[Full Text]
[PDF]
|
|
|
|
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V. Fuster, L. E. Ryden, D. S. Cannom, H. J. Crijns, A. B. Curtis, K. A. Ellenbogen, J. L. Halperin, J.-Y. Le Heuzey, G. N. Kay, J. E. Lowe, et al.
ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation) Developed in Collaboration With the European Heart Rhythm Association and the Heart Rhythm Society
J. Am. Coll. Cardiol.,
August 15, 2006;
48(4):
e149 - e246.
[Full Text]
[PDF]
|
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V. Fuster, L. E. Ryden, D. S. Cannom, H. J. Crijns, A. B. Curtis, K. A. Ellenbogen, J. L. Halperin, J.-Y. Le Heuzey, G. N. Kay, J. E. Lowe, et al.
ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): Developed in Collaboration With the European Heart Rhythm Association and the Heart Rhythm Society
Circulation,
August 15, 2006;
114(7):
e257 - e354.
[Full Text]
[PDF]
|
|
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|
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V. Fuster, L. E. Ryden, D. S. Cannom, H. J. Crijns, A. B. Curtis, K. A. Ellenbogen, J. L. Halperin, J.-Y. Le Heuzey, G. N. Kay, J. E. Lowe, et al.
ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation--Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): Developed in Collaboration With the European Heart Rhythm Association and the Heart Rhythm Society
Circulation,
August 15, 2006;
114(7):
700 - 752.
[Full Text]
[PDF]
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|
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Authors/Task Force Members, V. Fuster, L. E. Ryden, D. S. Cannom, H. J. Crijns, A. B. Curtis, K. A. Ellenbogen, J. L. Halperin, J.-Y. Le Heuzey, G. N. Kay, et al.
ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation executive summary: A report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients with Atrial Fibrillation) Developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society
Eur. Heart J.,
August 2, 2006;
27(16):
1979 - 2030.
[Full Text]
[PDF]
|
|
|
|
|
|
|
L. Friberg, N. Hammar, M. Ringh, H. Pettersson, and M. Rosenqvist
Stroke prophylaxis in atrial fibrillation: who gets it and who does not?: Report from the Stockholm Cohort-study on Atrial Fibrillation (SCAF-study)
Eur. Heart J.,
August 2, 2006;
27(16):
1954 - 1964.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
G. Y H Lip and A. Tello-Montoliu
Management of atrial fibrillation.
Heart,
August 1, 2006;
92(8):
1177 - 1182.
[Full Text]
[PDF]
|
|
|
|
|
|
|
C. S. van der Hooft, J. Heeringa, G. G. Brusselle, A. Hofman, J. C. M. Witteman, J. H. Kingma, M. C. J. M. Sturkenboom, and B. H. Ch. Stricker
Corticosteroids and the risk of atrial fibrillation.
Arch Intern Med,
May 8, 2006;
166(9):
1016 - 1020.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
G Y H Lip and C J Boos
Antithrombotic treatment in atrial fibrillation
Heart,
February 1, 2006;
92(2):
155 - 161.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
C. J. Boos, R. A. Anderson, and G. Y.H. Lip
Is atrial fibrillation an inflammatory disorder?
Eur. Heart J.,
January 2, 2006;
27(2):
136 - 149.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. L. Waldo, R. C. Becker, V. F. Tapson, K. J. Colgan, and for the NABOR Steering Committee
Hospitalized Patients With Atrial Fibrillation and a High Risk of Stroke Are Not Being Provided With Adequate Anticoagulation
J. Am. Coll. Cardiol.,
November 1, 2005;
46(9):
1729 - 1736.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
S. H. Ostermayer, M. Reisman, P. H. Kramer, R. V. Matthews, W. A. Gray, P. C. Block, H. Omran, A. L. Bartorelli, P. Della Bella, C. Di Mario, et al.
Percutaneous Left Atrial Appendage Transcatheter Occlusion (PLAATO System) to Prevent Stroke in High-Risk Patients With Non-Rheumatic Atrial Fibrillation: Results From the International Multi-Center Feasibility Trials
J. Am. Coll. Cardiol.,
July 5, 2005;
46(1):
9 - 14.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
C. Marini, F. De Santis, S. Sacco, T. Russo, L. Olivieri, R. Totaro, and A. Carolei
Contribution of Atrial Fibrillation to Incidence and Outcome of Ischemic Stroke: Results From a Population-Based Study
Stroke,
June 1, 2005;
36(6):
1115 - 1119.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. O'Donnell, G. Agnelli, and J. I. Weitz
Emerging therapies for stroke prevention in atrial fibrillation
Eur. Heart J. Suppl.,
May 1, 2005;
7(suppl_C):
C19 - C27.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
C. S. van der Hooft, J. Heeringa, G. van Herpen, J. A. Kors, J. H. Kingma, and B. H. Ch. Stricker
Drug-induced atrial fibrillation
J. Am. Coll. Cardiol.,
December 7, 2004;
44(11):
2117 - 2124.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. L. Page
Newly Diagnosed Atrial Fibrillation
N. Engl. J. Med.,
December 2, 2004;
351(23):
2408 - 2416.
[Full Text]
[PDF]
|
|
|
|
|
|
|
D. E. Singer, G. W. Albers, J. E. Dalen, A. S. Go, J. L. Halperin, and W. J. Manning
Antithrombotic Therapy in Atrial Fibrillation: The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy
Chest,
September 1, 2004;
126(3_suppl):
429S - 456S.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. L. McNamara, L. J. Tamariz, J. B. Segal, and E. B. Bass
Management of Atrial Fibrillation: Review of the Evidence for the Role of Pharmacologic Therapy, Electrical Cardioversion, and Echocardiography
Ann Intern Med,
December 16, 2003;
139(12):
1018 - 1033.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
D. E. Singer
A 60-Year-Old Woman With Atrial Fibrillation
JAMA,
October 22, 2003;
290(16):
2182 - 2189.
[Full Text]
[PDF]
|
|
|
|
|
|
|
T. J. Wang, J. M. Massaro, D. Levy, R. S. Vasan, P. A. Wolf, R. B. D'Agostino, M. G. Larson, W. B. Kannel, and E. J. Benjamin
A Risk Score for Predicting Stroke or Death in Individuals With New-Onset Atrial Fibrillation in the Community: The Framingham Heart Study
JAMA,
August 27, 2003;
290(8):
1049 - 1056.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. L. Waldo
Stroke Prevention in Atrial Fibrillation
JAMA,
August 27, 2003;
290(8):
1093 - 1095.
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. G. Hart, J. L. Halperin, L. A. Pearce, D. C. Anderson, R. A. Kronmal, R. McBride, E. Nasco, D. G. Sherman, R. L. Talbert, J. R. Marler, et al.
Lessons from the Stroke Prevention in Atrial Fibrillation Trials
Ann Intern Med,
May 20, 2003;
138(10):
831 - 838.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
V. Kuhlkamp, L. Seipel, E. C. Healy, K. Bhaskarabhatla, W. J. Manning, D. G. Wyse, I. C. Van Gelder, and H. J.G.M. Crijns
Atrial Fibrillation -- Rate versus Rhythm Control
N. Engl. J. Med.,
March 27, 2003;
348(13):
1284 - 1286.
[Full Text]
[PDF]
|
|
|
|
|
|
|
I. C. Van Gelder, V. E. Hagens, H. A. Bosker, J. H. Kingma, O. Kamp, T. Kingma, S. A. Said, J. I. Darmanata, A. J.M. Timmermans, J. G.P. Tijssen, et al.
A Comparison of Rate Control and Rhythm Control in Patients with Recurrent Persistent Atrial Fibrillation
N. Engl. J. Med.,
December 5, 2002;
347(23):
1834 - 1840.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
G. Y H Lip, R. G Hart, and D. S G Conway
ABC of antithrombotic therapy: Antithrombotic therapy for atrial fibrillation
BMJ,
November 2, 2002;
325(7371):
1022 - 1025.
[Full Text]
[PDF]
|
|
|
|
|
|
|
S. E. Straus, S. R. Majumdar, and F. A. McAlister
New Evidence for Stroke Prevention: Scientific Review
JAMA,
September 18, 2002;
288(11):
1388 - 1395.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
Y. Agmon, B. K. Khandheria, F. Gentile, and J. B. Seward
Clinical and Echocardiographic Characteristics of Patients With Left Atrial Thrombus and Sinus Rhythm: Experience in 20 643 Consecutive Transesophageal Echocardiographic Examinations
Circulation,
January 1, 2002;
105(1):
27 - 31.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
G.Y.H. Lip and F.L. L. S. Hee
Paroxysmal atrial fibrillation
QJM,
December 1, 2001;
94(12):
665 - 678.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
V. Fuster, L. E. Ryden, R. W. Asinger, D. S. Cannom, H. J. Crijns, R. L. Frye, J. L. Halperin, G. N. Kay, W. W. Klein, S. Levy, et al.
ACC/AHA/ESC Guidelines for the Management of Patients With Atrial Fibrillation: Executive Summary A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to Develop Guidelines for the Management of Patients With Atrial Fibrillation) Developed in Collaboration With the North American Society of Pacing and Electrophysiology
Circulation,
October 23, 2001;
104(17):
2118 - 2150.
[Full Text]
[PDF]
|
|
|
|
|
|
|
Guidelines for the management of patients with atrial fibrillation. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to develop guidelines for the management of patients with atrial fibrillation) developed in collaboration with the North American Society of Pacing and Electrophysiology
Eur. Heart J.,
October 2, 2001;
22(20):
1852 - 1923.
[PDF]
|
|
|
|
|
|
|
V. Fuster, L. E. Ryden, R. W. Asinger, D. S. Cannom, H. J. Crijns, R. L. Frye, J. L. Halperin, G. N. Kay, W. W. Klein, S. Levy, et al.
ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation: executive summary: A Report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to Develop Guidelines for the Management of Patients With Atrial Fibrillation) Developed in Collaboration With the North American Society of Pacing and Electrophysiology
J. Am. Coll. Cardiol.,
October 1, 2001;
38(4):
1231 - 1265.
[Full Text]
[PDF]
|
|
|
|
|
|
|
A Majeed, K Moser, and K Carroll
Trends in the prevalence and management of atrial fibrillation in general practice in England and Wales, 1994-1998: analysis of data from the general practice research database
Heart,
September 1, 2001;
86(3):
284 - 288.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
D S G CONWAY and G Y H LIP
Anticoagulation and atrial fibrillation
Postgrad. Med. J.,
July 1, 2001;
77(909):
487 - 487.
[Full Text]
[PDF]
|
|
|
|
|
|
|
S K S LAIRIKYENGBAM, A G DAVIES, and P D JONES
Implementation of antithrombotic management in atrial fibrillation
Postgrad. Med. J.,
July 1, 2001;
77(909):
488 - 488.
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. H. Falk
Atrial Fibrillation
N. Engl. J. Med.,
April 5, 2001;
344(14):
1067 - 1078.
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. G. Hart and J. L. Halperin
Atrial Fibrillation and Stroke : Concepts and Controversies
Stroke,
March 1, 2001;
32(3):
803 - 808.
[Full Text]
[PDF]
|
|
|
|
|
|
|
S. S. Chugh, J. L. Blackshear, W.-K. Shen, S. C. Hammill, and B. J. Gersh
Epidemiology and natural history of atrial fibrillation: clinical implications
J. Am. Coll. Cardiol.,
February 1, 2001;
37(2):
371 - 378.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. L. Page, J. A. Reiffel, and M. E. Tavel
Asymptomatic Atrial Fibrillation : Problems of Management
Chest,
February 1, 2001;
119(2):
628 - 631.
[Full Text]
[PDF]
|
|
|
|
|
|
|
G. W. Albers, J. E. Dalen, A. Laupacis, W. J. Manning, P. Petersen, and D. E. Singer
Antithrombotic Therapy in Atrial Fibrillation
Chest,
January 1, 2001;
119
(2009):
194S - 206S.
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. S. Go, E. M. Hylek, K. A. Phillips, L. H. Borowsky, L. E. Henault, Y. Chang, J. V. Selby, and D. E. Singer
Implications of Stroke Risk Criteria on the Anticoagulation Decision in Nonvalvular Atrial Fibrillation : The Anticoagulation and Risk Factors In Atrial Fibrillation (ATRIA) Study
Circulation,
July 4, 2000;
102(1):
11 - 13.
[Abstract]
[Full Text]
[PDF]
|
|
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Abstract
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