INSIDE THIS ISSUE OF JACC
Inside This Issue of JACC
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Atrial Fibrillation and Embolism
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Comparing AF Stroke Risk Algorithms.
Risk schemes can help target anticoagulant therapy for patients at highest risk for atrial fibrillation (AF)-related thromboembolism. Fang and colleagues tested the predictive ability of five commonly used methods in a cohort of over 13,000 patients who were followed for a median of 6 years and who were not using coumarins, though many were probably taking aspirin. The overall incidence of thromboembolic events was 2.1% per year. There was wide variation in the proportions of patients considered either low or high risk, but no risk scheme was clearly superior and all had only fair discriminating ability. Current risk schemes have comparable, but limited, ability to predict thromboembolism in persons with AF; better risk stratification algorithms are needed to improve the selection of AF patients for anticoagulant therapy. See page 810. See figure.
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Atrial Fibrillation and Embolism
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Optimal Antithrombotic Strategy in Patients with Recent Stents and AF.
A management problem arises when a patient, in whom long-term anticoagulation with coumarins is recommended, undergoes percutaneous coronary intervention. Ruiz-Nodar and colleagues reviewed the antithrombotic regimens and outcomes of over 400 patients with a history of atrial fibrillation (AF) who underwent PCI. Forty-one percent received aspirin and clopidogrel, and 50% were discharged with triple therapy (coumarins, aspirin, and clopidogrel). Nearly one-quarter of the patients died during follow-up and 12% suffered major bleeds. Those not prescribed coumadin were 3.4 times more likely to die, and 5 times more likely to suffer major adverse cardiac events. This nonrandomized study suggests that triple therapy with aspirin, clopidogrel, and coumadin is the preferred antithrombotic regimen in patients with AF who undergo cardiac stenting, but there may be significant confounding factors in this retrospective study. See page 818. See figure.
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Statins and Atrial Fibrillation
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Meta-Analysis Suggests Statins May Prevent Atrial Fibrillation.
Inflammation is involved in the development, recurrence and persistence of atrial fibrillation (AF) and statins are known to modulate several markers of inflammation. Fauchier and colleagues combined the results from 6 studies which randomized subjects to either statins or placebo (5 of 6 used atorvastatin) and documented the incidence of AF. Nearly all subjects had coronary artery disease; some of the trials were secondary prevention of AF and others used subjects at high risk of developing AF, such as those undergoing cardiac surgery. Overall, the use of statins was significantly associated with a decreased risk of AF with an odds ratio of 0.39. These results suggest that statins may decrease the risk of AF. See page 828.
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Atrial Fibrillation and Torsade
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Increased Risk of Torsades in Patients in Sinus Rhythm Compared to Those in AF.
Predicting which patients with drug-induced long QT syndrome (LQTS) will develop Torsades de Pointes (TdP) is challenging. Darbar and colleagues compared 40 patients with LQTS who did not develop TdP with 83 patients who did, despite both groups having similar QT prolongation. The main risk factors for TdP were hypokalemia and female sex; those who remained in atrial fibrillation during QT prolongation appeared to be at low risk for TdP. This study strongly suggests that despite ongoing rate irregularity, atrial fibrillation reduces the likelihood of developing TdP after the administration of drugs that prolong cardiac repolarization. See page 836. See figure.
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Ablation Therapy of Atrial Fibrillation
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Catheter Based AF Ablation May Improve Mortality in High Risk Patients.
While there is no apparent mortality benefit to pharmacologically maintaining sinus rhythm (SR), the benefits of catheter ablation remain unclear. Nademanee and collegaues performed atrial fibrillation (AF) substrate ablation guided by complex fractionated atrial electrogram (CFAE) mapping in almost 700 AF patients who were over 65 and had at least one other stroke risk factor. Over 80% of patients maintained SR; these patients had a 5-year survival rate of 92% compared with 64% for those whose AF recurred. Warfarin therapy was discontinued in 84% of the patients in SR post-ablation whose annual stroke rate was only 0.4%. These results suggest that CFAE-targeted ablation of AF is effective in maintaining SR and may allow patients to stop warfarin therapy, and improve their long term mortality. See page 843. See figure.
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Ablation Therapy of Atrial Fibrillation
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Cryothermic Ostial Pulmonary Vein Isolation in Paroxysmal Atrial Fibrillation.
Moreira and colleagues performed a trial to evaluate the effect of a more localized ablation strategy using cryothermy in patients with paroxysmal atrial fibrillation (AF); they hypothesized that patients with recent onset of AF may have a single pulmonary vein (PV) that is initiating the episodes. If the triggers for AF seemed to be isolated to only one PV, cryoisolation of only this PV was done. Otherwise, all PVs were isolated. An arrhythmogenic PV was found in 14% of patients, none of whom had an AF recurrence. For all patients, cryoablation achieved complete success in 49%, and an additional 33% had improvement. PV cryoisolation is effective in 82% of patients with recent onset paroxysmal AF; if the arrhythmogenic PV can be identified, there is no need to isolate all PVs. See page 850.
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Comparison of Risk Stratification Schemes to Predict Thromboembolism in People With Nonvalvular Atrial Fibrillation
- Margaret C. Fang, Alan S. Go, Yuchiao Chang, Leila Borowsky, Niela K. Pomernacki, Daniel E. Singer for the ATRIA Study Group
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Anticoagulant and Antiplatelet Therapy Use in 426 Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention and Stent Implantation: Implications for Bleeding Risk and Prognosis
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Antiarrhythmic Effect of Statin Therapy and Atrial Fibrillation: A Meta-Analysis of Randomized Controlled Trials
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Persistent Atrial Fibrillation Is Associated With Reduced Risk of Torsades de Pointes in Patients With Drug-Induced Long QT Syndrome
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Clinical Outcomes of Catheter Substrate Ablation for High-Risk Patients With Atrial Fibrillation
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Long-Term Follow-Up After Cryothermic Ostial Pulmonary Vein Isolation in Paroxysmal Atrial Fibrillation
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J. Am. Coll. Cardiol. 2008 51: 850-855.
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Atrial Fibrillation and Embolism
Atrial Fibrillation and Embolism
