Atrial Fibrillation

Jan 2nd, 2024

Clinical Practice Guidelines

The 2023 Guidelines for Atrial Fibrillation, issued by ACC/AHA/ACCP/HRS, provide an updated overview of recommendations for the diagnosis and management of atrial fibrillation (1).

 

Pharmacotherapy

Impact of Oral Anticoagulation

In the NOMED Study, the impact of oral anticoagulation on patients with atrial fibrillation was evaluated. This study involved 2,795 patients and compared the effects of long-term ECG monitoring and oral anticoagulation against a control group of patients without atrial fibrillation. The results showed that atrial fibrillation significantly increases the risk of death and stroke, but these risks can be substantially reduced with oral anticoagulation. This confirms the importance of managing atrial fibrillation as an independent risk factor for death, emphasizing the clinical significance of oral anticoagulation in these patients (2).

 

DOAC vs VKA Efficacy

 

The comparison between direct oral anticoagulants (DOAC) and vitamin K antagonists (VKA) in patients with hypertrophic cardiomyopathy (HCM) and atrial fibrillation was the focus of a meta-analysis. This analysis included seven observational studies and found that while the risk of thromboembolic events was similar between DOAC and VKA, DOAC was more effective in reducing mortality. This supports the clinical recommendation of using DOACs in patients with HCM and atrial fibrillation (3).

 

DOACs in Low Body Weight Atrial Fibrillation Patients

 

In a systematic review and meta-analysis, the effectiveness and safety of direct oral anticoagulants (DOACs) in low body weight patients with atrial fibrillation were examined. This study, which included 13 studies and 165,205 patients, found an increased risk of stroke-related events, composite outcomes, and mortality in low body weight patients using DOACs compared to non-low body weight patients. However, there was no significant difference in major bleeding events. These findings indicate the need for more targeted research and potentially a review of clinical guidelines for this subgroup (4).

Paroxysmal Atrial Fibrillation

 

The ANPROAF study, a randomized double-blind study, compared the efficacy and safety of antazoline and propafenone in converting paroxysmal atrial fibrillation to sinus rhythm. Involving 94 patients with paroxysmal non-valvular atrial fibrillation without heart failure, the study found comparable efficacy and safety between the two drugs, with a quicker conversion noted with antazoline. This positions antazoline as a viable alternative to propafenone in this patient population (5).

Thyroid-related Arrhythmias

 

A systematic review and meta-analysis of 10 cohort studies investigated the relationship between subclinical thyroid dysfunction and incident atrial fibrillation. The study did not specify the number of patients involved but included those with subclinical hyperthyroidism or hypothyroidism. The results indicated an increased risk of incident atrial fibrillation in both subclinical hyperthyroidism and hypothyroidism, thereby identifying these conditions as risk factors for atrial fibrillation (6).

 

Biomarkers in Atrial Fibrillation Fatigue

 

The association of various factors with fatigue in atrial fibrillation was examined through a multiple linear regression analysis in the ARIC visit 5 study. The study, involving 446 participants, analyzed the role of biomarkers and found that NT-proBNP and hs-TnT were associated with AF-related fatigue, depressive symptoms, and decreased physical function. This study highlighted that cardiac injury biomarkers and depressive symptoms are linked with AF-fatigue, while inflammation was not a significant factor (7).

 

Right Ventricular Dysfunction

 

An observational study focused on right ventricular dysfunction (RVD) in patients aged 18-80 years with acute left-sided heart failure and a left ventricular ejection fraction (LVEF) of less than 50%. The study, involving 195 patients, found that RVD was present in 48.7% of the patients and was a strong predictor of cardiovascular death and hospitalization for worsening heart failure. This underscores the prognostic importance of RVD and right ventricular dilatation in this patient group (8).

 

Pulsed Field Ablation Technique

 

A prospective study, titled "Respiratory Control in Pulsed Field Ablation of Atrial Fibrillation," involved 28 patients undergoing pulsed field ablation (PFA) for pulmonary vein and superior vena cava isolation. The study focused on the impact of respiratory control during PFA compared to PFA application during any phase of the respiratory cycle. The results showed a significant reduction in diaphragmatic contraction and dry cough with respiratory control, suggesting that this technique can reduce complications during PFA in atrial fibrillation treatment (9).

 

Catheter Ablation Outcomes

 

The relationship between atrial fibrillation progression and impaired left atrial (LA) functional reserve was examined in a prospective investigation involving 164 patients with atrial fibrillation, normal left ventricular function, and no heart failure. The study focused on the effects of catheter ablation and found impaired LA functional reserve in long-standing persistent atrial fibrillation, with improvement in LA size and function post-ablation. This highlights the benefits of sinus rhythm restoration and its relationship with AF progression (10).

 

Endothelialization in LAAO

 

A pilot study investigated the endothelialization in left atrial appendage occlusion (LAAO) devices in patients with atrial fibrillation and preexisting LAAO using coronary optic coherence tomography. This small study, involving 14 patients, observed varying degrees of endothelialization in LAAO devices, suggesting potential use of OCT in evaluating LAAO endothelialization to guide antithrombotic therapy (11).

 

  1. Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, et al. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2024;149(1):e1-e156.

  2. Mitrega K, Sredniawa B, Sokal A, Streb W, Kowalczyk J, Opolski G, et al. Does the atrial fibrillation still increase the risk of death? Results from the NOMED study in one-year follow-up. Pol Arch Intern Med. 2024.

  3. Lyu SQ, Zhu J, Wang J, Wu S, Zhang H, Shao XH, et al. The efficacy and safety of direct oral anticoagulants compared with vitamin K antagonist in patients with hypertrophic cardiomyopathy and atrial fibrillation. Thromb J. 2024;22(1):2.

  4. Elshafei MN, Salem M, El-Bardissy A, Abdelmoneim MS, Khalil A, Elhadad S, et al. Comparative Effectiveness and Safety of Direct Oral Anticoagulants in Low Body Weight Patients with Atrial Fibrillation: A Systematic Review and Meta-analysis. Cardiovasc Drugs Ther. 2024.

  5. Karwowski J, Wrzosek K, Mączyńska-Mazuruk R, Szmarowska K, Rekosz J, Wiktorska A, et al. Randomized double-blind study comparing the efficacy and safety between antazoline and propafenone for conversion of paroxysmal atrial fibrillation to sinus rhythm (AnProAF study). Pol Arch Intern Med. 2024.

  6. Singh H, Shahid MZ, Harrison SL, Lane DA, Lip GYH, Logantha S. Subclinical thyroid dysfunction and the risk of incident atrial fibrillation: A systematic review and meta-analysis. PLoS One. 2024;19(1):e0296413.

  7. Wood KA, Alam AB, Chen LY, Soliman EZ, Quyyumi AA, Alonso A. Factors Associated With Fatigue in Persons With Atrial Fibrillation in the Atherosclerosis Risk in Communities (ARIC) Study. Biol Res Nurs. 2024:10998004231225442.

  8. Shaker MM, Taha HS, Kandil HI, Kamal HM, Mahrous HA, Elamragy AA. Prognostic significance of right ventricular dysfunction in patients presenting with acute left-sided heart failure. Egypt Heart J. 2024;76(1):2.

  9. Jiang R, Liu Q, Chen L, Chen S, Wang Y, Cheng H, et al. Respiratory Control Minimizes Diaphragmatic Contraction and Dry Cough during Pulsed Field Ablation of Atrial Fibrillation. Europace. 2024.

  10. Hirose K, Nakanishi K, Daimon M, Iwama K, Yoshida Y, Mukai Y, et al. Association of Atrial Fibrillation Progression With Left Atrial Functional Reserve and Its Reversibility. J Am Heart Assoc. 2024;13(1):e032215.

  11. Chen JJ, Chiu FC, Chang SN, Cheng HL, Huang PS, Wu CK, et al. Pattern of Endothelialization in Left Atrial Appendage Occluder by Optic Coherence Tomography: A Pilot Study. J Am Heart Assoc. 2024;13(1):e030080.