D. Kosior

An Increase in Plasma Atrial Natriuretic Peptide Concentration During Exercise Predicts a Successful Cardioversion and Maintenance of Sinus Rhythm in Patients with Chronic Atrial Fibrillation

The aim of this study was to determine the value of an increase in plasma atrial natriuretic peptide (ANP) concentrations during submaximal exercise as a predictor of return of sinus rhythm (SR), and of its maintenance over a period of 6 months after cardioversion (CV) of chronic atrial fibrillation (AF). The study group included 42 patients with AF (mean duration 7 ± 7 months) and a controlled ventricular rate. They underwent submaximal exercise testing 24 hours before CV. Blood samples were collected at rest and at peak of exercise for measurement of plasma ANP concentrations. Thirty‐five of 42 patients were successfully cardioverted to SR. At 6 months, 23 patients remained in SR, while 12 had recurrence of AF. The plasma ANP concentrations before CV increased insignificantly during exercise in patients with unsuccessful CV or with recurrence of AF (60.8 ± 17.3 pg/mL to 64 ± 13.5 pg/mL, NS). The mean increase in plasma ANP concentration during exercise was significantly greater in the 23 patients who remained in SR than in the 19 patients unsuccessfully cardioverted or with recurrence of AF (17.5 ± 7.6 pg/mL vs 5.8 ± 4.5 pg/mL, P < 0.01). In multivariate logistic regression analysis, an increase in ANP plasma concentration was independently associated with successful CV and maintenance of SR up to 6 months of observation. In patients with chronic AF an exercise‐induced increase in ANP concentration predicts successful CV and maintenance of SR.

Long-term sinus rhythm maintenance after cardioversion of persistent atrial fibrillation: is the treatment's success predictable?

The aim of our study was to identify the clinical and echocardiographic predictors of long-term success of cardioversion in patients with persistent atrial fibrillation (AF). Our study comprised 104 patients (F/M 33/71; mean age 60.4 ± 7.9 years) assigned to SR restoration and maintenance with sequentially administered antiarrhythmic drugs. Their clinical and transthoracic echocardiographic (TTE) variables were recorded prior to cardioversion and examined for correlation with sinus rhythm (SR) maintenance at 1 year. The variables under consideration included age, gender, echo parameters such as long and short left atrial (LA) axis, LA and right atrial (RA) area, fractional shortening (FS) and left ventricular end-diastolic diameter, AF duration, New York Heart Association functional class, and concomitant diseases. Generalized additive logistic regression method was used to investigate impact of the selected variables on long-term SR maintenance. At 1 year, SR was present in 63.5% of patients. Left atrium area (LAar) > 28 cm (P < 0.02) and FS value >26% (P < 0.05), both measured at baseline, were significantly associated with SR maintenance after 1 year. Patients with large LAar values (>28 cm2) presented a significant decrease (31.45 ± 3.07 cm2 vs 28.94 ± 3.81 cm2; P < 0.008) during 30 days following SR maintenance. In patients with LAar >28 cm2 we noted an atrial decrease of 2.57 ± 3.2 cm2 (P < 0.004) during 30 days following SR restoration, which turned out to be an independent factor related to SR presence at 1 year of follow-up (relative risk 1.83; 95% confidence interval: 1.03–2.95; P < 0.01). Of all the considered variables only LA area and FS value seem to be relatively reliable predictors of SR sustainability at 1 year after an effective cardioversion of persistent AF.

Serial Antiarrhythmic Therapy: Role of Amiodarone in Prevention of Atrial Fibrillation Recurrence – A Lesson from the HOT CAFE Polish Study

Antiarrhythmic drug prophylaxis is known to improve long-term success of electrical cardioversion (CV) in persistent atrial fibrillation (AF). This prospective study evaluates the efficacy of sequential antiarrhythmic drug therapy in sinus rhythm (SR) maintenance after successful elective CV in patients with persistent nonvalvular AF. Materials and Methods: One hundred and twenty-eight patients (61 ± 8 years old) with persistent AF underwent CV. Mean AF duration preceding CV was 268 ± 99 days. Following SR restoration, patients were treated sequentially with either of the following antiarrhythmic drugs: propafenone, sotalol or disopyramide. Where arrhythmia recurred, patients received another CV and a new drug from the range defined above. Where such treatment failed, patients were loaded with 14.0- to16.0-gram doses of amiodarone and a third CV was performed. If the first CV failed to restore SR, patients received a loading dose of amiodarone followed by another CV. When successful, amiodarone was administered on continuous basis. Results: The first CV proved successful in 55.5% of patients. During 1-year of follow-up, 31 patients (43.7%) presented with SR were treated with one antiarrhythmic agent (median does not exist). Application of the second drug proved to be effective in 6 patients (15.0%; median 13 days). Amiodarone was administered as the third antiarrhythmic agent to patients who had AF recurrence on the first two antiarrhythmic agents (propafenone, sotalol or disopyramide). It proved to be effective in 18 patients (52.9%; median does not exist) remaining free from AF for a period of 1 year as of commencement of the sequential antiarrhythmic therapy. Fifty-seven patients, in whom the first CV was ineffective, received amiodarone. During the loading period, SR was restored in 7 patients (12.3%). The remaining 50 patients underwent repeated CV, with SR restored in 37 (74.0%) of them. Long-term amiodarone treatment maintained SR in 30 (68.2%) patients during the follow-up period. Amiodarone helped to maintain SR in a total of 56.5% of patients. Conclusions: Amiodarone seems to be the drug most effectively restoring and maintaining SR in patients with persistent AF resistant to CV and standard antiarrhythmic drug prophylaxis.

‘Syringe-in-the-Pocket’ – A New Approach to the Outpatient Thromboembolic Prophylaxis of Recurrent Atrial Fibrillation

Chronic anti-coagulation is not an attractive prospect to patients with atrial fibrillation (AF) after successful restoration of sinus rhythm. We researched the feasibility of self-screening for AF performed by instructed patients and, where necessary, prompt self-administration of an initial dose of low-molecular weight heparin (LMWH) prior to seeking medical attention. Materials and Methods: Persistent AF qualified to elective cardioversion was our focus. Two hundred and sixty-three consecutive patients (M/F: 179/84, mean age: 59.8 ± 8.6) were followed for a mean of 2.6 ± 1.7 years. All patients were trained to identify AF by palpation of the radial pulse and to self-inject LMWH in the case of arrhythmia recurrence. Two hundred and thirty-two patients who correctly recognized AF recurrence and those without episodes of AF during 4 weeks after cardioversion were equipped with nadroparine after acenocoumarol discontinuation. In 191 patients AF recurred during further observation, 172 of them correctly identified AF episodes, including 162 who performed LMWH injections at home. Seven patients who had performed LMWH injections presented with sinus rhythm on arrival to hospital, six patients had AF. Two out of 21 patients who failed to identify their AF episodes and one patient of those who correctly detected the AF recurrence, but failed to perform LMWH self-injection suffered from ischemic stroke (sensitivity 96.1%, specificity 60.4%). No side effects of domiciliary LMWH self-injection were identified. Conclusion: When properly trained, the majority of patients can accurately diagnose AF recurrence and self-inject an initial dose of LMWH, which makes it a feasible and potentially attractive anti-thromboembolic strategy.