Hein Heidbuchel

2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS

Citation for published version (Harvard): Kirchhof, P, Benussi, S, Kotecha, D, Ahlsson, A, Atar, D, Casadei, B, Castella, M, Diener, H-C, Heidbuchel, H, Hendriks, J, Hindricks, G, Manolis, AS, Oldgren, J, Popescu, BA, Schotten, U, Van Putte, B & Vardas, P 2016, 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS: The Task Force for the management of atrial fibrillation of the European Society of Cardiology (ESC). Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Endorsed by the European Stroke Organisation (ESO), European Heart Journal, vol. 37, no. 38, pp. 2893-2962. https://doi.org/10.1093/eurheartj/ehw210

2017 HRS expert consensus statement on magnetic resonance imaging and radiation exposure in patients with cardiovascular implantable electronic devices

Julia H. Indik, MD, PhD, FHRS, FACC, FAHA (Chair), J. Rod Gimbel, MD (Vice-Chair), Haruhiko Abe, MD,* Ricardo Alkmim-Teixeira, MD, PhD, Ulrika Birgersdotter-Green, MD, FHRS, Geoffrey D. Clarke, PhD, FACR, FAAPM,6,x Timm-Michael L. Dickfeld, MD, PhD, Jerry W. Froelich, MD, FACR,8,{ Jonathan Grant, MD, David L. Hayes, MD, FHRS, Hein Heidbuchel, MD, PhD, FESC,** Salim F. Idriss, MD, PhD, FHRS, FACC, Emanuel Kanal, MD, FACR, FISMRM, MRMD, Rachel Lampert, MD, FHRS, Christian E. Machado, MD, FHRS, CCDS, John M. Mandrola, MD, Saman Nazarian, MD, PhD, FHRS, Kristen K. Patton, MD, Marc A. Rozner, PhD, MD, CCDS, Robert J. Russo, MD, PhD, FACC, Win-Kuang Shen, MD, FHRS,21,xx Jerold S. Shinbane, MD, FHRS, Wee Siong Teo, MBBS (NUS), FRCP (Edin), FHRS,23,{{ William Uribe, MD, FHRS, Atul Verma, MD, FRCPC, FHRS, Bruce L. Wilkoff, MD, FHRS, CCDS, Pamela K. Woodard, MD, FACR, FAHA***

Telemonitoring-based feedback improves adherence to non-vitamin K antagonist oral anticoagulants intake in patients with atrial fibrillation

AimsnTo evaluate the effect of telemonitoring on adherence to non-vitamin K antagonist oral anticoagulants (NOACs) in atrial fibrillation (AF) patients.nnnMethods and resultsnA randomized, single-blind, crossover, controlled trial in 48 AF patients on once or twice daily (OD or BID) NOAC. The Medication Event Monitoring System tracked NOAC intake during three phases of 3xa0months each: daily telemonitoring, telemonitoring with immediate telephone feedback in case of intake errors, and an observation phase without daily transmissions. Unprotected days were defined asu2009≥u20093 oru2009≥u20091 consecutively missed doses for a BID or OD NOAC, respectively, or excess dose intake. Cost-effectiveness was calculated based on anticipated stroke reduction derived from patients risk profile and measured intake. Persistence over the entire study was 98%. Telemonitoring-only already led to very high taking and regimen adherence (97.4% respectively 93.8%). Nevertheless, direct feedback further improved both to 99.0% and 96.8%, respectively (Pu2009<u20090.001 respectively Pu2009=u20090.002). Observation without daily monitoring resulted in a significant waning of taking adherence (94.3%; Pu2009=u20090.049). Taking adherence was significantly higher for OD compared to BID NOAC, although unprotected days were similar. Feedback intervention had an incremental cost of €344xa0289 to prevent one stroke, but this could be as low as €15xa0488 in high-risk patients with low adherence and optimized technology.nnnConclusionnTelemonitoring resulted in high NOAC adherence due to the notion of being watched, as evidenced by the rapid decline during the observation period. Feedback further optimized adherence. Telemonitoring with or without feedback may be a cost-effective approach in high-risk patients deemed poorly adherent.

The why, when and how to test for obstructive sleep apnea in patients with atrial fibrillation

Sleep apnea is associated with increased cardiovascular risk and may be important in atrial fibrillation (AF) management. It is present in up to 62% of the AF population and is highly under-recognized and underdiagnosed. Obstructive sleep apnea (OSA) is strongly associated with AF and non-randomized trials have shown that its treatment can help to reduce AF recurrences and maintain sinus rhythm. The 2016 European Society of Cardiology guidelines for the management of AF recommend that AF patients should be questioned regarding the symptoms of OSA and that OSA-treatment should be optimized to improve AF treatment results. However, strategies on how to implement OSA testing in the standard work-up of AF patients are not provided in the guidelines. Additionally, overnight OSA monitoring rather than interrogation for OSA-related clinical signs alone may be necessary to reliably identify OSA in the majority of AF patients. This review summarizes the available clinical data on OSA in AF patients, and discusses the following key questions: Why and When is testing for OSA needed in AF patients? How and Where should it be performed and coordinated? and Who should test for OSA? To implement OSA testing in a cardiology or electrophysiology clinic, we propose a multidisciplinary integrated care approach based on a chronic care model. We describe the tools, infrastructure and coordination needed to test for OSA in the standard workup of patients with symptomatic AF prior to the initiation of directed invasive or pharmacological rhythm control management.

Differences in knowledge among patients with atrial fibrillation receiving non-vitamin K antagonist oral anticoagulants and vitamin K antagonists

BACKGROUNDnNon-vitamin K antagonist oral anticoagulants (NOACs) are increasingly used for stroke prevention in patients with atrial fibrillation (AF) worldwide. Few articles have compared current understanding of AF patients about the disease and anticoagulant therapy in relation to the medications used.nnnAIMnWe sought to compare the knowledge of AF and anticoagulation between AF patients treated with NOACs and those on vitamin K antagonists (VKAs).nnnMETHODSnWe used the Jessa AF Knowledge Questionnaire (JAKQ), developed and validated in Belgium. Patients were re-cruited at a tertiary centre in Kraków, Poland.nnnRESULTSnA total of 479 AF patients completed the JAKQ. Patients on NOACs (n = 276, 57.6%) compared with those on VKAs (n = 175, 36.5%) did not differ regarding demographic and clinical variables. The mean score of the JAKQ was very similar in the NOAC and VKA group (60.7 ± 17.0% vs. 61.6 ± 17.1%; p = 0.4, respectively). The differences in the proportion of correct responses referred to three questions. Consequences of AF, such as blood clots and cerebral infarction, were more obvious for patients on NOACs compared with those on VKAs (81.5% vs. 70.9%; p = 0.01). The patients on NOACs (78.7% vs. 67.6%; p = 0.009) more frequently considered consulting a physician for advice concerning anticoagulant treatment before surgery, while fewer patients on NOACs were aware of the need to take their medication even if they did not feel AF (76.1% vs. 89.7%; p = 0.0004). Only 25.9% of the VKA patients and 49.3% of the NOAC users knew what to do if they missed a dose of the anticoagulant.nnnCONCLUSIONSnThe knowledge of arrhythmia and anticoagulation is better regarding the safety issues among subjects on NOACs compared with those on VKAs. Irrespective of the type of oral anticoagulation therapy, education of AF patients should be improved.

Effectiveness and usability of an online tailored education platform for atrial fibrillation patients undergoing a direct current cardioversion or pulmonary vein isolation

BACKGROUNDnAtrial fibrillation (AF) care should strive for more informed, involved and empowered patients. However, few effective educational programs are available. The aim of this study was to evaluate the effectiveness of an online tailored education platform to inform AF patients undergoing a direct current cardioversion (DCC) or a pulmonary vein isolation (PVI).nnnMETHODSn120 AF patients requiring DCC or PVI were allocated to an online education group (nu202f=u202f35), a standard care group despite having online access (nu202f=u202f36; randomized with group 1), and a group without a computer/tablet/smartphone receiving standard care (nu202f=u202f49). The Jessa Atrial fibrillation Knowledge Questionnaire (JAKQ), supplemented with procedure-specific questions, had to be completed 1-3u202fweeks before hospitalization, at hospitalization, and 6 and/or 12u202fweeks post-procedurally.nnnRESULTSnMajor AF-related and procedure-related knowledge gaps were shown. The online tailored education group scored significantly better at hospitalization compared to baseline (Pu202f=u202f0.001). This knowledge increase was retained after 6 (Pu202f=u202f0.010) and 12 (Pu202f<u202f0.001) weeks. In the online standard care group there was no change in knowledge from planning till hospitalization (Pu202f=u202f1.000), although knowledge was improved 6u202fweeks post-procedurally (Pu202f=u202f0.010). Knowledge did not improve in the group without computer/tablet/smartphone at any time (Pu202f=u202f0.248). Most patients indicated that the platform was easy to use (87.9%), understandable (97.0%), and 72.7% indicated that an online platform was their preferred way to receive future AF-related information.nnnCONCLUSIONSnTailored online education is an effective strategy to improve AF- and procedure-related knowledge with lasting effects up to 12u202fweeks post-procedurally. The platform was positively evaluated by patients.

Effect of reinforced, targeted in-person education using the Jessa Atrial fibrillation Knowledge Questionnaire in patients with atrial fibrillation: A randomized controlled trial:

Background: The knowledge level of atrial fibrillation patients about their arrhythmia, its consequences and treatment is poor. The best strategy to provide education is unknown. Aim: To investigate the effect of reinforced targeted in-person education using the Jessa Atrial fibrillation Knowledge Questionnaire (JAKQ). Methods: Sixty-seven atrial fibrillation patients were randomized to standard care (including brochures) or targeted education. Follow-up visits were scheduled after one, three, six and 12 months. Targeted education during each visit focused on the knowledge gaps revealed by the JAKQ. Patients completed two questionnaires to assess their quality of life and symptom profile. Adherence to non-vitamin K antagonist oral anticoagulants was measured using electronic monitoring. Results: Sixty-two patients (31 education; 31 standard care) completed follow-up. Median baseline score on the JAKQ was similar in education (62.5%) and standard care group (56.3%; p=0.815). The intervention group scored significantly better over time (one month: 75.0%, 12 months: 87.5%; p<0.001) whereas there was no significant improvement in the control group (one month: 62.5%, 12 months: 62.5%; p=0.085). Providing targeted education after completion of the JAKQ required on average 6.9±4.6 min. Some improvements in quality of life, symptom burden and adherence were shown, without significant differences between the two groups (p-values between 0.282 and 0.677). Conclusion: The JAKQ is an effective tool for providing individualized education. A first targeted educational session significantly improved patients’ knowledge level. Additional educational sessions maintained and strengthened this effect. A larger scale study is warranted to evaluate the impact on adherence and outcome measures.

Uninterrupted administration of edoxaban vs vitamin K antagonists in patients undergoing atrial fibrillation catheter ablation: Rationale and design of the ELIMINATE-AF study.

Patients with atrial fibrillation (AF) are at an approximately 0.5% to 3% increased risk of thromboembolism during and immediately after catheter ablation. Treatment guidelines recommend periprocedural oral anticoagulation plus unfractionated heparin during ablation. Rivaroxaban and dabigatran are the only non–vitamin K oral anticoagulants for which there are randomized controlled trials assessing uninterrupted anticoagulation in patients undergoing catheter ablation of AF. Edoxaban, a direct factor Xa inhibitor, is noninferior vs warfarin for the prevention of stroke or systemic embolism with less major bleeding in patients with nonvalvular AF. The ELIMINATE‐AF (Evaluation of Edoxaban Compared With VKA in Subjects Undergoing Catheter Ablation of Nonvalvular Atrial Fibrillation) trial is a multinational, multicenter, prospective, randomized, open‐label, parallel‐group, blinded‐endpoint evaluation (PROBE) study to assess the safety and efficacy of once‐daily edoxaban 60u2009mg (30u2009mg in patients indicated for a dose reduction) vs vitamin K antagonists (VKA) in patients with nonvalvular AF undergoing catheter ablation (http://www.ClinicalTrials.gov: NCT02942576). A total of 560 patients are planned for randomization to edoxaban or VKA (2:1 ratio) to obtain 450 patients fully compliant with the protocol. Patients will complete 21 to 28u2009days of anticoagulation prior to the ablation and a 90‐day post‐ablation period. The primary efficacy endpoint is the composite of all‐cause death, stroke, and major bleeding. The primary safety endpoint is major bleeding. A magnetic resonance imaging substudy will assess the incidence of silent cerebral lesions post‐ablation. ELIMINATE‐AF will define the efficacy and safety of edoxaban for uninterrupted oral anticoagulation during catheter ablation of AF.

Not Every Potential Is What It Seems

A 73-year-old man with atrial fibrillation was referred for pulmonary vein (PV) isolation. Wide antral circumferential ablation was performed around the ipsilateral PVs. Following completion of the circles, adenosine test and pacing maneuvers were performed using a duodecapolar Lasso catheter (