Michael Oeff

The Registry of the German Competence NETwork on Atrial Fibrillation: patient characteristics and initial management

Aims The aim of this study was to describe the characteristics of patients with atrial fibrillation (AF) enrolled in the Central Registry of the German Competence NETwork on Atrial Fibrillation (AFNET) and to assess current medical practice in patients treated at various levels of medical care in Germany. Methods and results From February 2004 to March 2006, 9582 ambulatory and hospitalized patients with ECG-documented AF were enrolled by 194 participating study centres from all levels of medical care in Germany. Clinical type of AF was reported as paroxysmal in 2893, persistent in 1873, and permanent in 3134 patients or classified as a first episode in 1035 patients. Predisposing conditions were common and present in 87.6% of the patients. Most patients were symptomatic with AF (75.1%). Rhythm control in persistent AF was provided to 53.4% of the symptomatic patients and to 47.8% of the patients without symptoms. Anticoagulation for stroke prevention was given to 71.4% of the patients considered eligible by applicable guidelines and to 48.4% of patients with low risk where guidelines do not recommend anticoagulation. Conclusion This registry provides insight into current medical care of patients with AF in Germany. The use of oral anticoagulation in eligible patients was among the highest reported, whereas decisions on rate and rhythm control often do not follow current recommendations.

Comprehensive risk reduction in patients with atrial fibrillation: emerging diagnostic and therapeutic options-a report from the 3rd Atrial Fibrillation Competence NETwork/European Heart Rhythm Association consensus conference

While management of atrial fibrillation (AF) patients is improved by guideline-conform application of anticoagulant therapy, rate control, rhythm control, and therapy of accompanying heart disease, the morbidity and mortality associated with AF remain unacceptably high. This paper describes the proceedings of the 3rd Atrial Fibrillation NETwork (AFNET)/European Heart Rhythm Association (EHRA) consensus conference that convened over 60 scientists and representatives from industry to jointly discuss emerging therapeutic and diagnostic improvements to achieve better management of AF patients. The paper covers four chapters: (i) risk factors and risk markers for AF; (ii) pathophysiological classification of AF; (iii) relevance of monitored AF duration for AF-related outcomes; and (iv) perspectives and needs for implementing better antithrombotic therapy. Relevant published literature for each section is covered, and suggestions for the improvement of management in each area are put forward. Combined, the propositions formulate a perspective to implement comprehensive management in AF.

Personalized management of atrial fibrillation: Proceedings from the fourth Atrial Fibrillation competence NETwork/European Heart Rhythm Association consensus conference.

The management of atrial fibrillation (AF) has seen marked changes in past years, with the introduction of new oral anticoagulants, new antiarrhythmic drugs, and the emergence of catheter ablation as a common intervention for rhythm control. Furthermore, new technologies enhance our ability to detect AF. Most clinical management decisions in AF patients can be based on validated parameters that encompass type of presentation, clinical factors, electrocardiogram analysis, and cardiac imaging. Despite these advances, patients with AF are still at increased risk for death, stroke, heart failure, and hospitalizations. During the fourth Atrial Fibrillation competence NETwork/European Heart Rhythm Association (AFNET/EHRA) consensus conference, we identified the following opportunities to personalize management of AF in a better manner with a view to improve outcomes by integrating atrial morphology and damage, brain imaging, information on genetic predisposition, systemic or local inflammation, and markers for cardiac strain. Each of these promising avenues requires validation in the context of existing risk factors in patients. More importantly, a new taxonomy of AF may be needed based on the pathophysiological type of AF to allow personalized management of AF to come to full fruition. Continued translational research efforts are needed to personalize management of this prevalent disease in a better manner. All the efforts are expected to improve the management of patients with AF based on personalized therapy.

A roadmap to improve the quality of atrial fibrillation management: proceedings from the fifth Atrial Fibrillation Network/European Heart Rhythm Association consensus conference

At least 30 million people worldwide carry a diagnosis of atrial fibrillation (AF), and many more suffer from undiagnosed, subclinical, or silent AF. Atrial fibrillation-related cardiovascular mortality and morbidity, including cardiovascular deaths, heart failure, stroke, and hospitalizations, remain unacceptably high, even when evidence-based therapies such as anticoagulation and rate control are used. Furthermore, it is still necessary to define how best to prevent AF, largely due to a lack of clinical measures that would allow identification of treatable causes of AF in any given patient. Hence, there are important unmet clinical and research needs in the evaluation and management of AF patients. The ensuing needs and opportunities for improving the quality of AF care were discussed during the fifth Atrial Fibrillation Network/European Heart Rhythm Association consensus conference in Nice, France, on 22 and 23 January 2015. Here, we report the outcome of this conference, with a focus on (i) learning from our neighbours to improve AF care, (ii) patient-centred approaches to AF management, (iii) structured care of AF patients, (iv) improving the quality of AF treatment, and (v) personalization of AF management. This report ends with a list of priorities for research in AF patients.

Home telemonitoring in patients with chronic heart failure: a chance to improve patient care?

BACKGROUNDnTelemonitoring can improve the medical care, quality of life, and prognosis of chronically ill patients. This review article summarizes the current status of health services research on telemonitoring, focusing on patients with chronic congestive heart failure.nnnMETHODnThe Medline database was selectively searched for articles appearing from June 2001 to May 2008, with an emphasis on randomized, controlled trials.nnnRESULTSnThe available scientific data on vital signs monitoring are limited, yet there is evidence for a positive effect on some clinical endpoints, particularly mortality. Nonetheless, any possible improvement of patient-reported outcomes, such as the quality of life, still remains to be demonstrated.nnnCONCLUSIONSnThe data suggest that telemonitoring is effective, yet there is no evidence for superior outcomes with any particular model of care incorporating telemonitoring (i.e., monitoring of vital signs versus structured telephone monitoring). A valid criticism is that the individual components of home telemonitoring have not yet been separately tested in order to compare their individual effects.

Flecainide acetate for the treatment of atrial and ventricular arrhythmias

Introduction: Flecainide is a class Ic antiarrhythmic agent available in Europe since 1982. The clinical development program of flecainide provided good data on its antiarrhythmic effect for the prevention of ventricular and supraventricular arrhythmias. The Cardiac Arrhythmia Suppression Trial (CAST), conducted to test whether the arrhythmia suppression translates into prevention of sudden death, assessed the impact of flecainide and encainide therapy in patients with frequent ventricular ectopics and reduced left ventricular function who had survived an infarction. In that population, flecainide and encainide increased mortality. Consequently, sodium channel blockers are now rarely used to prevent sudden death and are not recommended in patients with heart failure. Current European and North American guidelines recommend the use of flecainide in carefully selected patients with atrial fibrillation (AF) and no documented structural heart disease. Areas covered: The aim of this review is to evaluate the available data on efficacy and safety of flecainide in all the spectrum of its indications including cardioversion of recent-onset AF, sinus rhythm maintenance in paroxysmal AF and management of ventricular tachyarrhythmias. Expert opinion: In the setting of AF and in carefully selected patients without structural heart disease, flecainide has shown a good efficacy and safety for both cardioversion and sinus rhythm maintenance.

The German Competence Network on Atrial Fibrillation (AFNET).

The German Competence Network on Atrial Fibrillation (AFNET) is an interdisciplinary national research network funded by the Federal Ministry of Education and Research (BMBF) since 2003. The AFNET aims at improving treatment of atrial fibrillation (AF), the most frequent sustained arrhythmia of the heart. The AFNET has established a nationwide patient registry on manifestation, diagnostics, and therapy of AF in Germany. The data analyzed to date demonstrate that patients with AF are likely to have multiple comorbidities (hypertension, valvular heart disease, coronary artery disease, diabetes mellitus) and an advanced age. Regarding oral anticoagulation, guideline adherence is very high. Basic research has identified specific changes in atrial tissue during AF-induced remodeling providing the rationale for novel therapeutic interventions. Clinical trials are being carried out to optimize pharmacological and nonpharmacological treatments. The ANTIPAF trial is designed to prove that angiotensin II receptor blockers reduce the incidence of paroxysmal AF. The Flec-SL trial tests the efficacy of a short-term treatment with antiarrhythmic drugs after cardioversion. The Gap-AF trial investigates the impact of complete pulmonary vein (PV) isolation versus incomplete circumferential PV ablation on AF recurrences. The effect of preventive pacing on the recurrence of paroxysmal AF is studied in the BACE-PACE trial.ZusammenfassungDas Kompetenznetz Vorhofflimmern (AFNET) ist ein interdisziplinäres bundesweites Forschungsnetzwerk, das seit 2003 vom Bundesministerium für Bildung und Forschung (BMBF) gefördert wird. Ziel des AFNET ist es, die Behandlung von Vorhofflimmern, der häufigsten klinisch bedeutsamen Herzrhythmusstörung, nachhaltig zu verbessern. Das AFNET hat ein deutschlandweites Patientenregister aufgebaut, mit dem eine Bestandsaufnahme der Manifestation sowie der Diagnostik und Therapie von Vorhofflimmern in Deutschland durchgeführt wird. Die bis jetzt analysierten Daten zeigen, dass Patienten mit Vorhofflimmern typischerweise vielfältige Begleiterkrankungen wie Hypertonie, Herzklappenfehler, koronare Herzkrankheit oder Diabetes mellitus sowie ein fortgeschrittenes Alter aufweisen. Bezüglich der oralen Antikoagulation ergeben die Registerdaten eine verhältnismäßig hohe Übereinstimmung mit den Leitlinien. In der Grundlagenforschung konnten spezifische Veränderungen des Vorhofgewebes identifiziert werden, die durch vorhofflimmerninduzierte Umbauvorgänge (Remodeling) hervorgerufen werden. Diese Erkenntnisse liefern die Grundlage für neue therapeutische Ansätze. In den klinischen Studien, die das AFNET durchführt, werden verbesserte medikamentöse und nichtmedikamentöse Behandlungsmethoden überprüft. Die ANTIPAF-Studie will beweisen, dass Angiotensin-II-Rezeptor-Blocker geeignet sind, das Auftreten von paroxysmalem Vorhofflimmern zu reduzieren. Die Flec-SL-Studie testet die Wirksamkeit einer antiarrhythmischen Kurzzeittherapie nach der Kardioversion. Die Gap-AF-Studie untersucht, ob eine vollständige Pulmonalvenenisolation einer unvollständigen überlegen ist. Die Wirkung der präventiven Schrittmacherstimulation zur Verhinderung von Vorhofflimmern wird in der BACE-PACE-Studie untersucht.

Low stroke risk after elective cardioversion of atrial fibrillation: An analysis of the Flec-SL trial

BACKGROUNDnCurrent recommendations for anticoagulation management during cardioversion are largely based on historical data and expert consensus.nnnMETHODS AND RESULTSnTo characterize current practice of anticoagulation during and after elective cardioversion for AF and the risk of stroke and bleeding events, all patients enrolled into the Flec-SL trial were analyzed for stroke/transient ischemic attack and major bleeds after cardioversion. Flec-SL (ISRCTN62728743, NCT00215774) enrolled 635 patients (mean age 63.7 ± 10.9, 66% male). 629 (99.1%) patients received periprocedural anticoagulation, 556 (87.6%) were adequately anticoagulated following current recommendations. 202 (31.8%) patients underwent transesophageal echocardiography-guided cardioversion. Electrical cardioversion was used in 508 patients (80.0%), pharmacological cardioversion in 127 (20%). Six patients suffered from stroke (n = 5) or transient ischemic attack (3 TIAs in 1 patient, event rate 0.9%, 95% CI 0.4-2.1), five others from major bleeds (event rate 0.8%, 95% CI 0.3-1.9), consistent with the low reported event rates in prior studies. Three strokes occurred in the first 5 days after cardioversion. Events were independent of type of cardioversion or the use of TEE to exclude thrombi.nnnCONCLUSIONnStrokes are rare in this large, prospectively followed cohort of patients undergoing cardioversion for AF and receiving antithrombotic therapy following local routine. These results support adherence to current recommendations for anticoagulation during cardioversion of AF.

Use of vitamin K antagonists for secondary stroke prevention depends on the treating healthcare provider in Germany – results from the German AFNET registry

BackgroundAnticoagulation using vitamin K antagonists (VKAs) significantly reduces the risk of recurrent stroke in stroke patients with atrial fibrillation (AF) and is recommended by guidelines.MethodsThe German Competence NETwork on Atrial Fibrillation established a nationwide prospective registry including 9,574 AF patients, providing the opportunity to analyse AF management according to German healthcare providers.ResultsOn enrolment, 896 (9.4xa0%) patients reported a prior ischaemic stroke or transient ischaemic attack. Stroke patients were significantly older, more likely to be female, had a higher rate of cardiovascular risk factors, and more frequently received anticoagulation (almost exclusively VKA) than patients without prior stroke history. Following enrolment, 76.4xa0% of all stroke patients without VKA contraindications received anticoagulation, which inversely associated with age (OR 0.95 per year; 95 % CI 0.92–0.97). General practitioners/internists (OR 0.40; 95 % CI 0.21–0.77) and physicians working in regional hospitals (OR 0.47; 95 % CI 0.29–0.77) prescribed anticoagulation for secondary stroke prevention less frequently than physicians working at university hospitals (reference) and office-based cardiologists (OR 1.40; 95 % CI 0.76–2.60). The impact of the treating healthcare provider was less evident in registry patients without prior stroke.ConclusionsIn the AFNET registry, anticoagulation for secondary stroke prevention was prescribed in roughly three-quarters of AF patients, a significantly higher rate than in primary prevention. We identified two factors associated with withholding oral anticoagulation in stroke survivors, namely higher age and—most prominently—treatment by a general practitioner/internist or physicians working at regional hospitals.

Telemedizin in der Kardiologie - Relevanz für die Praxis?!

Changes in the demographic structure, increasing multimorbidity in connection with a rise in the number of chronic illnesses and the absence of an effective coordination of the different levels of healthcare services with its discontinuous processes and redundancies will increase the economic burdens in the German health-care system. Recent developments and appropriate logistic premises nowadays offer a realistic basis for implementing remote medicine as a central service and information tool as well as an instrument controlling the information and data flow between patient, hospital and medical practitioner. This article highlights current and future strategies including diagnostic and therapeutic options. The focus will concentrate on patients with heart rhythm disturbances, advanced congestive heart failure, and patients with implantable devices, i.e., pacemaker and implantable cardioverter defibrillator (ICD).ZusammenfassungDer deutliche Zuwachs an Patienten mit chronischen Erkrankungen bei gleichzeitig verbesserungswürdiger Koordination der unterschiedlichen Versorgungsebenen (mit diskontinuierlichen Prozessen und Redundanzen) resultiert in steigenden Belastungen für das deutsche Gesundheitssystem. Aktuelle technische Entwicklungen bieten bereits eine realistische Basis, Telemonitoring als zentrales Service- und Informationstool zu implementieren und als Instrument zur Steuerung von Informations- und Datenfluss zwischen Patient, Krankenhaus und niedergelassenem Arzt zu nutzen. Der Fokus dieses Artikels liegt auf der Anwendung dieser innovativen Technologie auf dem Feld der Herzrhythmusstörungen, der Versorgung von Patienten mit Herzinsuffizienz sowie der Anwendung im Bereich der Betreuung von Patienten mit elektrischer Implantation (Herzschrittmacher, implantierbarer Kardioverter-Defibrillator) im Hinblick auf die Nutzung in Klinik und Praxis.AbstractChanges in the demographic structure, increasing multimorbidity in connection with a rise in the number of chronic illnesses and the absence of an effective coordination of the different levels of healthcare services with its discontinuous processes and redundancies will increase the economic burdens in the German health-care system. Recent developments and appropriate logistic premises nowadays offer a realistic basis for implementing remote medicine as a central service and information tool as well as an instrument controlling the information and data flow between patient, hospital and medical practitioner. This article highlights current and future strategies including diagnostic and therapeutic options. The focus will concentrate on patients with heart rhythm disturbances, advanced congestive heart failure, and patients with implantable devices, i.e., pacemaker and implantable cardioverter defibrillator (ICD).