Noura Zannad

Antiarrhythmic effect of statin therapy and atrial fibrillation a meta-analysis of randomized controlled trials.

OBJECTIVES To improve the evaluation of the possible antiarrhythmic effect of statins, we performed a meta-analysis of randomized trials with statins on the end point of incidence or recurrence of atrial fibrillation (AF). BACKGROUND The use of statins had been suggested to protect against AF in some clinical observational and experimental studies but has remained inadequately explored. METHODS A systematic review of controlled trials with statins was performed. Eligible studies had to have been randomized controlled parallel-design human trials with use of statins that collected data on incidence or recurrence of AF. RESULTS Six studies with 3,557 patients in sinus rhythm were included in the analysis. Three studies investigated the use of statins in patients with a history of paroxysmal AF (n = 1) or persistent AF undergoing electrical cardioversion (n = 2), and 3 investigated the use of statins in primary prevention of AF in patients undergoing cardiac surgery or after acute coronary syndrome. Incidence or recurrence of AF occurred in 386 patients. Overall, the use of statins was significantly associated with a decreased risk of AF compared with control (odds ratio [OR] 0.39, 95% confidence interval [CI] 0.18 to 0.85, p = 0.02). Benefit of statin therapy seemed more marked in secondary prevention of AF (OR 0.33, 95% CI 0.10 to 1.03, p = 0.06) than for new-onset or postoperative AF (OR 0.60, 95% CI 0.27 to 1.37, p = 0.23). CONCLUSIONS Use of statins was significantly associated with a decreased risk of incidence or recurrence of AF in patients in sinus rhythm with a history of previous AF or undergoing cardiac surgery or after acute coronary syndrome.

Focus Issue: Atrial FibrillationClinical Research: Statins and Atrial FibrillationAntiarrhythmic Effect of Statin Therapy and Atrial Fibrillation: A Meta-Analysis of Randomized Controlled Trials

OBJECTIVES To improve the evaluation of the possible antiarrhythmic effect of statins, we performed a meta-analysis of randomized trials with statins on the end point of incidence or recurrence of atrial fibrillation (AF). BACKGROUND The use of statins had been suggested to protect against AF in some clinical observational and experimental studies but has remained inadequately explored. METHODS A systematic review of controlled trials with statins was performed. Eligible studies had to have been randomized controlled parallel-design human trials with use of statins that collected data on incidence or recurrence of AF. RESULTS Six studies with 3,557 patients in sinus rhythm were included in the analysis. Three studies investigated the use of statins in patients with a history of paroxysmal AF (n = 1) or persistent AF undergoing electrical cardioversion (n = 2), and 3 investigated the use of statins in primary prevention of AF in patients undergoing cardiac surgery or after acute coronary syndrome. Incidence or recurrence of AF occurred in 386 patients. Overall, the use of statins was significantly associated with a decreased risk of AF compared with control (odds ratio [OR] 0.39, 95% confidence interval [CI] 0.18 to 0.85, p = 0.02). Benefit of statin therapy seemed more marked in secondary prevention of AF (OR 0.33, 95% CI 0.10 to 1.03, p = 0.06) than for new-onset or postoperative AF (OR 0.60, 95% CI 0.27 to 1.37, p = 0.23). CONCLUSIONS Use of statins was significantly associated with a decreased risk of incidence or recurrence of AF in patients in sinus rhythm with a history of previous AF or undergoing cardiac surgery or after acute coronary syndrome.

Incomplete recovery of mechanical and endocrine left atrial functions one month after electrical cardioversion for persistent atrial fibrillation: a pilot study

BackgroundRestoration of the mechanical and endocrine functions of the left atrium remains controversial after electrical cardioversion treatment for persistent atrial fibrillation. The objective of the prospective study was to describe the recovery of the endocrine and mechanical functions of the left atrium.MethodsEvaluation of left atrium recovery after electrical cardioversion by the new speckle-tracking echocardiography technique and proANP measurement.ResultsTwenty patients suffering from persistent atrial fibrillation with no alteration of left ventricular ejection fraction were prospectively evaluated at baseline and then one month later by echocardiography, measuring left atrial volume and left atrial deformation (MPALS), as well as the proANP and BNP concentrations. One month after cardioversion 10 patients remained in sinus rhythm and 10 showed recurrent atrial fibrillation. No significant differences between the two groups in terms of clinical, echocardiographic and endocrine parameters were observed at baseline evaluation. We observed a significant reduction of left atrial volume only in the sinus group, whereas restoration of the left atrial deformation was only partial (18%) in that group. By contrast, we registered no significant changes in ANP concentration at one month in either the sinus or the atrial fibrillation groups.ConclusionThese results suggest that restoration of left atrium mechanical function is only partial one month after treatment of persistent atrial fibrillation by electrical cardioversion, whereas a significant reduction of left atrial volume was noted, explaining the remaining high level of ANP in the sinus group.

Interventricular delay measurement using equilibrium radionuclide angiography before resynchronization therapy should be performed outside the area of segmental wall motion abnormalities

BackgroundThe aim of this study was to demonstrate that only mechanical dyssynchrony outside the area of segmental wall motion abnormalities (WMA) can be reduced by cardiac resynchronization therapy (CRT).Methods and resultsIncluded in the study were 28 consecutive patients with nonischaemic cardiomyopathy selected for CRT. Equilibrium radionuclide angiography (ERNA) was carried out before and after implantation of a multisite pacemaker. Patients were separated into two groups depending on the presence or absence of segmental WMA.ResultsA reduction in QRS duration was observed in all patients after CRT. The interventricular delay (IVD) decreased significantly after CRT only in patients without WMA (homogeneous contraction, HG group; IVD 44 ± 11.4° vs. 17 ± 3.1°, p = 0.04). In contrast, no significant decrease was observed in patients with WMA (WMA group; IVD 51 ± 6° vs. 38 ± 6°, p NS). However, when dyssynchrony was considered outside the WMA area, a significant reduction in IVD was obtained, in the same range as in the HG group (IVD 32 ± 3° vs. 19 ± 3°, p = 0.04). In 9 of 15 patients (60%) with a reduction in IVD after CRT, the left ventricle ejection fraction (LVEF) increased by about +10%. In contrast, in 13 of 13 patients (100%) with no reduction in IVD, no modification of LVEF was obtained. In the presence of segmental WMA without significant delays outside the WMA area, no reduction in IVD was observed and LVEF did not increase (IVD 34 ± 5° before CRT vs. 37 ± 7° after CRT; LVEF 19 ± 4% before CRT vs. 22 ± 3% after CRT, p NS).ConclusionERNA can be used to predict good mechanical resychronization (decrease in IVD) in patients after pacing. IVD has to be determined excluding the area of WMA in order to select patients who will show an increase in their left ventricle function after CRT.

A young patient with Danon disease receives two ICD shocks: why?

We report the case of an 18‐year‐old man with Danon disease, a genetic disorder inclunding a severe hypertrophic cardiomyopathy with very broad QRS, who had an implantable cardioverter defibrillator for primary prevention. Nine months after implantation, he received two inappropriate shocks due to R‐wave double counting during sinus tachycardia. We discuss how to avoid such inappropriate therapy. (PACE 2010; 618–619)

Des médicaments non anti-arythmiques peuvent-ils avoir un effet préventif sur la fibrillation auriculaire ? Non-antiarrhythmic drug therapy for the prevention of atrial fibrillation?

Resume L’absence de benefice net avec les strategies de controle du rythme sur celui de la frequence cardiaque en cas de fibrillation auriculaire (FA) pourrait etre liee aux effets indesirables des anti-arythmiques classiques. Parallelement a la recherche pour ameliorer l’efficacite et la securite d’emploi d’anti-arythmiques conventionnels, des therapeutiques ciblant les substrats anatomiques ou le remodelage auriculaire en amont des aspects electriques de la FA ont ete proposees comme nouvelle approche de traitement pharmacologique. Ces traitements potentiels de la FA incluent des classes differentes comme les inhibiteurs de l’enzyme de conversion de l’angiotensine (IEC), les antagonistes des recepteurs a l’angiotensine 2 (ARA2), les statines, les acides gras poly insatures ou les corticosteroides. Sur la base de donnees experimentales, des etudes cliniques ont apporte des informations sur le potentiel de ces traitements sur differentes populations de patients. En cas d’insuffisance cardiaque ou d’hypertension, les resultats paraissent suffisants pour justifier l’utilisation des IEC ou des ARA2 afin de diminuer le risque de FA, en plus du benefice clinique deja etabli par ailleurs. De meme, il est probable que l’utilisation de statines lorsqu’elles ont une indication reconnue soit associee a un benefice en terme de prevention de la FA. Neanmoins, dans la plupart des situations cliniques, ces donnees semblent insuffisantes pour justifier des modifications therapeutiques individuelles majeures et des grands essais controles randomises avec des criteres d’evaluation pertinents restent necessaires. Leurs resultats permettraient de mieux comprendre certains des mecanismes complexes aboutissant a la FA et de mieux quantifier le rapport benefice/risque de ces nouvelles approches therapeutiques.

[Non-antiarrhythmic drug therapy for the prevention of atrial fibrillation?].

Resume L’absence de benefice net avec les strategies de controle du rythme sur celui de la frequence cardiaque en cas de fibrillation auriculaire (FA) pourrait etre liee aux effets indesirables des anti-arythmiques classiques. Parallelement a la recherche pour ameliorer l’efficacite et la securite d’emploi d’anti-arythmiques conventionnels, des therapeutiques ciblant les substrats anatomiques ou le remodelage auriculaire en amont des aspects electriques de la FA ont ete proposees comme nouvelle approche de traitement pharmacologique. Ces traitements potentiels de la FA incluent des classes differentes comme les inhibiteurs de l’enzyme de conversion de l’angiotensine (IEC), les antagonistes des recepteurs a l’angiotensine 2 (ARA2), les statines, les acides gras poly insatures ou les corticosteroides. Sur la base de donnees experimentales, des etudes cliniques ont apporte des informations sur le potentiel de ces traitements sur differentes populations de patients. En cas d’insuffisance cardiaque ou d’hypertension, les resultats paraissent suffisants pour justifier l’utilisation des IEC ou des ARA2 afin de diminuer le risque de FA, en plus du benefice clinique deja etabli par ailleurs. De meme, il est probable que l’utilisation de statines lorsqu’elles ont une indication reconnue soit associee a un benefice en terme de prevention de la FA. Neanmoins, dans la plupart des situations cliniques, ces donnees semblent insuffisantes pour justifier des modifications therapeutiques individuelles majeures et des grands essais controles randomises avec des criteres d’evaluation pertinents restent necessaires. Leurs resultats permettraient de mieux comprendre certains des mecanismes complexes aboutissant a la FA et de mieux quantifier le rapport benefice/risque de ces nouvelles approches therapeutiques.

Des médicaments non anti-arythmiques peuvent-ils avoir un effet préventif sur la fibrillation auriculaire ?

Resume L’absence de benefice net avec les strategies de controle du rythme sur celui de la frequence cardiaque en cas de fibrillation auriculaire (FA) pourrait etre liee aux effets indesirables des anti-arythmiques classiques. Parallelement a la recherche pour ameliorer l’efficacite et la securite d’emploi d’anti-arythmiques conventionnels, des therapeutiques ciblant les substrats anatomiques ou le remodelage auriculaire en amont des aspects electriques de la FA ont ete proposees comme nouvelle approche de traitement pharmacologique. Ces traitements potentiels de la FA incluent des classes differentes comme les inhibiteurs de l’enzyme de conversion de l’angiotensine (IEC), les antagonistes des recepteurs a l’angiotensine 2 (ARA2), les statines, les acides gras poly insatures ou les corticosteroides. Sur la base de donnees experimentales, des etudes cliniques ont apporte des informations sur le potentiel de ces traitements sur differentes populations de patients. En cas d’insuffisance cardiaque ou d’hypertension, les resultats paraissent suffisants pour justifier l’utilisation des IEC ou des ARA2 afin de diminuer le risque de FA, en plus du benefice clinique deja etabli par ailleurs. De meme, il est probable que l’utilisation de statines lorsqu’elles ont une indication reconnue soit associee a un benefice en terme de prevention de la FA. Neanmoins, dans la plupart des situations cliniques, ces donnees semblent insuffisantes pour justifier des modifications therapeutiques individuelles majeures et des grands essais controles randomises avec des criteres d’evaluation pertinents restent necessaires. Leurs resultats permettraient de mieux comprendre certains des mecanismes complexes aboutissant a la FA et de mieux quantifier le rapport benefice/risque de ces nouvelles approches therapeutiques.

Enjeux cliniques morbi-mortalité, risques thromboemboliques

The atrial fibrillation is linked to an overmortality (x2), except in patients with lone atrial fibrillation. The severity of atrial fibrillation is due to the risk of thromboembolism event, especially stroke. This risk is very high in presence of rhumatismal mitral valve pathology or prosthetic valve. The annual risk of thromboembolism has been evaluated and the CHADS2 score defined from 0 to 6 In function of the CHADS2 score the risk of thromboembolism event is 1.9 to 18.2%/year. Other factors of thromboembolism accident are actually evaluated such as renal insufficiency, proteinuria. The main objective of atrial fibrillation treatment is the prevention of thromboembolism event. The antivitamin K agents proved their efficiency in term of mortality and morbidity justifying to identify the patients at risk of thromboembolism event.