| 1. |
- Almroth, Henrik, et al.
(författare)
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Atorvastatin and persistent atrial fibrillation following cardioversion : a randomized placebo-controlled multicentre study
- 2009
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Ingår i: European Heart Journal. - Philadelphia : Oxford University Press (OUP). - 0195-668X .- 1522-9645. ; 30:7, s. 827-833
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Tidskriftsartikel (refereegranskat)abstract
- AIMS: To evaluate the effect of atorvastatin in achieving stable sinus rhythm (SR) 30 days after electrical cardioversion (CV) in patients with persistent atrial fibrillation (AF). METHODS AND RESULTS: The study included 234 patients. The patients were randomized to treatment with atorvastatin 80 mg daily (n = 118) or placebo (n = 116) in a prospective, double-blinded fashion. Treatment was initiated 14 days before CV and was continued 30 days after CV. The two groups were well-balanced with respect to baseline characteristics. Mean age was 65 +/- 10 years, 76% of the patients were male and 4% had ischaemic heart disease. Study medication was well-tolerated in all patients but one. Before primary endpoint 12 patients were excluded. In the atorvastatin group 99 patients (89%) converted to SR at electrical CV compared with 95 (86%) in the placebo group (P = 0.42). An intention-to-treat analysis with the available data, by randomization group, showed that 57 (51%) in the atorvastatin group and 47 (42%) in the placebo group were in SR 30 days after CV (OR 1.44, 95%CI 0.85-2.44, P = 0.18). CONCLUSION: Atorvastatin was not statistically superior to placebo with regards to maintaining SR 30 days after CV in patients with persistent AF.
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| 2. |
- Almroth, Henrik, et al.
(författare)
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Safety of flecainide for atrial fibrillation : the Swedish atrial fibrillation cohort study
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Annan publikation (övrigt vetenskapligt/konstnärligt)abstract
- Background Little is known about the safety of flecainide in atrial fibrillation (AF). Whether current flecainide treatment practice in Sweden is associated with increased mortality compared to treatment with beta-blockers alone was investigated in patients with atrial fibrillation (AF).Methods and Results A total of 182,678 patients diagnosed with AF between 1 July 2005 and 31 December 2008 were identified through the Swedish National Hospital Discharge Register. These data were matched to data from the Prescribed Drug Register and information about death from the Total Population Register. The primary outcome was all cause mortality at the end of the study period, 1 Feb 2010. Flecainide was prescribed to 5381 patients (2.9%), and 64,918 patients (45.7%) received beta-blockers only. During follow-up, 2.8% and 30.8% of these patients died, respectively. After coarsened and exact matching, 2,178 patients (1.2% of total) on flecainide and beta-blockers had more similar baseline characteristics to 27,313 patients (15.3% of total) on beta-blockers only. In the main analysis, flecainide exposure was not associated with increased mortality (OR 0.27, 95% CI 0.21-0.36,P<0.001). In the matched flecainide population, 205 (9.4%) patients had underlying structural heart disease. Sixteen (28.6%) of the flecainide-exposed patients who died had structural heart disease. The patients who only received flecainide (n=264) had higher mortality rate than the patients who received flecainide and beta-blockers (6.8 versus 2.6%,P<0.001).Conclusions Flecainide is not associated with increased mortality in patients with AF compared to beta-blockers alone. Patients who die after receiving flecainide often have structural heart disease.
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| 3. |
- Almroth, Henrik, 1970-, et al.
(författare)
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The safety of flecainide treatment of atrial fibrillation : long-term incidence of sudden cardiac death and proarrhythmic events
- 2011
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Ingår i: Journal of Internal Medicine. - : John Wiley & Sons. - 0954-6820 .- 1365-2796. ; 270:3, s. 281-290
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Tidskriftsartikel (refereegranskat)abstract
- Objective:To assess the safety of long-term treatment with flecainide in patients with atrial fibrillation (AF), particularly with regard to sudden cardiac death (SCD) andproarrhythmic events.Design: Retrospective,observational cohort study.Setting.Single-centre study at Örebro University Hospital, Sweden.Setting: Single-centre study at Orebro University Hospital, Sweden.Subjects: A total of 112 patients with paroxysmal (51%) or persistent (49%) AF (mean age 60 ± 11 years) were included after identifying all patients with AF who initiated oral flecainide treatment (mean dose 203 ± 43 mg per day) between 1998 and 2006. Standard exclusion⁄inclusion criteria for flecainide were used,andflecainidetreatmentwasusually combined withanatrioventricular-blocking agent (89%).Main outcome measure: Death was classified as sudden or nonsudden according to standard definitions. Proarrhythmia was defined as cardiac syncope or lifethreatening arrhythmia.Results: Eight deaths were reported during a mean follow- up of 3.4 ± .4 years. Compared to the general population, the standardized mortality ratios were 1.57 (95% confidence interval (CI) 0.68–3.09) for allcause mortality and 4.16 (95% CI 1.53–9.06) for death from cardiovascular disease. Three deaths were classified as SCDs. Proarrhythmic events occurred in six patients (two each with wide QRS tachycardia, 1 : 1 conducted atrial flutter and syncope during exercise).Conclusion: We found an increased incidence of SCD or proarrhythmic events in this real-world study of flecainide used for the treatment of AF. The findings suggest that further investigation into the safety of flecainide for the treatment of patients with AF is warranted.
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| 4. |
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| 5. |
- Andersson, Jonas, et al.
(författare)
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Markers of fibrinolysis as predictors for maintenance of sinus rhythm after electrical cardioversion
- 2011
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Ingår i: Thrombosis Research. - : Elsevier BV. - 0049-3848 .- 1879-2472. ; 127:3, s. 189-192
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Tidskriftsartikel (refereegranskat)abstract
- No fibrinolytic component alone was found to be a predictor of recurrence of atrial fibrillation. In multivariate models lower PAI-1 mass was associated with sinus rhythm even after adjusting for CRP, markers of the metabolic syndrome and treatment with atorvastatin. Our findings suggest a patophysiological link between AF and PAI-1 mass but the relation to inflammation remains unclear.
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| 6. |
- Andersson, Jonas, et al.
(författare)
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NT-proBNP predicts maintenance of sinus rhythm after electrical cardioversion.
- 2015
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Ingår i: Thrombosis Research. - : Elsevier BV. - 0049-3848 .- 1879-2472. ; 135:2, s. 289-291
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: Atrial fibrillation (AF) is the most common arrhythmia. NT-proBNP is a fragment of the prohormone brain natriuretic peptide. Previous studies indicate that increased levels of NT-proBNP are associated with higher recurrence rates of AF after electrical cardioversion. Our null hypothesis was that NT-proBNP does not predict recurrence of AF after restoration of sinus rhythm.METHODS: We performed a hypothesis generating study within a double-blinded, placebo-controlled, randomized, prospective multicentre study of the effects of atorvastatin on recurrence of AF after electrical cardioversion. 199 patients with persistent AF and an indication for cardioversion were included in the present substudy. NT-proBNP was assessed prior to cardioversion. Cardioversion was performed according to local standard clinical practice on an elective outpatient basis. Patients were followed-up one month after cardioversion.RESULTS: 181 patients had a successful cardioversion and 91 of the study group remained in sinus rhythm at day 30. Recurrence of AF was observed in 108 patients at day 30. An optimal cutpoint for NT-proBNP at 500 ng/L predicted recurrence of AF after cardioversion (OR 2.94; 95% CI 1.30-6.63). In multivariate analysis adjusting for age, sex, hypertension, and treatment group strengthened the results (OR 3,56; 95% CI 1,44-8,81). When analysing the ROC curve of NT-proBNP in baseline and atrial fibrillation at day 30 the result was 0.57.CONCLUSION: NT-proBNP levels are a predictor of recurrence of AF 30 days after cardioversion. ROC curves indicates that the practical value of NT-proBNP for the individual patient is limited.
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| 7. |
- Aronsson, Mattias, 1989-, et al.
(författare)
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Designing an optimal screening program for unknown atrial fibrillation : a cost-effectiveness analysis.
- 2017
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Ingår i: Europace. - Oxford : Oxford University Press. - 1099-5129 .- 1532-2092. ; 19:10, s. 1650-1656
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Tidskriftsartikel (refereegranskat)abstract
- Aims: The primary objective of this study was to use computer simulations to suggest an optimal age for initiation of screening for unknown atrial fibrillation and to evaluate if repeated screening will add value.Methods and results: In the absence of relevant clinical studies, this analysis was based on a simulation model. More than two billion different designs of screening programs for unknown atrial fibrillation were simulated and analysed. Data from the published scientific literature and registries were used to construct the model and estimate lifelong effects and costs. Costs and effects generated by 2 147 483 648 different screening designs were calculated and compared. Program designs that implied worse clinical outcome and were less cost-effective compared to other programs were excluded from the analysis. Seven program designs were identified, and considered to be cost effective depending on what the health-care decision makers are ready to pay for gaining a quality-adjusted life-year (QALY). Screening at the age of 75 implied the lowest cost per gained QALY (€4 800/QALY).Conclusion: In conclusion, examining the results of more than two billion simulated screening program designs for unknown atrial fibrillation, seven designs were deemed cost-effective depending on how much we are prepared to pay for gaining QALYs. Our results showed that repeated screening for atrial fibrillation implied additional health benefits to a reasonable cost compared to one-off screening.
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| 8. |
- Arvanitis, Panagiotis, 1973-
(författare)
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Clinical evaluation and implications of left atrial remodeling in atrial fibrillation : From silent cerebral lesions and atrial stunning to novel electrocardiographic tools for prediction of arrhythmia outcome
- 2023
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Atrial fibrillation (AF) is the most common cardiac arrhythmia. Left atrial (LA) remodeling and reverse remodeling are associated with cerebral involvement and cognitive function (CF) changes. Risk stratification for AF related outcomes is essential in the management of patients with AF. This thesis aimed to 1) explore the effects of AF in a prospective cohort of anticoagulant-naïve patients, who underwent cardioversion (CV) within 48 hours after debut (Studies I and II) on i) occurrence of new silent thromboembolic events using brain magnetic resonance imaging, CF, cerebral biomarker ii) atrial remodeling and thrombogenicity using echocardiography, and hypercoagulability biomarkers; 2) identify novel electrocardiographic (ECG) predictors of 12-months AF recurrence, (Study III), in patients with non-permanent AF after CV or pulmonary vein isolation and study its effect on reverse atrial electrical remodeling (RAER) and 3) to evaluate traditional and novel ECG- and clinical predictors of new-onset AF (new-o-AF) on hospitalized Covid-19 patients (Study IV) and explore the impact of AF on clinical outcomes.In Papers I and II, acute silent cerebral lesions could not be identified. A higher incidence of white matter hyperintensities was associated with higher CHA2DS2-VASc-score. A transient increase in cerebral damage biomarker was observed. Persistent AF patients had inferior CF test results. LA stunning resolved within ten days. The reverse functional remodeling was incomplete in patients with AF history. Higher levels of hypercoagulability-related biomarkers were observed prior to CV. In Paper III, the novel Peq-time>33ms, from P-wave onset to the peak positive deflection, independently predicted 12-months AF recurrence. The P-leftward-area, from peak positive deflection to the offset of P-wave, showed the largest change during follow-up, describing RAER. Machine-learning predictive model including variables from the novel P-wave partitioning showed the best predictive performance.In Paper IV, the novel Peq-time>33ms, PR-interval>190ms and P-wave-duration>115ms were independent predictors of n-o-AF. Admission to the intensive care unit (ICU), need for respiratory support, advanced age, males and increased body mass index (BMI) independently predicted new-o-AF. Logistic regression predictive models including age, sex, BMI, ICU admission and Peq-time or PR-interval had the best balanced accuracy.In conclusion, our findings in Studies I and II might suggest an enhanced thrombogenicity, even in patients with low stroke risk, supporting the concept of anticoagulation pericardioversion. We introduced the novel Peq-time, independently predicting AF recurrence in Study III and, along with PR-interval, new-o-AF in Study IV. Predictive models of arrhythmia outcome could be implemented in individually-tailored AF management and surveillance.
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| 9. |
- Bagge, Louise
(författare)
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Surgical ablation for the treatment of atrial fibrillation in different patient populations : A study of clinical outcomes including rhythm, quality of life, atrial function and safety
- 2018
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Patients with atrial fibrillation (AF) have markedly reduced quality of life (QoL) and catheter ablation has become a useful tool in the rhythm control therapy. However, because of the poor outcome for patients with persistent AF, new surgical ablation strategies for rhythm control are emerging.The aims of this thesis were to evaluate QoL, the main indication for rhythm control, after three different types of surgical ablation for AF, two stand-alone epicardial AF ablation procedures and one concomitant procedure during mitral valve surgery (MVS), and to perform a long-term follow-up of one of the techniques with regard to rhythm outcome, left atrial function, exercise capacity and safety.As the first center in the Nordic countries to adopt the video-assisted epicardial pulmonary vein isolation and ganglionated plexi ablation combined with left atrial appendage excision (LAA), the freedom from AF at one year follow-up was found to be 71% and associated with improved exercise capacity, QoL and symptoms as well as preserved left atrial function and size. The most common complication was bleeding events (14%). After 10 years, the improved symptoms and QoL remained, reaching comparable levels of the general Swedish population, despite a marked decline in the rate of freedom from AF (36%). 4 strokes appeared during follow-up despite LAA excision in 3 of these patients.In order to improve the rhythm outcome for patients with longstanding persistent AF a box-lesion was added to the procedure. At one year follow-up, both symptoms and QoL improved and was indistinguishable from those in the Swedish general population.Finally, concomitant AF ablation during MVS did not improve QoL compared to MVS alone in a double blinded randomized controlled trial. Moreover, no difference was seen between patients in AF or sinus rhythm at one year follow-up, irrespective of the allocated therapy, indicating that their preoperative symptoms were mainly related to their valve disease.In conclusion, the stand-alone procedures using surgical ablation was found to be effective but at the expense of procedural complications. In contrast, the concomitant surgical AF ablation did not improve QoL, a finding that raises concerns regarding current recommendations for this procedure.
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| 10. |
- Barmano, Neshro, 1980-
(författare)
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Structured management, Symptoms, Health-related Quality of Life and Alcohol in Patients with Atrial Fibrillation
- 2019
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Atrial fibrillation (AF) is the most common cardiac arrhythmia, affecting at least 2.9 % of the Swedish population. Although AF is associated with increased risk of ischaemic stroke, there have been many reports on the underuse of oral anticoagulants (OAC) and non-adherence to guidelines in other areas as well. AF is also associated with disabling symptoms and decreased health-related quality of life (HRQoL), but some patients are asymptomatic. The reasons for the great variation of symptoms remain unclear. Furthermore, although research on AF has increased, studies have mainly focused on treatment, while studies on risk factors, such as alcohol consumption, have only recently gained attention.The aim of this thesis was to investigate whether structured care of patients with AF could improve guideline adherence and HRQoL compared to standard care, and to determine which factors affect symptoms and HRQoL prior to treatment with radiofrequency catheter ablation (RFA), as well as improvement after RFA. Furthermore, we aimed to examine the associations of alcohol consumption with cardiac biomarkers, the size of the left atrium (LA), and re-ablation.This thesis is based on two studies. In the ‘Structured Management and Coaching – Patients with Atrial Fibrillation’ (SMaC-PAF) study, 176 patients were recruited to the intervention group, receiving a structured follow-up programme, and 146 patients were recruited to the control group, receiving standard care. The two groups were compared in regard to adherence to guidelines and patient-reported outcome measures (PROMs) assessing symptoms and HRQoL.In the ‘Symptom burden, Metabolic profile, Ultrasound findings, Rhythm, neurohormonal activation, haemodynamics and health-related quality of life in patients with atrial Fibrillation’ (SMURF) study, 192 patients referred for their first RFA of AF were included. PROMs questionnaires were filled out, echocardiography was performed, and cardiac biomarkers were analysed. Alcohol consumption was assessed through interview and through analysis of ethyl glucuronide in hair (hEtG). AF recurrence and re-ablation within 12 months were examined.In the first study, after one year, 94% (n=112) and 74% (n=87) of patients with indication for OAC in the intervention and the control groups, respectively, actually received treatment with OAC (p <0.01). Both groups improved in anxiety and HRQoL scores over the year, but in the intervention group, arrhythmia-specific symptoms were less frequently experienced and the SF-36 scores were more similar to the norm population.In the second study, the most important predictors of arrhythmia-related symptoms and HRQoL prior to RFA were anxiety, depression and low-grade inflammation, while frequent AF attacks prior to RFA, freedom from AF recurrence after RFA, female gender, no enlarged LA, absence of diabetes, and the presence of heart failure were significant predictors of improvement in symptoms and HRQoL after RFA. Men with hEtG ≥7 pg/mg had higher levels of cardiac biomarkers, larger LA volumes and a higher re-ablation rate than men with hEtG <7 pg/mg, while no such findings were present in women.In conclusion, structured management was superior to standard care in patients with AF, emphasising the importance of structured care, adjusted to local requirements, in order to improve the care and well-being of patients with AF. Although the reasons for the great variety of symptoms in patients with AF still are not yet fully understood, it seems that psychological factors and inflammation play a role, and that improvement in symptoms and HRQoL after RFA is influenced by gender, diabetes, heart failure, LA size and the frequency of attacks before, as well as freedom from AF after, RFA. Finally, alcohol consumption corresponding to hEtG ≥7 pg/mg was associated with higher levels of cardiac biomarkers, larger LA size and a higher rate of re-ablation in men, implying that men with an hEtG-value ≥7 pg/mg have a higher risk for LA remodelling that could potentially lead to a deterioration of the AF situation.
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