| 1. |
- Bertaglia, Emanuele, et al.
(author)
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Atrial high-rate episodes : prevalence, stroke risk, implications for management, and clinical gaps in evidence
- 2019
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In: Europace. - : Oxford University Press (OUP). - 1099-5129 .- 1532-2092. ; 21:10, s. 1459-1467
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Research review (peer-reviewed)abstract
- Self-terminating atrial arrhythmias are commonly detected on continuous rhythm monitoring, e.g. by pacemakers or defibrillators. It is unclear whether the presence of these arrhythmias has therapeutic consequences. We sought to summarize evidence on the prevalence of atrial high-rate episodes (AHREs) and their impact on risk of stroke. We performed a comprehensive, tabulated review of published literature on the prevalence of AHRE. In patients with AHRE, but without atrial fibrillation (AF), we reviewed the stroke risk and the potential risk/benefit of oral anticoagulation. Atrial high-rate episodes are found in 10-30% of AF-free patients. Presence of AHRE slightly increases stroke risk (0.8% to 1%/year) compared with patients without AHRE. Atrial high-rate episode of longer duration (e.g. those >24 h) could be associated with a higher stroke risk. Oral anticoagulation has the potential to reduce stroke risk in patients with AHRE but is associated with a rate of major bleeding of 2%/year. Oral anticoagulation is not effective in patients with heart failure or survivors of a stroke without AF. It remains unclear whether anticoagulation is effective and safe in patients with AHRE. Atrial high-rate episodes are common and confer a slight increase in stroke risk. There is true equipoise on the best way to reduce stroke risk in patients with AHRE. Two ongoing trials (NOAH-AFNET 6 and ARTESiA) will provide much-needed information on the effectiveness and safety of oral anticoagulation using non-vitamin K antagonist oral anticoagulants in patients with AHRE.
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| 2. |
- Björkenheim, Anna, 1980-, et al.
(author)
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Assessment of Atrial Fibrillation–Specific Symptoms Before and 2 Years After Atrial Fibrillation Ablation : Do Patients and Physicians Differ in Their Perception of Symptom Relief?
- 2017
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In: JACC. - : Elsevier. - 2405-500X .- 2405-5018. ; 3:10, s. 1168-1176
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Journal article (peer-reviewed)abstract
- Objectives: The aim of this study was to evaluate patient-reported and physician-assessed atrial fibrillation (AF)–related symptoms after AF ablation.Background: Success of AF ablation is usually defined as freedom from AF, although symptom relief is often patients’ desire.Methods: Symptom relief was assessed as perceived by patients using the short, validated, AF-specific symptom questionnaire AF6 and as classified by physicians using the European Heart Rhythm Association (EHRA) classification at baseline and 6, 12, and 24 months after AF ablation. Recurrence of arrhythmia was documented by continuous electrocardiographic monitoring.Results: In total, 54 patients completed the 24-month follow-up. All 6 items on the AF6, AF6 sum score, and EHRA class improved significantly over time. The greatest improvement was seen during the first 6 months after ablation, but AF6 scores showed continued improvement up to 12 months, in contrast to EHRA class. There was a low correlation between AF6 score and EHRA class, but the predictive ability was low. Both AF6 scores and EHRA class were significantly correlated with AF burden at all times after ablation. A change of >9 points in AF6 sum score corresponded to a meaningful reduction in symptom severity.Conclusion: Patient-reported and physician-assessed outcomes were both useful in assessing symptom relief after AF ablation, although patient-reported outcomes were more sensitive tools. There was also a discrepancy between patient-reported and physician-assessed outcomes after ablation. Freedom from AF and a low AF burden most often resulted in a reduction of symptoms, but symptom relief also occurred despite little effect on the arrhythmia.
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| 3. |
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| 4. |
- Björkenheim, Anna, 1980-, et al.
(author)
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Patient-reported Outcomes In Relation To Continuously Monitored Rhythm Before And During Two Years After Atrial Fibrillation Ablation Using A Disease-specific And A Generic Instrument
- 2018
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Conference paper (peer-reviewed)abstract
- Background: Patients with AF have a lower health-related quality of life (HRQoL) than the general population.Objective: To assess the effect of AF ablation on AF-specific and generic patient-reported outcomes (PRO), compare it to a Swedish age- and sex-matched population and evaluate any association with the AF burden.Methods: Patients scheduled for AF ablation completed the generic SF-36 and the AF-specific PRO questionnaires before and six, 12 and 24 months after AF ablation. All patients underwent continuous ECG monitoring via an implantable loop recorder.Results: 54 patients completed the follow-up. After ablation, the generic SF-36 improved and both summary scores reached normative levels at 24 months, while physical functioning, role-physical and vitality remained lower than norms. Responders with an AF burden ≤0.5% at each visit after ablation reached the norms in all domains, while non-responders reached norms in only social functioning and MCS. All AF6 items and the sum score showed moderate to large improvement in both responders and non-responders. Higher AF burden was independently associated with poorer PCS and AF6 sum score. The AF sum score correlated with all SF-36 domains, but all AF6 items did not correlate with the SF-36 summary scores.Conclusion: The AF-specific AF6 questionnaire was more sensitive to changes in PRO related to AF burden than was the generic SF-36. Higher AF burden after ablation was associated with poorer AF-specific PRO and poorer generic physical but not mental health. Focusing on AF-specific symptoms and their impact on quality of life as an outcome after AF ablation is reasonable, as improving PROs is the main goal of AF ablation.
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| 5. |
- Björkenheim, Anna, 1980-, et al.
(author)
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Patient-reported outcomes in relation to continuously monitored rhythm before and during two years after atrial fibrillation ablation using a disease-specific and a generic instrument
- 2018
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Conference paper (peer-reviewed)abstract
- Background: Atrial fibrillation (AF) ablation improves patient-reported outcomes (PROs), irrespective of mode of intermittent rhythm monitoring.Purpose: To evaluate the use of an AF-specific and a generic PRO instrument during continuous rhythm monitoring two years after AF ablation.Methods: Fifty-four patients completed the generic SF-36 and the AF-specific AF6 questionnaires before and six, 12 and 24 months after AF ablation. All patients underwent continuous ECG monitoring via an implantable loop recorder. The generic PRO scores were compared to those of a Swedish age- and sex-matched population.Results: After ablation both summary scores reached normative levels at 24 months, while physical functioning, role-physical and vitality remained lower than norms. Responders to ablation (AF burden <0.5%) reached the norms in all individual SF-36 domains, while non-responders (AF burden >0.5%) reached norms only in social functioning. All AF6 items and the sum score showed moderate to large improvement in both responders and non-responders, although responders had significantly lower scores 24 months after ablation. Higher AF burden was independently associated with poorer PCS and AF6 sum score.Conclusions: The AF-specific AF6 questionnaire was more sensitive to changes related to AF burden than the generic SF-36. Patients improved as documented by both instruments, but a higher AF burden after ablation was associated with poorer AF-specific PROs and poorer generic physical but not mental health. Our results support the use of an AF-specific instrument, alone or in combination with a generic instrument, to assess the effect of ablation.
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| 6. |
- Björkenheim, Anna, 1980-, et al.
(author)
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Rhythm Control and its Relation to Symptoms During the First Two Years After Radiofrequency Ablation for Atrial Fibrillation
- 2016
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In: Pacing and Clinical Electrophysiology. - Hoboken, USA : Wiley-Blackwell Publishing Inc.. - 0147-8389 .- 1540-8159. ; 39:9, s. 914-925
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Journal article (peer-reviewed)abstract
- Objective: To evaluate rhythm control up to two years after AF ablation and its relation to reported symptoms.Background: The implantable loop recorder (ILR) continuously records the ECG, has an automatic AF detection algorithm and a possibility for patients to activate an ECG recording during symptoms.Methods: Fifty-seven patients (mean age 57±9 years, 60% male, 88% paroxysmal AF) underwent AF ablation following ILR implantation. Device data were downloaded at the ablation and three, six, 12, 18 and 24 months after ablation.Results: Fifty-four patients completed the two-year follow-up. Thirteen (24%) patients had no AF episodes detected by ILR during follow-up. Ten of 41 patients (24%) with AF recurrence were only detected by ILR and AF recurrences were detected earlier by ILR (P<0.001). The median AF burden in patients with AF recurrence was 5.7% (IQR 0.4-14.4) and was even lower in patients with AF only detected by ILR (P = 0.001). Forty-eight % of the patients indicated symptoms via the patient activator but 33% of those recordings were not due to AF. Early AF recurrence (within 3 months) was highly associated with later AF recurrence (P<0.001). AF burden >0.5% and longest >6h before the ablation were independent predictors of AF recurrence during intermittent but not continuous monitoring.Conclusions: After AF ablation, the AF burden was low throughout the 24 months follow-up. Nevertheless, symptoms were commonly indicated but one third of patient activated recordings did not show AF. Continuous monitoring was superior to intermittent follow-up in detecting AF episodes and assessing the AF burden.Clinical trial registration: URL: http://clinicaltrials.gov. Unique Identifier: NCT00697359.
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| 7. |
- Freedman, Ben, et al.
(author)
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Screening for Atrial Fibrillation A Report of the AF-SCREEN International Collaboration
- 2017
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In: Circulation. - : LIPPINCOTT WILLIAMS & WILKINS. - 0009-7322 .- 1524-4539. ; 135:19, s. 1851-
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Journal article (peer-reviewed)abstract
- Approximately 10% of ischemic strokes are associated with atrial fibrillation (AF) first diagnosed at the time of stroke. Detecting asymptomatic AF would provide an opportunity to prevent these strokes by instituting appropriate anticoagulation. The AF-SCREEN international collaboration was formed in September 2015 to promote discussion and research about AF screening as a strategy to reduce stroke and death and to provide advocacy for implementation of country-specific AF screening programs. During 2016, 60 expert members of AF-SCREEN, including physicians, nurses, allied health professionals, health economists, and patient advocates, were invited to prepare sections of a draft document. In August 2016, 51 members met in Rome to discuss the draft document and consider the key points arising from it using a Delphi process. These key points emphasize that screen-detected AF found at a single timepoint or by intermittent ECG recordings over 2 weeks is not a benign condition and, with additional stroke factors, carries sufficient risk of stroke to justify consideration of anticoagulation. With regard to the methods of mass screening, handheld ECG devices have the advantage of providing a verifiable ECG trace that guidelines require for AF diagnosis and would therefore be preferred as screening tools. Certain patient groups, such as those with recent embolic stroke of uncertain source (ESUS), require more intensive monitoring for AF. Settings for screening include various venues in both the community and the clinic, but they must be linked to a pathway for appropriate diagnosis and management for screening to be effective. It is recognized that health resources vary widely between countries and health systems, so the setting for AF screening should be both country-and health system-specific. Based on current knowledge, this white paper provides a strong case for AF screening now while recognizing that large randomized outcomes studies would be helpful to strengthen the evidence base.
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| 8. |
- Kirchhof, Paulus, et al.
(author)
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A roadmap to improve the quality of atrial fibrillation management : proceedings from the fifth Atrial Fibrillation Network/European Heart Rhythm Association consensus conference
- 2016
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In: Europace. - : Oxford University Press (OUP). - 1099-5129 .- 1532-2092. ; 18:1, s. 37-50
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Journal article (peer-reviewed)abstract
- 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.
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| 9. |
- Kotecha, Dipak, et al.
(author)
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Integrating new approaches to atrial fibrillation management : the 6th AFNET/EHRA Consensus Conference.
- 2018
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In: Europace. - : Oxford University Press (OUP). - 1099-5129 .- 1532-2092. ; 20:3, s. 395-407
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Journal article (peer-reviewed)abstract
- There are major challenges ahead for clinicians treating patients with atrial fibrillation (AF). The population with AF is expected to expand considerably and yet, apart from anticoagulation, therapies used in AF have not been shown to consistently impact on mortality or reduce adverse cardiovascular events. New approaches to AF management, including the use of novel technologies and structured, integrated care, have the potential to enhance clinical phenotyping or result in better treatment selection and stratified therapy. Here, we report the outcomes of the 6th Consensus Conference of the Atrial Fibrillation Network (AFNET) and the European Heart Rhythm Association (EHRA), held at the European Society of Cardiology Heart House in Sophia Antipolis, France, 17-19 January 2017. Sixty-two global specialists in AF and 13 industry partners met to develop innovative solutions based on new approaches to screening and diagnosis, enhancing integration of AF care, developing clinical pathways for treating complex patients, improving stroke prevention strategies, and better patient selection for heart rate and rhythm control. Ultimately, these approaches can lead to better outcomes for patients with AF.
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| 10. |
- Schnabel, Renate B., et al.
(author)
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Searching for Atrial Fibrillation Poststroke : A White Paper of the AF-SCREEN International Collaboration
- 2019
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In: Circulation. - 1524-4539. ; 140:22, s. 1834-1850
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Journal article (peer-reviewed)abstract
- Cardiac thromboembolism attributed to atrial fibrillation (AF) is responsible for up to one-third of ischemic strokes. Stroke may be the first manifestation of previously undetected AF. Given the efficacy of oral anticoagulants in preventing AF-related ischemic strokes, strategies of searching for AF after a stroke using ECG monitoring followed by oral anticoagulation (OAC) treatment have been proposed to prevent recurrent cardioembolic strokes. This white paper by experts from the AF-SCREEN International Collaboration summarizes existing evidence and knowledge gaps on searching for AF after a stroke by using ECG monitoring. New AF can be detected by routine plus intensive ECG monitoring in approximately one-quarter of patients with ischemic stroke. It may be causal, a bystander, or neurogenically induced by the stroke. AF after a stroke is a risk factor for thromboembolism and a strong marker for atrial myopathy. After acute ischemic stroke, patients should undergo 72 hours of electrocardiographic monitoring to detect AF. The diagnosis requires an ECG of sufficient quality for confirmation by a health professional with ECG rhythm expertise. AF detection rate is a function of monitoring duration and quality of analysis, AF episode definition, interval from stroke to monitoring commencement, and patient characteristics including old age, certain ECG alterations, and stroke type. Markers of atrial myopathy (eg, imaging, atrial ectopy, natriuretic peptides) may increase AF yield from monitoring and could be used to guide patient selection for more intensive/prolonged poststroke ECG monitoring. Atrial myopathy without detected AF is not currently sufficient to initiate OAC. The concept of embolic stroke of unknown source is not proven to identify patients who have had a stroke benefitting from empiric OAC treatment. However, some embolic stroke of unknown source subgroups (eg, advanced age, atrial enlargement) might benefit more from non-vitamin K-dependent OAC therapy than aspirin. Fulfilling embolic stroke of unknown source criteria is an indication neither for empiric non-vitamin K-dependent OAC treatment nor for withholding prolonged ECG monitoring for AF. Clinically diagnosed AF after a stroke or a transient ischemic attack is associated with significantly increased risk of recurrent stroke or systemic embolism, in particular, with additional stroke risk factors, and requires OAC rather than antiplatelet therapy. The minimum subclinical AF duration required on ECG monitoring poststroke/transient ischemic attack to recommend OAC therapy is debated.
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| 11. |
- Thrysoee, Lars, et al.
(author)
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Management of newly diagnosed atrial fibrillation in an outpatient clinic settingpatients perspectives and experiences
- 2018
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In: Journal of Clinical Nursing. - : WILEY. - 0962-1067 .- 1365-2702. ; 27:3-4, s. 601-611
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Journal article (peer-reviewed)abstract
- Aims and objectivesTo gain in-depth knowledge of patients experiences of the consultation processes at a multidisciplinary atrial fibrillation outpatient clinic in a university hospital in Denmark. BackgroundAtrial fibrillation is the most common cardiac arrhythmia associated with morbidity and mortality if not diagnosed and treated as recommended. Patients with newly diagnosed atrial fibrillation preferably should be managed in an outpatient setting which includes medical examination, patient education and decision-making on medical therapy. DesignThis is a qualitative study of 14 patients newly diagnosed with atrial fibrillation, ranging from asymptomatic patients, to those with mild to severe symptoms; they were all referred from general practitioners. MethodsData were generated in 2013-2015 using participant observation during each consultation, followed by individual interviews postconsultation. ResultsPatients were referred with limited information on AF and knowledge about the management consultation procedures. The consultations were performed in a professional way by the cardiologist as well as by the nurses with an emphasis on the medical aspects of atrial fibrillation. The understanding that atrial fibrillation is not a fatal disease in itself was very important for patients. At the same time, visiting the clinic was overwhelming, information was difficult to understand, and patients found it difficult to be involved in decision-making. ConclusionsThis study indicates that patients were uncertain on what AF was before as well as after their consultation. The communication was concentrated on the medical aspects of atrial fibrillation and visiting the clinic was an overwhelming experience for the patients. They had difficulty understanding what atrial fibrillation was, why they were treated with anticoagulation, and that anticoagulating was a lifelong treatment. Relevance for clinical practiceThis study demonstrates some lack of patient-centred care and an absence of tailored patient AF-related education. Furthermore, the study highlights the need for and importance of active patient involvement.
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