Management of Newly Detected Atrial Fibrillation: A Clinical Practice Guideline from the American Academy of Family Physicians and the American College of Physicians 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation. Developed with the special contribution of the European Heart Rhythm Association. Prevalence of atrial fibrillation in elderly subjects (the Cardiovascular Health Study). Distribution and Risk Profile of Paroxysmal, Persistent, and Permanent Atrial Fibrillation in Routine Clinical Practice: Insight From the Real-Life Global Survey Evaluating Patients With Atrial Fibrillation International Registry Advanced Age, Anticoagulation Intensity, and Risk for Intracranial Hemorrhage among Patients Taking Warfarin for Atrial Fibrillation Management of atrial fibrillation by primary care physicians in Germany: baseline results of the ATRIUM registry Prediction of uneventful cardioversion and maintenance of sinus rhythm from direct-current electrical cardioversion of chronic atrial fibrillation and flutter. Ibutilide to expedite ED therapy for recent-onset atrial fibrillation flutter. A single-center randomized, controlled trial investigating the efficacy of a mHealth ECG technology intervention to improve the detection of atrial fibrillation: the iHEART study protocol ESC-EURObservational Research Programme: the Atrial Fibrillation Ablation Pilot Study, conducted by the European Heart Rhythm Association. Superiority of ibutilide (a new class III agent) overdl-sotalol in converting atrial flutter and atrial fibrillation The cost-effectiveness of ibutilide versus electrical cardioversion in the conversion of atrial fibrillation and flutter to normal rhythm. The prevalence, incidence, management and risks of atrial fibrillation in an elderly Chinese population: a prospective study Focused 2012 update of the Canadian Cardiovascular Society atrial fibrillation guidelines: recommendations for stroke prevention and rate/rhythm control. [A longitudinal study on left atrial thrombosis in patients with non-rheumatic atrial fibrillation treated with anticoagulants]. Unexpected low prevalence of atrial fibrillation in cryptogenic ischemic stroke: a prospective study Rising Rates of Hospital Admissions for Atrial Fibrillation [Sotalol and quinidine/verapamil (Cordichin) in chronic atrial fibrillation--conversion and 12-month follow-up--a randomized comparison]. Atrial pacing for the prevention of atrial fibrillation after cardiovascular surgery. Positive pressure therapy in patients with cardiac arrhythmias and obstructive sleep apnea. Progression of atrial fibrillation in the REgistry on Cardiac rhythm disORDers assessing the control of Atrial Fibrillation cohort: clinical correlates and the effect of rhythm-control therapy. Hazards of postoperative atrial arrhythmias. Chronic atrial fibrillation--epidemiologic features and 14 year follow-up: a case control study. Incidence and prognostic significance of atrial fibrillation in acute myocardial infarction: the GISSI-3 data Efficacy and late recurrences with wide electrical pulmonary vein isolation for persistent and permanent atrial fibrillation. Efficacy and proarrhythmic hazards of pharmacologic cardioversion of atrial fibrillation: prospective comparison of sotalol versus quinidine. Asymptomatic atrial fibrillation: clinical correlates, management, and outcomes in the EORP-AF Pilot General Registry. Characterization of different subsets of atrial fibrillation in general practice in France: the ALFA study. The College of French Cardiologists. Outpatient treatment of recent-onset atrial fibrillation with the "pill-in-the-pocket" approach. Prevalence of atrial fibrillation in Spain. OFRECE study results. Rhythm or rate control in atrial fibrillation—Pharmacological Intervention in Atrial Fibrillation (PIAF): a randomised trial Cardioversion of paroxysmal atrial fibrillation in the emergency department. Atrial fibrillation and heart failure in cardiology practice: reciprocal impact and combined management from the perspective of atrial fibrillation: results of the Euro Heart Survey on atrial fibrillation. Conversion of recent onset paroxysmal atrial fibrillation to normal sinus rhythm: the effect of no treatment and high-dose amiodarone. A randomized, placebo-controlled study. Oral Propafenone To Convert Recent-Onset Atrial Fibrillation in Patients with and without Underlying Heart Disease Impact of long-term ECG recording on the detection of paroxysmal atrial fibrillation in patients after an acute ischemic stroke. Prevalence of atrial fibrillation and association of atrial fibrillation with prior and new thromboembolic stroke in older patients. Non-valvular atrial fibrillation in the elderly; preliminary results from the National AFTER (Atrial Fibrillation in Turkey: Epidemiologic Registry) Study. An evaluation of the strategy of maintenance of sinus rhythm by antiarrhythmic drug therapy after ablation and pacing therapy in patients with paroxysmal atrial fibrillation. The diagnostic accuracy of the MyDiagnostick to detect atrial fibrillation in primary care Randomized study of surgery for patients with permanent atrial fibrillation as a result of mitral valve disease. Real-life observations of clinical outcomes with rhythm- and rate-control therapies for atrial fibrillation RECORDAF (Registry on Cardiac Rhythm Disorders Assessing the Control of Atrial Fibrillation). Intravenous magnesium sulfate prophylaxis for atrial fibrillation after coronary artery bypass surgery. Atrial fibrillation: an observational study with outpatients. Nut consumption and risk of atrial fibrillation in the Physicians' Health Study Intravenous administration of diltiazem in the treatment of supraventricular tachyarrhythmias. Prognosis, disease progression, and treatment of atrial fibrillation patients during 1 year: follow-up of the Euro Heart Survey on atrial fibrillation. Effectiveness and costs of chemical versus electrical cardioversion of atrial fibrillation. Propafenone for conversion and prophylaxis of atrial fibrillation. Propafenone Atrial Fibrillation Trial Investigators. [A comparison between flecainide and sotalol in the prevention of recurrences of paroxysmal atrial fibrillation]. Termination of recent-onset atrial fibrillation/flutter in the emergency department: a sequential approach with intravenous ibutilide and external electrical cardioversion. Catheter ablation for atrial fibrillation in congestive heart failure. Conversion efficacy and safety of intravenous ibutilide compared with intravenous procainamide in patients with atrial flutter or fibrillation. Dofetilide in patients with congestive heart failure and left ventricular dysfunction: safety aspects and effect on atrial fibrillation. The Danish Investigators of Arrhythmia and Mortality on Dofetilide (DIAMOND) Study Group. The atrial fibrillation ablation pilot study: a European Survey on Methodology and results of catheter ablation for atrial fibrillation conducted by the European Heart Rhythm Association. Intravenous amiodarone versus verapamil for acute conversion of paroxysmal atrial fibrillation to sinus rhythm. A prospective, randomized trial of an emergency department observation unit for acute onset atrial fibrillation. Efficacy and safety of repeated intravenous doses of ibutilide for rapid conversion of atrial flutter or fibrillation. Ibutilide Repeat Dose Study Investigators. Effects of oral propafenone administration before electrical cardioversion of chronic atrial fibrillation: a placebo-controlled study. Differences in Clinical and Functional Outcomes of Atrial Fibrillation in Women and Men: Two-Year Results From the ORBIT-AF Registry. Continuous vs episodic prophylactic treatment with amiodarone for the prevention of atrial fibrillation: a randomized trial. Antiarrhythmics After Ablation of Atrial Fibrillation (5A Study) Prophylactic oral amiodarone compared with placebo for prevention of atrial fibrillation after coronary artery bypass surgery. Alcohol consumption and risk of incident atrial fibrillation in women. Palpitations are predictive of future atrial fibrillation. An 11-year follow-up of 22,815 men and women: the Tromsø Study The definition of valvular and non-valvular atrial fibrillation: results of a physicians' survey. Supraventricular Arrhythmia in Patients Having Noncardiac Surgery: Clinical Correlates and Effect on Length of Stay Intravenous dofetilide, a class III antiarrhythmic agent, for the termination of sustained atrial fibrillation or flutter. Intravenous Dofetilide Investigators. Emergency department use of intravenous procainamide for patients with acute atrial fibrillation or flutter. Treatment of atrial fibrillation and paroxysmal supraventricular tachycardia with bidisomide. The Atrial Fibrillation Investigation with Bidisomide (AFIB) Investigators. Cardiac rate normalization in chronic atrial fibrillation: comparison of long-term efficacy of treatment with amiodarone versus AV node ablation and permanent His-bundle pacing. Atrial fibrillation in patients with heart failure: Role of catheter ablation therapies. Cigarette smoking and risk of atrial fibrillation: the Rotterdam Study. Antiarrhythmic efficacy of azimilide in patients with atrial fibrillation. Maintenance of sinus rhythm after conversion to sinus rhythm. Atrial Fibrillation Following Out-of-Hospital Cardiac Arrest and Targeted Temperature Management—Are We Giving It the Attention it Deserves?* [A comparison between amiodarone and disopyramide in a delayed-release formulation in the prevention of recurrences of symptomatic atrial fibrillation]. Arrhythmia-provoking factors and symptoms at the onset of paroxysmal atrial fibrillation: A study based on interviews with 100 patients seeking hospital assistance Prevention of atrial fibrillation with moderate doses of amiodarone in the postoperative period of cardiac surgery is safe and effective in patients with high risk for developing this arrhythmia. Surgical ablation of atrial fibrillation during mitral-valve surgery. Atrial fibrillation in the setting of acute myocardial infarction: the GUSTO-I experience. Global Utilization of Streptokinase and TPA for Occluded Coronary Arteries. Early or Delayed Cardioversion in Recent‐Onset Atrial Fibrillation Randomized trial of rate-control versus rhythm-control in persistent atrial fibrillation: the Strategies of Treatment of Atrial Fibrillation (STAF) study. The Net Clinical Benefit of Warfarin Anticoagulation in Atrial Fibrillation Antiarrhythmic drug therapy and cardiac mortality in atrial fibrillation. The Stroke Prevention in Atrial Fibrillation Investigators. Dofetilide in patients with congestive heart failure and left ventricular dysfunction. Danish Investigations of Arrhythmia and Mortality on Dofetilide Study Group. Results of a Minimally Invasive Surgical Pulmonary Vein Isolation and Ganglionic Plexi Ablation for Atrial Fibrillation: Single-Center Experience With 12-Month Follow-Up Predictors and prognosis of paroxysmal atrial fibrillation in general practice in the UK Risk factors for stroke in patients with nonrheumatic atrial fibrillation: a case-control study. Prevalence, incidence and lifetime risk of atrial fibrillation: the Rotterdam study. Radiofrequency ablation as initial therapy in paroxysmal atrial fibrillation. Rapid loading of sotalol or amiodarone for management of recent onset symptomatic atrial fibrillation: a randomized, digoxin-controlled trial. Association of high intracellular, but not serum, heat shock protein 70 with postoperative atrial fibrillation. Orthostatic hypotension and long-term incidence of atrial fibrillation: the Malmö Preventive Project. Asymptomatic atrial fibrillation: demographic features and prognostic information from the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) study. Long-term follow-up of direct current cardioversion after cardiac surgery with special reference to quinidine1 Comparison of pharmacological and electrical cardioversion in permanent atrial fibrillation after prosthetic cardiac valve replacement: A prospective randomized trial Influence of obesity on outcomes in atrial fibrillation: yet another obesity paradox. Pulmonary vein isolation and autonomic denervation for the management of paroxysmal atrial fibrillation by a minimally invasive surgical approach. Outcomes of Medicare Beneficiaries Undergoing Catheter Ablation for Atrial Fibrillation A comparison of rate control and rhythm control in patients with recurrent persistent atrial fibrillation. National patterns of warfarin use in atrial fibrillation. Contemporary management of patients undergoing atrial fibrillation ablation: in-hospital and 1-year follow-up findings from the ESC-EHRA atrial fibrillation ablation long-term registry Fibrillation in patients subjected to coronary artery bypass grafting. Left atrial ablation versus biatrial ablation for persistent and permanent atrial fibrillation: a prospective and randomized study. Lack of evidence of increased mortality among patients with atrial fibrillation taking digoxin: findings from post hoc propensity-matched analysis of the AFFIRM trial. A comparison of amiodarone and digoxin for treatment of supraventricular arrhythmias after cardiac surgery. Valsartan for prevention of recurrent atrial fibrillation. A multicenter risk index for atrial fibrillation after cardiac surgery. Atrial fibrillation and flutter. Immediate control and conversion with intravenously administered verapamil. Efficacy of intravenous ibutilide for rapid termination of atrial fibrillation and atrial flutter: a dose-response study. Does intensity of rate control influence outcome in persistent atrial fibrillation? Data of the RACE study. Arrhythmias after coronary bypass surgery. Maintenance of sinus rhythm with oral d,l-sotalol therapy in patients with symptomatic atrial fibrillation and/or atrial flutter. d,l-Sotalol Atrial Fibrillation/Flutter Study Group. Ibutilide versus amiodarone in atrial fibrillation: A double-blinded, randomized study Amiodarone as a first-choice drug for restoring sinus rhythm in patients with atrial fibrillation: a randomized, controlled study. Amiodarone versus sotalol for atrial fibrillation. Morbidity and mortality in 229 elderly patients with nonrheumatic atrial fibrillation. A five-year follow-up. Pulmonary venous isolation versus additional substrate modification as treatment for paroxysmal atrial fibrillation Predictors of congestive heart failure in the elderly: the Cardiovascular Health Study. Atrial fibrillation is associated with an increased risk for mortality and heart failure progression in patients with asymptomatic and symptomatic left ventricular systolic dysfunction: a retrospective analysis of the SOLVD trials. Studies of Left Ventricular Dysfunction. Radiofrequency Catheter Ablation and Antiarrhythmic Drug Therapy: A Prospective, Randomized, 4-Year Follow-Up Trial: The APAF Study Subclinical atrial fibrillation and the risk of stroke. Women hospitalized with atrial fibrillation: gender differences, trends and outcome from a 20-year registry in a Middle Eastern country (1991-2010). Cardioversion Guided by Transesophageal Echocardiography: The ACUTE Pilot Study: A Randomized, Controlled Trial Asymptomatic or "silent" atrial fibrillation: frequency in untreated patients and patients receiving azimilide. Preoperative high-dose atorvastatin for prevention of atrial fibrillation after cardiac surgery: a randomized controlled trial. Predictors, prevention, and long-term prognosis of atrial fibrillation after coronary artery bypass graft operations. Clinical course of recent-onset atrial fibrillation treated with oral propafenone. Control of Heart Rate Versus Rhythm in Rheumatic Atrial Fibrillation: A Randomized Study Rates of hemorrhage during warfarin therapy for atrial fibrillation Prevalence of undiagnosed atrial fibrillation and of that not being treated with anticoagulant drugs: the AFABE study. Cryptogenic stroke and underlying atrial fibrillation. Atrial fibrillation in patients with cryptogenic stroke. Rate Control versus Rhythm Control for Atrial Fibrillation after Cardiac Surgery. Managing emergency department patients with recent-onset atrial fibrillation. Control of rate versus rhythm in rheumatic atrial fibrillation: a randomized study. [Efficacy of metoprolol in prevention of supraventricular arrhythmias after coronary artery bypass grafting]. Rate control vs rhythm control in patients with nonvalvular persistent atrial fibrillation: the results of the Polish How to Treat Chronic Atrial Fibrillation (HOT CAFE) Study. Atrial fibrillation among African Americans, Hispanics and Caucasians: clinical features and outcomes from the AFFIRM trial. Left atrial radiofrequency ablation during cardiac surgery in patients with atrial fibrillation. Perioperative magnesium supplementation to prevent atrial fibrillation after off-pump coronary artery surgery: a randomized controlled study. Patient knowledge and perceptions of atrial fibrillation and anticoagulant therapy: effects of an educational intervention programme. The West Birmingham Atrial Fibrillation Project. Bleeding during warfarin and aspirin therapy in patients with atrial fibrillation: the AFASAK 2 study. Atrial Fibrillation Aspirin and Anticoagulation. Serum potassium levels and the risk of atrial fibrillation: the Rotterdam Study. The value of class IC antiarrhythmic drugs for acute conversion of paroxysmal atrial fibrillation or flutter to sinus rhythm. Effects of diltiazem pretreatment on direct-current cardioversion in patients with persistent atrial fibrillation: a single-blind, randomized, controlled study. Landiolol hydrochloride for prevention of atrial fibrillation after coronary artery bypass grafting: new evidence from the PASCAL trial. Usefulness of bedside tissue Doppler echocardiography and B-type natriuretic peptide (BNP) in differentiating congestive heart failure from noncardiac cause of acute dyspnea in elderly patients with a normal left ventricular ejection fraction and permanent, nonvalvular atrial fibrillation: insights  Atrial fibrillation and mortality in an elderly population. Success of serial external electrical cardioversion of persistent atrial fibrillation in maintaining sinus rhythm; a randomized study. Age and gender influences on rate and duration of paroxysmal atrial fibrillation. Conversion efficacy of intravenous ibutilide compared with intravenous amiodarone in patients with recent-onset atrial fibrillation and atrial flutter. Comorbidity associated with atrial fibrillation: a general practice-based study. The efficacy of quinidine and disopyramide in the maintenance of sinus rhythm after electroconversion from atrial fibrillation. A double-blind study comparing quinidine, disopyramide and placebo.
Atrial fibrillation is the most common type of arrhythmia in adults . It is more common as patients age ; the prevalence is 1 % among those younger than age 60 years and increases to more than 8 % in those older than age 80 years . When data are adjusted for age , men are affected more often than women . Cardiac conditions associated with the development of atrial fibrillation are hypertension , rheumatic mitral valve disease , coronary artery disease , and congestive heart failure . Noncardiac causes include hyperthyroidism , hypoxic pulmonary conditions , surgery , and alcohol intoxication . Patients with atrial fibrillation may have symptoms of hemodynamic compromise , such as irregular palpitations and lightheadedness , or more vague symptoms , such as malaise , but may be asymptomatic . Patients with atrial fibrillation are at increased risk for thromboembolic disease . The purpose of this guideline is to make recommendations on the pharmacologic management of newly detected atrial fibrillation in primary care . The target patient population is adult patients with first-detected atrial fibrillation , defined as the presence of symptoms or electrocardiographic evidence of atrial fibrillation . The American College of Cardiology/American Heart Association has recommended using first-detected atrial fibrillation regardless of whether it is symptomatic or self-limited , recognizing that there can be uncertainty about the duration of the episode and about previous undetected episodes ( 1 ) . This guideline does not apply to patients with postoperative or postmyocardial infa rct ion atrial fibrillation , patients with class IV heart failure , patients already taking antiarrhythmic drugs , or patients with valvular disease . The target physician audience is internists and family physicians dedicated to primary care . This guideline is based on the accompanying background paper by McNamara and colleagues ( 2 ) and on the evidence report Management of New-Onset Atrial Fibrillation ( 3 ) , which was produced by the Johns Hopkins Evidence -based Practice Center under contract to the Agency for Healthcare Research and Quality ( AHRQ ) , Rockville , Maryl and . The American Academy of Family Physicians ( AAFP ) and the American College of Physicians ( ACP ) created this guideline in collaboration . The Joint AAFP/ACP Panel review ed the evidence and developed and grade d the recommendations ( Table 1 ) . The guideline was then approved by both organizations . The guideline makes recommendations in the following areas : rate control versus rhythm control , stroke prevention and anticoagulation , electrical cardioversion versus pharmacologic cardioversion , the role of transesophageal echocardiography in guiding therapy , and maintenance therapy . Table 1 . The Guyatt Approach to Grading Recommendations * Section 1 : Rate Control versus Rhythm Control One of the fundamental questions in the management of atrial fibrillation is whether to attempt cardioversion . The answer to this question depends on whether rate control or rhythm control provides more effective protection from thromboembolic events , improved mortality , better relief of symptoms , or improved quality of life . Another significant clinical question is whether certain population s , such as women , patients with hypertension or congestive heart failure , or young people with structurally healthy hearts , have better outcomes with one or the other strategy . Four studies have compared rate control with rhythm control . The study sample s have generally involved older patients ( > 65 years of age ) , and women and younger patients with healthy hearts and paroxysmal atrial fibrillation have not been well represented ( 5 ) . The Atrial Fibrillation Follow-up Investigation of Rhythm Management ( AFFIRM ) trial compared rhythm control versus rate control , and use of anticoagulation was recommended in both arms ( 6 ) . More than 4000 patients who were at least 65 years of age or who had at least 1 risk factor for stroke or death , such as hypertension , diabetes , previous stroke , or poor ventricular function , were followed for a mean of 3.5 years . Slightly more than one third of the patients were enrolled after their first episode of atrial fibrillation , and more than 90 % had had their qualifying episode within the previous 6 weeks . In more than two thirds of patients , the qualifying episode lasted at least 2 days . The average patient age was 70 years . Sixty-one percent of patients were men , and 89 % were white . Seventy-one percent of patients had hypertension , 38 % had coronary heart disease , 18 % had previously had failure of antiarrhythmic therapy , and 12 % had no apparent heart disease ( lone atrial fibrillation ) . Patients were r and omly assigned to rate or rhythm control , and their physicians chose the specific therapies ( pharmacologic first , then nonpharmacologic if needed ) . Anticoagulation was continued indefinitely in the rate-control group and was encouraged in the rhythm-control group but could be stopped at the physician 's discretion if sinus rhythm had been maintained for at least 4 , and preferably 12 , consecutive weeks with antiarrhythmic therapy . The prevalence of sinus rhythm in the rhythm-control group was 82 % , 73 % , and 63 % at 1 , 3 , and 5 years , respectively . The prevalence of sinus rhythm in the rate-control group was 34.6 % at 5 years . The primary end point in the AFFIRM trial , overall mortality , was not statistically significantly different between the groups . However , the rhythm-control strategy was associated with a higher risk for death than the rate-control strategy among older patients , those without congestive heart failure , and those with coronary disease .  Rates of stroke also did not differ between groups ; 70 % of all strokes occurred in patients who had stopped receiving anticoagulation or who had subtherapeutic international normalized ratios ( < 2.0 ) . More hospitalizations were reported in the rhythm-control group ( P < 0.001 ) . Another recent study , the RAte Control versus Electrical cardioversion for persistent atrial fibrillation ( RACE ) study , r and omly assigned patients to receive aggressive rhythm control or rate control ( 7 ) . This was a smaller study , involving 522 patients ( mean age , 68 years ) . Sixty-four percent of patients were men , 49 % had hypertension , and 27 % had coronary artery disease . All patients had persistent atrial fibrillation lasting less than 1 year and had had at least 1 previous electrical cardioversion ( a maximum of 2 previous cardioversions was permitted for study inclusion ) . The primary end point was a composite of cardiovascular mortality , heart failure , thromboembolic complications , bleeding , pacemaker implantation , and severe side effects of antiarrhythmic drugs . Again , no difference was seen between groups in the primary composite end point . As in the AFFIRM study , most of the strokes occurred in patients whose anticoagulation had been halted or patients whose international normalized ratio was subtherapeutic ( < 2.0 ) . In post hoc analysis , a benefit for rate control over rhythm control was seen in patients with hypertension and in women . Since this was a post hoc analysis , these results will need to be confirmed by further studies . Of note , despite an aggressive treatment protocol , at the end of follow-up only 39 % of the patients in the rhythm-control group were in sinus rhythm . The Pharmacological Intervention in Atrial Fibrillation ( PIAF ) trial r and omly assigned 252 patients 18 to 75 years of age with new-onset or permanent symptomatic atrial fibrillation ( mean duration of atrial fibrillation , approximately 4 months ) to rate control with diltiazem or aggressive conversion ( many times if necessary ) and maintenance therapy with amiodarone ( 8) . The primary end point of the study was improvement in symptoms related to atrial fibrillation . After 1 year of follow-up , relief of symptoms was similar in both groups , as were quality -of-life measures . Walking distance was improved in the rhythm-control group , but hospital admissions were more frequent in this group . Although final results are not yet available , preliminary reports of the Strategies of Treatment of Atrial Fibrillation ( STAF ) trial have been presented ( 9 ) . Patients were r and omly assigned to receive anticoagulation for 3 weeks before conversion and for 4 weeks after attempted conversion , with antiarrhythmic therapy to maintain sinus rhythm , or to long-term anticoagulation and rate control . ( Patients included in this study had at least 1 previous conversion attempt . ) After more than 1.5 years of follow-up , no difference was seen between the groups in rates of the primary end points of death , stroke , transient ischemic attacks , cardiopulmonary resuscitation , or thromboembolism . Of interest , only 40 % of patients in the rhythm-control group were still in sinus rhythm at 1 year , and all primary end points occurred in patients in atrial fibrillation , even in the rhythm-control group . This result has created speculation about whether fewer events would have occurred if anticoagulation had been continued indefinitely in the conversion group . It also suggests that despite aggressive rhythm management , a substantial number of patients can not maintain sinus rhythm . In general , the trial sample s were older and male and had risk factors for stroke , such as hypertension , congestive heart failure , and coronary disease . Certain subgroups of patients with atrial fibrillation , such as younger patients with healthy hearts or paroxysmal atrial fibrillation , were not well represented in the trials . Therefore , it is not certain whether these subgroups of patients may benefit from more aggressive rhythm control or rate control . Recommendation 1 : Rate control with chronic anticoagulation is the recommended strategy for the majority of patients with atrial fibrillation . Rhythm control has not been shown to be superior to rate control ( with chronic anticoagulation ) in reducing morbidity and mortality and may be inferior in some patient subgroups to rate control . Rhythm ACCF : American College of Cardiology Foundation ACCP : American College of Chest Physicians ACS : acute coronary syndrome ACT : Atrial arrhythmia Conversion Trial ADONIS : American – Australian – African trial with DronedarONe In atrial fibrillation or flutter for the maintenance of Sinus rhythm AF : atrial fibrillation AHA : American Heart Association AND ROMEDA : ANtiarrhythmic trial with DROnedarone in Moderate-to-severe congestive heart failure Evaluating morbidity DecreAse APHRS : Asia Pacific Heart Rhythm Society aPTT : activated partial thromboplastin time ARB : angiotensin-receptor blocker ARISTOTLE : Apixaban for Reduction In STroke and Other ThromboemboLic Events in atrial fibrillation ATHENA : A placebo-controlled , double-blind , parallel arm Trial to assess the efficacy of dronedarone 400 mg b.i.d . for the prevention of cardiovascular Hospitalization or death from any cause in patiENts with Atrial fibrillation/atrial flutter ATRIA : AnTicoagulation and Risk factors In Atrial fibrillation AVERROES : Apixaban VErsus acetylsalicylic acid ( ASA ) to Reduce the Rate Of Embolic Stroke in atrial fibrillation patients who have failed or are unsuitable for vitamin K antagonist treatment AVRO : A prospect i ve , r and omized , double-blind , Active-controlled , superiority study of Vernakalant vs. amiodarone in Recent Onset atrial fibrillation b.i.d : bis in die ( twice daily ) b.p.m . : beats per minute CABANA : Catheter ABlation vs . ANtiarrhythmic drug therapy for Atrial fibrillation CABG : coronary artery bypass graft CAP : Continued Access to Protect AF CHA2DS2-VASc : Congestive heart failure or left ventricular dysfunction Hypertension , Age ≥75 ( doubled ) , Diabetes , Stroke (doubled)-Vascular disease , Age 65–74 , Sex category ( female ) CHADS2 : Congestive heart failure , Hypertension , Age ≥75 , Diabetes , Stroke ( doubled ) CI : confidence interval CRAFT : Controlled R and omized Atrial Fibrillation Trial CrCl : creatinine clearance DAFNE : Dronedarone Atrial FibrillatioN study after Electrical cardioversion DIONYSOS : R and omized Double blind trIal to evaluate efficacy and safety of drOnedarone ( 400 mg b.i.d . ) vs . amiodaroNe ( 600 mg q.d . for 28 daYS , then 200 mg qd thereafter ) for at least 6 mOnths for the maintenance of Sinus rhythm in patients with atrial fibrillation EAST : Early treatment of Atrial fibrillation for Stroke prevention Trial EHRA : European Heart Rhythm Association ECG : electrocardiogram EMA : European Medicines Agency ERATO : Efficacy and safety of dRonedArone for The cOntrol of ventricular rate during atrial fibrillation EURIDIS : EURopean trial In atrial fibrillation or flutter patients receiving Dronedarone for the maIntenance of Sinus rhythm FAST : atrial Fibrillation catheter Ablation vs . Surgical ablation Treatment FDA : Food and Drug Administration Flec-SL : Flecainide Short-Long trial HAS-BLED : Hypertension , Abnormal renal/liver function , Stroke , Bleeding history or predisposition , Labile INR , Elderly , Drugs/alcohol concomitantly HF-PEF : heart failure with preserved ejection fraction HF-REF : heart failure with reduced ejection fraction HR : hazard ratio HRS : Heart Rhythm Society ICH : intracranial haemorrhage INR : international normalized ratio i.v . : intravenous J-RHYTHM : Japanese RHYTHM management trial for atrial fibrillation LAA : left atrial appendage LoE : level of evidence LVEF : left ventricular ejection fraction MANTRA-PAF : Medical ANtiarrhythmic Treatment or Radiofrequency Ablation in Paroxysmal Atrial Fibrillation NICE : National Institute for Health and Clinical Excellence NOAC : novel oral anticoagulant NSAID : non-steroidal anti-inflammatory drug NYHA : New York Heart Association OAC : oral anticoagulant or oral anticoagulation o.d . : omni die ( every day ) PALLAS : Permanent Atrial fibriLLAtion outcome Study using dronedarone on top of st and ard therapy PCI : percutaneous coronary intervention PREVAIL : Prospect i ve R and omized EVAluation of the LAA closure device In patients with atrial fibrillation v s. Long-term warfarin therapy PROTECT AF : WATCHMAN LAA system for embolic PROTECTion in patients with Atrial Fibrillation PT : prothrombin time RAAFT : Radio frequency Ablation Atrial Fibrillation Trial RE-LY : R and omized Evaluation of Long-term anticoagulant therapY with dabigatran etexilate ROCKET-AF : Rivaroxaban Once daily oral direct factor Xa inhibition Compared with vitamin K antagonism for prevention of stroke and Embolism Trial in atrial fibrillation RRR : relative risk reduction TE : thromboembolism TIA : transient ischaemic attack t.i.d . : ter in die ( three times daily ) TOE : transoesophageal echocardiogram TTR : time in therapeutic range VKA : vitamin K antagonist Guidelines summarize and evaluate all currently available evidence on a particular issue with the aim of assisting physicians in selecting the best management strategy for an individual patient suffering from a given condition , taking into account the impact on Atrial  fibrillation ( AF ) is a common arrhythmia in elderly persons and a common cause of embolic stroke . Most studies of the prevalence and correlates of AF have used selected , hospital-based population s. The Cardiovascular Health Study is a population -based , longitudinal study of risk factors for coronary artery disease and stroke in 5,201 men and women aged > or = 65 years .  AF  was diagnosed in 4.8 % of women and in 6.2 % of men at the baseline examination , and prevalence was strongly associated with advanced age in women . Prevalence of AF  was 9.1 % in men and women with clinical cardiovascular disease , 4.6 % in patients with evidence of sub clinical but no clinical cardiovascular disease , and only 1.6 % in subjects with neither clinical nor sub clinical cardiovascular disease . A history of congestive heart failure , valvular heart disease and stroke , echocardiographic evidence of enlarged left atrial dimension , abnormal mitral or aortic valve function , treated systemic hypertension , and advanced age were independently associated with the prevalence of AF .  The low prevalence of AF in the absence of clinical and sub clinical cardiovascular disease calls into question the existence and clinical usefulness of the concept of so-called " lone atrial fibrillation " in the elderly Background — There is a paucity of international data on the various types of atrial fibrillation ( AF ) outside the highly selected population s from r and omized trials . This study aim ed to describe patient characteristics , risk factors , comorbidities , symptoms , management strategy , and control of different types of AF in real-life practice . Methods and Results — Real-life global survey evaluating patients with atrial fibrillation ( RealiseAF ) was a contemporary , large-scale , cross-sectional international survey of patients with AF who had ≥1 episode in the past 12 months . Investigators were r and omly selected to avoid bias . Among 9816 eligible patients from 831 sites in 26 countries , 2606 ( 26.5 % ) had paroxysmal , 2341 ( 23.8 % ) had persistent , and 4869 ( 49.6 % ) had permanent AF . As AF progressed from paroxysmal to persistent and permanent forms , the prevalence of comorbidities , such as heart failure ( 32.9 % , 44.3 % , and 55.6 % ) , coronary artery disease ( 30.0 % , 32.9 % , and 34.3 % ) , cerebrovascular disease ( 11.7 % , 10.8 % , and 17.6 % ) , and valvular disease ( 16.7 % , 21.2 % , and 35.8 % ) , increased , and the prevalence of lone AF decreased . Similarly , there was an increase in mean CHADS2 [ cardiac failure , hypertension , age , diabetes , stroke ( doubled ) ] score ( 1.7 , 1.8 , and 2.2 ) , and more than half of patients ( 51.0 % , 56.7 % , and 67.3 % ) qualified for oral anticoagulants . Almost 90 % of patients received ≥1 antiarrhythmic drug , but > 60 % had European Heart Rhythm Association symptom scores from II to IV . Furthermore , 40.7 % of persistent and 49.8 % of permanent AF patients were still in AF with a heart rate > 80 beats per minute . Conclusions — This survey disclosed high cardiovascular risks and an unmet need in daily practice for patients with any type of AF , especially those with the permanent form Context The appropriate level of warfarin anticoagulation in elderly patients with atrial fibrillation has been debated because of an age-associated increase in intracerebral hemorrhage . Contribution Patients with atrial fibrillation and intracerebral hemorrhage who were receiving anticoagulation were matched with similar patients who did not develop intracerebral hemorrhage . Although intracerebral hemorrhage was associated with increasing age ( especially > 85 years ) and increasing international normalized ratios ( INRs ) ( especially > 3.5 ) , the incidence of intracerebral hemorrhage was not statistically different in patients with INRs less than 2.0 and those with INRs between 2.0 and 3.0 . This was true even among those older than 75 years of age . Implication s Risk for intracerebral hemorrhage is not diminished in elderly patients with atrial fibrillation when anticoagulation is maintained below an INR of 2.0 . The Editors Intracranial hemorrhage is the most dangerous complication of warfarin anticoagulant therapy because of its high short-term risk for death and severe neurologic deficit ( 1 - 5 ) . Warfarin is extremely effective in reducing the risk for ischemic stroke associated with atrial fibrillation ( 6 , 7 ) . However , fear of hemorrhage may prompt some physicians to avoid prescribing anticoagulation ( 8) , especially in elderly patients , who appear to have a higher risk for hemorrhage ( 8 - 13 ) . Prominent recent guidelines recommend using lower-intensity anticoagulation for the primary prevention of stroke in patients older than 75 years of age who have atrial fibrillation ( 14 ) and suggest a target international normalized ratio ( INR ) range of 1.6 to 2.5 , despite evidence that the risk for ischemic stroke increases sharply at INRs less than 2.0 ( 15 , 16 ) . Previous studies have not thoroughly addressed the relationship of age and anticoagulation intensity to the risk for intracranial hemorrhage among patients with atrial fibrillation ( 1 , 2 ) . A study of 121 patients with warfarin-associated intracranial hemorrhage used the now-out date d prothrombin time ratio as a measure of anticoagulation intensity and did not specifically address risk in patients with atrial fibrillation ( 1 ) . Earlier studies also included patients receiving anticoagulation for mechanical valves , whose risk-to-benefit ratio is different from that of patients with atrial fibrillation ( 1 , 2 , 17 ) . As the number of individuals with atrial fibrillation increases ( 18 - 21 ) and as a greater proportion of older adults receive anticoagulant therapy ( 22 ) , more precise data are needed about the association of age , INR , and risk for intracranial hemorrhage . Intracranial hemorrhage , although critically important , is an uncommon complication among patients with atrial fibrillation who are receiving anticoagulation . As a result , r and omized trials and cohort studies have difficulty accumulating enough hemorrhage events to powerfully assess risk factors . To address these limitations , we performed a large casecontrol study to evaluate the relationship of increasing age and INR to the risk for intracranial hemorrhage among patients with nonvalvular atrial fibrillation . Methods Case- Patients We performed a casecontrol study comparing 2 groups : 1 ) case- patients with nonvalvular atrial fibrillation who developed intracranial hemorrhage while taking warfarin and 2 ) controls who were receiving anticoagulation for nonvalvular atrial fibrillation but did not develop intracranial hemorrhage . We found potential case- patients using the Partners HealthCare System Research Patient Data Registry , which can identify patients with specific International Classification of Diseases , Ninth Revision , Clinical Modification ( ICD-9-CM ) diagnoses by search ing the Massachusetts General Hospital billing system . We search ed for patients 18 years of age or older who had diagnoses of atrial fibrillation ( ICD-9-CM code 427.31 ) and intracranial hemorrhage ( ICD-9-CM codes 430 , 431 , 432.0 , 432.1 , 432.9 ) at any time from October 1993 to June 2002 . By 1993 , nearly all prothrombin time ratios at the hospital were reported as INRs . We review ed medical records to confirm whether patients were eligible , that is , whether they had intracranial hemorrhage documented by computed tomography or magnetic resonance imaging and documentation of warfarin therapy for atrial fibrillation at the time of the event . We excluded patients who were not taking warfarin at the time of hemorrhage ; those who were receiving anticoagulation for rheumatic heart disease , mitral stenosis , or mechanical valve placement ; those whose event was an ischemic stroke with hemorrhagic conversion ; or those in whom clinical factors may have led to hemorrhage independent of warfarin therapy . These factors included underlying anatomic brain abnormalities ( such as tumors or aneurysms ) , antecedent major head trauma ( skull fracture , trauma with loss of consciousness , motor vehicle injury , or neurosurgical procedures ) , or platelet count less than 50 109 cells/L. Starting in July 1994 , consecutive patients with intracerebral hemorrhage have been enrolled through the Massachusetts General Hospital emergency department as part of a longitudinal cohort study ( 23 ) . To vali date our automated search strategy , we compared our case-patient list with the list of patients identified through the cohort study and found that our search strategy missed only 4 patients with intracerebral hemorrhage . We obtained data on patient date of birth , sex , and ethnicity from computerized records . The type of hemorrhage ( intracerebral , subdural , subarachnoid , intraventricular , or epidural ) was determined through review of radiology reports . Data on presenting symptoms , history of minor head trauma , concomitant aspirin use , and disposition status were obtained from review of the admission medical record and were recorded on a st and ardized data collection form . We recorded the INR measurement obtained closest to the onset of symptoms . If an INR was not available or fresh frozen plasma or vitamin K was administered before the measurement , we considered INR data missing . We review ed medical charts for documentation of the following comorbid conditions : history of cerebrovascular disease ( defined as previous ischemic stroke or carotid artery disease ) , hypertension , congestive heart failure , coronary artery disease , diabetes mellitus , and cancer ( excluding nonmelanoma skin cancer ) . Controls Controls were sample d from patients managed by the Massachusetts General Hospital Anticoagulation Management Services clinic , which followed approximately 1000 patients receiving anticoagulation for atrial fibrillation at any given time during the study period . All patients who were followed in the anticoagulation clinic , received anticoagulation for atrial fibrillation , and had an INR measurement obtained in the same month and year as the given case date were assigned a r and om number . Six controls per case-patient were then r and omly selected . We matched case- patients to controls by INR date to account for any technical changes in INR testing that may have occurred over time . Because of this sampling method , an individual patient could potentially serve as a control for more than 1 case-patient ( 24 ) . Like case- patients , controls were 18 years of age or older ; were receiving anticoagulation for atrial fibrillation ; and had no documented rheumatic heart disease , mitral stenosis , or valve replacement . We sought data on potential confounders of the association of age , INR , and risk for intracranial hemorrhage , focusing on relevant comorbid conditions and combined use of aspirin with warfarin . We review ed available computerized discharge summaries , outpatient clinic notes , and medication lists from up to 2 years before the admission date . If combination warfarin and aspirin use was not documented , patients were considered to not be taking aspirin . Statistical Analysis Case- patients were categorized by type of hemorrhage : intracerebral , subdural , and other ( subarachnoid , intraventricular , or epidural ) . Clinical differences between types of hemorrhage were compared by using the KruskalWallis test for continuous variables ( age and INR ) and chi-square tests for categorical variables . We compared case- patients with controls by using multivariable conditional logistic regression , matching on INR date . Patient age was divided into 5-year intervals that were coded as indicator variables , and the odds of intracranial hemorrhage for each interval were compared with the odds of hemorrhage at a referent age of 70 to 74 years . The INR was divided into a set of ordered intervals that were coded as indicator variables . The relative odds for intracranial hemorrhage at each interval were calculated by using an INR of 2.0 to 3.0 as the referent category . In addition to age , INR , sex , and ethnicity , the following variables were included in the multivariable models to control for potential confounding effects of clinical factors and aspirin use : cerebrovascular disease , hypertension , congestive heart failure , coronary artery disease , diabetes mellitus , cancer , and concomitant aspirin use . If no records were available for review , comorbid conditions and aspirin use were coded as missing . We used multiple imputations for missing data on ethnicity , comorbid conditions , and aspirin use ( 25 ) . We tested for interactions between age and INR and comorbid conditions using 2-way interactions . None of the interaction terms were included in the model if they were not statistically significant when tested collectively . We tested the model 's goodness of fit using the HosmerLemeshow method ( 26 ) . Because the hospital 's anticoagulation clinic did not follow some case- patients before the event , and since factors relating to differences in outpatient care and monitoring could have confounded our analyses , we repeated these analyses in the subgroup of case- patients managed by the anticoagulation clinic . These restricted analyses Background In contrast to surveys in cardiologist setting s , presentation and management of  atrial fibrillation ( AF ) in primary care patients is less well studied . Methods and results The prospect i ve ATRIUM ( OutpatientRegistry Upon Morbidity of Atrial Fibrillation ) collected data from patients with AF seen by 730 physicians representing a r and om sample of all primary care physicians in Germany . ATRIUM enrolled 3,667 patients ( mean age , 72 ± 9 years ; 58 % male , mean CHADS2 score 2.2 ± 1.3 ) , 994 ( 27.1 % ) with paroxysmal , 944 ( 25.7 % ) with persistent or long-st and ing persistent and 1,525 ( 41.6 % ) with permanent AF ( no AF type was specified in 204 patients ) . Mean duration since initial diagnosis of AF was 61 ± 66 months ( median 42 , interquartile range 14–88 ) . Reported symptoms included palpitations ( 43 % ) , shortness of breath ( 49 % ) , fatigue ( 49 % ) , dizziness ( 37 % ) and angina ( 20 % ) . Most common concomitant conditions were hypertension ( 84 % ) , heart failure ( 43 % ) , coronary artery disease ( 345 % ) , diabetes ( 35 % ) and chronic kidney disease ( 20 % ) . Prior myocardial infa rct ion was present in 11 % of patients , prior stroke in 10 % and prior transient ischemic attack in 10 % .  Antithrombotic medication was used by 93 % of the patients ( oral anticoagulants , 83 % ) .  Rate control  therapy was reported in 75 % and rhythm control therapy in 33 % , often added to rate control . Drugs for rhythm and rate control included ß-blockers ( 75 % ) , calcium antagonists ( 15 % ) , digitalis ( 29 % ) , sodium channel blockers of type IA ( quinidine , 1.0 % ) or IC ( flecainide or propafenone , 5 % ) , and potassium channel blockers including amiodarone ( 11 % ) . In the year prior to enrollment , 46 % of the patients had been cardioverted ( 23 % by drugs , 22 % electrically ) , catheter ablation had been performed in 5 % , and 10 % received a pacemaker or  defibrillator . A high proportion ( 44 % ) of the patients were hospitalized in the year prior to enrollment . Conclusions Patients with AF managed in primary care often receive guideline -conforming therapy including antithrombotic therapy , rate control and rhythm control ( numbers given above ) . Despite this apparent adherence , almost half of the patients were hospitalized in the year prior to enrollment , suggesting that the therapies applied do not stabilize patients sufficiently to keep them out of hospital The present study was undertaken to reassess prospect ively the immediate and long-term results of direct-current electrical cardioversion in chronic atrial fibrillation or atrial flutter , and to determine factors predicting clinical outcome of the arrhythmia after direct-current cardioversion .  Two-hundred forty-six patients underwent direct-current electrical cardioversion  and were followed during a mean of 260 days . Multivariate analysis was used to identify factors predicting short- and long-term arrhythmia outcome . Cardioversion was achieved in 70 % of patients with atrial fibrillation and in 96 % of patients with atrial flutter . Stepwise logistic regression analysis revealed that arrhythmia duration ( p less than 0.001 ) , type of arrhythmia ( fibrillation vs flutter , p less than 0.02 ) and age ( p less than 0.05 ) independently influenced conversion rate . On an actuarial basis , 42 and 36 % of patients remained in sinus rhythm during 1 and 2 years , respectively . Multivariate regression analysis revealed that the type of arrhythmia ( p = 0.0008 ) , low precardioversion functional class ( p = 0.002 ) and the presence of nonrheumatic mitral valve disease ( p = 0.03 ) independently increased the length of the arrhythmia-free episode . Rheumatic heart disease shortened this period ( p = 0.03 ) . In conclusion , patients having a high probability of conversion together with a prolonged post-shock arrhythmia-free episode can be identified . This may improve the cost-benefit ratio of cardioversion OBJECTIVE Ibutilide is a type III antiarrhythmic agent approved for the pharmacologic conversion of atrial fibrillation ( AF ) and atrial flutter ( AFl ) . Previous studies conducted outside the ED setting have demonstrated conversion rates of 60 % to 80 % . This response has been highest in patients with recent-onset AF-AFl . These observations and the 4-hour half-life of ibutilide suggest that it may be an excellent drug with which to treat AF-AFl in the ED . The purpose of the study was to examine the efficacy and safety of ibutilide in terminating AF-AFl in patients who present to the ED with symptoms of less than 3 days ' duration , neither angina nor heart failure , and no comorbid conditions that require admission . METHODS Among 36 enrolled patients , the admission electrocardiogram demonstrated AF in 26 and AFl in 10 .  Ibutilide 1 mg was administered intravenously for 10 minutes . If sinus rhythm was not present 10 minutes after the infusion concluded , a second infusion of 1 mg was given . Successful conversion was defined as restoration of sinus rhythm within 1 hour after the last dose of ibutilide . RESULTS Sixteen ( 61.5 % ) of 26 patients with AF and 9 ( 90 % ) of 10 patients with AFl converted to sinus rhythm ( overall conversion rate=69 % ) . The mean time to arrhythmia termination was 19+/-9 minutes . The mean stay in the ED was 16.2 hours . No significant complications occurred . CONCLUSION We conclude that ibutilide is an excellent therapy option for restoring sinus rhythm in the ED . Its use may obviate the need for admission , avoid the risks and inconveniences of general anesthesia to perform electrical cardioversion , and reduce the ED length of stay in selected patients with recent-onset atrial arrhythmias Background Atrial fibrillation is a major public health problem and is the most common cardiac arrhythmia , affecting an estimated 2.7 million Americans . The true prevalence of atrial fibrillation is likely underestimated because episodes are often sporadic ; therefore , it is challenging to detect and record an occurrence in a “ real world ” setting . To date , mobile health tools that promote earlier detection and treatment of atrial fibrillation and improvement in self-management behaviors and knowledge have not been evaluated . This study will be the first to address the epidemic problem of atrial fibrillation with a novel approach utilizing advancements in mobile health electrocardiogram technology to empower patients to actively engage in their healthcare and to evaluate impact on quality of life and quality -adjusted life years . Furthermore , sending a daily electrocardiogram transmission , coupled with receiving educational and motivational text messages aim ed at promoting self-management and a healthy lifestyle may improve the management of chronic cardiovascular conditions ( e.g. , hypertension , diabetes , heart failure , etc . ) . Therefore , we are currently conducting a r and omized controlled trial to assess the efficacy of a mobile health intervention , iPhone ® Helping Evaluate Atrial fibrillation Rhythm through Technology ( iHEART ) versus usual cardiac care . Methods The iHEART study is a single center , prospect i ve , r and omized controlled trial . A total of 300 participants with a recent history of atrial fibrillation will be enrolled . Participants will be r and omized 1:1 to receive the iHEART intervention , receiving an iPhone ® equipped with an AliveCor ® Mobile ECG and accompanying Kardia application and behavioral altering motivational text messages or usual cardiac care for 6 months . Discussion This will be the first study to investigate the utility of a mobile health intervention in a “ real world ” setting . We will evaluate the ability of the iHEART intervention to improve the detection and treatment of recurrent atrial fibrillation and assess the intervention 's impact on improving clinical outcomes , quality of life , quality -adjusted life-years and disease-specific knowledge . Trial registration NCT02731326 ; Verified April AIMS The Atrial Fibrillation Ablation Pilot Study is a prospect i ve , multinational registry conducted by the European Heart Rhythm Association of the European Society of Cardiology that has been design ed to describe the clinical epidemiology of patients undergoing an atrial fibrillation ( AFib ) ablation procedure  , and the diagnostic/therapeutic processes applied in these patients across Europe . We present the results of the short-term ( in-hospital ) analysis . METHODS AND RESULTS A total of 72 centres in 10 European countries were asked to enrol 20 consecutive patients scheduled for a first AFib ablation procedure . Between October 2010 and May 2011 , 1410 patients were included , of which 1391 underwent an AFib ablation ( 98.7 % ) . The median age was 60 years [ inter-quartile range ( IQR ) 52 - 66 ] , and 28 % were females . Two-thirds presented paroxysmal AFib and 38 % lone AFib . Symptoms were present in 86 % . The indications for ablation were mostly symptomatic AFib , but in over a third of patients there was also a desire for a drug-free lifestyle and the maintenance of sinus rhythm . Pulmonary vein isolation was attempted in 98.4 % of patients , the roof line in 21.3 % and the mitral isthmus line in 12.8 % . Complex-fractionated atrial electrograms were targeted in 17.9 % and the ganglionated plexi in 3.3 % . Complications occurred in 7.7 % , of which 1.7 % was major ( i.e. cardiac perforation , myocardial infraction , endocarditis , cardiac arrest , stroke , hemothorax , pneumothorax , and sepsis ) . The median duration of hospitalization was 3 days ( IQR 2 - 4 ) . At discharge , 91.4 % of patients were in sinus rhythm , 88.3 % of patients were given vitamin K antagonists , and 67 % antiarrhythmic medication . There was one death after the ablation procedure . CONCLUSION The AFib Ablation Pilot Study provides crucial information on AF ablation in clinical practice across Europe . These data are relevant for further improvement of the management strategies of patients suffering from atrial fibrillation Objective To compare the efficacy and safety of a single dose of ibutilide , a new class III antiarrhythmic drug , with that of dl-sotalol in terminating chronic atrial fibrillation or flutter in haemodynamically stable patients . Design Double blind , r and omised study . Setting 43 European hospitals . Patients 308 patients ( mean age 60 years , 70 % men , 48 % with heart disease ) with sustained atrial fibrillation ( n = 251 ) or atrial flutter ( n = 57 ) ( duration three hours to 45 days ) were r and omised to three groups to receive a 10 minute infusion of 1 mg ibutilide ( n = 99 ) , 2 mg ibutilide ( n = 106 ) , or 1.5 mg/kg dl-sotalol ( n = 103 ) . Infusion was discontinued at termination of the arrhythmia . Main outcome measure Successful conversion of atrial fibrillation or flutter , defined as termination of arrhythmia within one hour of treatment . Results Both drugs were more effective against atrial flutter than against atrial fibrillation .  Ibutilide was superior to dl-sotalol for treating atrial flutter ( 70 % and 56%v 19 % ) , while the high dose of ibutilide was more effective for treating atrial fibrillation than dl-sotalol ( 44 % v 11 % ) and the lower dose of ibutilide ( 44%v 20 % , p < 0.01 ) . The mean ( SD ) time to arrhythmia termination was 13 ( 7 ) minutes with 2 mg ibutilide , 19 ( 15 ) minutes with 1 mg ibutilide , and 25 ( 17 ) minutes with dl-sotalol . In all patients , the duration of arrhythmia before treatment was a predictor of arrhythmia termination , although this was less obvious in the group that received 2 mg ibutilide . This dose converted almost 48 % of atrial fibrillation that was present for more than 30 days . Concomitant use of digitalis or nifedipine and prolongation of the QTc interval were not predictive of arrhythmia termination . Bradycardia ( 6.5 % ) and hypotension ( 3.7 % ) were more common side effects withdl-sotalol . Of 211 patients given ibutilide  , two ( 0.9 % ) who received the higher dose developed polymorphic ventricular tachycardia , one of whom required direct current cardioversion . Conclusion Ibutilide ( given in 1 or 2 mg doses over 10 minutes ) is highly effective for rapidly terminating persistent atrial fibrillation or atrial flutter . This new class III drug , under monitored conditions , is a potential alternative to currently available cardioversion options Atrial fibrillation and atrial flutter are cardiac rhythm disorders that are often symptomatic and may interfere with the heart 's function , limiting its effectiveness . These arrhythmias are responsible for a large number of hospitalizations at a significant cost to the healthcare system . Electrical cardioversion ( EC ) is the most common nonpharmacologic intervention used to convert atrial fibrillation and atrial flutter to normal rhythm . Electrical cardioversion is highly successful in converting patients to normal rhythm ; however , it is more traumatic and re source intensive than pharmacologic treatment . Recently , a new rapid-acting drug , ibutilide , was approved for the conversion of atrial fibrillation and atrial flutter . Ibutilide is administered through intravenous infusion and does not require anesthetization of the patient , as is required for EC . A decision-tree model was developed to estimate the cost-effectiveness of ibutilide therapy compared with EC therapy . Clinical outcomes were based on a phase III trial of ibutilide , and re source use was based on the literature and physician clinical judgment . A stepped conversion regimen of first-line ibutilide followed by EC for patients who fail to convert is less expensive and has a higher conversion rate than first-line EC . Sensitivity analysis shows that our results are robust to changes in cost and effectiveness estimates Background There is limited information on prevalent and incident atrial fibrillation in Chinese . We aim ed to investigate the prevalence , incidence , management and risks of atrial fibrillation in an elderly Chinese population . Methods In a population —based prospect i ve study in elderly ( ≥60 years ) Chinese , we performed cardiovascular health examinations including a 12-lead electrocardiogram at baseline in 3,922 participants  and biennially during follow-up in 2,017 participants . We collected information on vital status during the whole follow-up period . Results The baseline prevalence of atrial fibrillation was 2.0 % ( n = 34 ) in 1718 men and 1.6 % ( n = 36 ) in 2204 women . During a median 3.8 years of follow-up , the incidence rate of atrial fibrillation ( n = 34 ) was 4.9 per 1000 person-years ( 95 % confidence interval [ CI ] , 3.4–6.9 ) . In univariate analysis , both the prevalence and incidence of atrial fibrillation were higher with age advancing ( P < 0.0001 ) and in the presence of coronary heart disease ( P ≤ 0.02 ) . Of the 104 prevalent and incident cases of atrial fibrillation , only 1 ( 1.0 % ) received anticoagulant therapy ( warfarin ) . These patients with atrial fibrillation , compared with those with sinus rhythm , had significantly higher risks of all-cause ( n = 261 , hazard ratio [ HR ] 1.87 , 95 % CI , 1.09–3.20 , P = 0.02 ) , cardiovascular ( n = 136 , HR 3.78 , 95 % CI 2.17–6.58 , P < 0.0001 ) and stroke mortality ( n = 44 , HR 6.31 , 95 % CI 2.81–14.19 , P = 0.0003 ) . Conclusions Atrial fibrillation was relatively frequent in elderly Chinese , poorly managed and associated with higher risks of mortality The Canadian Cardiovascular Society ( CCS ) published the complete set of 2010 Atrial Fibrillation ( AF ) Guidelines in the January , 2011 issue of the Canadian Journal of Cardiology . During its deliberations , the CCS Guidelines Committee engaged to a timely review of future evidence , with periodic composition of focused up date s to address clinical ly important advances . In 2011 , results were published from 3 pivotal AF trials : the Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared with Vitamin K Antagonist for Prevention of Stroke and Embolism Trial in Atrial Fibrillation ( ROCKET-AF ) , the Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation ( ARISTOTLE ) study , and the Permanent Atrial Fibrillation Outcome Study Using Dronedarone on Top of St and ard Therapy ( PALLAS ) , comparing dronedarone with placebo in patients with permanent AF and additional cardiovascular disease risk-factor burden . Each of these large r and omized trials provided clear results with major implication s for AF management . Other important evidence that has emerged since the 2010 Guidelines includes findings about prediction instruments for AF-associated stroke and bleeding risk , stroke risk in paroxysmal-AF patients , risk-benefit considerations related to oral anticoagulation in patients with chronic kidney disease , and risk/benefit considerations in the use of antiplatelet agents , alone and in combination with each other or with oral anticoagulants , in AF patients . The Guidelines Committee judged that this extensive and important new evidence required focused updating of the 2010 Guidelines with respect to stroke prevention and rate/rhythm control . This report presents the details of the new recommendations , along with the background and rationale BACKGROUND Although atrial thrombosis is common in patients with non-rheumatic atrial fibrillation ( NRAF ) ( 6 - 27 % ) , there are no studies about the effect that anticoagulant or antiplatelet drugs have on it . AIM OF THE STUDY We have investigated the role of anticoagulant therapy , followed by family physicians , on left atrial thrombosis detected via transesophageal echocardiography ( TEE ) in patients with NRAF . METHODS Sixty patients enrolled in the TASAF ( Trieste Area Study on non-rheumatic Atrial Fibrillation ) ( 60 % males , mean age 72 + /- 7 years , 17 % with lone atrial fibrillation , duration of arrhythmia 111 + /- 79 months ) , in whom we found a left atrial and /or left atrial appendage thrombus via TEE , were anticoagulated .  The thrombus was in the left atrial appendage in 57 patients and in the left atrium in the others . In 28 of them it was mobile and in 50 , the left atrial appendage flow was low or absent . Lastly , in 46 patients we found  spontaneous echocontrast  and a bilobate appendage was present in 8 of them . At follow-up , we repeated the TEE to evaluate the effect of the therapy on the atrial thrombosis . RESULTS Only 53 patients received anticoagulant therapy  ( 45 correctly ) , while 7 were treated with antiplatelet drugs by their family physicians . After a mean follow-up of 16 months , all patients underwent a repeat TEE and the thrombus was no longer evident in 35 cases ( 58 % ) . The thrombosis disappeared in 26 ( 58 % ) of the 45 patients who correctly took anticoagulant therapy and in 5 of the 8 who were not adequately anticoagulated . Moreover , we did n't observe the thrombus in 4 of the 7 patients who were treated with antiplatelet drugs . There was no significant statistical difference between the benefits of anticoagulants and antiplatelet therapy in dissolving left atrial thrombosis . During follow-up , we recorded only one embolic event in the retina . None of the patients on antiplatelet drugs complained of any side effects , whereas in 5 of the 53 on anticoagulant therapy , we recorded one fatal intracranial hemorrhage , one gastric hemorrhage and three minor complications . CONCLUSIONS Left atrial thrombosis in NRAF disappears in anticoagulated patients in an high percentage of cases ( the therapy probably acts on more recent thrombi ) . Moreover , this therapy decreases the incidence of embolic events , although it increases the risk of hemorrages . Since the management of this preventive treatment in general medicine is very difficult , we hope that our health organization will establish Anticoagulation Clinics for the central ized management of this therapy Purpose Ischemic stroke is a frequent pathology with high rate of recurrence and significant morbidity and mortality . There are several causes of stroke , affecting prognosis , outcomes , and management , but in many cases , the etiology remains undetermined . We hypothesized that atrial fibrillation was involved in this pathology but underdiagnosed by st and ard methods . The aim of the study was to determine the incidence of atrial fibrillation in cryptogenic ischemic stroke by using continuous monitoring of the heart rate over several months . The secondary objective was to test the value of atrial vulnerability assessment in predicting spontaneous atrial fibrillation . Methods and results We prospect ively enrolled 24 patients under 75 years of age , 15 men and 9 women of mean age 49 years , who within the last 4 months had experienced cryptogenic stroke diagnosed by clinical presentation and brain imaging and presumed to be of cardioembolic mechanism . All causes of stroke were excluded by normal 12-lead ECG , 24-h Holter monitoring , echocardiography , cervical Doppler , hematological , and inflammatory tests . All patients underwent electrophysiological study . Of the patients , 37.5 % had latent atrial vulnerability , and 33.3 % had inducible sustained arrhythmia . Patients were secondarily implanted with an implantable loop recorder to look for spontaneous atrial fibrillation over a mean follow-up interval of 14.5 months . No sustained arrhythmia was found . Only one patient had non-significant episodes of atrial fibrillation . Conclusion In this study , symptomatic atrial fibrillation or AF with fast ventricular rate has not been demonstrated by the implantable loop recorder  in patients under 75 years with unexplained cerebral ischemia . The use of this device should not be generalized in the systematic evaluation of these patients . In addition , this study attests that the assessment of atrial vulnerability is poor at predicting spontaneous arrhythmia in such patients Background : Atrial fibrillation is a common arrhythmia associated with excess morbidity and mortality . We studied temporal changes in hospital admission rates for atrial fibrillation using data from a prospect i ve population -based cohort study spanning 2 decades ( the Copenhagen City Heart Study ) . Methods : The study included baseline data collected in 1981 through 1983 on 10,955 persons age 40 to 79 years and baseline data collected in 1991 through 1994 on 7212 persons age 40 to 79 years . We used hospital diagnosis data from the Danish National Hospital Discharge Register to determine the rate of first hospital admission for atrial fibrillation during 7 years following each of the 2 baseline data collecting periods . Changes in admission rates were analyzed using Cox proportional hazard models . Results : During the 2 7-year periods , 379 subjects were admitted with a hospital diagnosis of atrial fibrillation . The rate of hospital admissions for atrial fibrillation increased among both men and women from the first to the second period ( relative risk = 1.6 ; 95 % confidence interval = 1.3–1.9 [ adjusted for age , sex , prior myocardial infa rct ion , arterial hypertension , diabetes mellitus , electrocardiographic left ventricular hypertrophy , decreased lung function , smoking , height , and weight ] ) . Conclusion : During the latest 10 to 20 years , there has been a 60 % increase in hospital admissions for atrial fibrillation independent of changes in known risk factors . This increase could result from changes in admission threshold or coding practice s , or it could reflect a genuine increase in the population incidence of atrial fibrillation Atrial fibrillation is one of the most common arrhythmias , leading at least in a subset of patients to severe symptoms ( palpitations , weakness , syncope ) , and to hemodynamic impairment especially in the clinical setting of left ventricular dysfunction . Thus , in many cases restauration of sinus rhythm is indicated because of the negative effects of reduced cardiac output .  Quinidine has been the first line drug for many years and has been proven to be highly effective especially when combined with Verapamil . But there is growing concern about using quinidine and other class I-anti-arrhythmic agents because of some hints in clinical trials for increased longterm mortality on these drugs . This study was undertaken to test the efficacy of Sotalol , a beta-blocker with additional strong class-III antiarrhythmic action , compared to a fixed combination of Quinidine and Verapamil for conversion of chronic atrial fibrillation and maintenance of sinus rhythm after medical or electrical cardioversion . To avoid early proarrhythmic effects , potassium values in the range of " high"-normal values ( > 4.3 mval/L ) were tried to be obtained . 82 patients were r and omly assigned to receive either  Sotalol or Quinidine/Verapamil . There was no difference between the groups as far as the underlying heart disease , duration of atrial fibrillation ( mean 219 days ) and other clinical features including echocardiographic parameters were concerned . The dose of the drug was weight-related individually adjusted , and the drug was continued thereafter . If sinus rhythm could not be established at that time , electric cardioversion was performed and the drug was continued in lower dosage thereafter . ( ABSTRACT TRUNCATED AT 250 WORDS OBJECTIVE The purpose of this study was to determine the efficacy of atrial pacing in the prevention of atrial fibrillation following cardiovascular surgery . BACKGROUND Although pharmacologic therapy has been used to help prevent postoperative atrial fibrillation , it suffers from limited efficacy and adverse effects . In the nonoperative setting , novel pacing strategies have been shown to reduce recurrences of atrial fibrillation and prolong arrhythmia-free periods in patients with paroxysmal atrial arrhythmias . METHODS A total of 154 patients ( 115 men ; mean age , 65 + /- 10 years ; ejection fraction , 53 + /- 10 % ) undergoing cardiac surgery ( coronary artery bypass surgery , 88.3 % ; aortic valve replacement , 4.5 % ; coronary bypass + aortic valve replacement , 7.1 % ) had right and left atrial epicardial pacing electrodes placed at the time of surgery . Patients were r and omized to either no pacing , right atrial ( RAP ) , left atrial ( LAP ) or biatrial pacing ( BAP ) for 72 h after surgery . Beta-adrenergic blocking agents were administered concurrently to all patients following surgery . RESULTS There was a reduction in the incidence of postoperative atrial fibrillation from 37.5 % in patients receiving no postoperative pacing to 17 % ( p < 0.005 ) in patients assigned to one of the three pacing strategies . The length of hospital stay was reduced by 22 % from 7.8 + /- 3.7 days to 6.1 + /- 2.3 days ( p = 0.003 ) in patients assigned to postoperative atrial pacing . The incidence of atrial fibrillation was lower in each of the paced groups ( RAP , 8 % ; LAP , 20 % ; BAP , 26 % ) compared with patients who did not receive postoperative pacing ( 37.5 % ) . CONCLUSION Postoperative atrial pacing , in conjunction with beta-blockade , significantly reduced both the incidence of atrial fibrillation and the length of hospital stay following cardiovascular surgery . Additional studies are needed to determine the most effective anatomic pacing site BACKGROUND Positive pressure therapy ( CPAP ) in patients with cardiac arrhythmias and obstructive sleep apnea ( OSAS ) may have favorable effects by correcting intermittent hypoxemia and sympathetic activation . OBJECTIVE To assess the effect of CPAP added to pharmacological treatment in the rate control and prevention of arrhythmias recurrence in patients with OSA . MATERIAL S AND METHODS Prospect i ve , interventional study study which included patients diagnosed with OSAS ( cardiorespiratorypolygraphy , AHI>5/hour ) , and arrhythmias ( ECG , Holter ECG ) , divided in two groups : group A ( pharmacological therapy only ) and group B ( pharmacological therapy and CPAP ) . The patients were evaluated at enrollment ( T0 ) , at 3 and 6 months ( T3 and T6 ) regarding the type , severity and recurrence of cardiac arrhythmias . RESULTS 36 patients ( 31 men ) , mean age : 63.2 ± 12 years were enroled . In group A : 7 patients with ventricular extrasystoles , 8 with permanent atrial fibrillation , 1 patient with atrial flutter and 2 patients with paroxystic supraventricular tachycardia . In group B : 8 patients with ventricular extrasystoles , 5 with permanent atrial fibrillation , 2 patients with recurrent episodes of atrial fibrillation and 3 with paroxystic supraventricular tachycardia . A positive correlation ( r : 0.74 , p < 0.001 ) between Oxygen Desaturation Index and AHI was found . At T6 , 12 patients from group B , and 18 from group A were evaluated . In group B , the mean heart rate in patients with atrial fibrillation was 69/min . , lower than in group A ( 82/min . ) , no cases with recurrent atrial fibrillation were found , and more patients with class II Lown ventricular extrasystoles passed in class I Lown , compared to group A. In group B , heart rate statistically correlated with AHI ( r : 0.53 , p < 0.005 ) . CONCLUSION In patients with OSAS , adding CPAP to pharmacological therapy has favorable effects on preventing recurrences , heart rate control in patients with atrial fibrillation and in reducing frequency and /or severity of ventricular extrasystoles INTRODUCTION Paroxysmal atrial fibrillation ( AF ) may progress to persistent AF . We studied the clinical correlates and the effect of rhythm-control strategy on AF progression . METHODS RecordAF was a worldwide prospect i ve survey of AF management . Consecutive eligible patients with recent-onset AF were included and allocated to rate or rhythm control according to patient/physician choice . A total of 2,137 patients were followed up for 12 months . Atrial fibrillation progression was defined as a change from paroxysmal to persistent/permanent AF . RESULTS Progression of AF occurred in 318 patients ( 15 % ) after 1 year . Patients with AF progression  were older ; had a higher diastolic blood pressure ; and more often had a history of coronary artery disease , stroke or transient ischemic attack , hypertension , or heart failure . Patients treated with rhythm control were less likely to show progression than those treated only with rate control ( 164/1542 [ 11 % ] vs 154/595 [ 26 % ] , P < .001 ) . Multivariable analysis showed that history of heart failure ( odds ratio [ OR ] 2.2 , 95 % CI 1.7 - 2.9 , P < .0001 ) , history of hypertension ( OR 1.5 , 95 % CI 1.1 - 2.0 , P = .01 ) , and rate control rather than rhythm control ( OR 3.2 , 95 % CI 2.5 - 4.1 , P < .0001 ) were independent predictors of AF progression . The propensity score-adjusted OR of AF progression in patients with rate rather than rhythm control was 3.3 ( 95 % CI 2.4 - 4.6 , P < .0001 ) . CONCLUSIONS Although heart failure and hypertension are associated with AF progression , rhythm control is associated with lower risk of AF progression Between January 1 , 1986 , and December 31 , 1991 , 4,507 adult patients underwent cardiac surgical procedures requiring cardiopulmonary bypass .  Of these patients , 3,983 patients who did not undergo operation for supraventricular tachycardia and who were in normal sinus rhythm preoperatively form the study group for the present study . Postoperatively , all patients were monitored continuously for the development of arrhythmias until the time of hospital discharge . The incidence of atrial arrhythmias requiring treatment for the most commonly performed operative procedures were as follows : coronary artery bypass grafting , 31.9 % ; coronary artery bypass grafting and mitral valve replacement , 63.6 % ; coronary artery bypass grafting and aortic valve replacement , 48.8 % ; and heart transplantation , 11.1 % . For all patients considered collectively , the risk factors associated with an increased incidence of postoperative atrial arrhythmias ( p < 0.05 by multivariate logistic regression ) included increasing patient age , preoperative use of digoxin , history of rheumatic heart disease , chronic obstructive pulmonary disease , and increasing aortic cross-clamp time . Postoperative atrial fibrillation was associated with an increased incidence of postoperative stroke ( 3.3 % versus 1.4 % ; p < 0.0005 ) , increased length of hospitalization in the intensive care unit ( 5.7 versus 3.4 days ; p = 0.001 ) and postoperative nursing ward ( 10.9 versus 7.5 days ; p = 0.0001 ) , increased incidence of postoperative ventricular tachycardia or fibrillation ( 9.2 % versus 4.0 % ; p < 0.0005 ) , and an increased need for placement of a permanent pacemaker ( 3.7 % versus 1.6 % ; p < 0.0005 ) . These data provide a basis for targeting specific patient subgroups for prospect i ve , r and omized trials of therapeutic modalities design ed to decrease the incidence of postoperative atrial arrhythmias In a r and omly selected population of 9067 individuals , 32 - 64 years of age in 1967 - 1970 , 25 ( 0.28 % ) had chronic atrial fibrillation ( CAF ) . Eight had lone atrial fibrillation .  In 1984 the cases were compared with an age- and sex-matched control group of 50 and found to have more cerebrovascular accidents ( 6 versus 2 ; P less than 0.05 ) , congestive heart failure ( 9 versus 1 ; P less than 0.001 ) , and valvular rheumatic heart disease ( 3 versus 0 ) or history consistent with rheumatic fever ( 6 versus 0 ; P less than 0.01 ) . The mortality in the CAF group was 60 % higher due to an excess in cardiovascular ( relative risk 6.1 ; P less than 0.05 ) and cerebrovascular ( relative risk 12.2 ; P less than 0.05 ) causes . The prevalence or incidence of ischaemic or hypertensive heart disease or the presence of coronary risk factors did not significantly differ in the two groups . By M-mode echocardiography the left atrial size , left ventricular enddiastolic dimension and left ventricular mass were increased in the CAF patients , while the systolic left ventricular shortening was significantly less . Thus , the prevalence of CAF is low in a r and omly selected population 32 - 64 years of age and CAF is not strongly associated with ischaemic heart disease or hypertension . The CAF patients have an increased risk of dying prematurely particularly from cerebrovascular causes , even in the absence of valve disease BACKGROUND Atrial fibrillation is the most common supraventricular arrhythmia in patients with acute myocardial infa rct ion . Recent advances in pharmacological treatment of myocardial infa rct ion may have changed the impact of this arrhythmia . OBJECTIVE To assess the incidence and prognosis of atrial fibrillation complicating myocardial infa rct ion in a large population of patients receiving optimal treatment , including angiotensin converting enzyme ( ACE ) inhibitors .  METHODS Data were derived from the GISSI-3 trial , which included 17 944 patients within the first 24 hours after acute myocardial infa rct ion . Atrial fibrillation was recorded during the hospital stay , and follow up visits were planned at six weeks and six months . Survival of the patients at four years was assessed through census offices . RESULTS The incidence of in-hospital atrial fibrillation or flutter was 7.8 % . Atrial fibrillation was associated with indicators of a worse prognosis ( age > 70 years , female sex , higher Killip class , previous myocardial infa rct ion , treated hypertension , high systolic blood pressure at entry , insulin dependent diabetes , signs or symptoms of heart failure ) and with some adverse clinical events ( reinfa rct ion , sustained ventricular tachycardia , ventricular fibrillation ) . After adjustment for other prognostic factors , atrial fibrillation remained an independent predictor of increased in-hospital mortality : 12.6%v 5 % , adjusted relative risk ( RR ) 1.98 , 95 % confidence interval ( CI ) 1.67 to 2.34 . Data on long term mortality ( four years after acute myocardial infa rct ion ) confirmed the persistent negative influence of atrial fibrillation ( RR 1.78 , 95 % CI 1.60 to 1.99 ) . CONCLUSIONS Atrial fibrillation is an indicator of worse prognosis after acute myocardial infa rct ion , both in the short term and in the long term , even in an unselected population AIMS Early recurrences of atrial arrhythmia after wide electrically isolating ablation for atrial fibrillation ( AF ) are well described , but the long-term risk of recurrence for patients with persistent and permanent AF has not been studied in detail . METHODS AND RESULTS Fifty-six consecutive patients [ 45 men ( 80.4 % ) , age 55.9 + /- 8.7 years ] with persistent [ 39(69.6 % ) ] or permanent [ 17(30.4 % ) ] AF were followed for 21.6 + /- 8.8 months after ablation . Atrial fibrillation duration prior to ablation was 6.4 + /- 5.6 years .  Electrically isolating lesions encircling the left and right pulmonary veins ( PVs ) in pairs were created . After 1.5 + /- 0.7 procedures , 48 ( 85.7 % ) had sinus rhythm ( SR ) at 21.6 + /- 8.8 months of follow-up : achieved with 1 procedure in 27 ( 56.3 % ) and without anti-arrhythmics in 30 ( 62.5 % ) . Atrial fibrillation recurrence was observed in 69.6 % after the first and 46.4 % after the last procedure . Of those with late recurrences ( > 90 days ) following the last procedure , most [ 18 ( 69.2 % ) ] did not have early recurrences . Pre-procedural AF duration ( P = 0.007 ) and female gender ( P = 0.005 ) were independent predictors of recurrence following the last procedure . CONCLUSION Circumferential PV isolation is effective in most patients with persistent or permanent AF . However , repeat procedures are frequently required . Late recurrences are common and not precluded by the absence of early post-procedural arrhythmias OBJECTIVES This study compared the efficacy and safety of sotalol and quinidine for conversion and prevention of recurrent  atrial fibrillation .  BACKGROUND Atrial fibrillation is the most common arrhythmia . Pharmacologic therapy has been advocated for both immediate restoration of sinus rhythm and prevention of recurrent atrial fibrillation .  Quinidine is the therapeutic mainstay for both purpose s , but its safety has recently been question ed . Although sotalol has been used successfully to maintain sinus rhythm after direct current cardioversion , its efficacy in pharmacologically reverting atrial fibrillation has not been examined . METHODS Fifty consecutive patients with persistent atrial fibrillation were r and omized to receive quinidine or sotalol for up to 7 days to restore sinus rhythm . Patients were followed up for 6 months . RESULTS Quinidine was more effective than sotalol in terminating atrial fibrillation ( 60 % vs. 20 % , p = 0.009 ) . When nonresponders to drug therapy underwent subsequent direct current cardioversion , total conversion rates in the quinidine and sotalol groups were comparable ( 88 % vs. 68 % , p = 0.17 ) , as was the efficacy of the two drugs in preventing recurrent atrial fibrillation . Side effects necessitating drug discontinuation were more often observed with quinidine . No patient receiving sotalol but four patients receiving quinidine had drug-associated arrhythmia ( torsade de pointes in three patients , sustained ventricular tachycardia in one patient ) . Precordial QT dispersion determined on the surface electrocardiogram ( ECG ) increased with quinidine ( mean + /- SD 34 + /- 9 vs. 44 + /- 16 ms , p = 0.02 ) , indicating enhanced inhomogeneity in ventricular repolarization . There was no change in QT dispersion in patients receiving sotalol ( 36 + /- 18 vs. 40 + /- 17 ms , p = 0.44 ) . CONCLUSIONS Quinidine is more effective than sotalol in terminating atrial fibrillation but is associated with more side effects . The proarrhythmic risk may be related to quinidine 's propensity to increase disparity in ventricular repolarization . This risk warrants careful ECG monitoring during the 1st 4 to 7 days of therapy . Because most proarrhythmic effects occurred shortly after restoration of sinus rhythm , observation should continue > or = 2 to 3 days after sinus rhythm is reestablished OBJECTIVE Atrial fibrillation is often asymptomatic , but outcomes require further characterization . The study objective was to investigate the clinical presentation , management , and outcomes in asymptomatic and symptomatic patients with atrial fibrillation who were prospect ively enrolled in the EurObservational Research Programme - Atrial Fibrillation ( EORP-AF ) Pilot General Registry . METHODS A total of 3119 patients were enrolled , and 1237 ( 39.7 % ) were asymptomatic ( European Heart Rhythm Association [ EHRA ] score I ) . Among symptomatic patients , 963 ( 51.2 % ) had mild symptoms ( EHRA score II ) and 919 ( 48.8 % ) had severe or disabling symptoms ( EHRA III-IV ) . Permanent atrial fibrillation was 3-fold more common in asymptomatic patients than in symptomatic patients . RESULTS On multivariate analysis , male gender ( odds ratio [ OR ] , 1.630 ; 95 % confidence interval [ CI ] , 1.384 - 1.921 ) , older age ( OR , 1.019 ; 95 % CI , 1.012 - 1.026 ) , previous myocardial infa rct ion ( OR , 1.681 ; 95 % CI , 1.350 - 2.093 ) , and limited physical activity ( OR , 1.757 ; 95 % CI , 1.495 - 2.064 ) were associated significantly with asymptomatic ( EHRA I ) atrial fibrillation . Fully asymptomatic atrial fibrillation ( absence of current and previous symptoms ) was present in 520 patients ( 16.7 % ) and was associated independently with male gender , age , and previous myocardial infa rct ion . Appropriate guideline -based prescription of oral anticoagulants  was lower in these patients , and  aspirin  was prescribed more frequently . Mortality at 1 year was more than 2-fold higher in asymptomatic patients compared with symptomatic patients ( 9.4 % vs 4.2 % , P < .0001 ) and was associated independently with older age and comorbidities , including chronic kidney disease and chronic heart failure . CONCLUSIONS Asymptomatic atrial fibrillation is common in daily cardiology practice and is associated with elderly age , more comorbidities , and high thromboembolic risks . A higher 1-year mortality was found in asymptomatic patients compared with symptomatic patients BACKGROUND The clinical presentation and causes of  atrial fibrillation ( AF )  in the 1990s may differ from AF seen 2 to 3 decades ago . It was the objective of this prospect i ve study to characterize various clinical presentations and underlying conditions of patients with AF observed in general practice in France . METHODS AND RESULTS The study population comprised 756 patients ( 19 to 95 years of age ) with electrocardiographically documented AF subdivided into paroxysmal ( < 7 days ) , chronic ( last episode > 1 month ) and recent onset AF(persistent > 7 days and < 1 month ) .  Symptoms were present in 670 patients ( 88.6 % ) . The relative prevalences of paroxysmal , chronic , and recent onset AF were 22.1 % , 51.4 % , and 26.4 % , respectively . Cardiac disorders , present in 534 patients ( 70.6 % ) , included hypertension ( 39.4 % ) , coronary artery disease ( 16.6 % ) , and myocardial diseases ( 15.3 % ) as the most common . Rheumatic valvular disease represented a common cause in women ( 25 . 0 % ) but not in men ( 8.0 % ) . The paroxysmal group differed by a high percentage of palpitations ( 79.0 % ) and a low percentage of underlying heart disease ( 53.9 % ) . With a mean follow-up of 8.6+/-3.7 months , 28 patients ( 3.7 % ) died , including 6 fatal cerebrovascular accidents . Among the 728 patients who survived , congestive heart failure occurred in 30 patients ( 4.1 % ) , and embolic complications occurred in 13 patients ( 1.8 % ) . In the paroxysmal AF group , 13 patients ( 8.0 % ) developed chronic AF and 51 ( 31.3 % ) had AF recurrences . At the time of follow-up , 53 patients ( 14.3 % ) from the chronic AF group and 108 patients ( 55.7 % ) from the recent onset AF group were in sinus rhythm . CONCLUSIONS This large-scale study establishes the current demographic profile of out-of-hospital patients with AF and highlights some of the changes that have occurred in the past decades , including a particular shift in cardiac causes toward nonrheumatic AF . This study also demonstrates significant differences between various subsets of AF BACKGROUND In-hospital administration of flecainide and propafenone in a single oral loading dose has been shown to be effective and superior to placebo in terminating atrial fibrillation . We evaluated the feasibility and the safety of self-administered oral loading of flecainide and propafenone in terminating atrial fibrillation of recent onset outside the hospital . METHODS We administered either flecainide or propafenone orally to restore sinus rhythm in 268 patients with mild heart disease or none who came to the emergency room with atrial fibrillation of recent onset that was hemodynamically well tolerated . Of these patients , 58 ( 22 percent ) were excluded from the study because of treatment failure or side effects . Out-of-hospital self-administration of flecainide or propafenone -- the " pill-in-the-pocket " approach -- after the onset of heart palpitations was evaluated in the remaining 210 patients ( mean age [ + /-SD ] , 59+/-11 years ) . RESULTS During a mean follow-up of 15+/-5 months , 165 patients ( 79 percent ) had a total of 618 episodes of arrhythmia ; of those episodes , 569 ( 92 percent ) were treated 36+/-93 minutes after the onset of symptoms . Treatment was successful in 534 episodes ( 94 percent ) ; the time to resolution of symptoms was 113+/-84 minutes . Among the 165 patients with recurrences , the drug was effective during all the arrhythmic episodes in 139 patients ( 84 percent ) . Adverse effects were reported during one or more arrhythmic episodes by 12 patients ( 7 percent ) , including atrial flutter at a rapid ventricular rate in 1 patient and noncardiac side effects in 11 patients . The numbers of monthly visits to the emergency room and hospitalizations were significantly lower during follow-up than during the year before the target episode ( P<0.001 for both comparisons ) . CONCLUSIONS In a selected , risk-stratified population of patients with recurrent atrial fibrillation , pill-in-the-pocket treatment is feasible and safe , with a high rate of compliance by patients , a low rate of adverse events , and a marked reduction in emergency room visits and hospital admissions INTRODUCTION AND OBJECTIVES Atrial fibrillation is associated with substantial morbidity and mortality and both its incidence and prevalence are high . Nevertheless , comprehensive data on this condition in Spain are lacking . The aim of this study was to estimate the prevalence of atrial fibrillation in Spain . METHODS A cross-sectional study was conducted in the general Spanish population older than 40 years . Two-stage r and om sampling was used , in which first-stage units were primary care physicians r and omly selected in every Spanish province and second-stage units were 20 r and omly selected persons drawn from each participating physician 's assigned population . The reported prevalence was st and ardized for the age and sex distribution of the Spanish population . The  electrocardiogram recordings  were read central ly . RESULTS Overall , 8343 individuals were evaluated . The mean age was 59.2 years ( 95 % confidence interval , 58.6 - 59.8 years ) , and 52.4 % of the participants were female . The overall age-adjusted prevalence of atrial fibrillation was 4.4 % ( 95 % confidence interval , 3.8 - 5.1 ) . Prevalence was similar in both sexes , men 4.4 % ( 3.6 - 5.2 ) and women 4.5 % ( 3.6 - 5.3 ) , rising with increasing age older than 60 years . In patients older than 80 years , the prevalence was 17.7 % ( 14.1 - 21.3 ) . In 10 % of patients an unknown atrial fibrillation was diagnosed . CONCLUSIONS The prevalence of atrial fibrillation in the general Spanish population older than 40 years is high , at 4.4 % . The prevalence is similar in both sexes and rises steeply above 60 years of age . It is estimated that there are over 1 million patients with atrial fibrillation in the Spanish population , of whom over 90,000 are undiagnosed BACKGROUND Atrial fibrillation is the most commonly encountered sustained cardiac arrhythmia . Restoration and maintenance of sinus rhythm is believed by many physicians to be superior to rate control only . However , there are no prospect i ve data that compare both therapeutic strategies . METHODS The Pharmacological Intervention in Atrial Fibrillation ( PIAF ) trial was a r and omised trial in 252 patients with atrial fibrillation of between 7 days and 360 days duration , which compared rate ( group A , 125 patients ) with rhythm control ( group B , 127 patients ) . In group A , diltiazem was used as first-line therapy and amiodarone was used in group B. The primary study endpoint was improvement in symptoms related to atrial fibrillation . FINDINGS Over the entire observation period of 1 year , a similar proportion of patients reported improvement in symptoms in both groups ( 76 responders at 12 months in group A vs 70 responders in group B , p=0.317 ) . Amiodarone administration result ed in pharmacological restoration of sinus rhythm in 23 % of patients . Walking distance in a 6 min walk test was better in group B compared with group A , but assessment of quality of life showed no differences between groups . The incidence of hospital admission was higher in group B ( 87 [ 69 % ] out of 127 vs 30 [ 24 % ] out of 125 in group A , p=0.001 ) . Adverse drug effects more frequently led to a change in therapy in group B ( 31 [ 25 % ] patients compared with 17 [ 14 % ] in group A , p=0.036 ) . INTERPRETATION With respect to symptomatic improvement in patients with atrial fibrillation , the therapeutic strategies of rate versus rhythm control yielded similar clinical results overall . However , exercise tolerance is better with rhythm control , although hospital admission is more frequent . These data may serve as a basis to select therapy in individual patients STUDY OBJECTIVE Patients presenting to the emergency department with acute atrial fibrillation are traditionally admitted to hospital . The objective of this study was to review the success and safety of ED cardioversion and discharge of patients with acute atrial fibrillation . METHODS This health records survey included a cohort sample of consecutive patients presenting with acute atrial fibrillation to the ED of a university-affiliated tertiary hospital . Patients who were in unstable condition on presentation , who had a complicating cardiac diagnosis , or those with other medical or surgical conditions requiring admission were excluded from the study analysis . Patient visit information was entered into a data base that included demographics and clinical presentation , investigations , ED therapy , complications , consultations , disposition , and follow up . Patient visits were then categorized into the following groups : no ED intervention , spontaneous resolution , heart rate control , attempted chemical cardioversion , or electrical cardioversion . The data were analyzed using descriptive methods . RESULTS Of the 289 eligible patients seen during an 18-month period , 62 % ( 180 ) underwent attempted chemical cardioversion with a 50 % success rate and 28 % ( 80 ) had attempted electrical cardioversion with a 89 % success rate . Ninety-three percent of electrical cardioversions were performed by emergency physicians . There was an overall 6 % ( 19 ) complication rate , 95 % of which were regarded as minor . One patient had a complication caused by a rate control medication , which necessitated hospital admission . Ninety-seven percent ( 280 ) of the patients were discharged home directly from the ED . CONCLUSION Cardioversion and immediate discharge of patients who present to the ED with acute atrial fibrillation appears to be both safe and effective . This management approach should be prospect ively evaluated in multiple setting OBJECTIVES Our aim was to identify shortcomings in the management of patients with both atrial fibrillation ( AF ) and heart failure ( HF ) . BACKGROUND AF and HF often coincide in cardiology practice , and they are known to worsen each other 's prognosis , but little is known about the quality of care of this combination . METHODS In the observational Euro Heart Survey on AF , 5,333 AF patients were enrolled in 182 centers across 35 European Society of Cardiology member countries in 2003 and 2004 . A follow-up survey was performed after 1 year . RESULTS At baseline , 1,816 patients ( 34 % ) had HF .  Recommended therapy for HF with left ventricular systolic dysfunction ( LVSD ) with a beta-blocker and either an angiotensin-converting enzyme inhibitor ( ACEI ) or angiotensin II receptor blocker was prescribed in 40 % of HF patients , while 29 % received the recommended drug therapy for both LVSD-HF and AF , consisting of the combination of a beta-blocker , either ACEI or angiotensin II receptor blocker , and oral anticoagulation .  Rate control was insufficient with 40 % of all HF patients with permanent AF having a heart rate < or = 80 beats/min . In the total cohort , HF patients had a higher risk for mortality ( 9.5 % vs. 3.3 % ; p < 0.001 ) , ( progression of ) HF ( 24.8 % vs. 5.0 % ; p < 0.001 ) , and AF progression ( 35 % vs. 19 % ; p < 0.001 ) during 1-year follow-up . Of all recommended drugs for AF and LVSD-HF , only ACEI prescription was associated with improved survival during 1-year follow-up ( odds ratio : 0.51 [ 95 % confidence interval : 0.31 to 0.85 ] ; p = 0.011 ) . CONCLUSIONS The prescription rate of guideline -recommended drug therapy for AF and LVSD-HF is low . R and omized controlled trials targeting this highly prevalent subgroup with AF and HF are warranted BACKGROUND Spontaneous conversion of recent onset paroxysmal atrial fibrillation  to  normal sinus rhythm  occurs commonly and is not affected by low-dose amiodarone treatment . METHODS In a r and omized , placebo-controlled trial of 100 patients with paroxysmal atrial fibrillation of recent onset ( < 48 h ) we compared the effects of treatment with continuous intravenous amiodarone 125 mg per hour ( total 3 g ) and intravenous placebo .  Patients in the placebo group who did not convert to normal sinus rhythm within 24 h were started on amiodarone therapy . RESULTS Conversion to normal sinus rhythm occurred within 24 h in 32 of 50 patients ( 64 % ) in the placebo group , most of whom converted within 8 h. Lower conversion rates were observed in patients with hypertension , ischaemic heart disease or congestive heart failure and in patients with echocardiographic findings of left atrial diameter above 45 mm , ejection fraction below 45 % or significant mitral regurgitation . However , in most patients these clinical or echocardiographic risk factors of decreases in conversion rate were not present . In such patients the spontaneous conversion rate was approximately 90 % . The conversion rate during 24 h of treatment in the amiodarone group was 92 % ( P=0.0017 , compared to the placebo group ) . In this group , the conversion rate was largely unaffected by baseline characteristics . Of the 18 patients who did not convert with placebo , 15 ( 85 % ) converted after being crossed over to amiodarone . All patients not responding to high-dose amiodarone were in chronic atrial fibrillation within 1 month . In patients still in atrial fibrillation after 8 h of treatment , the pulse rate decreased significantly more in the amiodarone as compared to the placebo group ( 83+/-15 vs 114+/-20 beats . min(-1 ) , P=0.0014 ) . CONCLUSION The spontaneous conversion of recent onset paroxysmal atrial fibrillation is high and approaches 90 % in specific clinical and echocardiographically defined subgroups . Intravenous high-dose amiodarone safely facilitates conversion of paroxysmal atrial fibrillation . However , such treatment should be reserved for patients with unfavourable risk factor profiles , not converting during 8 h of observation or requiring rate control The optimal way to convert recent-onset atrial fibrillation to sinus rhythm is a subject of much debate . The effectiveness of intravenous propafenone  has been shown [ 1 - 3 ] , but the full antiarrhythmic effect of this regimen depends not only on the parent compound but on its 5-hydroxylated metabolite [ 4 , 5 ] . This dependence provides a strong rationale for the use of oral loading regimens [ 3 ] . Results of previous controlled studies have shown that oral loading of propafenone is highly effective in converting recent-onset atrial fibrillation to sinus rhythm [ 6 , 7 ] . Safety is a major concern with antiarrhythmic therapy . One of the primary proarrhythmic risks of propafenone and flecainide is the transformation of atrial fibrillation to flutter with 1:1 atrioventricular conduction and hemodynamic impairment [ 8 - 10 ] . We sought to determine whether the effectiveness and safety of propafenone differ in patients who have structural heart disease and patients who do not . Methods From June 1990 to June 1994 , consecutive patients with recent-onset atrial fibrillation ( 7 days ) who presented to one of three centers were considered for enrollment .  Onset of arrhythmia was documented by electrocardiography or by an abrupt onset of palpitations with subsequent evidence of atrial fibrillation on electrocardiography . Patients were excluded for any of the following reasons : age greater than 80 years , heart failure greater than NYHA ( New York Heart Association ) class II , mean ventricular rate during atrial fibrillation less than 70 beats/min , recent myocardial infa rct ion ( within < 6 months ) , unstable angina pectoris , previous or current electrocardiographic evidence ventricular preexcitation or complete bundle-branch block , previous electrocardiographic evidence of second- or third-degree atrioventricular block or bifascicular block , the sick sinus syndrome , hypokalemia ( potassium level < 3.5 mEq/L ) , renal or hepatic failure with severe hypoxia ( Pao 2 < 55 mm Hg ) , severe metabolic disturbances , or known thyroid dysfunction . Patients who were receiving long-term digoxin therapy or antiarrhythmic drugs or had received such treatments within 8 hours before study entry were also excluded . Patients who had atrial fibrillation that lasted 72 hours or longer were enrolled only if they were receiving long-term  warfarin therapy for anticoagulation . Patients provided informed consent . Eligible patients had a 24-hour Holter monitor applied ; after 1 to 2 hours of observation to assess the stability of atrial fibrillation , they were r and omly assigned by center in a single-blind manner to receive propafenone ( 300 mg in two tablets as a single oral dose ) or placebo . All patients received intravenous saline throughout the study period . The electrocardiogram was monitored by telemetry , blood pressure was measured every 2 hours , and 12-lead electrocardiography was done every hour for the first 4 hours and then every 2 hours for the next 4 hours . When patients converted to sinus rhythm , 12-lead electrocardiography was done immediately . Conversion was defined as a stable sinus rhythm that lasted for at least 1 hour . Eight hours after the study drug was administered , physicians could continue treatment with the study drug or switch to a different therapeutic option . Holter monitor tapes were analyzed by two blinded observers using computer scanning systems ( Marquette 8000 , Milwaukee , Wisconsin , and Del Mar Avionics , Irvine , California ) to determine the time of conversion to sinus rhythm and whether an abnormal rhythm was present . Within 24 hours after enrollment , echocardiography was done for each patient and left atrial diameter was measured in the left parasternal long-axis view . On the basis of clinical history and the results of physical examination , echocardiography , and chest radiography , patients were classified as having structural heart disease ( defined as the presence of cardiac abnormalities other than atrial fibrillation ) , hypertension without structural heart disease ( defined as previously recognized systemic hypertension according to the criteria of the World Health Organization ) , or neither . Continuous outcomes and baseline characteristics of the patients were compared by using the chi-square statistic and t-test as appropriate . The rates of conversion to sinus rhythm were assessed at 3 and 8 hours . Odds ratios and corresponding CIs were calculated according to the methods of Gardner and Altman [ 11 ] . We did logistic regression analysis to describe how the interaction of treatment with the presence or absence of heart disease and hypertension affected the probability of conversion to sinus rhythm . Analyses were done using SPS software , version 6.1.3 ( SPS , Inc. , Chicago , Illinois ) . Results Patients During the study period , 407 patients presented to the three centers and were screened for eligibility . Two hundred forty-three patients were eligible , and 240 gave consent . A total of 164 patients were excluded for one or more of the following reasons : age greater than 80 years ( n = 10 ) , heart failure greater than NYHA class II ( n = 33 ) , recent myocardial infa rct ion ( n = 20 ) , bundle-branch block ( n = 24 ) , the sick sinus syndrome ( n = 6 ) , severe hypoxia ( n = 13 ) , thyroid dysfunction ( n = 12 ) , and previous antiarrhythmic treatment ( n = 63 ) . Two hundred forty patients were r and omly assigned to receive propafenone ( n = 119 ) or placebo ( n = 121 ) . The two groups were similar with regard to age , sex , cause of atrial fibrillation , NYHA class , left atrial dimension ( measured by echocardiography ) , structural heart disease , and hypertension ( Table 1 ) . The duration of atrial fibrillation before r and omization ranged from 2.5 to 120 hours and did not differ significantly between the treatment groups . Table 1 . Patient Characteristics Conversion to Sinus Rhythm and Presence of Heart Disease The probability of conversion to sinus rhythm was greater after propafenone than after placebo at 3 and 8 hours ( P < 0.001 ) ( Figure 1 ) . Corresponding odds ratios were 3.8 ( 95 % CI , 2.1 to 6.8 ) at 3 hours and 5.4 ( CI , 3.0 to 9.4 ) at 8 hours . Figure 1 . Conversion to sinus rhythm within 8 hours in patients receiving propafenone or placebo . At 8 hours , the probability of conversion to sinus rhythm was significantly higher in the propafenone group than in the placebo group for patients who had heart disease ( odds ratio , 21.7 [ CI , 5.9 to 80.1 ] ; P < 0.001 ) , patients who had hypertension ( odds ratio , 6.4 [ CI , 2.3 to 17.6 ] ; P < 0.001 ) , and patients who did not have structural heart disease ( odds ratio , 2.8 [ CI , 1.2 to 6.7 ] ; P = 0.02 ) . Conversion rates at 8 hours for patients receiving propafenone were similar among the three heart disease subgroups , but conversion rates for patients receiving placebo differed significantly ( 56 % for patients without structural heart disease , 27 % for patients with hypertension , and 17 % patients with structural heart disease [ P = 0.009 by logistic regression model ] ) . At 3 hours , the probability of conversion to sinus rhythm was higher in the propafenone group than in the placebo group for patients who did not have heart disease ( 48 % for propafenone compared with 26 % for placebo ; odds ratio , 2.6 [ CI , 1.2 to 6.0 ] ; P = 0.02 ) , patients who had hypertension ( 41 % for propafenone compared with 16 % for placebo ; odds ratio , 3.5 [ CI , 1.2 to 10.5 ] ; P = 0.02 ) , and patients who had structural heart disease ( 47 % for propafenone compared with 7 % for placebo ; odds ratio , 12.3 [ CI , 2.5 to 60.5 ] ; P < 0.001 ) . By logistic regression analysis , no significant correlation between heart disease and treatment was seen at 3 hours ( P = 0.2 ) . Mean time SD for conversion to sinus rhythm within 8 hours was 181 118 minutes for propafenone and 181 112 minutes for placebo ( P > 0.2 ) . Adverse Effects Sustained atrial flutter or tachycardia ( lasting 1 min ) occurred in eight patients ( 7 % ) receiving propafenone and seven patients ( 6 % ) receiving placebo ( P > 0.2 ) , regardless of heart disease status . Among these patients , atrioventricular conduction was 2:1 in two patients receiving propafenone ( heart rate , 115 to 140 beats/min ) and three patients receiving placebo ( heart rate , 120 to 150 beats/min ) , 3:1 in six patients receiving propafenone ( heart rate , 60 to 95 beats/min ) and three patients receiving placebo ( heart rate , 60 to 100 beats/min ) , and 1:1 in one patient receiving placebo ( heart rate , 240 beats/min ) . This patient developed atrial flutter and collapsed . Pauses in ventricular rate lasting longer than 2 seconds were seen in one patient ( 1 % ) receiving propafenone and three patients ( 2 % ) receiving placebo ( P > 0.2 ) . Among patients receiving propafenone , nine ( 8 % ) had the following adverse effects : QRS complexes of the electrocardiogram greater than 120 ms ( n = 3 ) , hypotension ( n = 2 ) , slight hypotension and bradycardia at conversion ( n = 3 ) , and phases of junctional rhythm after conversion ( n = 1 ) . No ventricular proarrhythmic effects occurred . Discussion Oral loading of propafenone was effective for conversion to sinus rhythm in our study , as it has been in smaller studies [ 3 , 6 , 7 , 12 , 13 ] . The recent findings of Wijffels and colleagues [ 14 ] in a model of chronic atrial fibrillation in animals indicate that electrophysiologic remodeling occurs within a few hours of persistent atrial fibrillation and results primarily from changes in atrial refractoriness that enhance the persistence of atrial fibrillation . This observation provides a strong rationale for prompt conversion to sinus rhythm . Therefore , oral loading of propafenone ( which has an effectiveness similar to that of intravenous propafenone [ 3 ] ) offers many advantages over such regimens as oral quinidine and intravenous amiodarone , which require titration of dose or a longer period of time to achieve an effect [ 6 , 13 , 15 ] . In controlled trials , propafenone was shown to be more effective and to take effect more quickly than amiodarone [ 13 ] or digoxin plus quinidine [ 6 ] . Intravenous amiodarone  was no more effective than placebo An ECG recording time of 24 hours has a low yield to detect atrial arrhythmias in patients after an acute ischemic stroke . The present study investigated whether a recording time of 72 instead of 24 hours detects paroxysmal atrial fibrillation in more patients . The study prospect ively included 82 consecutive patients 2 - 3 weeks after an acute ischemic stroke . All patients had sinus rhythm in the resting ECGs and no history of atrial fibrillation or flutter . The frequency of atrial fibrillation was assessed after 24 , 48 , and 72 hours of ambulatory ECG monitoring . An ECG monitoring time of 72 hours documented paroxysmal atrial fibrillation in five ( 6 % ) patients . The episode of paroxysmal atrial fibrillation occurred in only one patient within 24 hours . The other patients had their first episode of atrial fibrillation between 24 and 48 hours ( n = 2 ) and between 48 and 72 hours ( n = 2 ) . These five patients were older ( age = 70 + /- 5 years ) , whereas the mean age of the remaining patients was 59 + /- 13 years . All five patients had cardiovascular disease in comparison to 36 of 77 patients and reported palpitations in comparison to 6 of 77 of the remaining patients . In conclusion , ambulatory ECG monitoring over 72 hours detected after the first recording day four of five patients in whom paroxysmal atrial fibrillation could be documented for the first time . The 72-hour recording time improved , compared to the 24-hour period , the detection of paroxysmal atrial fibrillation in patients after an ischemic stroke . It seems to be more efficient to perform prolonged ECG recording mainly in older patients with a cardiovascular disease and /or a history of palpitations OBJECTIVE To correlate atrial fibrillation with the incidence of new thromboembolic ( TE ) stroke  in older patients with and without prior TE stroke . DESIGN In a prospect i ve study of 2101 older patients ,  electrocardiograms  showed that atrial fibrillation was present in 283 patients ( 13 % ) . At 42-month mean follow-up , atrial fibrillation was associated with the incidence of new TE stroke in patients with and without prior TE stroke . SETTING A large long-term health care facility where 2101 older patients were studied . PATIENTS The 2101 patients included 1451 women and 650 men , mean age 81 + /- 8 years ( range 60 to 103 ) . MEASUREMENTS AND MAIN RESULTS Atrial fibrillation was present in 283 of 2101 patients ( 13 % ) . The mean age was 84 + /- 7 years in patients with atrial fibrillation and 81 + /- 8 years in patients with sinus rhythm ( P = .0001 ) . The prevalence of atrial fibrillation was 5 % in patients aged 60 to 70 years , 14 % in patients aged 71 to 80 years , 13 % in patients aged 81 to 90 years , and 22 % in patients aged 91 to 103 years ( P < .0001 ) . Mean follow-up was 31 + /- 18 months in patients with atrial fibrillation and 44 + /- 27 months in patients with sinus rhythm ( P = .0001 ) . Previous TE stroke occurred in 123 of 283 patients ( 43 % ) with atrial fibrillation and in 431 of 1818 patients ( 24 % ) with sinus rhythm ( P < .0001 ) . New TE stroke occurred in 131 of 283 patients ( 46 % ) with atrial fibrillation and in 303 of 1818 patients ( 17 % ) with sinus rhythm ( P < .0001 ) . The log-rank test showed that patients with atrial fibrillation had a significantly higher probability of developing new TE stroke than those with sinus rhythm ( P < .0001 ) . The multivariate Cox regression model showed that independent risk factors for new TE stroke were male sex ( relative risk = 1.3 ) , prior TE stroke ( relative risk = 3.1 ) , and atrial fibrillation ( relative risk = 3.3 ) . CONCLUSIONS Atrial fibrillation , prior TE stroke , and male sex are independent risk factors for the development of new TE stroke in older patients OBJECTIVE This study aim ed at the assessment of the clinical approach to atrial fibrillation ( AF ) in the older population and the consistency with the guidelines based on the records of the multicenter , prospect i ve AFTER ( Atrial Fibrillation in Turkey : Epidemiologic Registry ) study . PATIENTS AND METHODS 2242 consecutive patients admitted to the Cardiology Outpatient Clinics of 17 different tertiary Health Care Centers with at least one AF attack determined on electrocardiographic examination , were included in the study . Among the patients included in the study , 631 individuals aged 75 years and older were analyzed . RESULTS The mean age of the patients was determined as 80.3±4.2 years . The most frequent type of AF in geriatric population was the persistent-permanent type with a percentage of 88 % . 60 % of the patients with AF were female . Hypertension was the most common co-morbidity in patients with AF ( 76 % ) . While in 16 % of patients a history of stroke , transient ischemic attack or systemic thromboembolism was present , a history of bleeding was present in 14 % of the patients . 37 % of the patients were on warfarin treatment and 60 % of the patients were on aspirin treatment . In 38 % of the patients who were on oral anticoagulant  treatment , INR level was in the effective range . CONCLUSIONS The rate of anticoagulant  use in the elderly with AF was 37 % and considering the reason of this situation was the medication not being prescribed by the physician , one should pay more attention particularly in the field of treatment AIMS Permanent atrial fibrillation develops in many patients after ablation and pacing therapy .  We compared a strategy that initially allowed patients to remain in atrial fibrillation with a strategy that initially attempted to restore and maintain sinus rhythm . METHODS AND RESULTS In this multicentre r and omized controlled trial , 68 patients affected by severely symptomatic paroxysmal atrial fibrillation were assigned , after successful atrioventricular junction ablation and pacing treatment  , to antiarrhythmic drug therapy with amiodarone , propafenone , flecainide or sotalol and were compared with 69 patients assigned , after successful AV junction ablation and pacing treatment , to no antiarrhythmic drug therapy . The patients were followed-up for 12 to 24 months ( mean 16+/-4 ) . The drug arm patients had a 57 % reduction in the risk of developing permanent atrial fibrillation ( 21 % vs 37 % , P=0.02 ) . Evaluation after 12 months revealed similar quality of life scores and echocardiographic parameters in the two groups , but the drug arm patients had more episodes of heart failure and hospitalizations ( P=0.05 ) . The outcome was similar between the 40 patients who developed permanent atrial fibrillation and the 97 who did not . CONCLUSION Conventional antiarrhythmic therapy reduces the risk of development of permanent atrial fibrillation after ablation and pacing therapy . The present data do not support the concept that the development of permanent atrial fibrillation is related to an adverse outcome when a perfect control of heart rate is obtained by ablation and pacing Background Atrial fibrillation is very common in people aged 65 or older . This condition increases the risk of death , congestive heart failure and thromboembolic conditions . Many patients with atrial fibrillation are asymptomatic and a cerebrovascular accident ( CVA ) is often the first clinical presentation . Guidelines concerning the prevention of CVA recommend monitoring the heart rate in patients aged 65 or older . Recently , the MyDiagnostick ( Applied Biomedical Systems BV , Maastricht , The Netherl and s ) was introduced as a new screening tool which might serve as an alternative for the less accurate pulse palpation . This study was design ed to explore the diagnostic accuracy of the MyDiagnostick for the detection of atrial fibrillation . Methods A phase II diagnostic accuracy study in a convenience sample of 191 subjects recruited in primary care . The majority of participants were patients with a known history of atrial fibrillation ( n = 161 ) .  Readings of the MyDiagnostick were compared with electrocardiographic recordings . Sensitivity and specificity and their 95 % confidence interval were calculated using 2x2 tables . Results A prevalence of 54 % for an atrial fibrillation rhythm was found in the study population at the moment of the study . A combination of three measurements with the MyDiagnostick for each patient showed a sensitivity of 94 % ( 95 % CI 87 – 98 ) and a specificity of 93 % ( 95 % CI 85 – 97 ) . Conclusion The MyDiagnostick is an easy-to-use device that showed a good diagnostic accuracy with a high sensitivity and specificity for atrial fibrillation in a convenience sample in primary care . Future research is needed to determine the place of the MyDiagnostick in possible screening or case-finding strategies for atrial fibrillation BACKGROUND The Cox Maze procedure has been used to treat atrial fibrillation in patients with mitral valve disease . Recently , ectopic foci , originating in the pulmonary veins , were demonstrated in patients with atrial fibrillation , and the indication was that their arrhythmia could have a focal origin . In the light of this new evidence , a simplified surgical technique to isolate the pulmonary veins was developed to eliminate permanent atrial fibrillation in patients undergoing mitral valve surgery . This study compares three surgical procedures proposed to maintain sinus rhythm after mitral valve surgery . METHODS A prospect i ve clinical trial of 30 patients with mitral valve disease and permanent atrial fibrillation who had undergone mitral valve surgery were r and omized in accordance with the type of surgery used on each : ( 1 ) . associated en bloc isolation of pulmonary veins , ( 2 ) . the Maze procedure , or ( 3 ) . mitral valve correction alone . The preoperative clinical characteristics were similar in the three groups . RESULTS The overall postoperative complications were similar in all three groups . The cardiopulmonary bypass time and the aortic cross-clamping time were shorter in the control group , but this factor bore no relation to increased morbidity in the intervention groups . The relative risk of atrial fibrillation after surgery was 0.08 in the group undergoing isolation of pulmonary veins ( p = 0.010 ; 95 % confidence interval , 0.01 to 0.71 ) and 0.20 in the Maze group ( p = 0.044 ; 95 % confidence interval , 0.04 to 1.02 ) compared with the control group . CONCLUSIONS En bloc isolation of pulmonary veins associated with mitral valve surgery appears to be safe and just as effective as the Maze procedure in maintaining sinus rhythm in patients with permanent atrial fibrillation OBJECTIVES RECORDAF is the first worldwide , prospect i ve , observational survey of management of atrial fibrillation ( AF ) in unselected , community-based patients . BACKGROUND Primary outcomes were therapeutic success and clinical outcomes associated with rhythm-control and rate-control strategies . METHODS Patients with recent-onset AF were included ( n = 5,604 ) . Treatment strategy ( rhythm control or rate control ) was noted at baseline . Follow-up was 12 months . Therapeutic success required that strategy was unchanged without clinical events . Further maintenance of sinus rhythm was required in the rhythm-control group , and heart rate ≤80 beats/min in the rate-control group . RESULTS Data from 5,171 patients were assessable . Therapeutic success was 54 % overall ( rhythm control 60 % vs. rate control 47 % ) , a result driven by control of AF : rhythm control , 81 % vs. rate control , 74 % . After adjustment for propensity score quintiles , the rhythm-control strategy was significantly related to superior therapeutic success ( odds ratio : 1.34 , 95 % confidence interval : 1.15 to 1.55 ; p = 0.0002 ) . Clinical events occurred in 18 % of patients . The arrhythmia management strategy was not predictive of clinical events . The type ( persistent ) , presence at baseline visit , and duration ( > 3 months ) of AF , together with age older than 75 years and the presence of heart failure , predicted progression to permanent AF . The choice of rhythm control reduced the likelihood of AF progression ( odds ratio : 0.20 , 95 % confidence interval : 0.17 to 0.25 ; p < 0.0001 ) . CONCLUSIONS Clinical outcomes in AF patients were driven mainly by hospitalizations for arrhythmia/proarrhythmia and other cardiovascular causes , but not by the choice of rate or rhythm strategy . Rhythm-control patients progressed less rapidly to permanent AF OBJECTIVE Atrial fibrillation is a rhythm disorder commonly seen early after coronary artery bypass grafting , and it increases morbidity . METHODS To investigate the effectiveness of magnesium sulfate in the prophylaxis of atrial fibrillation , we conducted a prospect i ve , r and omized , placebo-controlled clinical study on 200 consecutive patients in whom we performed elective and initial coronary artery bypass grafting operations . In each group 50 % of patients underwent beating-heart operations . In the treatment group 100 patients ( 76 men and 24 women ; mean age , 57.63 + /- 9.68 years ) received 24.34 mEq ( 3 g ) of magnesium sulfate in 100 mL of saline solution that was administered over 2 hours ( 50 mL/h ) preoperatively , perioperatively , and at postoperative days 0 , 1 , 2 , and 3 . In the control group 100 patients ( 74 men and 26 women ; mean age , 59.96 + /- 9.29 years ) received only 100 mL of saline solution according to the same administration schedule as the treatment group . RESULTS Atrial fibrillation developed in 15 patients from the treatment group and in 16 patients from the control group . The arrhythmia developed after 37.87 + /- 12.76 and 45.26 + /- 15.27 hours in the treatment and control groups , respectively . Although a significant relationship was found between low magnesium sulfate levels and increased incidence of atrial fibrillation ( P < .05 ) , when the incidence of postoperative atrial fibrillation is concerned , no significant difference was found between the 2 groups ( P > .05 ) . Also , no significant difference was found between operations with cardiopulmonary bypass and beating-heart operations in terms of atrial fibrillation incidence ( P > .05 ) . However , atrial fibrillation extended the duration of hospital stay in both groups ( P < .05 ) . CONCLUSION Our findings indicate that magnesium sulfate infusion alone is not sufficient for the prophylaxis of atrial fibrillation BACKGROUND Atrial fibrillation ( AF ) is the most common sustained arrhythmia with serious clinical consequences in the absence of treatment . However , there are limited data on the treatment of these patients in Argentina . The objective was to describe the therapeutic management of patients with nonacute AF by Argentinean cardiologists and to determine the incidence of clinical events after 12 months follow-up . METHODS The Atrial Fibrillation study in Argentina ( FARAON ) was an observational , descriptive , prospect i ve , national , and multicentric study that included out patients with AF , followed for 12 months . The study included 38 sites in Argentina . Each research er included the first 10 patients who met the inclusion criteria of being over 21 and also being an AF carrier documented by electrocardiogram or Holter within 12 months prior to or at the time of enrollment . RESULTS A total of 373 patients were included , mean age 70 ± 11.5 years , 40 % women ; 65 % had AF rhythm at the time of inclusion , 57 % had permanent AF , and 56 % were asymptomatic . At the time of enrollment , 40 % of physicians opted for rhythm control strategy . β-blockers and amiodarone were the most used drugs . Patients with rhythm control drugs had higher success rate than those with frequency control drug therapy ( 80 % vs 57 % ) . CONCLUSION Cardiologists in Argentina receive patients with AF that are mostly permanent AF . More than half of the patients are asymptomatic . They opt primarily by controlling the pace . When choosing antiarrhythmic drugs , nearly half of them indicated amiodarone Background Atrial Fibrillation is highly prevalent in clinical practice affecting approximately 2.3 million people in USA and 4.5 million people in European Union . The aim of the study was to examine the association between  nut consumption and incident atrial fibrillation . Methods Prospect i ve cohort of 21,054 male participants of Physicians ' Health Study I.  Nut consumption was estimated using food frequency question naire and incident atrial fibrillation was ascertained through yearly follow-up question naires . Cox regression was used to estimate relative risks of atrial fibrillation . Results The average age was 54.6 ± 9.5 years ( 40.7 - 87.1 ) . During a mean follow up of 20 years ( median 24 years ) , 3,317 cases of atrial fibrillation occurred . The crude incidence rate was 7.6 , 7.4 , 8.2 , 7.9 , and 6.8 cases/1000 person-years for people reporting nut consumption of rarely/never , 1 - 3/month , 1/per week , 2 - 6/week , and ≥ 7/week , respectively . Multivariable adjusted hazard ratios ( 95 % CI ) for incident atrial fibrillation were 1.00 ( ref ) , 1.00 ( 0.90 - 1.11 ) , 1.09 ( 0.97 - 1.21 ) , 1.07 ( 0.95 - 1.21 ) , and 0.91 ( 0.70 - 1.17 ) for nut consumption from the lowest to the highest category of nut consumption ( p for trend 0.26 ) . No statistically significant association between nut consumption and atrial fibrillation was found when stratified by body mass index ( BMI < 25 vs ≥ 25 kg/m2 ) or age ( < 65 vs. ≥ 65 years ) . Conclusions Our data did not show an association between nut consumption and incident atrial fibrillation among US male physicians UNLABELLED The aim of the study was to investigate the efficacy of diltiazem bolus intravenous administration , compared to disopyramide , in the treatment of various types of paroxysmal supraventricular tachyarrhythmias . METHOD Fifty patients ( 23 males , 27 females , mean age 47.7 + /- 15.2 years ) with paroxysmal supraventricular tachyarrhythmia ( 20 with paroxysmal atrial tachycardia , 23 with paroxysmal atrial fibrillation and rapid ventricular response and 7 with atrial fluttering ) were studied . Diltiazem at a dose of 0.25 - 0.30 mg/kg BW or disopyramide at a dose of 50 mg were given bolus IV . If conversion of the arrhythmia to sinus rhythm could not be achieved with the initial drug , the alternate was given . The order of administration of the drugs was r and om , independent of the type of the arrhythmia . Before and during drug administration detailed clinical examination and frequent blood pressure ( BP ) measurements were performed . Twenty-four hour Holter monitoring was done in all patients , starting with the administration of the antiarrhythmic drug . RESULTS 1 ) Paroxysmal atrial tachycardia : diltiazem administration converted the arrhythmia to sinus rhythm in all patients while disopyramide in only 1 of 9 patients who received this drug . 2 ) Paroxysmal atrial fibrillation : disopyramide converted the arrhythmia in 5 patients without significant change in ventricular response in the others . Diltiazem did not convert the arrhythmia though it caused significant decrease in ventricular response ( < 100 bpm ) and in 1 patient an important bradycardia ( 45 bpm ) . 3 ) Atrial fluttering : disopyramide converted the arrhythmia to sinus rhythm in 1 patient without significant change in the ventricular response in the others . Diltiazem caused significant decrease in the ventricular response without conversion to sinus rhythm . During conversion to sinus rhythm an AV junctional rhythm of short duration ( < 1 min ) was noticed in 5 patients and a short pause ( < 2 sec ) with or without an initial premature contraction in the remaining 21 . Disopyramide administration was not associated with side effects .  Diltiazem administration cause small ( < 20 mm Hg ) , transient ( < 30 min ) decrease of BP without symptoms with the exception of the patient with bradycardia in whom the BP decrease was significant ( 90/60 from 160/80 mm Hg ) followed by intense symptoms which lasted for six hours . CONCLUSIONS Diltiazem administration is extremely effective in conversion of paroxysmal atrial tachycardia to sinus rhythm . In addition it retards ventricular response in patients with atrial fibrillation and fluttering . Compared to disopyramide these effects of diltiazem are more pronounced and clinical ly pertinent AIMS To gain insight in the prognosis and treatment of atrial fibrillation ( AF ) patients during 1-year follow-up in the Euro Heart Survey ( EHS ) on AF . METHODS AND RESULTS The EHS enrolled 5333 AF patients in 2003 - -2004 . One-year follow-up data were available for 80 % . Of first detected AF patients , 46 % did not have a recurrence during 1 year , paroxysmal AF largely remained paroxysmal AF ( 80 % ) , and 30 % of persistent AF progressed to permanent AF . Many treatment changes occurred since baseline . Oral anticoagulation was started in 19 % and discontinued in 16 % of all patients . Of patients initially on rhythm control 27 % did not receive rhythm control during follow-up , whereas 15 % of patients initially on rate control received rhythm control . Mortality was highest in permanent AF ( 8.2 % ) , but also substantial in first detected AF ( 5.7 % ) . In multivariable analysis , sinus rhythm at baseline was associated with lower mortality , but no significant effect was observed regarding the application of either rhythm or rate control . CONCLUSION The EHS on AF provides unique prospect i ve observational data on AF progression , long-term treatment , prognosis , and determinants of adverse outcome of the total clinical spectrum of AF in a European cardiology-based patient cohort BACKGROUND Atrial fibrillation is the most common sustained cardiac arrhythmia and has an important impact on costs of medical assistance . Traditional interventions to convert atrial fibrillation to sinus rhythm are antiarrhythmic drugs and external electrical cardioversion . However , the best option for starting the cardioversion is not well established . METHODS In a multicentre r and omised trial of 139 patients with persistent atrial fibrillation lasting less than 6 months , we compared the effectiveness and the cost-effectiveness ratio of initial treatment with chemical or electrical cardioversion .  Subjects who did not achieve sinus rhythm with chemical cardioversion  were considered to undergo electrical cardioversion and vice-versa . RESULTS The efficacy of the initial attempt for cardioversion was similar with chemical or electrical cardioversion ( 74 vs. 73 % , P=0.95 ) . However , the strategy of starting with antiarrhythmic drugs was more effective than with electrical procedure ( 96 vs. 84 % , P=0.0016 ) . Initiating with chemical cardioversion  was also less expensive than with electrical cardioversion ( 1240 US dollars vs. 1917 US dollars ; P=0.002 ) . Life-threatening complications occurred only during chemical cardioversion ( 5 % ) , all of them in patients with structural heart disease . CONCLUSIONS In patients with persistent atrial fibrillation of less than 6 months , initial chemical or electrical cardioversion appear to be similar but the strategy of starting the cardioversion with antiarrhythmic drugs is more effective and less expensive than starting with the electrical procedure . Patients with structural heart disease undergoing chemical cardioversion seem to be more susceptible to severe complications Pharmacologic therapy is widely used for restoration of sinus rhythm and prevention of recurrences of atrial fibrillation .  Because concerns have been raised about their potential proarrhythmic effects , therapeutic regimens should be evaluated by placebo-controlled studies to determine their efficacy and safety . One hundred thirty-six patients with persistent atrial fibrillation were r and omized to receive propafenone 2 mg/kg over 30 minutes , followed by oral propafenone 150 mg 3 times daily or matching placebo . Nonresponders to intravenous therapy underwent direct-current cardioversion . Both responders to intravenous therapy and converters to sinus rhythm after direct-current cardioversion were followed for 6 months in a double-blind oral treatment period of propafenone 150 mg 3 times daily or matching placebo .  Pharmacologic conversion to sinus rhythm was achieved in 29 % of the patients taking propafenone and in 17 % of patients taking placebo ( p > or = 0.10 ) . Subsequent direct-current cardioversion in nonresponders was equally successful ( 70 % ) in both groups ( p > or = 0.10 ) . The proportion of patients free from recurrent symptomatic arrhythmia at 6 months was 67 % for the propafenone and 35 % for the placebo group ( p < 0.01 ) . Time to atrial fibrillation relapse was more favorable with propafenone than with placebo ( p < 0.001 ) . The incidence of drug-related side effects was 10 % in the propafenone group and 14 % in the placebo group . Thus , " slow " infusion of propafenone seems to be of limited value for terminating atrial fibrillation . Oral propafenone at a low dosage 150 mg 3 times daily is well tolerated and effective in maintaining sinus rhythm for 6 months after pharmacologic or electrical restoration of sinus rhythm OBJECTIVES Aim of the present study was to assess the efficacy and safety of flecainide ( F ) and sotalol ( S ) for the prevention of recurrences of paroxysmal atrial fibrillation ( PAF ) . METHODS Sixty-six patients with PAF ( > or = 3 episodes of atrial fibrillation in the last year ) in sinus rhythm , were r and omized to pharmacological oral treatment with F  ( 20 patients -Group A ) , with S ( 20 patients -Group B ) and placebo ( P ) ( 26 patients -Group C ) . During the follow-up ( one year duration ) were evaluated on I , III , VI and XII months the number and tolerance of the atrial fibrillation recurrences , cardiac and /or noncardiac side effects .  The patients with more than two recurrences in the same follow-up interval withdrew from the study . In each patient 14 clinical and laboratory variables were evaluated . RESULTS After 12 months were arrhythmia-free respectively 70 % of Group A patients , 60 % of Group B patients , 27 % of Group C patients . Univariate analysis showed that treatment with F was related to decrease of atrial fibrillation recurrences ( one recurrence 67 % , two recurrences 81 % , three recurrences 81 % ) , treatment with S was related to decrease of recurrences ( two recurrences 59 % ) ; the variable most significantly related to the risk of arrhythmia recurrence is the higher value of basal cardiac rate ( one recurrence t = 2.15 , two t = 2.22 , three t = 2.96 , four t = 2.06 ) . There was not statistically significant difference in maintenance of sinus rhythm at the end of the follow-up between the groups of patients on F and S ( p = 0.163 ) ; treatment efficacy was significantly higher than P ( p = 0.002 ) . Multivariate analysis showed that treatment with F and S decreases the risk of arrhythmia recurrence respectively of 85 % and 76 % versus placebo at the end of the follow-up . The incidence of cardiac and /or noncardiac side effects was not clinical ly significant . CONCLUSION F and S are both effective and safe for prevention of PAF , with 70 % and 60 % respectively of patients arrhythmia-free after 12 months of treatment . Side effects were common , but clinical ly significant adverse events were uncommon . A higher value of basal cardiac rate was predictive of atrial fibrillation recurrences in the patients during treatment Safety and effectiveness are the goals in treating patients with arrhythmias . In an open prospect i ve study , we observed the efficacy and safety of up to 2 mg intravenous ibutilide , a new class III antiarrhythmic agent in haemodynamically stable patients presenting in the emergency department ( ED ) with symptoms of recent-onset ( < 48 h ) atrial fibrillation/flutter . Arrhythmia termination within 90 min , haemodynamic parameters and proarrhythmic effects were assessed . Non-responders to the ibutilide infusion underwent external electrical cardioversion .  We included 51 patients . In 31 patients therapeutic intervention with intravenous ibutilide was successful within 90 min ( 61 % ) . In another seven patients conversion to sinus rhythm occurred after 90 min without any other intervention ( 14 % ) . Blood pressure remained stable and no relevant proarrhythmic effects were observed . The 13 patients who did not respond to ibutilide treatment underwent successful external electrical cardioversion . The overall conversion rate was 100 % . Forty-seven patients ( 92 % ) were discharged within a median of 9 h and managed as out patients . In conclusion , in haemodynamically stable patients with recent-onset atrial fibrillation/flutter intravenous ibutilide and external electrical cardioversion for conversion to sinus rhythm turned out to be effective and safe . The short duration of admission makes this strategy attractive for use in the ED BACKGROUND Congestive heart failure and atrial fibrillation often coexist , and each adversely affects the other with respect to management and prognosis . We prospect ively evaluated the effect of catheter ablation for atrial fibrillation on left ventricular function in patients with heart failure . METHODS We studied 58 consecutive patients with congestive heart failure and a left ventricular ejection fraction of less than 45 percent who were undergoing catheter ablation for atrial fibrillation .  We selected as controls 58 patients without congestive heart failure who were undergoing ablation for atrial fibrillation , matched according to age , sex , and classification of atrial fibrillation . We evaluated the patients ' left ventricular function and dimensions , symptom score , exercise capacity , and quality of life at baseline and at months 1 , 3 , 6 , and 12 . RESULTS After a mean ( + /-SD ) of 12+/-7 months , 78 percent of the patients with congestive heart failure and 84 percent of the controls remained in sinus rhythm ( P=0.34 ) ( 69 percent and 71 percent , respectively , were in sinus rhythm without the administration of antiarrhythmic drugs ) . The patients with congestive heart failure had significant improvement in left ventricular function ( increases in the ejection fraction and fractional shortening of 21+/-13 percent and 11+/-7 percent , respectively ; P<0.001 for both comparisons ) , left ventricular dimensions ( decreases in the diastolic and systolic diameters of 6+/-6 mm and 8+/-7 mm , respectively ; P=0.03 and P<0.001 , respectively ) , exercise capacity , symptoms , and quality of life . The ejection fraction improved significantly not only in patients without concurrent structural heart disease ( 24+/-10 percent , P<0.001 ) and those with inadequate rate control before ablation ( 23+/-10 percent , P<0.001 ) , but also in those with coexisting heart disease ( 16+/-14 percent , P<0.001 ) and adequate rate control before ablation ( 17+/-15 percent , P<0.001 ) . CONCLUSIONS Restoration and maintenance of sinus rhythm by catheter ablation without the use of drugs in patients with congestive heart failure and atrial fibrillation significantly improve cardiac function , symptoms , exercise capacity , and quality of life OBJECTIVES This multicenter study compared the efficacy and safety of ibutilide versus procainamide for conversion of recent-onset atrial flutter or fibrillation . BACKGROUND Ibutilide fumarate is an intravenous ( IV ) class III antiarrhythmic agent that has been shown to be significantly more effective than placebo in the pharmacologic conversion of atrial flutter and fibrillation to sinus rhythm . Procainamide is commonly used for conversion of recent-onset atrial fibrillation to normal sinus rhythm . METHODS One hundred twenty-seven patients ( age range 22 to 92 years ) with atrial flutter or fibrillation of 3 h to 90 days ' ( mean 21 days ) duration were r and omized to receive either two 10-min IV infusions of 1 mg of ibutilide fumarate , separated by a 10-min infusion of 5 % dextrose in sterile water , or three successive 10-min IV infusions of 400 mg of procainamide hydrochloride . RESULTS Of the 127 patients , 120 were evaluated for efficacy : 35 ( 58.3 % ) of 60 in the ibutilide group compared with 11 ( 18.3 % ) of 60 in the procainamide group had successful termination within 1.5 h of treatment ( p < 0.0001 ) . Seven patients were found to have violated the protocol and were not included in the final evaluation . In the patients with atrial flutter , ibutilide had a significantly higher success rate than procainamide ( 76 % [ 13 of 17 ] vs. 14 % [ 3 of 22 ] , p=0.001 ) . Similarly , in the atrial fibrillation group , ibutilide had a significantly higher success rate than procainamide ( 51 % [ 22 of 43 ] vs. 21 % [ 8 of 38 ] , p=0.005 ) . One patient who received ibutilide , which was found to be a protocol violation , had sustained polymorphic ventricular tachycardia requiring direct current cardioversion . Seven patients who received procainamide became hypotensive . CONCLUSIONS This study establishes the superior efficacy of ibutilide over procainamide when administered to patients to convert either atrial fibrillation or atrial flutter to sinus rhythm .  Hypotension was the major adverse effect seen with procainamide . A low incidence of serious proarrhythmia was seen with the administration of ibutilide occurring at the end of infusion INTRODUCTION . Atrial fibrillation is a frequent cause of worsening of symptoms in patients with congestive heart failure . The drugs currently available for maintenance of sinus rhythm all have major side effects . METHODS . In 34 Danish coronary care units , 1518 patients with congestive heart failure and reduced left ventricular systolic function were r and omized to receive either placebo or a new class III antiarrhythmic drug , dofetilide . The dose of dofetilide was adjusted according to the presence of atrial fibrillation , the length of the QT interval , and renal function . Patients were continuously monitored electrocardiographically for the first 3 days of the study . The primary end point was all-cause mortality and follow-up was for at least 1 year . RESULTS . In the dofetilide/placebo groups , 311/317 patients  died ( 41%/42 % ) . The hazard ratio for dofetilide treatment was 0.95 ( 95 % confidence interval , 0.81 - 1.11 ) . Treatment with dofetilide reduced worsening of heart failure significantly ( hazard ratio , 0.75 ; 0.63 - 0.89 ) . After 1 year , 61 % of patients with atrial fibrillation at the start of the study had converted to sinus rhythm on dofetilide , vs. 33 % in the placebo group . After conversion to sinus rhythm , 78%/43 % of patients in the dofetilide/placebo groups remained in sinus rhythm for at least 1 year . There were 25 instances ( 3 % ) of torsade de pointes ventricular tachycardia in the dofetilide group and none in the placebo group . CONCLUSION . In patients with congestive heart failure , dofetilide can effectively convert atrial fibrillation to sinus rhythm and maintain sinus rhythm after conversion . Hospitalization for congestive heart failure is reduced . Dofetilide does not affect mortality . (c)2001 by CHF , AIMS The Atrial Fibrillation Ablation Pilot Study is a prospect i ve registry design ed to describe the clinical epidemiology of patients undergoing an atrial fibrillation ( AFib ) ablation  , and the diagnostic/therapeutic processes applied across Europe . The aims of the 1-year follow-up were to analyse how centres assess in routine clinical practice the success of the procedure and to evaluate the success rate and long-term safety/complications . METHODS AND RESULTS Seventy-two centres in 10 European countries were asked to enrol 20 consecutive patients undergoing a first AFib ablation procedure .  A web-based case report form captured information on pre-procedural , procedural , and 1-year follow-up data . Between October 2010 and May 2011 , 1410 patients were included and 1391 underwent an AFib ablation ( 98.7 % ) . A total of 1300 patients ( 93.5 % ) completed a follow-up control 367 ± 42 days after the procedure . Arrhythmia documentation was done by an  electrocardiogram  in 76 % ,  Holter-monitoring  in 52 % ,  transtelephonic monitoring in 8 % , and /or implanted systems in 4.5 % . Over 50 % became asymptomatic . Twenty-one per cent were re-admitted due to post-ablation arrhythmias . Success without antiarrhythmic drugs was achieved in 40.7 % of patients ( 43.7 % in paroxysmal AF ; 30.2 % in persistent AF ; 36.7 % in long-lasting persistent AF ) . A second ablation was required in 18 % of the cases and 43.4 % were under antiarrhythmic treatment . Thirty-three patients ( 2.5 % ) suffered an adverse event , 272 ( 21 % ) experienced a left atrial tachycardia , and 4 patients died ( 1 haemorrhagic stroke , 1 ventricular fibrillation in a patient with ischaemic heart disease , 1 cancer , and 1 of unknown cause ) . CONCLUSION The AFib Ablation Pilot Study provided crucial information on the epidemiology , management , and outcomes of catheter ablation of AFib in a real-world setting . The methods used to assess the success of the procedure appeared at least suboptimal . Even in this context , the 12-month success rate appears to be somewhat lower to the one reported clinical trials Abstract Amiodarone and verapamil are well-known antiarrhythmic drugs used for treatment of ventricular and supraventricular arrhythmias . Although verapamil is the drug of choice for control of the atrioventricular node , it has also been reported to terminate atrial fibrillation . 1–3 Amiodarone has been used extensively for drug-refractory ventricular tachycardia but seldom for termination of paroxysmal atrial fibrillation . 4–6 To our knowledge , no comparative study with amiodarone and verapamil has been reported . Because of this , we compared the efficacy of intravenous amiodarone versus verapamil for conversion of paroxysmal atrial fibrillation to sinus rhythm in a single-blind r and omized study STUDY OBJECTIVE An emergency department ( ED ) observation unit protocol for the management of  acute onset atrial fibrillation  is compared with routine hospital admission and management . METHODS Adult patients presenting to the ED with atrial fibrillation of less than 48 hours ' duration without hemodynamic instability or other comorbid conditions requiring hospitalization were enrolled . Participants were r and omized to either ED observation unit care or routine inpatient care .  The ED observation unit protocol included pulse rate control , cardiac monitoring , re assessment , and electrical cardioversion if atrial fibrillation persisted . Patients who reverted to sinus rhythm were discharged with a cardiology follow-up within 3 days , whereas those still in atrial fibrillation were admitted . All cases were followed up for 6 months and adverse events recorded . RESULTS Of the 153 patients , 75 were r and omized to the ED observation unit and 78 to routine inhospital care . Eighty-five percent of ED observation unit patients converted to sinus rhythm versus 73 % in the routine care group ( difference 12 % ; 95 % confidence interval [ CI ] -1 % to 25 % ] ; P=.06 ) . The median length of stay was 10.1 versus 25.2 hours ( difference 15.1 hours ; 95 % CI 11.2 to 19.6 ; P<.001 ) for ED observation unit and inhospital care respectively . Nine ED observation unit patients required inpatient admission . Eleven percent of the ED observation unit group had recurrence of atrial fibrillation during follow-up versus 10 % of the routine inpatient care group ( difference 1 % ; 95 % CI -9 % to 11 % ; P=.93 ) . There was no significant difference between the groups in the frequency of hospitalization or the number of tests , and the number of adverse events during follow-up was similar in the 2 groups . CONCLUSION An ED observation unit protocol that includes electrical cardioversion is a feasible alternative to routine hospital admission for acute onset of atrial fibrillation and results in a shorter initial length of stay BACKGROUND Currently available antiarrhythmic drugs have limited efficacy for acute termination of atrial fibrillation and flutter , especially if the arrhythmia is not of recent onset . The purpose of this multicenter study was to determine the efficacy and safety of repeated doses of intravenous ibutilide , a class III antiarrhythmic drug , in terminating atrial fibrillation or flutter . METHODS AND RESULTS Two hundred sixty-six patients with sustained atrial fibrillation ( n = 133 ) or flutter ( n = 133 ) , with an arrhythmia duration of 3 hours to 45 days , were r and omized to receive up to two 10-minute infusions , separated by 10 minutes , of ibutilide ( 1.0 and 0.5 mg or 1.0 and 1.0 mg ) or placebo . The conversion rate was 47 % after ibutilide and 2 % after placebo ( P < .0001 ) . The two ibutilide dosing regimens did not differ in conversion efficacy ( 44 % versus 49 % ) . Efficacy was higher in atrial flutter than fibrillation ( 63 % versus 31 % , P < .0001 ) . In atrial fibrillation but not flutter , conversion rates were higher in patients with a shorter arrhythmia duration or a normal left atrial size . Arrhythmia termination occurred a mean of 27 minutes after start of the infusion . Of 180 ibutilide-treated patients , 15 ( 8.3 % ) developed polymorphic ventricular tachycardia during or soon after the infusion . The arrhythmia required cardioversion in 3 patients ( 1.7 % ) and was nonsustained in 12 patients ( 6.7 % ) . CONCLUSIONS Intravenous ibutilide given in repeated doses is effective in rapidly terminating atrial fibrillation and flutter and under monitored conditions is an alternative to current cardioversion options OBJECTIVES Our aim was to evaluate the benefits and risks of administering propafenone before electrical defibrillation for chronic atrial fibrillation . BACKGROUND In this context , an antiarrhythmic drug-although potentially useful in preventing early recurrence of arrhythmia-could adversely affect the defibrillation threshold and reduce the cardioversion success rate . METHODS We r and omly assigned 100 patients with chronic atrial fibrillation to oral treatment with either placebo ( 51 patients ) or 750 mg/day of propafenone ( 49 patients ) for 48 h before administration of direct current shock . After successful cardioversion , all patients received propafenone therapy and were followed up for 48 h. RESULTS Before defibrillation , three patients in the propafenone group ( 6.1 % ) had reversion to sinus rhythm and one had sustained ventricular tachycardia . Shock efficacy ( 82.4 % vs. 84.4 % ) and the cumulative effective energy ( 395 + /- 258 vs. 421 + /- 236 J ) were not different between the placebo and propafenone groups . In the propafenone group , 11 patients had their arrhythmia transformed into atrial flutter and required a lower energy level for arrhythmia conversion than did the other patients with continued atrial fibrillation ( 245 + /- 197 vs. 493 + /- 215 J , p < 0.01 ) ; the latter patients showed a trend ( p < 0.10 ) toward higher energy requirements than that of patients who received placebo . The incidence of asymptomatic bradyarrhythmias was higher in the propafenone group ( 28.9 % vs. 7.1 % , p < 0.02 ) , but more patients who received placebo had early recurrence of atrial fibrillation ( 16.7 % vs. 0 % , p < 0.02 ) . Two days after cardioversion , more patients given propafenone ( 73.5 % vs. 52.9 % , p < 0.05 ) were discharged from the hospital with sinus rhythm . During the in-hospital stay , propafenone was withdrawn from six patients ( 6.6 % ) because of side effects . CONCLUSIONS Propafenone , given before electrical cardioversion for chronic atrial fibrillation does not affect the mean defibrillation threshold or the rate of successful arrhythmia conversion . It decreases the recurrence of atrial fibrillation early after shock , thus allowing more patients to be discharged from the hospital with sinus rhythm IMPORTANCE Despite the frequency of  atrial fibrillation ( AF )  in clinical practice , relatively little is known about sex differences in symptoms and quality of life and how they may affect treatment and outcomes . OBJECTIVE To determine whether symptoms , quality of life , treatment , and outcomes differ between women and men with AF . DESIGN , SETTING , AND PARTICIPANTS This observational cohort study included 10 135 patients with AF . The Outcomes Registry for Better Informed Treatment of Atrial Fibrillation is a prospect i ve , nationwide , multicenter outpatient registry of patients with incident and prevalent AF enrolled at 176 sites between June 2010 and August 2011 . MAIN OUTCOMES AND MEASURES Symptoms , quality of life as measured by Atrial Fibrillation Effects on Quality of Life scores , AF treatment , cardiovascular outcomes , stroke or non- central nervous system embolism , and all-cause mortality . RESULTS Overall , 4293 of the cohort ( 42 % ) were female . Compared with men , women were older ( 77 years ; interquartile range [ IQR ] , 69 - 83 , vs 73 years ; IQR , 65 - 80 ; P < .001 ) and had higher median CHA2DS2-VASc scores ( 5 ; IQR , 4 - 6 , vs 3 ; IQR , 2 - 5 ; P < .001 ) , but less sleep apnea ( 578 [ 13.5 % ] vs 1264 [ 21.6 % ] ; P < .001 ) . Only 32.1 % of women ( n = 1378 ) were asymptomatic ( European Heart Rhythm Association class I ) compared with 42.5 % of men ( n = 2483 ) in unadjusted analyses ( P < .001 ) . Women had lower ( more severe ) unadjusted baseline overall Atrial Fibrillation Effects on Quality of Life scores ( n = 2007 ; 80 ; IQR , 62 - 92 vs 83 ; IQR , 69 - 94 ; P < .001 ) . Women had similar rates of anticoagulation and similar time in therapeutic range . In follow-up , women experienced lower risk-adjusted all-cause mortality ( adjusted hazard ratio , 0.57 ; 95 % CI , 0.49 - 0.67 ) and cardiovascular death ( adjusted hazard ratio , 0.56 ; 95 % CI , 0.44 - 0.72 ) ; however , they had a higher risk for stroke or non- central nervous system embolism ( adjusted hazard ratio , 1.39 ; 95 % CI , 1.05 - 1.84 ; P = .02 ) compared with men . CONCLUSIONS AND RELEVANCE Women with AF have more symptoms and worse quality of life . Despite higher risk , women have lower risk-adjusted all-cause and cardiovascular death compared with men , but higher stroke rates . Future studies should focus on how treatment and interventions specifically affect AF-related quality of life and cardiovascular outcomes in women . TRIAL REGISTRATION clinical trials.gov Identifier : NCT01165710 CONTEXT Amiodarone effectively suppresses atrial fibrillation but causes many adverse events . OBJECTIVE To compare major events in patients r and omized to receive episodic amiodarone treatment with those who received continuous amiodarone treatment  while still aim ing to prevent atrial fibrillation . DESIGN , SETTING , AND PARTICIPANTS A r and omized trial of 209 ambulatory patients with recurrent symptomatic persistent atrial fibrillation , conducted from December 2002 through March 2007 at 7 Dutch medical centers . INTERVENTION Patients were r and omly assigned to receive either episodic or continuous amiodarone treatment after electrical cardioversion following amiodarone loading . Episodic amiodarone treatment was discontinued after a month of sinus rhythm and reinitiated if atrial fibrillation relapsed ( 1 month peri-electrical cardioversion ) . In the continuous treatment group amiodarone was maintained throughout . MAIN OUTCOME MEASURES The primary end point was a composite of amiodarone and underlying heart disease-related major events . The secondary end points were all-cause mortality and cardiovascular hospitalizations . RESULTS After a median follow-up of 2.1 years ( range , 0.4 - 2.5 years ) , 51 ( 48 % ) of those receiving episodic treatment vs 64 ( 62 % ) receiving continuous treatment had sinus rhythm ( P = .05 ) . There were 85 atrial fibrillation recurrences ( 80 % ) among the episodic treatment group vs 56 ( 54 % ) in the continuous treatment group ( P < .001 ) . No significant difference existed in the incidence of the primary composite end point between each group ( 37 [ 35 % ] episodic vs 34 [ 33 % ] continuous ; incidence rate difference , 0.2 ; 95 % confidence interval [ CI ] , -10.2 to 10.6 ) . However , there were nonstatistically significant differences in the incidence of amiodarone-related major events ( 20 [ 19 % ] episodic vs 25 [ 24 % ] continuous ; incidence rate difference , -2.0 ; 95 % CI , -8.7 to 4.6 ) and underlying heart disease-related major events ( 17 [ 16 % ] episodic vs 9 [ 9 % ] continuous ; incidence rate difference , 3.6 ; 95 % CI , -1.6 to 8.7 ) . All-cause mortality and cardiovascular hospitalizations were higher among those receiving episodic treatment ( 56 [ 53 % ] vs 35 [ 34 % ] , P = .02 ) . CONCLUSIONS In this study population , there was no difference in the composite of amiodarone and cardiac major adverse events between groups . However , patients receiving episodic treatment had a significantly increased rate of atrial fibrillation recurrence and a significantly higher rate of all-cause mortality and cardiovascular hospitalizations . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00392431 Background — Atrial arrhythmias are common early after atrial fibrillation ( AF ) ablation . We hypothesized that empirical antiarrhythmic drug ( AAD ) therapy for 6 weeks after AF ablation would reduce the occurrence of atrial arrhythmias . Methods and Results — We r and omized consecutive patients with paroxysmal AF undergoing ablation to empirical antiarrhythmic therapy ( AAD group ) or no antiarrhythmic therapy ( no-AAD group ) for the first 6 weeks after ablation . In the no-AAD group , only atrioventricular nodal blocking agents were prescribed . All patients wore a transtelephonic monitor for 4 weeks after discharge and were reevaluated at 6 weeks . The primary end point of the study was a composite of ( 1 ) atrial arrhythmias lasting more than 24 hours ; ( 2 ) atrial arrhythmias associated with severe symptoms requiring hospital admission , cardioversion , or initiation/change of antiarrhythmic drug therapy ; and ( 3 ) intolerance to antiarrhythmic agent requiring drug cessation .  Of 110 enrolled patients ( age 55±9 years , 71 % male ) , 53 were r and omized to AAD and 57 to no-AAD . There was no difference in baseline characteristics between groups . During the 6 weeks after ablation , fewer patients reached the primary end point in the AAD compared with the no-AAD group ( 19 % versus 42 % ; P=0.005 ) . There remained fewer events in the AAD group ( 13 % versus 28 % ; P=0.05 ) when only end points of AF > 24 hours , arrhythmia-related hospitalization , or electrical cardioversion were compared . Conclusions — AAD treatment during the first 6 weeks after AF ablation is well tolerated and reduces the incidence of clinical ly significant atrial arrhythmias and need for cardioversion/hospitalization for arrhythmia management BACKGROUND Postoperative atrial fibrillation occurs in 20 % to 40 % of patients undergoing coronary artery bypass grafting ( CABG ) and contributes to delayed recovery , increased length of stay , and increased hospital cost . Measures at preventing postoperative atrial fibrillation have had mixed results . We report a double-blind trial comparing oral amiodarone with placebo for the prevention of atrial fibrillation after CABG . METHODS AND RESULTS All patients undergoing CABG were considered eligible . Exclusion criteria included bradycardia ( < 50 beats/min ) , prior Atrial fibrillation , concurrent therapy with antiarrhythmic drugs , or concomitant valve surgery . Patients were given 2 g of amiodarone ( 73 patients ) or placebo ( 70 patients ) in divided doses 1 to 4 days before surgery and 400 mg daily for 7 days postoperatively . Atrial fibrillation occurred in 24.7 % ( 18 of 43 ) of patients receiving amiodarone and 32 . 8 % ( 23 of 70 ) of patients receiving placebo ( P = .30 ) . Heart rate at onset of atrial fibrillation was 133.4 + /- 26.6 beats/min for amiodarone compared with 152.9 + /- 31.6 beats/min for placebo ( P = . 04 ) . Duration of atrial fibrillation was 10.2 + /- 8.1 hours for amiodarone compared with 16.2 + /- 27.5 hours for placebo ( P = .67 ) . Patients receiving both beta-blockade and amiodarone  had a 16.7 % incidence of atrial fibrillation compared with 31.9 % in the remaining patients ( P = .10 ) . Atrial fibrillation was associated with an increased cost of $ 7011 compared with those who remained in sinus rhythm ( $ 23,869 + /- $ 20,894 vs $ 16,857 + /- $ 5401 in sinus rhythm ) . Hospital cost of those taking amiodarone was $ 18,895 + /- $ 13,267 compared with $ 18,839 + /- $ 11,537.18 for placebo ( P = .42 ) . CONCLUSION Postoperative CABG atrial fibrillation is associated with prolonged hospital stay and increased cost . Prophylactic oral amiodarone did not statistically alter the incidence or duration of atrial fibrillation after CABG , although favorable trends were noted . Hospital cost was not affected by therapy with amiodarone CONTEXT Previous studies suggest that consuming moderate to high amounts of alcohol on a regular basis might increase the risk of developing  atrial fibrillation  in men but not in women . However , these studies were not powered to investigate the association of alcohol consumption and atrial fibrillation among women . OBJECTIVE To prospect ively assess the association between regular alcohol consumption  and incident atrial fibrillation among women . DESIGN , SETTING , AND PARTICIPANTS Participants were 34 715 initially healthy women participating in the Women 's Health Study , a completed r and omized controlled trial conducted in the United States . Participants were older than 45 years and free of atrial fibrillation at baseline and underwent prospect i ve follow-up from 1993 to October 31 , 2006 .  Alcohol consumption  was assessed via question naires at baseline and at 48 months of follow-up and was grouped into 4 categories ( 0 , > 0 and < 1 , > or = 1 and < 2 , and > or = 2 drinks per day ) . Atrial fibrillation was self-reported on the yearly question naires and subsequently confirmed by electrocardiogram and medical record review . MAIN OUTCOME MEASURE Time to first episode of atrial fibrillation . RESULTS Over a median follow-up of 12.4 years , 653 cases of incident atrial fibrillation were confirmed . Age-adjusted incidences among women consuming 0 ( n = 15,370 ) , more than 0 and less than 1 ( n = 15,758 ) , 1 or more and less than 2 ( n = 2228 ) , and 2 or more ( n = 1359 ) drinks per day were 1.59 , 1.55 , 1.27 , and 2.25 events/1000 person-years of follow-up . Thus , compared with nondrinking women , women consuming 2 or more drinks per day had an absolute risk increase of 0.66 events/1000 person-years . The corresponding multivariate-adjusted hazard ratios ( HRs ) for incident atrial fibrillation were 1 , 1.05 ( 95 % CI , 0.88 - 1.25 ) , 0.84 ( 95 % CI , 0.58 - 1.22 ) , and 1.60 ( 95 % CI , 1.13 - 2.25 ) , respectively . The increased hazard in the small group of women consuming 2 or more drinks per day persisted when alcohol intake was up date d at 48 months ( HR , 1.49 ; 95 % CI , 1.05 - 2.11 ) or when women were censored at their first cardiovascular event ( HR , 1.68 ; 95 % CI , 1.18 - 2.39 ) . CONCLUSIONS Among healthy middle-aged women , consumption of up to 2 alcoholic beverages per day was not associated with an increased risk of incident atrial fibrillation . Heavier consumption of 2 or more drinks per day , however , was associated with a small but statistically significant increased risk of atrial fibrillation Background : Atrial fibrillation ( AF ) is a common cardiac arrhythmia which increases morbidity and mortality . Identification of risk factors is therefore important . We examined the impact of palpitations and cardiovascular risk factors in prediction of AF ( all types ) and lone AF in a large population -based cohort . Design : We carried out a prospect i ve population -based cohort study . Methods : A total of 22,815 participants from a population survey in 1994–1995 were followed-up for a mean of 11.1 years . Mean age at baseline was 46 years . Measurements of height , weight , blood pressure , heart rate , total cholesterol and high-density lipoprotein (HDL)-cholesterol , and information on palpitations , diabetes , angina , myocardial infa rct ion , and antihypertensive treatment were obtained at baseline . The outcome measure was first-ever AF , documented on an electrocardiogram .  Cox proportional hazards regression model was used to estimate hazard ratios ( HRs ) for AF . Results : Palpitations were associated with increased risk of AF in both women ( HR 1.62 , 95 % confidence interval [ CI ] 1.29–2.02 ) and men ( HR 1.91 , 95 % CI 1.54–2.35 ) . For hypertension the HR for AF was 1.98 ( 1.46 - 2.69 ) in women and 1.40 ( 1.13 - 1.74 ) in men . The HR for 1 SD increase in body mass index ( BMI ) was 1.16 ( 1.06–1.27 ) in women and 1.47 ( 1.32–1.63 ) in men . Body height and BMI were associated with increased risk for lone AF in men . Conclusion : Palpitations , hypertension and BMI were predictive of future atrial fibrillation in both sexes AIMS To assess different aspects of the definition of valvular/non-valvular atrial fibrillation  ( AF ) used in clinical practice by physicians who usually treat this condition . METHODS AND RESULTS We prospect ively conducted a web-based survey including cardiologists and internists who attended continuing medical education courses on cardiovascular medicine . A question naire was drawn up , containing 17 questions clustered into five main topics : ( A ) known rheumatic aetiology ; ( B ) site/type of valve involvement ; ( C ) prosthetic heart valve ; ( D ) haemodynamic relevance ; ( E ) miscellaneous . The overall response rate was 22.4 % ( 21.1 % for cardiologists and 24 % for internists ) . Coexistence of both medical history of rheumatic disease and clinical signs of valvular involvement were considered as essential prerequisites for the diagnosis of rheumatic AF by half of the respondents , and one-third assumed that lone aortic valve disease was sufficient for AF to be defined as valvular . A similar proportion of respondents considered that in the presence of mitral regurgitation , AF had to be defined as valvular . The majority of responding physicians considered the degree of valvular defect of lesser importance for the definition of valvular or non-valvular origin of AF . CONCLUSION We found important heterogeneity and uncertainties in the answers given by physicians who usually treat patients with AF , as evidence of the lack of precise and unique definitions of the origin of AF ( valvular/non-valvular ) . It is urgent to issue clear widely accepted definitions of the origin of AF , which should improve clinical practice and research Supraventricular arrhythmia after noncardiac surgery is common [ 1 , 2 ] . Much of the data on the epidemiology and consequences of perioperative supraventricular arrhythmia in patients undergoing noncardiac surgery were collected before recent advances in anesthetic and monitoring techniques were made [ 3 ] . This clinical syndrome may have been influenced by such trends as the aging of the general population and the increased use of -blockers and calcium-channel blockers . To test the hypothesis that supraventricular arrhythmia remains a frequent event that is associated with major adverse outcomes after surgery , we studied a consecutive sample of 4181 patients who underwent major , nonemergency , noncardiac procedures and were in sinus rhythm at the preoperative evaluation . Our findings provide insight into the contemporary epidemiology and natural history of perioperative supraventricular arrhythmia . Methods Patients All patients 50 years of age or older who underwent major , nonemergency , noncardiac procedures at Brigham and Women 's Hospital , Boston , Massachusetts , from 18 July 1989 to 28 February 1994 were eligible for the study . Major noncardiac procedures were defined as those associated with an expected length of stay of 2 or more days . Procedures were electively scheduled or were done during inpatient admissions . The Brigham and Women 's Hospital Human Research Committee approved the enrollment and clinical data collection protocol s. Patients were included in this analysis if they were in sinus rhythm at the preoperative evaluation . Of the 4315 consecutive patients enrolled in the overall study , 4181 ( 97 % ) met this criterion and constituted the study sample for this analysis . Data Collection The data collection protocol is described elsewhere ( [ 4 ] ; Lee TH , Marcantonio ER , Mangione CM , Thomas EJ , Cook EF , Sugarbaker DJ , et al. Derivation and prospect i ve validation of a simple index for prediction of cardiac risk of major noncardiac surgery . In preparation ) . In brief , patients who provided informed consent for the full study protocol had preoperative evaluations done by study personnel , who used a structured data form . These evaluations included detailed medical histories , physical examinations , and laboratory testing . Intraoperative data were obtained from anesthesia flow sheets and surgeons ' notes . For patients who did not have this evaluation because they could not be approached or because they refused to participate in the interview portion of the study , clinical data were obtained from the structured evaluation performed by the anesthesiologist noted in the medical record . This data source was also used to obtain American Society of Anesthesiologists ( ASA ) classifications for all patients . Consenting patients agreed to postoperative sampling of creatine kinase . If total creatine kinase levels were elevated , creatine kinase-MB levels were measured immediately after surgery , at 8 p.m. on the evening of surgery , and on the next two mornings . For other enrolled patients , creatine kinase-MB testing was done according to the physician 's orders . Electrocardiography was performed in the recovery room and 1 , 3 , and 5 days after surgery if the patient remained hospitalized . Study personnel review ed charts daily for the occurrence of complications . Classification of Outcome The perioperative period was divided into two parts : the intraoperative period , which ended at the patient 's departure from the operating room , and the postoperative period . A perioperative supraventricular arrhythmia was diagnosed whenever a patient was noted by his or her physicians or by the study 's research personnel to have new onset of atrial fibrillation , atrial flutter , paroxysmal atrial tachycardia , multifocal atrial tachycardia , or regular supraventricular tachyarrhythmia without discernible P waves . For the purpose of this study , only episodes of supraventricular arrhythmia that were reported to be persistent or were treated with specific therapies were considered in the analysis . Review of records for a r and omly selected subset of 60 patients with supraventricular arrhythmia revealed that 87 % received specific treatment ( cardioversion or antiarrhythmic therapy ) . The postoperative occurrence of major cardiac events was classified by a single review er [ who was blinded to preoperative clinical data ] on the basis of postoperative clinical information , including cardiac enzyme measurements , electrocardiograms , and clinical events . Criteria for perioperative myocardial infa rct ion were 1 ) a new Q wave lasting 0.04 seconds or longer , 2 ) creatine kinase-MB levels greater than 5 % of an elevated total creatine kinase level with a typical increase and decrease in creatine kinase-MB levels , and 3 ) creatine kinase-MB levels greater than 3 % of an elevated total creatine kinase level in the setting of electrocardiographic changes consistent with ischemia [ 4 ] . Major cardiac events were myocardial infa rct ion , cardiogenic pulmonary edema , ventricular fibrillation or primary cardiac arrest , and sustained complete heart block . Intermediate cardiac events , recorded by study research personnel on the basis of record review , were congestive heart failure without pulmonary edema , myocardial ischemia with documented electrocardiographic changes , and documented ventricular tachycardia . Noncardiac events were pulmonary embolism , cerebrovascular accident , noncardiac pulmonary edema , respiratory failure requiring intubation , renal failure requiring dialysis , gastrointestinal bleeding , bacteremia , pneumonia , urinary tract infection , and wound infection . Statistical Analysis Univariate analyses of the correlation between clinical characteristics and the occurrence of perioperative supraventricular arrhythmia were performed by using a chi-square test and the Fisher exact test for categorical variables and a t-test or Wilcoxon test for continuous variables . Variables with a P value less than 0.10 were then entered into the multiple regression analysis . Stepwise logistic regression analysis was used to determine independent correlates of supraventricular arrhythmia . A two-sided P value less than 0.05 was considered statistically significant . Clinical ly relevant variables from the regression model were analyzed for potential interactions . Potentially significant interaction terms were considered in the regression models . In the analysis of the association between intraoperative events and the occurrence of supraventricular arrhythmia , only postoperative episodes of supraventricular arrhythmia were included ( n = 256 ) . A clinical ly significant hypotensive episode during surgery was defined as a decrease of one third in the original systolic blood pressure or a systolic blood pressure less than 90 mm Hg . Linear regression models were used to estimate the independent variation in length of stay attributable to supraventricular arrhythmia ; these models controlled for age , sex , preoperative clinical characteristics , ASA classification , type of procedure , and postoperative events ( major and intermediate cardiac events and noncardiac events ) . The log transformation of length of stay was used because of the non-normal distribution of this variable . The adjusted hospital days attributable to supraventricular arrhythmia were estimated from the percentage change in length of stay by using the geometric mean of length of stay from the final model . Results The patients ' mean age ( SD ) was 66 9 years . A total of 2244 patients ( 54 % ) were male , 563 ( 14 % ) were diabetic , 609 ( 15 % ) had a history of myocardial infa rct ion , 244 ( 6 % ) had congestive heart failure , and 1366 ( 33 % ) had evidence of ischemic heart disease . The types of procedures performed were orthopedic ( 35 % ) , thoracic ( 12 % ) , abdominal ( 12 % ) , abdominal aortic aneurysm ( 5 % ) , other vascular ( 16 % ) , and other general surgical ( 20 % ) procedures . A new perioperative supraventricular arrhythmia developed in 317 patients ( 7.6 % ) ( Table 1 ) . Less than 25 % of patients who had supraventricular arrhythmia had more than one episode of arrhythmia . Atrial fibrillation and supraventricular tachycardia without discernible P waves were the most frequent types of supraventricular arrhythmia and usually occurred in the postoperative period . The time of occurrence of postoperative supraventricular arrhythmia peaked during the first 3 days after surgery ( Figure 1 ) . This pattern of occurrence after surgery was similar for all types of supraventricular arrhythmia . Table 1 . Prevalence of Perioperative Supraventricular Arrhythmia  in 4181 Patients Undergoing Noncardiac Surgery *  Figure 1 . Distribution of  supraventricular arrhythmias ( SVA ) according to the time of first occurrence among the 256 patients who developed arrhythmias after surgery . Correlates of Supraventricular Arrhythmia Compared with patients who did not develop supraventricular arrhythmia , patients who developed this arrhythmia were significantly older and were more likely to be male ; to have a history of myocardial infa rct ion , congestive heart failure , diabetes , chronic lung disease , cancer , or arrhythmia ; to have evidence of clinical ly significant valvular disease ( such as systolic murmurs of grade III or higher ) on physical examination ; and to have premature atrial complexes on preoperative electrocardiography ( Table 2 ) . Table 2 . Univariate Analysis of Preoperative Correlates of Perioperative Supraventricular Arrhythmia * Preoperative use of calcium-channel blockers , digoxin , procainamide , and quinidine was more common in patients who developed supraventricular arrhythmia . Use of -blockers did not differ between the two groups . Patients with ASA classification III or IV were more likely to develop supraventricular arrhythmia . The most significant univariate correlate of supraventricular arrhythmia was the type of procedure performed . Patients who had abdominal aortic aneurysm repair or an intrathoracic , abdominal , or other vascular procedure had an increased risk for perioperative OBJECTIVES This study sought to determine the safety and efficacy of a single bolus of intravenous dofetilide , a pure class III antiarrhythmic agent , for the termination of sustained atrial fibrillation or flutter . BACKGROUND Dofetilide is a highly selective blocker of the rapid component of the delayed rectifier current causing action potential prolongation . These effects , and preliminary clinical data , suggest that it may be effective in the treatment of atrial fibrillation and flutter . METHODS Ninety-one patients with sustained atrial fibrillation ( 75 patients ) or flutter ( 16 patients ) were entered into a double-blind , r and omized multicenter study of one of two doses of dofetilide ( 4 or 8 micrograms/kg body weight ) or placebo . RESULTS Dofetilide  effectively terminated the arrhythmia in 31 % of patients receiving 8 micrograms/kg , a statistically significant difference from those receiving 4 micrograms/kg ( conversion rate 12.5 % , p < 0.05 ) or placebo ( no conversion , p < 0.01 ) . Patients with atrial flutter had a greater response to dofetilide ( 54 % conversion rate ) than those with atrial fibrillation ( 14.5 % conversion rate , p < 0.001 ) . CONCLUSIONS Intravenous dofetilide can convert sustained atrial fibrillation or flutter to sinus rhythm . However , its efficacy is greater in flutter -- a response that contrasts with the poorer response seen with class I agents . This finding potentially represents an important advance in the pharmacologic termination of atrial flutter OBJECTIVES Acute atrial fibrillation and flutter are very common arrhythmias seen in emergency department ( ED ) patients , but there is no consensus for their optimal management . The objective of this study was to examine the efficacy and safety of intravenous ( IV ) procainamide for acute atrial fibrillation or flutter . METHODS This health records review included a consecutive cohort of ED patients with acute-onset atrial fibrillation or atrial flutter who received IV procainamide at one university hospital ED during a five-year period . The st and ard clinical protocol involved IV infusion of 1 g of procainamide over 60 minutes , followed by electrical cardioversion if necessary . A trained observer extracted data from the original clinical records . Outcome measurements included conversion to sinus rhythm , adverse events , and relapse up to seven days . RESULTS The 341 study patients had a mean age of 63.9 years ( SD + /- 15.5 years ) , and 56.6 % were male . The conversion rates were 52.2 % ( 95 % confidence interval = 47 % to 58 % ) for 316 atrial fibrillation cases and 28.0 % ( 95 % confidence interval = 13 % to 46 % ) for 25 atrial flutter cases . Mean dose given was 860.7 mg ( SD + /- 231.2 mg ) , and median time to conversion was 55 minutes . Adverse events occurred in 34 cases ( 10.0 % ) : hypotension , 8.5 % ; bradycardia , 0.6 % ; atrioventricular block , 0.6 % ; and ventricular tachycardia , 0.3 % . There were no cases of torsades de pointes , cerebrovascular accident , or death . Most patients ( 94.4 % ) were discharged home , but 2.9 % of patients returned with a recurrence of atrial fibrillation within seven days . CONCLUSIONS This study of acute atrial fibrillation or flutter patients treated in the ED with IV procainamide suggests that this treatment is safe and effective in this setting . Procainamide should be prospect ively compared with other ED strategies BACKGROUND Atrial fibrillation and paroxysmal supraventricular tachycardia are common disorders of the heart rhythm for which antiarrhythmic drug therapy is commonly prescribed . The Atrial Fibrillation Investigation with Bidisomide ( AFIB ) study was a r and omized , placebo-controlled clinical trial design ed to accomplish three goals in a single protocol : ( 1 ) to determine the efficacy of the antiarrhythmic drug bidisomide in the treatment of these two arrhythmias ; ( 2 ) to establish the appropriate dose range for bidisomide ; and ( 3 ) to detect an adverse mortality effect of bidisomide if one were present in patients with atrial fibrillation . METHODS AND RESULTS In this clinical trial , 1227 patients with atrial fibrillation and 187 with paroxysmal supraventricular tachycardia were r and omly assigned to bidisomide ( 200 , 400 , or 600 mg BID ) or placebo ; patient groups with each arrhythmia were analyzed separately . Symptomatic recurrences of atrial fibrillation and paroxysmal supraventricular tachycardia were documented with the use of transtelephonic ECG monitoring . The time to the first symptomatic arrhythmia recurrence was measured in each patient and compared among treatment groups . Among the atrial fibrillation patients , there was no significant difference in the time to first symptomatic recurrence between the placebo group and any of the three bidisomide treatment groups ; the hazard ratios ( placebo : treatment ) were 1.19 , 1.03 , and 1.14 for bidisomide 200 , 400 , and 600 mg BID , respectively . Among paroxysmal supraventricular tachycardia patients , there was a similar lack of a significant treatment effect ; the hazard ratios were 1.30 , 1.93 , and 1.59 for bidisomide 200 , 400 , and 600 mg BID , respectively . In the primary safety analysis of mortality , 3 of 493 patients taking placebo  died , compared with 9 of 488 patients taking one of the two higher doses of bidisomide ( P>.10 ) . CONCLUSIONS Bidisomide in the doses tested did not have a clinical ly important antiarrhythmic effect . The AFIB study provided a novel clinical trial design to test antiarrhythmic drugs for both safety and efficacy Chronic atrial fibrillation ( AF ) is a common arrhythmia with significant morbidity and mortality . AF has been the subject of considerable attention and intensive clinical research in recent years . Current opinion on the management of AF favors the restoration and maintenance of normal ventricular rhythm . This has several potential benefits , including the alleviation of arrhythmia-associated symptoms and hemodynamic improvements . Maintenance of frequents normalization of ventricular rhythm ( NVR ) can be achieved with antiarrhythmic drug therapy or with AV node radiofrequency ablation ( RFA ) and permanent ventricular pacing . Recent interest has focused on the use of class III antiarrhythmic agents , such as amiodarone hydrochloride . This investigation compared amiodarone to AV node RFA and permanent pacing of the His-bundle area in maintaining NVR in patients with resistant chronic AF . After 12 months of treatment with amiodarone ( 200 to 400 mg/d ) 30 % of patients remained in NVR , 30 % were in transitional phase of improvement , and 40 % showed negative effect . Only a few patients in this group developed ocular or hepatic side effects . On one year follow-up was achieved in 100 % of cases without any clinical ly significant side effects being seen . In conclusion , analysis of the results of this study suggests that low-dose amiodarone is well tolerated in the management of chronic AF in a selected patient population . The more aggressive interventional radiofrequency ablation technique is significantly more effective and more reliable in the long-term clinical treatment of drug-resistant AF Atrial fibrillation ( AF ) represents the most common sustained cardiac arrhythmia in patients with heart failure ( HF ) . AF in HF patients is associated with worsening of symptoms and also results in a substantial increase in mortality . Although HF patients in sinus rhythm have a better outcome than patients with AF , several r and omized studies investigating pharmacological rhythm control versus rate control have shown no advantage of one strategy over the other in terms of patient outcomes . Catheter-based ablation therapy is a newer therapeutic option with a rapidly evolving and changing role in the management of this arrhythmia . In the present review , the authors discuss the epidemiology , pathophysiology and prognostic significance of AF in patients with HF . Exclusively addressed are studies investigating catheter-based ablation for rhythm-control and rate-control therapies in the management of AF in HF patients BACKGROUND Cigarette smoking is an important risk factor for cardiovascular disease , but it is unknown whether it also contributes to the risk of atrial fibrillation . METHODS AND RESULTS The study is part of the Rotterdam Study , a population -based cohort study among subjects aged > or = 55 years . The association between cigarette smoking and the risk of atrial fibrillation was examined in 5,668 subjects without atrial fibrillation at baseline . During a median follow-up of 7.2 years , 371 cases of atrial fibrillation were identified . Relative risks ( RR ) were calculated with 95 % CIs using the Cox proportional hazards model , adjusted for age , gender , body mass index , hypertension , systolic blood pressure , serum cholesterol level , diabetes mellitus , left ventricular hypertrophy on the electrocardiogram , prevalent and incident myocardial infa rct ion , prevalent heart failure , and the use of pulmonary medication . After multivariate adjustment , current smokers and former smokers had increased risks of atrial fibrillation as compared to never smokers ( RR 1.51 , 95 % CI 1.07 - 2.12 ; and RR 1.49 , 95 % CI 1.14 - 1.97 , respectively ) . No differences were found between men and women . CONCLUSIONS The results of this prospect i ve , population -based study show that current and former smoking of cigarettes are associated with increased risk of atrial fibrillation BACKGROUND Azimilide dihydrochloride ( azimilide ) is an investigational antiarrhythmic drug that has been tested in patients with a variety of arrhythmias . In patients with atrial fibrillation , it has shown excellent efficacy in some previous trials and minimal efficacy in others . METHODS Patients who had symptomatic atrial fibrillation for > 48 hours but < 6 months were eligible for this multicenter , r and omized , placebo-controlled clinical trial . Patients were admitted to a hospital and r and omly assigned to receive either azimilide 125 mg or a matched placebo twice daily for 3 days and then once daily . Patients who were in sinus rhythm spontaneously or had sinus rhythm restored by electric cardioversion on day 4 were discharged from the hospital .  Recurrence of atrial fibrillation was documented by electrocardiogram . In the primary efficacy analysis , time to recurrence in the 2 treatment groups was compared with the log-rank test in the subgroup of patients with structural heart disease . Safety was assessed as deaths , adverse events , and serious adverse events . RESULTS A total of 446 patients were r and omized in the study ; 314 were in the subgroup with structural heart disease . The median time to arrhythmia recurrence in both treatment groups with structural heart disease was 13 days , and the difference between treatments was not significant ( P = .4596 , n = 314 ) . The relative risk for recurrence ( placebo : azimilide ) was 1.104 ( 95 % CI 0.849 - 1.436 ) . There was 1 death in the placebo group and 3 in the azimilide group . CONCLUSIONS Azimilide did not demonstrate clinical ly important or statistically significant efficacy in reducing the risk for arrhythmia recurrence in patients with structural heart disease who were in atrial fibrillation and converted to sinus rhythm Objectives : Atrial fibrillation has been associated with increased mortality in the general population and mixed population s of critical ill . Atrial fibrillation can also affect patients during post – cardiac arrest care . We sought to assess the prognostic implication s of atrial fibrillation following out-of-hospital cardiac arrest , including relation to the level of targeted temperature management . Design : A post hoc analysis of a prospect i ve r and omized trial . Setting : Thirty-six ICUs . Patients : We included 897 ( 96 % ) of the 939 comatose out-of-hospital cardiac arrest survivors from the targeted temperature management trial ( year , 2010–2013 ) with data on heart rhythm on day 2 . Interventions : Targeted temperature management at 33 ° C or 36 ° C . Measurements and Main Results : Endpoints included cumulative proportion of atrial fibrillation following out-of-hospital cardiac arrest and 180-day all-cause mortality and specific death causes stratified by atrial fibrillation . Atrial fibrillation on day 2 was used as primary endpoint analyses to exclude effects of short-term atrial fibrillation related to resuscitation and initial management . The cumulative proportions of atrial fibrillation were 15 % and 11 % on days 1 and 2 , respectively . Forty-three percent of patients with initial atrial fibrillation the first day were reported with sinus rhythm on day 2 . No difference was found between the groups treated with targeted temperature management at 33 ° C and 36 ° C . Patients affected by atrial fibrillation had significantly higher 180-day mortality ( atrial fibrillation : 66 % vs no-atrial fibrillation : 43 % ; plogrank < 0.0001 and unadjusted hazard ratio , 1.75 [ 1.35–2.30 ] ; p < 0.0001 ) . The association between atrial fibrillation and higher mortality remained significant ( adjusted hazard ratio , 1.34 [ 1.01–1.79 ] ; p < 0.05 ) adjusted for potential confounders . Atrial fibrillation was independently associated with increased risk of cardiovascular death and multiple-organ failure ( adjusted hazard ratio , 2.07 [ 1.39–3.09 ] ; p < 0.001 ) , whereas no association with higher risk of death from cerebral causes was found . Conclusions : Atrial fibrillation was independently associated with higher mortality , primarily driven by cardiovascular causes and multiple-organ failure , and may thus identify a vulnerable sub population . Whether treatment to prevent atrial fibrillation is associated with an improved prognosis remains to be established In order to compare the efficacy in preventing recurrencies of symptomatic atrial fibrillation of amiodarone ( A. ) and slow release disopyramide ( D.RET . ) , 76 consecutive patients with recent onset atrial fibrillation ( 1 to 24 hrs . ) were enrolled . In 20 ( 26 % ) conversion to sinus rhythm was obtained by electrical cardioversion , and in 56 ( 74 % ) by oral quinidine loading . Forty-one patients ( group A ) were assigned at r and om to treatment with D.RET . ( 250 mg twice daily ) and 35 patients ( group B ) to amiodarone treatment ( 1200 mg daily for 10 days , and subsequently 200 mg daily ) . The two groups were similar as to age , sex and cardiac pathology . Patients were followed as to clinical condition , st and ard and dynamic ECG after one and three months and every three months subsequently for an average of 13.2 months ( group A ) and 14.1 months ( group B ) . Six group A patients ( 14 % ) were excluded from follow-up on account of side effects which arose during the first week of treatment . Crises of symptomatic atrial fibrillation occurred in 20 patients of group A ( 57 % ) and in 11 ( 32 % ) group patients ; this difference is statistically significant ( p less than 0.05 ) . Four ( 10 % ) group A patients stopped taking the drug due to side effects of an anticholinergic type , and three ( 8.5 % ) patients developed hyperthyroidism during follow-up . The authors therefore come to the conclusion that amiodarone is more effective than slow-release disopyramide in preventing recurrencies of atrial fibrillation ; besides untoward side effects are less frequent with amiodarone Background Surprisingly little information on symptoms of paroxysmal atrial fibrillation is available in scientific literature . Using question naires , we have analyzed the symptoms associated with arrhythmia attacks . Methods One hundred r and omly-selected patients with idiopathic paroxysmal atrial fibrillation filled in a structured question naire . Results Psychic stress was the most common factor triggering arrhythmia ( 54 % ) , followed by physical exertion ( 42 % ) , tiredness ( 41 % ) coffee ( 25 % ) and infections ( 22 % ) . Thirty-four patients cited alcohol , 26 in the form of red wine , 16 as white wine and 26 as spirits . Among these 34 , red wine and spirits produced significantly more episodes of arrhythmia than white wine ( p = 0.01 and 0.005 respectively).Symptoms during arrhythmia were palpitations while exerting ( 88 % ) , reduced physical ability ( 87 % ) , palpitations at rest ( 86 % ) , shortage of breath during exertion ( 70 % ) and anxiety ( 59 % ) . Significant differences between sexes were noted regarding swollen legs ( women 21 % , men 6 % , p = 0.027 ) , nausea ( women 36 % , men 13 % , p = 0.012 ) and anxiety ( females 79 % , males 51 % , p = 0.014 ) . Conclusion Psychic stress was the commonest triggering factor in hospitalized patients with paroxysmal atrial fibrillation .  Red wine and spirits were more proarrhythmic than white wine . Symptoms in women in connection with attacks of arrhythmia vary somewhat from those in men OBJECTIVE To assess if prophylaxis with moderate doses of amiodarone in the postoperative period of cardiac surgery ( coronary artery bypass grafting and /or valve surgery ) , reduces the incidence of atrial fibrillation in patients with high risk for developing this arrhythmia . METHODS A r and omized and prospect i ve clinical study involving 68 patients who underwent elective cardiac surgery . Mean age was 64 years and 59 % of participants were males . Patients with three or more risk factors for atrial fibrillation , according to the literature , were r and omized into two groups to receive or not prophylaxis with amiodarone in the first postoperative day . The dose administered ranged from 600 mg/day to 900 mg/day , intravenously , on the first postoperative day , followed by 400 mg/day orally until hospital discharge or until completing seven days . The other patients , who presented two or fewer risk factors , were followed up until hospital discharge . All patients were evaluated by means of cardiac and /or electrocardiographic monitoring . RESULTS In the group treated with amiodarone , 7 % of patients presented atrial fibrillation , whereas in the control group 70 % of patients developed arrhythmia . Among the non-r and omized individuals ( with two or fewer risk factors ) , only 24 % presented atrial fibrillation . CONCLUSION The prophylactic use of amiodarone was effective in the prevention of atrial fibrillation in patients with three or more risk factors for this arrhythmia . This treatment can be useful to reduce stay at the Intensive Care Unit and , consequently , the complications originating from longer hospitalization BACKGROUND Among patients undergoing mitral-valve surgery , 30 to 50 % present with atrial fibrillation , which is associated with reduced survival and increased risk of stroke .  Surgical ablation of atrial fibrillation has been widely adopted , but evidence regarding its safety and effectiveness is limited . METHODS We r and omly assigned 260 patients with persistent or long-st and ing persistent atrial fibrillation who required mitral-valve surgery  to undergo either surgical ablation ( ablation group ) or no ablation ( control group ) during the mitral-valve operation . Patients in the ablation group underwent further r and omization to pulmonary-vein isolation or a biatrial maze procedure . All patients underwent closure of the left atrial appendage . The primary end point was freedom from atrial fibrillation at both 6 months and 12 months ( as assessed by means of 3-day Holter monitoring ) . RESULTS More patients in the ablation group than in the control group were free from atrial fibrillation at both 6 and 12 months ( 63.2 % vs. 29.4 % , P<0.001 ) . There was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrial maze procedure ( 61.0 % and 66.0 % , respectively ; P=0.60 ) . One-year mortality was 6.8 % in the ablation group and 8.7 % in the control group ( hazard ratio with ablation , 0.76 ; 95 % confidence interval , 0.32 to 1.84 ; P=0.55 ) . Ablation was associated with more implantations of a permanent pacemaker than was no ablation ( 21.5 vs. 8.1 per 100 patient-years , P=0.01 ) . There were no significant between-group differences in major cardiac or cerebrovascular adverse events , overall serious adverse events , or hospital readmissions . CONCLUSIONS The addition of atrial fibrillation ablation to mitral-valve surgery significantly increased the rate of freedom from atrial fibrillation at 1 year among patients with persistent or long-st and ing persistent atrial fibrillation , but the risk of implantation of a permanent pacemaker was also increased . ( Funded by the National Institutes of Health and the Canadian Institutes of Health Research ; Clinical Trials.gov number , NCT00903370 . ) OBJECTIVES We examined the clinical predictors and angiographic and clinical outcomes associated with  atrial fibrillation in the setting of acute myocardial infa rct ion ( MI ) . BACKGROUND This condition has been studied primarily in prethrombolytic era small trials . METHODS We compared baseline clinical characteristics , short-term clinical and angiographic outcomes and 1-year mortality of patients enrolled in the Global Utilization of Streptokinase and TPA for Occluded Coronary Arteries ( GUSTO-I ) trial with atrial fibrillation on admission electrocardiography ( n = 1,026 [ 2.5 % ] ) or after enrollment ( n = 3,254 [ 7.9 % ] ) and those without atrial fibrillation ( n = 36,611 [ 89.6 % ] ) . Univariable and multivariable analyses were used to assess relations between baseline factors and the development of atrial fibrillation . RESULTS Patients with any atrial fibrillation more often had three-vessel coronary artery disease and initial Thrombolysis in Myocardial Infa rct ion ( TIMI ) grade < 3 flow than those without the arrhythmia . In-hospital stroke was increased in patients with atrial fibrillation ( 3.1 % vs. 1.3 % , p = 0.0001 ) , mainly ischemic stroke ( 1.8 % vs. 0.5 % , p = 0.0001 ) . Significant multivariable predictors of later atrial fibrillation included advanced age , higher peak creatine kinase levels , worse Killip class and increased heart rate . The unadjusted mortality rate was significantly higher at 30 days ( 14.3 % vs. 6.2 % , p = 0.0001 ) and at 1 year ( 21.5 % vs. 8.6 % , p < 0.0001 ) in patients with atrial fibrillation . The adjusted 30-day mortality rate remained significantly higher with any ( odds ratio [ OR ] 1.3 , 95 % confidence interval [ CI ] 1.2 to 1.4 ) or later ( OR 1.4 , 95 % CI 1.3 to 1.5 ) atrial fibrillation but not with baseline atrial fibrillation ( OR 1.1 , 95 % CI 0.88 to 1.3 ) . CONCLUSIONS Atrial fibrillation in the setting of acute MI independently predicts stroke and 30-day mortality . More aggressive treatment strategies in this subgroup may be warranted and deserve further study BACKGROUND Patients with recent‐onset atrial fibrillation commonly undergo immediate restoration of sinus rhythm by pharmacologic or electrical cardioversion . However , whether immediate restoration of sinus rhythm is necessary is not known , since atrial fibrillation often terminates spontaneously . METHODS In a multicenter , r and omized , open‐label , noninferiority trial , we r and omly assigned patients with hemodynamically stable , recent‐onset ( < 36 hours ) , symptomatic atrial fibrillation in the emergency department to be treated with a wait‐ and ‐see approach ( delayed‐cardioversion group ) or early cardioversion . The wait‐ and ‐see approach involved initial treatment with rate‐control medication only and delayed cardioversion if the atrial fibrillation did not resolve within 48 hours . The primary end point was the presence of sinus rhythm at 4 weeks . Noninferiority would be shown if the lower limit of the 95 % confidence interval for the between‐group difference in the primary end point in percentage points was more than ‐10 . RESULTS The presence of sinus rhythm at 4 weeks occurred in 193 of 212 patients ( 91 % ) in the delayed‐cardioversion group and in 202 of 215 ( 94 % ) in the early‐cardioversion group ( between‐group difference , ‐2.9 percentage points ; 95 % confidence interval [ CI ] , ‐8.2 to 2.2 ; P=0.005 for noninferiority ) . In the delayed‐cardioversion group , conversion to sinus rhythm within 48 hours occurred spontaneously in 150 of 218 patients ( 69 % ) and after delayed cardioversion in 61 patients ( 28 % ) . In the early‐cardioversion group , conversion to sinus rhythm occurred spontaneously before the initiation of cardioversion in 36 of 219 patients ( 16 % ) and after cardioversion in 171 patients ( 78 % ) . Among the patients who completed remote monitoring during 4 weeks of follow‐up , a recurrence of atrial fibrillation occurred in 49 of 164 patients ( 30 % ) in the delayed‐cardioversion group and in 50 of 171 ( 29 % ) in the early‐cardioversion group . Within 4 weeks after r and omization , cardiovascular complications occurred in 10 patients and 8 patients , respectively . CONCLUSIONS In patients presenting to the emergency department with recent‐onset , symptomatic atrial fibrillation , a wait‐ and ‐see approach was noninferior to early cardioversion in achieving a return to sinus rhythm at 4 weeks . ( Funded by the Netherl and s Organization for Health Research and Development and others ; RACE 7 ACWAS Clinical Trials.gov number , NCT02248753 . OBJECTIVES This study was design ed to compare two treatment strategies in patients with atrial fibrillation(AF ) :  rhythm-control ( restoration and maintenance of sinus rhythm ) and rate-control ( pharmacologic or invasive rate-control and anticoagulation ) . BACKGROUND Atrial fibrillation is the most common arrhythmia . It is unclear whether a strategy of rhythm- or rate-control is better in terms of mortality , morbidity , and quality of life . METHODS The Strategies of Treatment of Atrial Fibrillation ( STAF ) multicenter pilot trial r and omized 200 patients ( 100 per group ) with persistent AF to rhythm- or rate-control .  The combined primary end point was a combination of death , cardiopulmonary resuscitation , cerebrovascular event , and systemic embolism . RESULTS After 19.6 + /- 8.9 months ( range 0 to 36 months ) there was no difference in the primary end point between rhythm-control ( 9/100 ; 5.54%/year ) and rate-control ( 10/100 ; 6.09%/year ; p = 0.99 ) . The percentage of patients in sinus rhythm in the rhythm-control group after up to four cardioversions during the follow-up period ( rate-control group ) was 23 % ( 0 % ) at 36 months . Eighteen primary end points occurred in atrial fibrillation ; only one occurred in sinus rhythm ( p = 0.049 ) . CONCLUSIONS The STAF pilot study showed no differences between the two treatment strategies in all end points except hospitalizations . These data suggest that there was no benefit in attempting rhythm-control in these patients with a high risk of arrhythmia recurrence . It remains unclear whether the results in the rhythm-control group would have been better if sinus rhythm had been maintained in a higher proportion of patients , as all but one end point occurred during AF Context Guidelines for prescribing anticoagulants in atrial fibrillation do not use contemporary stroke rates or account for intracranial bleeding risk . Contribution The authors studied 6-year rates of ischemic stroke and intracranial hemorrhage in 13559 adults with nonvalvular atrial fibrillation . They calculated ischemic stroke rates in patients receiving and not receiving warfarin ( treatment benefit ) and intracranial hemorrhage rates ( treatment harm ) . Benefit minus harm ( net treatment benefit ) was highest in patients with previous stroke , age older than 84 years , and others with high stroke risk . Caution Patients received warfarin according to clinical judgment , not r and omly . Implication Age and other stroke risk factors should drive the decision to use warfarin in atrial fibrillation . The Editors Warfarin anticoagulation is very efficacious in preventing thromboembolism ( primarily ischemic stroke but also systemic thromboembolism ) in patients with atrial fibrillation and is highly effective in practice ( 1 , 2 ) . Nonetheless , warfarin therapy increases the risk for major hemorrhage and is burdensome for both physicians and patients . Therefore , clinical guidelines ( 3 , 4 ) recommend warfarin only for patients with atrial fibrillation who are considered to be at intermediate or high risk for ischemic stroke . However , these risk-based anticoagulation guidelines have substantial limitations . First , they do not explicitly account for the risk for fatal and disabling hemorrhage due to warfarin . Second , they are primarily based on studies conducted more than 15 years ago . Recent studies ( 2 , 5 , 6 ) of patients with atrial fibrillation suggest a lower absolute risk for stroke while not receiving warfarin therapy , perhaps reflecting better treatment of hypertension or other risk factors . Finally , the net clinical benefit of risk-based recommendations for anticoagulation in patients with atrial fibrillation has not been demonstrated in large population s followed for long periods . In our observational study , we quantify the net clinical benefit of warfarin anticoagulation , defined as the estimated reduction in rate of thromboembolism , mainly ischemic stroke , minus 1.5 times the estimated increase in rate of intracranial hemorrhage attributable to warfarin therapy in st and ard stroke risk subgroups in the community-based cohort of patients in the ATRIA ( AnTicoagulation and Risk Factors In Atrial Fibrillation ) Study . Methods Study Population The ATRIA Study cohort consists of 13559 adults with diagnosed nonvalvular atrial fibrillation who received care within Kaiser Permanente of Northern California , a large integrated health care delivery system . Cohort assembly is described in detail elsewhere ( 2 , 7 ) . In brief , we identified patients with a diagnosis of atrial fibrillation between 1 July 1996 and 31 December 1997 by search ing outpatient data bases for internal medicine or cardiology visits in which an International Classification of Diseases , Ninth Revision , Clinical Modification ( ICD-9-CM ) , diagnosis of atrial fibrillation ( 427.31 ) was assigned and by search ing electrocardiographic data bases for a diagnosis of atrial fibrillation . The date of the first diagnosis of atrial fibrillation during the period of cohort assembly was considered the patient 's index date . Cohort assembly was finalized by November 1998 , and the cohort was followed through 30 September 2003 with a combination of retrospective ( back to July 1996 ) and prospect i ve ( through September 2003 ) review of health plan data bases and medical records . Patients who died or withdrew from the health plan during follow-up were censored at their date of death or on the last day of the month in which they terminated their membership . Date of death was ascertained from health plan clinical or administrative files , the California Automated Mortality Linkage System , or the Social Security Administration Death Master File . The institutional review boards at Massachusetts General Hospital and the Kaiser Foundation Research Institute approved the research . Patient Characteristics We search ed data bases of clinical inpatient and ambulatory visits ( outpatient clinic and emergency department ) during the 5 years before each patient 's index date to identify previously diagnosed ischemic stroke , heart failure , coronary heart disease , and hypertension by using relevant ICD-9-CM codes ( 2 ) . We used a vali date d , comprehensive health plan diabetes registry to identify patients with diabetes mellitus . Ascertainment of these stroke risk factors was vali date d against review of sample s of outpatient medical records ; crude agreement was high ( 78 % to 96 % ) , and corresponding statistics ranged from 0.51 to 0.89 . Of note , stroke risk prediction based on risk factors ascertained in the ATRIA Study was in good agreement with risk schemes generated by pooled r and omized trial and chart-based cohort study data ( 2 , 810 ) . Information from medical care received at both health plan and nonhealth plan facilities was obtained through these data bases . Data on age and sex were obtained from administrative data bases . Warfarin Exposure We determined warfarin exposure on the basis of information from automated clinical , pharmacy , and laboratory data bases by using methods described elsewhere ( 2 ) . We vali date d this computerized approach in 1207 patients by comparing it with warfarin status documented in their medical record at the time of an outcome event ; the result ing statistic was 0.84 . Nearly all discrepancies were due to transient discontinuation of warfarin treatment . If medical chart review of an outcome event showed that the patient stopped receiving warfarin within 5 days before the event , the event was considered to take place while the patient was receiving warfarin . For patients considered to be receiving warfarin  , an adapted linear interpolation method was used to determine the person-time spent in the therapeutic international normalized ratio ( INR ) range of 2.0 to 3.0 ( 11 ) . If the interval between consecutive INR measurements was greater than 8 weeks , the INR person-time for this period was considered not available . Outcome Assessment Thromboembolic Events We search ed hospitalization and billing cl aims data bases through 30 September 2003 for primary ICD-9-CM discharge diagnoses that indicated potential thromboembolism , including ischemic stroke and other systemic embolism ( ICD-9-CM codes available on request ) ( 2 ) . For both potential thromboembolic events and hemorrhagic events , medical record analysts obtained the relevant medical records by using a structured protocol . We did not investigate hospitalizations with the selected discharge diagnosis codes in a secondary position , because such hospitalizations rarely were prompted by new thromboembolic events . We estimate that our rates of ischemic stroke would have been increased relatively by 6 % had we review ed all such hospitalizations ( 2 ) . We defined a vali date d ischemic stroke as a sudden neurologic deficit lasting more than 24 hours , corresponding to a vascular territory in the absence of primary hemorrhage , that was not explained by other causes ( for example , trauma or infection ) . We defined a valid peripheral embolism as being identified by radiographic imaging , intraoperative examination , or pathologic findings ( with no atherosclerotic disease in the affected artery ) . Thromboembolic events occurring after hospital admission , generally as a complication of medical care , were not included as outcome events . Two members of the physician outcomes review committee review ed all potential thromboembolic events by using a formal protocol . Disagreements were resolved by a third committee member or by a consulting neurologist , if needed . Intracranial Hemorrhage We search ed hospitalization and billing data bases for primary and secondary discharge diagnoses of intracranial hemorrhage , including intraparenchymal , subdural , subarachnoid , and other hemorrhage ( ICD-9-CM codes available on request ) . We excluded intracranial hemorrhage associated with a concomitant discharge diagnosis of major trauma ( ICD-9-CM codes 852.1 , 852.3 , 852.5 , and 853.1 ) and events not leading to hospitalization or those that occurred as a complication of a hospitalization for another problem . Net Clinical Benefit We defined the core net clinical benefit of warfarin therapy in atrial fibrillation as the annualized rate of thromboembolic events ( TE rate ) prevented minus the annualized rate of intracranial hemorrhages ( ICH rate ) induced , multiplied by a weighting factor . The following equation illustrates this definition : The weighting factor reflects the relative impact , in terms of death and disability , of an intracranial hemorrhage ( including intracerebral , subdural , subarachnoid , and other hemorrhages ) while receiving warfarin versus experiencing an ischemic stroke while not receiving warfarin ( 12 ) . We assigned our base case a weighting factor of 1.5 , reflecting outcomes in the ATRIA Study cohort ( 13 , 14 ) . We also provide additional sensitivity analyses by using weighting factors of 1.0 and 2.0 . For 10 % of potential thromboembolic events and intracranial hemorrhages identified by ICD-9-CM codes , the patients ' medical records were unavailable or contained insufficient information to determine whether a valid event had occurred . We did not include these events . For events with missing clinical information , the ratio of patients receiving warfarin to those not receiving warfarin was similar to the ratio for vali date d events . Making the improbable assumption that all such potential events met our validity criteria increased our estimate of unadjusted overall net clinical benefit by only 0.07 % per year . Statistical Analysis We calculated incidence rates of thromboembolism and intracranial hemorrhage as the number of events per 100 person-years of follow-up . Because individual participants in the ATRIA Study cohort could have alternating periods of receiving and not receiving warfarin , we BACKGROUND AND OBJECTIVES The relation between cardiac mortality and antiarrhythmic drug administration has not been fully determined . This relation was analyzed in 1,330 patients enrolled in the Stroke Prevention in Atrial Fibrillation Study , a r and omized clinical trial comparing warfarin , aspirin and placebo for the prevention of ischemic stroke or systemic embolism in patients with nonvalvular atrial fibrillation . METHODS Patients who received antiarrhythmic drug therapy for atrial fibrillation in this study were compared with patients not receiving antiarrhythmic agents . The relative risk of cardiac mortality , including arrhythmic death , in patients receiving antiarrhythmic drug therapy  was determined and adjusted for other cardiac risk factors . RESULTS In patients receiving antiarrhythmic drug therapy , cardiac mortality was increased 2.5-fold ( p = 0.006 , 95 % confidence interval [ CI ] 1.3 to 4.9 ) and arrhythmic death was increased 2.6-fold ( p = 0.02 , 95 % CI 1.2 to 5.6 ) . Among patients with a history of congestive heart failure , those given antiarrhythmic medications had a relative risk of cardiac death of 4.7 ( p less than 0.001 , 95 % CI 1.9 to 11.6 ) compared with that of patients not so treated ; the relative risk of arrhythmic death in the treated group was 3.7 ( p = 0.01 , 95 % CI 1.3 to 10.4 ) . Patients without a history of congestive heart failure had no increased risk of cardiac mortality ( relative risk 0.70 , 95 % CI 0.2 to 3.1 ) during antiarrhythmic drug therapy . After exclusion of 23 patients with documented ventricular arrhythmias and adjustment for other variables predictive of cardiac death , patients receiving antiarrhythmic drugs were not at increased risk of cardiac death or arrhythmic death . However , in patients with a history of heart failure who received antiarrhythmic drug therapy , the relative risk of cardiac death was 3.3 ( p = 0.05 , 95 % CI 0.99 to 11.1 ) and that of arrhythmic death was 5.8 ( p = 0.009 , 95 % CI 1.5 to 21.7 ) compared with the risk in patients not taking antiarrhythmic medications . CONCLUSIONS Although antiarrhythmic drug therapy was not r and omly determined in this trial , the data suggest that in patients with atrial fibrillation and a history of congestive heart failure , the risk of such therapy may outweigh the potential benefit of maintaining sinus rhythm BACKGROUND Atrial fibrillation occurs frequently in patients with congestive heart failure and commonly results in clinical deterioration and hospitalization . Sinus rhythm may be maintained with antiarrhythmic drugs , but some of these drugs increase the risk of death . METHODS We studied 1518 patients with symptomatic congestive heart failure and severe left ventricular dysfunction at 34 Danish hospitals . We r and omly assigned 762 patients to receive dofetilide , a novel class III antiarrhythmic agent , and 756 to receive placebo in a double-blind study . Treatment was initiated in the hospital and included three days of cardiac monitoring and dose adjustment . The primary end point was death from any cause . RESULTS During a median follow-up of 18 months , 311 patients in the dofetilide group ( 41 percent ) and 317 patients in the placebo group ( 42 percent ) died ( hazard ratio , 0.95 ; 95 percent confidence interval , 0.81 to 1.11 ) . Treatment with dofetilide significantly reduced the risk of hospitalization for worsening congestive heart failure ( risk ratio , 0.75 ; 95 percent confidence interval , 0.63 to 0.89 ) . Dofetilide was effective in converting atrial fibrillation to sinus rhythm . After one month , 22 of 190 patients with atrial fibrillation at base line ( 12 percent ) had sinus rhythm restored with dofetilide , as compared with only 3 of 201 patients ( 1 percent ) given placebo . Once sinus rhythm was restored , dofetilide was significantly more effective than placebo in maintaining sinus rhythm ( hazard ratio for the recurrence of atrial fibrillation , 0.35 ; 95 percent confidence interval , 0.22 to 0.57 ; P<0.001 ) . There were 25 cases of torsade de pointes in the dofetilide group ( 3.3 percent ) as compared with none in the placebo group . CONCLUSIONS In patients with congestive heart failure and reduced left ventricular function , dofetilide was effective in converting atrial fibrillation , preventing its recurrence , and reducing the risk of hospitalization for worsening heart failure .  Dofetilide had no effect on mortality Background —The Cox Maze procedure for treatment of medically refractory atrial fibrillation ( AF ) is limited by its complexity and requirement for cardiopulmonary bypass . Long-term follow-up and success using criteria established by the Heart Rhythm Society/European Heart Rhythm Association/European Cardiac Arrhythmia Society consensus statement have not been reported for surgical AF ablation . We describe the results of using a thorascopic approach and radiofrequency energy to perform bilateral pulmonary vein isolation and left atrial ganglionic plexi ablation for treatment of AF . Methods and Results —Forty-five ( 33 paroxysmal ; 12 persistent ) consecutive patients underwent thorascopic bilateral radiofrequency pulmonary vein isolation , ganglionic plexi ablation , ligament of Marshall ablation , and left atrial appendage exclusion by a single surgeon . Forty-three patients were prospect ively followed without antiarrhythmic drugs for a minimum of 1 year with a 30-day continuous event monitor or pacemaker interrogation at 6 and 12 months . Failure was defined as any atrial tachyarrhythmia of > 30 seconds ’ duration occurring > 90 days after surgery . Mean follow-up was 516±181 days ( 202 to 858 days ) . Twenty-eight ( 65 % ) patients had no atrial tachyarrhythmia > 30 seconds by 1 year , and 15 ( 35 % ) patients had atrial tachyarrhythmia recurrences by 1 year . Eight of 15 patients with recurrent AF had catheter ablation result ing in elimination and /or reduction of AF episodes in 7 of 8 patients . Four of 15 patients had AF elimination or reduction with antiarrhythmic drugs alone . Three patients did not benefit from surgery and received rate control only . There were no deaths ; 1 phrenic nerve injury and 2 pleural effusions were the only major complications . Conclusions —The single procedure success at 1-year follow-up for surgical pulmonary vein isolation and ganglionic plexi ablation is 65 % . Atrial tachyarrhythmia recurrences after surgery are usually responsive to catheter ablation and /or antiarrhythmic drugs Background Natural history of paroxysmal atrial fibrillation ( AF ) is not very well documented . Clinical experience suggests that paroxysmal AF could progress to chronic AF with estimates ranging between 15 and 30 % over a period of 1–3 years . We performed an epidemiologic study to eluci date the natural history of paroxysmal AF , this study estimated its incidence in a general practice setting , identified associated factors and analyzed the progression into chronic AF as well as the mortality rate . Methods Using the UK General Practice Research Data base ( GPRD ) , we identified patients aged 40–89 years with a first-recorded episode of paroxysmal AF during 1996 .  Risk factors were assessed using 525 incident paroxysmal AF cases confirmed by the general practitioner ( GP ) and a r and om sample of controls . We follow-up paroxysmal AF patients and estimated their mortality rate and progression to chronic AF . Results The incidence of paroxysmal AF was 1.0 per 1,000 person-years . Major risk factors for paroxysmal AF were age and prior valvular heart disease , ischaemic heart disease , heart failure and hyperthyroidism . During a mean follow-up of 2.7 years , 70 of 418 paroxysmal AF patients with complete information progressed to chronic AF . Risk factors associated with progression were valvular heart disease ( OR 2.7 , 95 % CI 1.2–6.0 ) and moderate to high alcohol consumption ( OR 3.0 , 95 % CI 1.1–8.0 ) . Paroxysmal AF patients did not carry an increased risk of mortality , compared to an age and sex matched sample of the general population . There was a suggestion of a small increased risk among patients progressing to chronic AF ( RR 1.5 , 96 % CI 0.8–2.9 ) . Conclusion Paroxysmal AF is a common arrhythmia in the general practice setting , increasing with age and commonly associated with other heart diseases . It sometimes is the initial presentation and then progress to chronic AF . A history of valvular heart disease and alcohol consumption are associated with this progression PURPOSE R and omized controlled trials have demonstrated that anticoagulant therapy is very effective at preventing stroke among patients with nonrheumatic atrial fibrillation . However , these trials have reported too few strokes for powerful risk factor analysis . Observational studies may provide additional information . The purpose of this study was to identify risk factors in a larger number of patients with stroke and nonrheumatic atrial fibrillation , using case-control methodology . PATIENTS AND METHODS We identified all patients discharged from one hospital over an 8-year period who met our case definition of nonrheumatic atrial fibrillation and ischemic stroke ( n = 134 ) , and compared them with contemporaneous control subjects who were discharged with nonrheumatic atrial fibrillation without stroke ( n = 131 ) . RESULTS Cases and controls were similar in terms of duration of atrial fibrillation ; proportion with paroxysmal atrial fibrillation ; percentage with a past medical history of angina , myocardial infa rct ion , congestive heart failure , diabetes , or smoking ; and mean left atrial size . In contrast , cases were significantly older than controls ( 78.5 versus 74.8 years , p = 0.002 ) and more likely to have a history of hypertension ( 55 % versus 38 % , p = 0.0093 ) . The relative odds for stroke was 1.91 for patients with hypertension , 1.73 for patients older than 75 years , and 3.26 for patients with both factors . CONCLUSIONS Our analysis suggests that age and hypertension should be considered when deciding upon long-term anticoagulant therapy to prevent stroke in patients with nonrheumatic atrial fibrillation AIMS We aim ed to investigate the prevalence and incidence of atrial fibrillation ( AF )  in a large European population -based study . METHODS AND RESULTS The study is part of the Rotterdam study , a population -based prospect i ve cohort study among subjects aged 55 years and above . The prevalence at baseline was assessed in 6808 participants .  Incidence of AF was investigated during a mean follow-up period of 6.9 years in 6432 persons . We identified 376 prevalent and 437 incident cases . Overall prevalence was 5.5 % , rising from 0.7 % in the age group 55 - 59 years to 17.8 % in those aged 85 years and above . The overall incidence rate was 9.9/1000 person-years . The incidence rate in the age group 55 - 59 years was 1.1/1000 person-years , rose to 20.7/1000 person-years in the age group 80 - 84 years and stabilized in those aged 85 years and above . Prevalence and incidence were higher in men than in women . The lifetime risk to develop AF at the age of 55 years was 23.8 % in men and 22.2 % in women . CONCLUSION In this prospect i ve study in a European population , the prevalence and incidence of AF increased with age and were higher in men than in women . The high lifetime risk to develop AF was similar to North American epidemiological data BACKGROUND There are limited data comparing radiofrequency catheter ablation with antiarrhythmic drug therapy as first-line treatment in patients with paroxysmal atrial fibrillation . METHODS We r and omly assigned 294 patients with paroxysmal atrial fibrillation and no history of antiarrhythmic drug use to an initial treatment strategy of either  radiofrequency catheter ablation  ( 146 patients ) or therapy with class IC or class III antiarrhythmic agents ( 148 patients ) . Follow-up included 7-day Holter-monitor recording at 3 , 6 , 12 , 18 , and 24 months . Primary end points were the cumulative and per-visit burden of atrial fibrillation ( i.e. , percentage of time in atrial fibrillation on Holter-monitor recordings ) . Analyses were performed on an intention-to-treat basis . RESULTS There was no significant difference between the ablation and drug-therapy groups in the cumulative burden of atrial fibrillation ( 90th percentile of arrhythmia burden , 13 % and 19 % , respectively ; P=0.10 ) or the burden at 3 , 6 , 12 , or 18 months . At 24 months , the burden of atrial fibrillation was significantly lower in the ablation group than in the drug-therapy group ( 90th percentile , 9 % vs. 18 % ; P=0.007 ) , and more patients in the ablation group were free from any atrial fibrillation ( 85 % vs. 71 % , P=0.004 ) and from symptomatic atrial fibrillation ( 93 % vs. 84 % , P=0.01 ) . One death in the ablation group was due to a procedure-related stroke ; there were three cases of cardiac tamponade in the ablation group . In the drug-therapy group , 54 patients ( 36 % ) underwent supplementary ablation . CONCLUSIONS In comparing radiofrequency ablation with antiarrhythmic drug therapy as first-line treatment in patients with paroxysmal atrial fibrillation , we found no significant difference between the treatment groups in the cumulative burden of atrial fibrillation over a period of 2 years . ( Funded by the Danish Heart Foundation and others ; MANTRA-PAF Clinical Trials.gov number , NCT00133211 . ) BACKGROUND Amiodarone and sotalol are commonly used for the maintenance of sinus rhythm , but the efficacy of these agents administered as high-dose infusions for rapid conversion of atrial fibrillation is unknown . Use in this context would facilitate drug initiation in patients in whom ongoing prophylactic therapy is indicated . METHODS We assessed the efficacy and safety of rapid high-dose intravenous infusions of amiodarone and sotalol for heart rate control and rapid reversion to sinus rhythm in patients who came to the emergency department with recent-onset symptomatic atrial fibrillation . Patients ( n = 140 ) were r and omized to receive 1.5mg/kg of sotalol infused in 10 minutes , 10mg/kg of amiodarone in 30 minutes , or 500 microg of digoxin in 20 minutes . Electrical cardioversion was attempted for patients not converting to sinus rhythm within 12 hours . RESULTS The rapid infusion of sotalol or amiodarone result ed in more rapid rate control than digoxin . Each of the 3 trial strategies result ed in similar rates of pharmacological conversion to sinus rhythm  ( amiodarone , 51 % ; sotalol , 44 % ; digoxin , 50 % ; P = not significant ) . The overall rates of cardioversion after trial drug infusion and defibrillation were high for all groups ( amiodarone , 94 % ; sotalol , 95 % , ; digoxin , 98 % ; P = not significant ) , but there was a trend toward a higher incidence of serious adverse reactions in the amiodarone group . CONCLUSION The rapid infusion of sotalol or amiodarone in patients with symptomatic recent-onset atrial fibrillation results in rapid control of ventricular rate . Even with high-dose rapid infusions , all 3 agents are associated with a poor overall reversion rate within 12 hours . Almost all patients were returned to sinus rhythm with a combination of pharmacological therapy and electrical cardioversion BACKGROUND Atrial fibrillation is a common arrhythmia , after cardiac surgery . Reperfusion injury and inflammation associated with cardiac surgery are thought to be involved in its pathogenesis . We hypothesized that cytoprotective effects associated with heat shock protein 70 ( HSP70 ) could counteract these proarrhythmic insults . We therefore set out to examine the influence of heat shock protein 70 on the incidence of postoperative atrial fibrillation . METHODS We prospect ively recruited 80 patients undergoing elective coronary artery bypass surgery . Blood sample s were collected preoperatively . Right atrial tissue was obtained at surgery . Incidence of postoperative atrial fibrillation and its duration were noted . Using a nested case-control design , 15 patients who developed atrial fibrillation were matched for operative procedure , age , sex , and beta-blocker usage , with 15 controls from the remaining patients . Atrial heat shock protein 70 was subsequently quantified by immunohistochemistry . Serum heat shock protein was measured using enzyme-linked immunosorbent assay and high sensitivity C-reactive protein was determined by immunoturbidometric assay . RESULTS Intracellular HSP70 level was significantly higher in patients who did not develop atrial fibrillation ( 35 + /- 13 vs 19 + /- 15 ; p = 0.006 ) . Atrial HSP70 level negatively correlated with atrial fibrillation ; independent of other risk factors ( odds ratio = 0.90 ; 95 % confidence interval 0.84 to 0.99 , p = 0.02 ) . Serum HSP70 levels were similar in both groups ( p = 0.81 ) and did not correlate with intracellular levels ( p = 0.38 ) . Preoperative C-reactive protein levels were similar in both groups ( p = 0.93 ) . CONCLUSIONS Intracellular , but not serum , HSP70 level is negatively correlated with postoperative atrial fibrillation . This suggests a cardioprotective and an antiarrhythmic role for intracellular HSP70 OBJECTIVES Orthostatic hypotension ( OH ) , a common manifestation of autonomic dysfunction , has been identified as an independent risk factor for all-cause mortality and incident cardiovascular disease . However , the role of OH in the development of atrial fibrillation has not been studied . DESIGN We investigated the incidence of atrial fibrillation in relation to baseline presence of OH according to international consensus criteria in the Swedish population -based prospect i ve cohort of the Malmö Preventive Project . The study sample consisted of 33,346 individuals ( 67.3 % men ; mean age , 45.6 ± 7.4 years ; range , 26 - 61 years ) . The association between OH and incidence of atrial fibrillation during follow-up was assessed using the Kaplan-Meier method and multivariable Cox proportional hazard models , taking into account conventional risk factors for atrial fibrillation . RESULTS At baseline , 1987 participants ( 6.1 % ) met the diagnostic criteria for OH . Over a follow-up period of approximately 24 years , 2312 individuals ( 3.0 events/1000 person-years ) were diagnosed with new-onset atrial fibrillation . Of these , 196 had OH at baseline ( 4.6 events/1000 person-years amongst all OH-positive individuals ) . In a multivariable Cox regression analysis , OH predicted incidence of atrial fibrillation independently of other risk factors ( hazard ratio [ HR ] : 1.30 ; 95 % confidence interval [ CI ] : 1.05 - 1.61 ; P = 0.016 ) , and this association was significant in hypertensive ( HR : 1.44 ; 95%CI : 1.10 - 1.88 ; P = 0.008 ) , but not in normotensive participants ( HR : 1.10 ; 95%CI : 0.77 - 1.58 ; P = 0.60 ) . CONCLUSIONS The presence of OH predicts the incidence of atrial fibrillation in middle-aged hypertensive individuals , independently of conventional risk factors . Further studies of the association of autonomic dysfunction and OH with atrial fibrillation are needed BACKGROUND Atrial fibrillation  ( AF ) may occur without symptoms . Little is known about demographic features and prognostic information in patients with asymptomatic AF . METHODS In the AFFIRM study , 4060 patients were r and omized to either rhythm or rate control . At baseline , patients were identified as asymptomatic if they answered " no " to a 15-item question naire related to cardiac symptoms during AF in the 6 months before study entry . RESULTS There were 481 ( 12 % ) asymptomatic patients at baseline . Compared with symptomatic patients , asymptomatic patients were more often men and had a lower incidence of coronary artery disease and congestive heart failure , but had more cerebrovascular events . Asymptomatic patients had a longer duration of AF , a lower maximum heart rate , and better left ventricular function . They received fewer cardiac medications and fewer therapies to maintain sinus rhythm . At 5 years , there was a trend for better survival in asymptomatic patients ( 81 % vs 77 % , P = .058 ) , and they were more likely to be free from disabling stroke or anoxic encephalopathy , major bleeding , and cardiac arrest ( 79 % vs 67 % , P = .024 ) . However , mortality and major events were similar after correction for baseline differences . CONCLUSIONS Patients with asymptomatic AF have less serious heart disease but more cerebrovascular disease . Asymptomatic patients receive different therapies than symptomatic patients . However , the absence of symptoms and the differences in treatment does not confer a more favorable prognosis when differences in baseline clinical parameters are considered . Anticoagulation should be considered in these patients The results of the long-term follow-up of 119 patients who had DC cardioversion performed are described . All patients had had corrective cardiac surgery for chronic rheumatic valvar heart disease . The poor prognosis for maintenance of sinus rhythm in this type of patient is emphasized . Of the total patients , 83 per cent were converted to sinus rhythm , but relapses were common in those who had atrial fibrillation before operation . Only 40 per cent of such patients maintained sinus rhythm for 2 months , 15 per cent for 1 year , and 9 per cent for 2 years . By contrast , when atrial fibrillation occurred for the first time in the post-operative period , 82 per cent maintained sinus rhythm for 2 years after conversion . Post-operative DC cardioversion is in general not recommended for patients with rheumatic heart disease and atrial fibrillation unless atrial fibrillation occurs for the first time in the post-operative period . A controlled trial of prophylactic quinidine is reported and shows no significant increase in the number of patients remaining in sinus rhythm as compared with a control group not receiving quinidine Objective To compare the efficacy of electrical versus pharmacological cardioversion following prosthetic cardiac valve replacement in patients with permanent atrial fibrillation ( AF ) . Methods Patients with permanent AF who had undergone prosthetic cardiac valve replacement , who had a cardiothoracic ratio ≤0.5 and a left atrial diameter ≤50 mm for ≥6 months after surgery were r and omly divided to receive either electrical or pharmacological cardioversion . Patients in the electrical cardioversion group were given direct-current synchronized electrical defibrillation under general anaesthesia . Patients in the pharmacological cardioversion group were given oral combination therapy with amiodarone , captopril and simvastatin for 3 months . Results A total of 115 patients received either electrical cardioversion ( n = 59 ) or pharmacological cardioversion ( n = 56 ) ; reversion to sinus rhythm occurred in 98.3 % and 26.8 % , respectively . Recurrence rates were similar in the two groups ( 3.4 % and 6.7 % for electrical and pharmacological cardioversion , respectively ) . No deaths or severe complications were reported . Conclusion Electrical cardioversion has a favourable safety profile and appears to be a more effective method than pharmacological cardioversion for the treatment of permanent AF after cardiac valve replacement , once the heart has returned close to its normal size BACKGROUND Obese patients have favorable outcomes in congestive heart failure , hypertension , peripheral vascular disease , and coronary artery disease . Obesity also has been linked with increased incidence of atrial fibrillation , but its influence on outcomes in atrial fibrillation patients has not been investigated . The objective of this research is to investigate the effect of obesity on outcomes in atrial fibrillation . METHODS The Atrial Fibrillation Follow-up Investigation of Rhythm Management ( AFFIRM ) study was one of the largest multicenter trials of atrial fibrillation , with 4060 patients . Subjects were r and omized to rate versus rhythm-control strategy . We performed a post hoc analysis of the National Heart , Lung and Blood Institute limited access data set of atrial fibrillation patients who had body mass index ( BMI ) data available in the AFFIRM study . BMI data were not available on 1542 patients . Patients with BMI > or=18.5 were split into normal ( 18.5 - 25 ) , overweight ( 25 - 30 ) , and obese ( > 30 ) categories as per BMI ( kg/m(2 ) ) . Multivariate Cox proportional hazards regression was used on the eligible 2492 patients . End points were all-cause mortality and cardiovascular mortality . RESULTS Over three fourths of all patients in our cohort were overweight or obese . There were 304 deaths ( 103 among normal weight , 108 among overweight , and 93 among obese ) and 148 cardiovascular deaths ( 54 among normal weight , 41 among overweight , and 53 among obese ) over a mean period of 3 years of patient follow-up . On multivariate analysis , overweight ( hazard ratio [ HR ] 0.64 ; 95 % confidence interval [ CI ] , 0.48 - 0.84 ; P=.001 ) and obese ( HR 0.80 ; 95 % CI , 0.68 - 0.93 ; P=.005 ) categories were associated with lower all-cause mortality as compared with normal weight . Overweight ( HR 0.40 ; 95 % CI , 0.26 - 0.60 ; P < .001 ) and obese patients ( HR 0.77 ; 95 % CI , 0.62 - 0.95 ; P=.01 ) also had lower cardiovascular mortality as compared with the normal weight patients . CONCLUSIONS Although in prior studies , obesity has been associated with increased risk of atrial fibrillation , an obesity paradox exists for outcomes in atrial fibrillation . Obese patients with atrial fibrillation appear to have better long-term outcomes than nonobese patients BACKGROUND Advances in technology such as epicardial bipolar radiofrequency pulmonary vein isolation , ganglionated plexi identification , and isolation and thoracoscopic left atrial appendage exclusion have enabled less invasive surgical options for management of atrial fibrillation . METHODS We performed a prospect i ve , nonr and omized study of consecutive patients with symptomatic paroxysmal atrial fibrillation undergoing a video-assisted , minimally invasive surgical ablation procedure .  The procedure consisted of bilateral , epicardial pulmonary vein isolation with bipolar radiofrequency , partial autonomic denervation , and selective excision of the left atrial appendage . Minimum follow-up was 1 year with long-term monitoring ( 24-hour continuous , 14-day event or pacemaker interrogation ) . RESULTS Between March 2005 and January 2008 , 52 patients ( 35 male ) , mean age 60.3 years ( range , 42 - 79 years ) underwent the procedure . The left atrial appendage was isolated in 88.0 % ( 44/50 ) . Average hospital stay was 5.2 days ( range 3 - 10 days ) . There were no operative deaths or major adverse cardiac events . On long-term monitoring , freedom from atrial fibrillation/flutter/tachycardia was 86.3 % ( 44/51 ) and 80.8 % ( 42/52 ) at 6 and 12 months , respectively . Antiarrhythmic drugs were stopped in 33 of 37 patients and warfarin in 30 of 37 of the patients in whom ablation was successful at 12 months . Freedom from symptoms attributed to atrial fibrillation/flutter/tachycardia was 78.0 % ( 39/50 ) at 6 months and 63.8 % ( 30/47 ) at 12 months . CONCLUSIONS Minimally invasive surgical ablation is effective in the management of paroxysmal atrial fibrillation as evidence d by freedom from atrial arrythmias by long-term monitoring at 12 months . Measuring success using clinical symptoms underestimated clinical success as compared with long-term monitoring Background — Atrial fibrillation is common among older persons .  Catheter ablation is increasingly used in patients for whom medical therapy has failed . Methods and Results — We conducted a retrospective cohort study of all fee-for-service Medicare beneficiaries ≥65 years of age who underwent catheter ablation for atrial fibrillation between July 1 , 2007 , and December 31 , 2009 . The main outcome measures were major complications within 30 days and mortality , heart failure , stroke , hospitalization , and repeat ablation within 1 year . A total of 15 423 patients underwent catheter ablation for atrial fibrillation . Mean age was 72 years ; 41 % were women ; and > 95 % were white . For every 1000 procedures , there were 17 cases of hemopericardium requiring intervention , 8 cases of stroke , and 8 deaths within 30 days . More than 40 % of patients required hospitalization within 1 year ; however , atrial fibrillation or flutter was the primary discharge diagnosis in only 38.4 % of cases . Eleven percent of patients underwent repeat ablation within 1 year . Renal impairment ( hazard ratio , 2.07 ; 95 % confidence interval , 1.66–2.58 ) , age ≥80 years ( hazard ratio , 3.09 ; 95 % confidence interval , 2.32–4.11 ) , and heart failure ( hazard ratio , 2.54 ; 95 % confidence interval , 2.07–3.13 ) were major risk factors for 1-year mortality . Advanced age was a major risk factor for all adverse outcomes . Conclusions — Major complications after catheter ablation for atrial fibrillation were associated with advanced age but were fairly infrequent . Few patients underwent repeat ablation . R and omized trials are needed to inform risk-benefit calculations for older persons with drug-refractory , symptomatic atrial fibrillation BACKGROUND Maintenance of sinus rhythm is the main therapeutic goal in patients with atrial fibrillation . However , recurrences of atrial fibrillation and side effects of antiarrhythmic drugs offset the benefits of sinus rhythm . We hypothesized that ventricular rate control is not inferior to the maintenance of sinus rhythm for the treatment of atrial fibrillation . METHODS We r and omly assigned 522 patients who had persistent atrial fibrillation after a previous electrical cardioversion to receive treatment aim ed at rate control or rhythm control . Patients in the rate-control group received oral anticoagulant drugs and rate-slowing medication . Patients in the rhythm-control group underwent serial cardioversions and received antiarrhythmic drugs and oral anticoagulant drugs . The end point was a composite of death from cardiovascular causes , heart failure , thromboembolic complications , bleeding , implantation of a pacemaker , and severe adverse effects of drugs . RESULTS After a mean ( + /-SD ) of 2.3+/-0.6 years , 39 percent of the 266 patients in the rhythm-control group had sinus rhythm , as compared with 10 percent of the 256 patients in the rate-control group . The primary end point occurred in 44 patients ( 17.2 percent ) in the rate-control group and in 60 ( 22.6 percent ) in the rhythm-control group . The 90 percent ( two-sided ) upper boundary of the absolute difference in the primary end point was 0.4 percent ( the prespecified criterion for noninferiority was 10 percent or less ) . The distribution of the various components of the primary end point was similar in the rate-control and rhythm-control groups . CONCLUSIONS Rate control is not inferior to rhythm control for the prevention of death and morbidity from cardiovascular causes and may be appropriate therapy in patients with a recurrence of persistent atrial fibrillation after electrical cardioversion BACKGROUND Despite consensus that patients with atrial fibrillation benefit from warfarin sodium anticoagulation , little is known about national trends and predictors of anticoagulant use . METHODS We analyzed 1062 visits by patients with atrial fibrillation to r and omly selected office-based physicians included in the National Ambulatory Medical Care Surveys in 1980 , 1981 , 1985 , and 1989 through 1993 .  Warfarin and aspirin use in these patients was extrapolated to national patterns and logistic regression was used to determine independent predictors . RESULTS Patients with atrial fibrillation made an estimated 1.3 ( 1980 ) to 3.1 ( 1992 ) million annual visits to physicians .  Warfarin use in atrial fibrillation increased from 7 % in 1980 and 1981 to 32 % in 1992 and 1993 ( P < .001 for trend ) . In 1992 and 1993 , patients 80 years or older were significantly less likely to be taking warfarin  ( 19 % ) compared with younger patients ( 36 % ) , but showed similar rates of increase from 1980 and 1981 to 1992 and 1993 . In 1992 and 1993 ,  anticoagulation therapy  was significantly more likely to be reported in visits to cardiologists ( 32 % ) and general internists ( 40 % ) compared with general and family practitioners ( 15 % ) , but was similar in women ( 34 % ) and men ( 30 % ) . Residents of the South ( 16 % ) had significantly lower rates of warfarin use than those in other regions of the United States ( 36 % ) .  Aspirin use increased from 3 % to 10 % ( P = .001 for trend ) and showed little overlap with warfarin use . Multiple logistic regression indicated that more recent year , residence outside the South , patient aged 65 to 74 years , and visits to cardiologists and internists increased the likelihood of warfarin use . CONCLUSIONS Anticoagulant use for atrial fibrillation has increased dramatically . The substantial increase from 1989 and 1990 to 1992 and 1993 coincided with the publication of several r and omized clinical trials reporting the benefits of warfarin . Although it is unrealistic to expect universal warfarin use , the 1992 and 1993 rate of 32 % is probably suboptimal given the benefit of anticoagulation in preventing embolic strokes . The oldest patients , in whom warfarin may have its greatest benefit , appear to have the lowest rates of anticoagulant use Aims The ESC-EHRA Atrial Fibrillation Ablation Long-Term registry is a prospect i ve , multinational study that aims at providing an accurate picture of contemporary real-world ablation for atrial fibrillation ( AFib ) and its outcome . Methods and results A total of 104 centres in 27 European countries participated and were asked to enrol 20–50 consecutive patients scheduled for first and re-do AFib ablation .  Pre-procedural , procedural and 1-year follow-up data were captured on a web-based electronic case record form . Overall , 3630 patients were included , of which 3593 underwent an AFib ablation ( 98.9 % ) . Median age was 59 years and 32.4 % patients had lone atrial fibrillation .  Pulmonary vein isolation was attempted in 98.8 % of patients and achieved in 95–97 % . AFib-related symptoms were present in 97 % . In-hospital complications occurred in 7.8 % and one patient died due to an atrioesophageal fistula . One-year follow-up was performed in 3180 ( 88.6 % ) at a median of 12.4 months ( 11.9–13.4 ) after ablation : 52.8 % by clinical visit , 44.2 % by telephone contact and 3.0 % by contact with the general practitioner . At 12-months , the success rate with or without antiarrhythmic drugs ( AADs ) was 73.6 % . A significant portion ( 46 % ) was still on AADs . Late complications included 14 additional deaths ( 4 cardiac , 4 vascular , 6 other causes ) and 333 ( 10.7 % ) other complications . Conclusion AFib ablation in clinical practice is mostly performed in symptomatic , relatively young and otherwise healthy patients . Overall success rate is satisfactory , but complication rate remains considerable and a significant portion of patients remain on AADs . Monitoring after ablation shows wide variations . Antithrombotic treatment after ablation shows insufficient guideline -adherence OBJECTIVE Atrial fibrillation is the most frequently encountered postoperative arrhythmic complication after coronary artery bypass grafting .  Ischemic preconditioning has proved a potent endogenous factor in suppressing ischemia-reperfusion-induced arrhythmias . The protective effect of ischemic preconditioning on atrial fibrillation after coronary artery bypass grafting has not been studied . The purpose of the present study was to investigate whether ischemic preconditioning had an effect on postoperative atrial fibrillation in patients undergoing coronary artery bypass grafting . METHODS Eighty-five patients undergoing coronary artery bypass grafting  were r and omized into ischemic preconditioning and control groups . Holter data from 24-hour electrocardiography were collected 1 day before the operation to the second postoperative day . Atrial fibrillation was registered as positive if any atrial fibrillation event occurred . RESULTS The overall incidence of postoperative atrial fibrillation and sustained atrial fibrillation was 34.1 % and 27.1 % , respectively . The occurrence of atrial fibrillation was significantly lower in the ischemic preconditioning group ( 21.4 % in patients undergoing ischemic preconditioning and 46.5 % in control subjects , P = .015 ) . Preoperative recent unstable angina did not influence the incidence of atrial fibrillation . Patients with atrial fibrillation had longer intensive care unit stays and compromised postoperative hemodynamic outcomes . Binary logistic regression analysis showed that  ischemic preconditioning , preoperative mean heart rate , and postoperative pulmonary capillary wedge pressure were the independent predictors of atrial fibrillation . CONCLUSIONS Postcoronary artery bypass grafting atrial fibrillation is associated with more complicated postoperative outcome . Higher preoperative heart rate and postoperative pulmonary capillary wedge pressure were the independent predictors of atrial fibrillation . Recent unstable angina is not related to the occurrence of postcoronary artery bypass grafting atrial fibrillation . Ischemic preconditioning significantly suppresses postcoronary artery bypass grafting atrial fibrillation , suggesting that ischemic preconditioning can be used as an effective prophylactic method for postoperative atrial fibrillation OBJECTIVES The aim of this study was to compare -- in patients with persistent and permanent atrial fibrillation (AF)--the  efficacy and safety of left atrial ablation with that of a biatrial approach . BACKGROUND Left atrium-based catheter ablation of AF , although very effective in the paroxysmal form of the arrhythmia , has an insufficient efficacy in patients with persistent and permanent AF . METHODS Eighty highly symptomatic patients ( age , 58.6 + /- 8.9 years ) with persistent ( n = 43 ) and permanent AF ( n = 37 ) , refractory to antiarrhythmic drugs , were r and omized to two different ablation approaches guided by electroanatomical mapping . A procedure including circumferential pulmonary vein , mitral isthmus , and cavotricuspid isthmus ablation was performed in 41 cases ( left atrial ablation group ) . In the remaining 39 patients ( biatrial ablation group ) , the aforementioned approach was integrated by the following lesions in the right atrium : intercaval posterior line , intercaval septal line , and electrical disconnection of the superior vena cava . RESULTS During follow-up ( mean duration 14 + /- 5 months ) , AF recurred in 39 % of patients in the left atrial ablation group and in 15 % of patients in the biatrial ablation group ( p = 0.022 ) . Multivariable Cox regression analysis showed that ablation technique was an independent predictor of AF recurrence during follow-up . CONCLUSIONS In patients with persistent and permanent AF , circumferential pulmonary vein ablation , combined with linear lesions in the right atrium , is feasible , safe , and has a significantly higher success rate than left atrial and cavotricuspid ablation alone AIMS Digoxin is recommended for long-term rate control in paroxysmal , persistent , and permanent atrial fibrillation ( AF ) . While some analyses suggest an association of digoxin with a higher mortality in AF , the intrinsic nature of this association has not been examined in propensity-matched cohorts , which is the objective of the current study . METHODS AND RESULTS In Atrial Fibrillation Follow-up Investigation of Rhythm Management ( AFFIRM ) , 4060 patients with paroxysmal and persistent AF were r and omized to rate ( n = 2027 ) vs. rhythm ( n = 2033 ) control strategies . Of these , 1377 received digoxin as initial therapy and 1329 received no digoxin at baseline . Propensity scores for digoxin use were estimated for each of these 2706 patients and used to assemble a cohort of 878 pairs of patients receiving and not receiving digoxin , who were balanced on 59 baseline characteristics . Matched patients had a mean age of 70 years , 40 % were women , and 11 % non-white . During the 3.4 years of the mean follow-up , all-cause mortality occurred in 14 and 13 % of matched patients receiving and not receiving digoxin , respectively [ hazard ratio ( HR ) associated with digoxin use : 1.06 ; 95 % confidence interval ( CI ) : 0.83 - 1.37 ; P = 0.640 ] . Among matched patients , digoxin had no association with all-cause hospitalization ( HR : 0.96 ; 95 % CI : 0.85 - 1.09 ; P = 0.510 ) or incident non-fatal cardiac arrhythmias ( HR : 0.90 ; 95 % CI : 0.37 - 2.23 ; P = 0.827 ) . Digoxin had no multivariable-adjusted or propensity score-adjusted associations with these outcomes in the pre-match cohort . CONCLUSIONS In patients with paroxysmal and persistent AF , we found no evidence of increased mortality or hospitalization in those taking digoxin as baseline initial therapy Despite the widespread use of amiodarone in non-surgical patients , its role in the management of supraventricular tachyarrhythmias after cardiac surgery is not clear . We set out to compare the relative efficacy of amiodarone and digoxin in the management of  atrial fibrillation and flutter in the early postoperative period . This prospect i ve r and omised trial comprised 30 patients , previously in sinus rhythm , who developed sustained atrial fibrillation or flutter following myocardial revascularisation , valve surgery or combined procedures .  Amiodarone was administered as an intravenous loading dose followed by a continuous infusion . Digoxin was given as an intravenous loading dose followed by oral maintenance therapy . Electrocardiographic and haemodynamic monitoring  was continued for 24 h after the commencement of treatment . There was a marked reduction in heart rate in both groups , mainly in the first 6 h , from 146 to 89 beats per minute in the amiodarone group and from 144 to 95 in the digoxin group . At the end of the 24 h , one of the 15 patients in the amiodarone group and 3 of the 15 patients in the digoxin group remained in atrial fibrillation . No patient in either group developed adverse reactions . We conclude that intravenous amiodarone therapy is safe and at least as effective as digoxin in the initial management of arrhythmias after cardiac surgery BACKGROUND Atrial fibrillation is the most common cardiac arrhythmia , and no current therapy is ideal for control of this condition . Experimental studies suggest that angiotensin II-receptor blockers ( ARBs ) can influence atrial remodeling , and some clinical studies suggest that they may prevent atrial fibrillation . METHODS We conducted a large , r and omized , prospect i ve , placebo-controlled , multicenter trial to test whether the ARB valsartan could reduce the recurrence of atrial fibrillation . We enrolled patients who were in sinus rhythm but had had either two or more documented episodes of atrial fibrillation in the previous 6 months or successful cardioversion for atrial fibrillation in the previous 2 weeks . To be eligible , patients also had to have underlying cardiovascular disease , diabetes , or left atrial enlargement . Patients were r and omly assigned to receive valsartan or placebo . The two primary end points were the time to a first recurrence of atrial fibrillation and the proportion of patients who had more than one recurrence of atrial fibrillation over the course of 1 year . RESULTS A total of 1442 patients were enrolled in the study .  Atrial fibrillation recurred in 371 of the 722 patients ( 51.4 % ) in the valsartan group , as compared with 375 of 720 ( 52.1 % ) in the placebo group ( adjusted hazard ratio , 0.97 ; 96 % confidence interval [ CI ] , 0.83 to 1.14 ; P=0.73 ) . More than one episode of atrial fibrillation occurred in 194 of 722 patients ( 26.9 % ) in the valsartan group and in 201 of 720 ( 27.9 % ) in the placebo group ( adjusted odds ratio , 0.89 ; 99 % CI , 0.64 to 1.23 ; P=0.34 ) . The results were similar in all predefined subgroups of patients , including those who were not receiving angiotensin-converting-enzyme inhibitors . CONCLUSIONS Treatment with valsartan was not associated with a reduction in the incidence of recurrent atrial fibrillation . ( Clinical Trials.gov number , NCT00376272 . CONTEXT Atrial fibrillation is a common , but potentially preventable , complication following coronary artery bypass graft ( CABG ) surgery . OBJECTIVES To assess the nature and consequences of atrial fibrillation after CABG surgery and to develop a comprehensive risk index that can better identify patients at risk for atrial fibrillation . DESIGN , SETTING , AND PARTICIPANTS Prospect i ve observational study of 4657 patients undergoing CABG surgery between November 1996 and June 2000 at 70 centers located within 17 countries , selected using a systematic sampling technique . From a derivation cohort of 3093 patients , associations between predictor variables and postoperative atrial fibrillation were identified to develop a risk model , which was assessed in a validation cohort of 1564 patients . MAIN OUTCOME MEASURE New-onset atrial fibrillation after CABG surgery . RESULTS A total of 1503 patients ( 32.3 % ) developed atrial fibrillation after CABG surgery . Postoperative atrial fibrillation was associated with subsequent greater re source use as well as with cognitive changes , renal dysfunction , and infection . Among patients in the derivation cohort , risk factors associated with atrial fibrillation were advanced age ( odds ratio [ OR ] for 10-year increase , 1.75 ; 95 % confidence interval [ CI ] , 1.59 - 1.93 ) ; history of atrial fibrillation ( OR , 2.11 ; 95 % CI , 1.57 - 2.85 ) or chronic obstructive pulmonary disease ( OR , 1.43 ; 95 % CI , 1.09 - 1.87 ) ; valve surgery ( OR , 1.74 ; 95 % CI , 1.31 - 2.32 ) ; and postoperative withdrawal of a beta-blocker ( OR , 1.91 ; 95 % CI , 1.52 - 2.40 ) or an angiotensin-converting enzyme ( ACE ) inhibitor ( OR 1.69 ; 95 % CI , 1.38 - 2.08 ) . Conversely , reduced risk was associated with postoperative administration of beta-blockers ( OR , 0.32 ; 95 % CI , 0.22 - 0.46 ) , ACE inhibitors ( OR , 0.62 ; 95 % CI , 0.48 - 0.79 ) , potassium supplementation ( OR , 0.53 ; 95 % CI , 0.42 - 0.68 ) , and nonsteroidal anti-inflammatory drugs ( OR , 0.49 ; 95 % CI , 0.40 - 0.60 ) . The result ing multivariable risk index had adequate discriminative power with an area under the receiver operating characteristic ( ROC ) curve of 0.77 in the validation sample . Forty-three percent ( 640/1503 ) of patients who had atrial fibrillation after CABG surgery experienced more than 1 episode of atrial fibrillation . Predictors of recurrent atrial fibrillation included older age , history of congestive heart failure , left ventricular hypertrophy , aortic atherosclerosis , bicaval venous cannulation , withdrawal of ACE inhibitor or beta-blocker therapy , and use of amiodarone or digoxin ( area under the ROC curve of 0.66 ) . Patients with recurrent atrial fibrillation had longer hospital stays and experienced greater infectious , renal , and neurological complications than those with a single episode . CONCLUSIONS We have developed and vali date d models predicting the occurrence of atrial fibrillation  after CABG surgery based on an analysis of a large multicenter international cohort . Our findings suggest that treatment with beta-blockers , ACE inhibitors , and /or nonsteroidal anti-inflammatory drugs may offer protection . Atrial fibrillation after CABG surgery is associated with important complications The safety and efficacy of the intravenous ( IV ) calcium channel blocker , verapamil , in controlling the ventricular response or converting to sinus rhythm patients with atrial flutter or atrial fibrillation were assessed . Seventeen patients ( nine with atrial flutter and eight with atrial fibrillation ) with these arrhythmias that were difficult to control pharmacologically were chosen for the study . All patients at the time of study were receiving digoxin .  Either verapamil or placebo was chosen r and omly and a bolus of 0.075 mg/kg ( up to 5 mg ) was administered . Twelve patients had a marked reduction in their ventricular response after IV administration of verapamil ( seven with atrial flutter and five with atrial fibrillation ) . None of these 12 patients converted ( nonconverters ) . The average reduction in heart rate was from 120 + /- 6 beats per minute to a minimum of 83 + /- 13 beats per minute within 20 minutes after drug administration . Verapamil was found to convert five patients with atrial arrhythmias to sinus rhythm ( two with atrial flutter and three with atrial fibrillation ) ( converters ) . In addition , three patients with atrial arrhythmias of less than one month who did not convert with parenteral drug therapy converted within 24 hours while receiving the oral drug . Converters had their supraventricular arrhythmias of significantly shorter duration ( median , three hours v 30 days ) and tended to have smaller left atrial size ( 3.8 + /- 0.7 cm v 4.3 + /- 1.3 cm ) compared with the nonconverters . We conclude that verapamil is safe and effective when administered IV to patients with atrial flutter and fibrillation for control of ventricular response . In short duration atrial arrhythmias , conversion to sinus rhythm is likely once the ventricular response is controlled OBJECTIVES Currently available antiarrhythmic drugs have limited efficacy for short-term , rapid termination of atrial fibrillation and atrial flutter . BACKGROUND Ibutilide fumarate is an investigational class III antiarrhythmic agent that prolongs repolarization by increasing the slow inward sodium current and by blocking the delayed rectifier current . It can be administered intravenously and has a rapid onset of electrophysiologic effects . METHODS The efficacy and safety of ibutilide were studied in 200 patients with atrial flutter > 3 h in duration or atrial fibrillation 3 h to 90 days in duration . Patients were r and omized to receive a single intravenous dose of placebo or an infusion of ibutilide fumarate at 0.005 , 0.010 , 0.015 or 0.025 mg/kg body weight over 10 min . Conversion was defined as termination of the atrial arrhythmia during or within 60 min after infusion . Forty-one patients received placebo  and 159 received ibutilide ( 0.005 mg/kg [ n = 41 ] , 0.010 mg/kg [ n = 40 ] , 0.015 mg/kg [ n = 38 ] or 0.025 mg/kg [ n = 40 ] ) . RESULTS The arrhythmia terminated in 34 % of drug-treated patients . The rates of successful arrhythmia termination were 3 % for placebo and 12 % , 33 % , 45 % and 46 % , respectively , for 0.005- , 0.010- , 0.015- and 0.025-mg/kg ibutilide . The placebo and 0.005-mg/kg ibutilide groups had lower success rates than all other dose groups ( p < 0.05 ) . The mean time to termination of the arrhythmia was 19 min ( range 3 to 70 ) from the start of infusion . Successful arrhythmia termination was not affected by enlarged left atrial diameter , decreased ejection fraction , presence of valvular heart disease or the use of concomitant medications ( beta-adrenergic blocking agents , calcium channel blocking agents or digoxin ) . Arrhythmia termination was not predicted by the magnitude of corrected QT interval prolongation but was associated with a shorter duration of atrial arrhythmia . The most frequent adverse events in ibutilide-treated patients were sustained and nonsustained polymorphic ventricular tachycardia ( 3.6 % ) . All patients with sustained polymorphic ventricular tachycardia were successfully treated with direct current cardioversion and had no recurrence . The occurrence of proarrhythmia did not correlate with ibutilide plasma concentration . CONCLUSIONS These data demonstrate that ibutilide is able to rapidly terminate atrial fibrillation and atrial flutter BACKGROUND Large trials have demonstrated that rate control is an acceptable alternative for rhythm control . However , optimal heart rate during atrial fibrillation ( AF ) remains unknown . Aim of this analysis was to compare outcome between rate control > or = 80 and < 80 beat/min in patients with persistent atrial fibrillation . METHODS In the RAte Control versus Electrical cardioversion for persistent atrial fibrillation study , 522 patients were included , and 256 were r and omized to rate control . This post hoc analysis included patients r and omized to rate control . Patients were divided according to their mean resting heart rate during follow-up , < 80 beat/min ( n = 75 ) or > or = 80 beat/min ( n = 139 ) . The end point , a composite of cardiovascular mortality , heart failure , thromboembolic complications , bleeding , pacemaker implantation , and severe drug side effects , was compared between both groups . RESULTS During follow-up ( 2.3 + /- 0.6 years ) , a significant difference between both groups in heart rate was observed ( 72 + /- 5 vs 90 + /- 8 beat/min ; P < .001 ) . Rate control drugs were not significantly different between both groups . New York Heart Association class and fractional shortening remained unchanged in both groups . There were 17 ( 23 % ) end points in the low heart rate group and 24 ( 17 % ) in the higher heart rate group ( absolute difference , 5.4 [ -7.3 to 8.2 ] ; P = ns ) . Independent predictors for the primary end point were coronary artery disease , digoxin use , and interrupted anticoagulation , not high heart rate . Quality of life was comparable in both groups during follow-up . CONCLUSIONS In patients treated with a rate control strategy  , no differences were observed in terms of cardiovascular morbidity , mortality , and quality of life between the observed differences in level of rate control throughout follow-up Ninety patients undergoing coronary bypass surgery were studied prospect ively by bedside and subsequent ambulatory electrocardiographic monitoring to investigate the incidence , possible causes , and prevention of atrial fibrillation . Patients with good left ventricular function were divided r and omly into a control group or groups treated with digoxin or propranolol . In the control group the incidence of atrial fibrillation was 27 % and of significant ventricular extrasystoles 3 % . Propranolol reduced the incidence of atrial fibrillation ( 14.8 % ) , whereas digoxin had no effect and increased the incidence of ventricular extrasystoles . Age , sex , severity of symptoms , cardiomegaly , heart failure , previous myocardial infa rct ion , and number of grafts did not affect the result . The operative myocardial ischaemic time was related to the occurrence of atrial fibrillation . There was also a significant relation between atrial fibrillation and bundle branch block . Atrial fibrillation is common after coronary artery grafting ; it may be due to diffuse myocardial ischaemia or hypothermic injury . The incidence may be reduced by beta blockade Currently d , l-sotalol is widely used to prevent recurrence of atrial fibrillation and /or atrial flutter , although a r and omized dose-response study has not previously been conducted to guide therapy for this indication . This study summarizes findings of a double-blind , placebo-controlled , multicenter , r and omized trial evaluating the efficacy , safety , and dose-response relation of 3 fixed doses of d , l-sotalol ( 80 , 120 , and 160 mg twice daily ) for the maintenance of sinus rhythm in 253 patients with atrial fibrillation and /or atrial flutter . All patients were in sinus rhythm at r and omization . Treatment ( 69 patients on placebo , 59 on 80 mg , 63 on 120 mg , and 62 on 160 mg given twice daily ) was continued for 12 months or until documented recurrence of symptomatic atrial fibrillation and /or flutter . Transtelephonic electrocardiographic monitoring  was used to detect symptomatic recurrences . Demographic characteristics were not different in the 4 groups . Structural heart disease was present in 57 % of patients . Patients with a history of heart failure were excluded . The time from r and omization to symptomatic arrhythmia recurrence was significantly longer in the 2 higher d , l-sotalol dose groups than in the placebo group . The median times to recurrence were 27 , 106 , 229 , and 175 days for the placebo , 80 , 120 , and 160 mg groups , respectively . There were no deaths or cases of torsade de pointes , sustained ventricular tachycardia , or ventricular fibrillation reported . Thus , d , l-sotalol appeared to be both safe and effective in maintaining sinus rhythm in patients with symptomatic atrial fibrillation and /or flutter . Further , the 120-mg twice daily dose appeared to provide the most favorable benefit and /or risk Objective Ibutilide , a class III antiarrhythmic drug , has been shown to convert atrial fibrillation to sinus rhythm more rapidly than procainamide or sotalol . Our objective was to compare the efficacy and safety of ibutilide and amiodarone in patients after cardiac surgery . Design Prospect i ve , r and omized , double-blinded study . Setting Intensive care unit of a university hospital . Patients Forty adults with an onset of atrial fibrillation within 3 hrs after admission . Interventions Before the administration of antiarrhythmic drugs , a 24-hr Holter electrocardiograph was attached . Patients in the ibutilide group received ibutilide 0.008 mg/kg body weight over 10 mins ; treatment was repeated if atrial fibrillation or flutter persisted . If sinus rhythm was not achieved within 4 hrs , amiodarone 5 mg/kg was administered over 30 mins , followed by amiodarone 15 mg/kg over 24 hrs . Patients in the amiodarone group received amiodarone 5 mg/kg over 30 mins , followed by amiodarone 15 mg/kg over 24 hrs if atrial fibrillation or flutter continued . Measurements and Main Results Within the first 4 hrs , atrial fibrillation was converted in nine of 20 patients ( 45 % ) in group ibutilide and in ten of 20 patients ( 50 % ) in group amiodarone ( not significant ) . Mean time for conversion overall was 385 mins in group ibutilide and 495 mins in group amiodarone ( not significant ) . In group amiodarone , the protocol was discontinued in two patients because of severe arterial hypotension . Atrial fibrillation recurred in 11 of 20 patients ( 55 % ) in group ibutilide and in seven of 20 patients ( 35 % ) in group amiodarone ( not significant ) . Ventricular arrhythmia did not occur during the first 24 hrs of the protocol . Conclusions Ibutilide has no significant advantage over amiodarone for the conversion of atrial fibrillation to sinus rhythm in either time to conversion or conversion overall , but severe hypotension was not seen with ibutilide STUDY OBJECTIVES To investigate the efficacy and safety of amiodarone administered as the drug of first choice in the conversion of atrial fibrillation , regardless of its duration . DESIGN : Prospect i ve , r and omized , controlled clinical study . SETTING : Tertiary cardiac referral center . PATIENTS Two-hundred eight consecutive patients ( 102 men ; mean [ + /- SD ] age , 65 + /- 10 years ) with atrial fibrillation . INTERVENTIONS One-hundred eight patients received amiodarone , and 100 patients received placebo treatment . Patients r and omized to amiodarone received 300 mg IV for 1 h , and then 20 mg/kg for 24 h. They were also given 600 mg/d orally , divided into three doses , for 1 week , and thereafter 400 mg/d for 3 weeks . Patients r and omized to placebo treatment received an identical amount of saline solution IV over 24 h , and oral placebo treatment for 1 month . MEASUREMENTS AND RESULTS Baseline clinical characteristics were similar in the two groups . Conversion to sinus rhythm was achieved in 87 of 108 patients ( 80.05 % ) who received amiodarone , and in 40 of 100 patients ( 40 % ) in the placebo group ( p < 0.0001 ) . Statistical analysis showed that the duration of the arrhythmia and the size of the left atrium affected both the likelihood of conversion to sinus rhythm and the time to conversion in both groups . No side effects requiring discontinuation of treatment were observed in either group . CONCLUSIONS Amiodarone appears to be safe and effective in the termination of atrial fibrillation . However , extreme cases with a large left atrium and long-lasting arrhythmia need long-term therapy BACKGROUND The optimal pharmacologic means to restore and maintain sinus rhythm in patients with atrial fibrillation remains controversial . METHODS In this double-blind , placebo-controlled trial , we r and omly assigned 665 patients who were receiving anticoagulants and had persistent atrial fibrillation to receive amiodarone ( 267 patients ) , sotalol ( 261 patients ) , or placebo ( 137 patients ) and monitored them for 1 to 4.5 years . The primary end point was the time to recurrence of atrial fibrillation beginning on day 28 , determined by means of weekly transtelephonic monitoring . RESULTS Spontaneous conversion occurred in 27.1 percent of the amiodarone group , 24.2 percent of the sotalol group , and 0.8 percent of the placebo group , and direct-current cardioversion failed in 27.7 percent , 26.5 percent , and 32.1 percent , respectively . The median times to a recurrence of atrial fibrillation were 487 days in the amiodarone group , 74 days in the sotalol group , and 6 days in the placebo group according to intention to treat and 809 , 209 , and 13 days , respectively , according to treatment received . Amiodarone was superior to sotalol ( P<0.001 ) and to placebo ( P<0.001 ) , and sotalol was superior to placebo ( P<0.001 ) . In patients with ischemic heart disease , the median time to a recurrence of atrial fibrillation was 569 days with amiodarone therapy and 428 days with sotalol therapy ( P=0.53 ) . Restoration and maintenance of sinus rhythm significantly improved the quality of life and exercise capacity . There were no significant differences in major adverse events among the three groups . CONCLUSIONS Amiodarone and sotalol are equally efficacious in converting atrial fibrillation to sinus rhythm .  Amiodarone is superior for maintaining sinus rhythm , but both drugs have similar efficacy in patients with ischemic heart disease . Sustained sinus rhythm is associated with an improved quality of life and improved exercise performance BACKGROUND In the elderly the impact of atrial fibrillation on mortality and morbidity is substantial . Oral anticoagulant therapy reduces the risk of stroke by 70 % ; nevertheless , it remains largely underused . We evaluated , in a community prospect i ve study , the factors associated with embolic events and death and the feasibility of oral anticoagulant therapy managed by general practitioners . METHODS We enrolled at the Trieste Cardiovascular Center 229 patients aged > or = 65 years with non-rheumatic atrial fibrillation . At baseline , each patient underwent a transesophageal echocardiography and received instructions about oral anticoagulation . Patients were regularly followed by their general practitioner and finally evaluated at the Center . RESULTS At baseline , the mean age was 73 years , 14 % of patients were free of heart disease , 27 % had had a previous embolic event , and 33 % had an atrial thrombus . After a 5-year follow-up , 85 % of the patients had been admitted to hospital , 17 % had suffered an embolic event , and 35 % were dead . Diabetes and the presence of a low flow in the left atrial appendage were predictive of embolic events . Heart failure , spontaneous echocontrast and aortic plaques were predictive of death . Anticoagulant therapy increased from 14 to 34 % but the incidence of major bleeding did not change . The patients on anticoagulant therapy at follow-up constituted the group with the worst cardiovascular profile and embolic rate , but had a lower death rate ( 19 % ) compared with those on antiplatelet therapy ( 32 % ) and with those without antithrombotic therapy ( 67 % ) . The hospitalization rates were respectively 78 , 83 and 100 % . CONCLUSIONS In a group of elderly patients followed by their general practitioner with the support of a specialized cardiologic unit , oral anticoagulant therapy was well tolerated and associated with a significant decrease in mortality and hospitalization Background Pulmonary vein isolation alone is ineffective in maintaining sinus rhythm in up to one third of patients with paroxysmal atrial fibrillation ( AF ) . We compared pulmonary vein antral isolation plus additional limited ablation along the inferoposterior left atrium and epicardially within the adjacent coronary sinus ( PVAI + CS ) to pulmonary vein antral isolation ( PVAI ) alone in patients with paroxysmal AF . Methods Forty-two consecutive patients with paroxysmal AF were prospect ively r and omized to PVAI vs. PVAI + CS . All patients were seen 3 , 6 , 12 , and 18 months after ablation and underwent 24-h ambulatory Holter monitoring . Results Following a single procedure , 17 out of 22 patients ( 77 % ) remained arrhythmia free off antiarrhythmic medication after PVAI at 18 months vs. 10 out of 20 ( 50 % ) after PVAI + CS ( p < 0.01 ) . After PVAI , three patients had recurrent paroxysmal AF , and two had atrial tachycardia , whereas after PVAI + CS , three patients had recurrent paroxysmal AF , and seven had atrial tachycardia . All patients in the PVAI + CS group with atrial tachycardia who underwent a second procedure were found to have peri-mitral macro-reentry as the underlying mechanism . Eighty-one percent of patients remained arrhythmia free off medication after 1.09 procedures in the PVAI group vs. 80 % after 1.35 procedures in the PVAI + CS group ( p < 0.01 ) . Conclusion The addition of limited ablation along the inferoposterior left atrium and within the adjacent coronary sinus to PVAI alone did not reduce the recurrence rate of paroxysmal atrial fibrillation and was associated with an increased rate of peri-mitral macro-reentrant atrial tachycardia OBJECTIVES We sought to characterize the predictors of incident congestive heart failure ( CHF ) , as determined by central adjudication , in a community-based elderly population . BACKGROUND The elderly constitute a growing proportion of patients admitted to the hospital with CHF , and CHF is a leading source of morbidity and mortality in this group . Elderly patients differ from younger individuals diagnosed with CHF in terms of biologic characteristics . METHODS We analyzed data from the Cardiovascular Health Study , a prospect i ve population -based study of 5,888 elderly people > 65 years old ( average 73 + /- 5 , range 65 to 100 ) at four locations . Multiple laboratory measures of cardiovascular structure and function , blood chemistries and functional assessment s were obtained . RESULTS During an average follow-up of 5.5 years ( median 6.3 ) , 597 participants developed incident CHF ( rate 19.3/1,000 person-years ) . The incidence of CHF increased progressively across age groups and was greater in men than in women . On multivariate analysis , other independent predictors included prevalent coronary heart disease , stroke or transient ischemic attack at baseline , diabetes , systolic blood pressure ( BP ) , forced expiratory volume 1 s , creatinine > 1.4 mg/dl , C-reactive protein , ankle-arm index < 0.9 , atrial fibrillation , electrocardiographic ( ECG ) left ventricular ( LV ) mass , ECG ST-T segment abnormality , internal carotid artery wall thickness and decreased LV systolic function . Population -attributable risk , determined from predictors of risk and prevalence , was relatively high for prevalent coronary heart disease ( 13.1 % ) , systolic BP > or = 140 mm Hg ( 12.8 % ) and a high level of C-reactive protein ( 9.7 % ) , but was low for subnormal LV function ( 4.1 % ) and atrial fibrillation ( 2.2 % ) . CONCLUSIONS The incidence of CHF is high in the elderly and is related mainly to age , gender , clinical and sub clinical coronary heart disease , systolic BP and inflammation . Despite the high relative risk of subnormal systolic LV function and atrial fibrillation , the actual population risk of these for CHF is small because of their relatively low prevalence in community-dwelling elderly people OBJECTIVE This study undertook to determine if the presence of atrial fibrillation in patients with asymptomatic and symptomatic left ventricular dysfunction was associated with increased mortality and , if so , whether the increase could be attributed to progressive heart failure or arrhythmic death . BACKGROUND Atrial fibrillation is a common condition in heart failure with the potential to impact hemodynamics and progression of left ventricular systolic dysfunction as well as the electrophysiologic substrate for arrhythmias . The available data do not conclusively define the effect of atrial fibrillation on prognosis in heart failure . METHODS A retrospective analysis of the Studies of Left Ventricular Dysfunction Prevention and Treatment Trials was conducted that compared patients with atrial fibrillation to those in sinus rhythm at baseline  for the risk of all-cause mortality , progressive pump-failure death and arrhythmic death . RESULTS The patients with atrial fibrillation at baseline , compared to those in sinus rhythm , had greater all-cause mortality ( 34 % vs. 23 % , p < 0.001 ) , death attributed to pump-failure ( 16.7 % vs. 9.4 % , p < 0.001 ) and were more likely to reach the composite end point of death or hospitalization for heart failure ( 45 % vs. 33 % , p < 0.001 ) , but there was no significant difference between the groups in arrhythmic deaths . After multivariate analysis , atrial fibrillation remained significantly associated with all-cause mortality ( relative risk [ RR ] 1.34 , 95 % confidence interval [ CI ] 1.12 to 1.62 , p=0.002 ) , progressive pump-failure death ( RR 1.42 , 95 % CI 1.09 to 1.85 , p=0.01 ) , the composite end point of death or hospitalization for heart failure ( RR 1.26 , 95 % CI 1.03 to 1.42 , p=0.02 ) , but not arrhythmic death ( RR 1.13 ; 95 % CI 0.75 to 1.71 ; p=0.55 ) . CONCLUSIONS The presence of atrial fibrillation in patients with asymptomatic and symptomatic left ventricular systolic dysfunction is associated with an increased risk for all-cause mortality , largely explained by an increased risk for pump-failure death . These data suggest that atrial fibrillation is associated with progression of left ventricular systolic dysfunction Background — Information on comparative outcome between radiofrequency catheter ablation ( RFA ) and antiarrhythmic drugs ( AADs ) > 1 year after r and omization is important for clinical decision-making . Methods and Results — A total of 198 patients ( age , 56±10 years ) with paroxysmal atrial fibrillation were r and omly assigned to RFA ( 99 patients ) or to AADs ( 99 patients ) . We evaluated efficacy of RFA or AADs in a comparable 48-month follow-up period according to intention-to-treat analysis . Cardiac rhythm was assessed with daily transtelephonic transmissions . Quality of life was also analyzed . At 4 years , among the 99 patients first assigned to RFA , the procedure was repeated because of recurrent atrial fibrillation/atrial tachycardia in 27 patients ( 27.3 % ) . Among the 99 patients r and omly assigned to AADs , 87 ( 87.9 % ) crossed over to undergo RFA and 4 years after r and om assignment only 12 ( 12.1 % ) were in sinus rhythm with AAD alone without ablation . Despite the high level of crossovers , at 4 years the intention-to-treat analysis showed that 72.7 % of patients in the ablation arm and 56.5 % of those initially r and omly assigned to AADs were free of recurrent atrial fibrillation/atrial tachycardia ( P=0.017 ) . During the follow-up , 19.2 % of AAD patients progressed to persistent atrial fibrillation before switching to RFA . RFA significantly improved quality of life ( P<0.001 ) , whereas before crossing over to RFA , patients receiving AADs showed poorer quality of life . Except for new left atrial tachycardia , there were no serious complications caused by RFA . Conclusions — With follow-up extended to 4 years after r and omly assigned , ablation remains superior to antiarrhythmic drug in these patients with paroxysmal atrial fibrillation . Clinical Trial Registration — URL : http://www . clinical trials.gov . Unique identifier : NCT00340314 BACKGROUND One quarter of strokes are of unknown cause , and sub clinical atrial fibrillation may be a common etiologic factor . Pacemakers can detect sub clinical episodes of rapid atrial rate , which correlate with electrocardiographically documented atrial fibrillation . We evaluated whether sub clinical episodes of rapid atrial rate detected by implanted devices were associated with an increased risk of ischemic stroke in patients who did not have other evidence of atrial fibrillation . METHODS We enrolled 2580 patients , 65 years of age or older , with hypertension and no history of atrial fibrillation , in whom a pacemaker or defibrillator had recently been implanted . We monitored the patients for 3 months to detect sub clinical atrial tachyarrhythmias ( episodes of atrial rate > 190 beats per minute for more than 6 minutes ) and followed them for a mean of 2.5 years for the primary outcome of ischemic stroke or systemic embolism .  Patients with pacemakers  were r and omly assigned to receive or not to receive continuous atrial overdrive pacing . RESULTS By 3 months , sub clinical atrial tachyarrhythmias detected by implanted devices had occurred in 261 patients ( 10.1 % ) . Sub clinical atrial tachyarrhythmias were associated with an increased risk of clinical atrial fibrillation ( hazard ratio , 5.56 ; 95 % confidence interval [ CI ] , 3.78 to 8.17 ; P<0.001 ) and of ischemic stroke or systemic embolism ( hazard ratio , 2.49 ; 95 % CI , 1.28 to 4.85 ; P=0.007 ) . Of 51 patients who had a primary outcome event , 11 had had sub clinical atrial tachyarrhythmias detected by 3 months , and none had had clinical atrial fibrillation by 3 months . The population attributable risk of stroke or systemic embolism associated with sub clinical atrial tachyarrhythmias was 13 % . Sub clinical atrial tachyarrhythmias remained predictive of the primary outcome after adjustment for predictors of stroke ( hazard ratio , 2.50 ; 95 % CI , 1.28 to 4.89 ; P=0.008 ) . Continuous atrial overdrive pacing did not prevent atrial fibrillation . CONCLUSIONS Sub clinical atrial tachyarrhythmias , without clinical atrial fibrillation , occurred frequently in patients with pacemakers and were associated with a significantly increased risk of ischemic stroke or systemic embolism . ( Funded by St. Jude Medical ; ASSERT Clinical Trials.gov number , NCT00256152 . ) BACKGROUND Most of the published research on atrial fibrillation ( AF ) is limited to studies in the developed world and included mainly Caucasian patients . Data about women with AF among other ethnicities is very limited . OBJECTIVES The aim of this study was to compare the clinical characteristics , treatment and outcome of women to men hospitalized with AF in a middle-eastern country . METHODS Retrospective analysis of prospect i ve registry of all patients hospitalized with AF in Qatar from 1991 through 2010 was made . Clinical characteristics , management , and outcomes of AF patients were compared according to gender . RESULTS During the 20-years period ; 1417 women and 2432 men were hospitalized for AF . Women were 5 years older and more likely to have diabetes mellitus , hypertension , and chronic renal impairment and were also less likely to be current smokers and to have ischemic heart disease and impaired left ventricular function when compared to men . There was no gender preference in the use of anticoagulation . The prevalence of concomitant ischemic heart disease and hypertension increased , while the prevalence of valvular heart disease and heart failure decreased among patients hospitalized with AF over the study period . In-hospital mortality and stroke rates were comparable between the two groups . CONCLUSIONS Women hospitalized with atrial fibrillation were older in age and had higher prevalence of co-morbid cardiovascular risk factors compared to men whereas , mortality and stroke rates were comparable A trial fibrillation is characterized by a lack of organized electrical and mechanical atrial activity that results in an irregular heartbeat and increased risks for congestive heart failure , thromboembolism , and death [ 1 - 3 ] . Since 1962 , direct-current cardioversion has been used to restore sinus rhythm in patients with atrial fibrillation [ 4 ] . However , successful cardioversion , with the sudden resumption of sinus rhythm , is itself associated with an increased risk for embolic stroke , which can result when thrombi in the left atrial appendage are dislodged [ 5 - 12 ] . Transesophageal echocardiography ( TEE ) is an excellent method with which to detect thrombi in the left atrial appendage [ 13 - 19 ] . Its use has therefore been proposed as a way to allow cardioversion to be done earlier and more safely than would be possible with conventional therapy , which consists of a total of 7 weeks of treatment with warfarin [ 14 - 23 ] . Recent studies [ 15 - 19 ] indicate that TEE-guided cardioversion with short-term anticoagulation therapy may have several advantages over the conventional approach . These advantages include a decreased risk for embolism , which results from the avoidance of cardioversion in patients who have thrombi in the left atrial appendage [ 15 ] ; a decreased risk for bleeding , which occurs because anticoagulation therapy can be briefer [ 19 ] ; greater initial conversion to and long-term maintenance of sinus rhythm , which result from doing cardioversion earlier [ 18 , 19 ] ; and greater cost-effectiveness , which results from the decreased incidence of embolic stroke [ 17 ] . The ACUTE ( Assessment of Cardioversion Using Transesophageal Echocardiography ) Pilot Study was a multicenter , r and omized clinical trial design ed to compare TEE-guided cardioversion with conventional management of cardioversion in patients with atrial fibrillation who have cardioversion [ 19 ] . The study had two objectives : to assess the general feasibility of a TEE-guided approach to cardioversion and to determine the general safety of the TEE-guided approach by comparing its clinical outcome with those of conventional management . Methods Patient Selection Patients who were c and i date s for electrical cardioversion were eligible for inclusion if they had atrial fibrillation , or atrial flutter with a history of atrial fibrillation , lasting longer than 2 days . Patients were excluded if they had received anticoagulant therapy for more than 7 days , had required urgent cardioversion as a result of hemodynamic instability , had had a cardioembolic event within the previous month , had contraindications to TEE or warfarin , were women with childbearing potential in whom pregnancy could not be excluded , were unable to give informed consent , or were unable to return for a follow-up visit . Our study protocol was approved by the institutional review boards at all clinical sites , and all patients provided written informed consent in advance . Study Protocol Patients who met the inclusion criteria were r and omly assigned to receive either a  conventional or a  TEE-guided approach to cardioversion .  R and omization was done using presealed , opaque envelopes that were computer generated and distributed to each clinical site ( Figure 1 ) . R and om assignments were stratified by site and were generated in blocks of six . Figure 1 . The ACUTE ( Assessment of Cardioversion Using Transesophageal Echocardiography ) study protocol . The conventional approach to cardioversion was that recommended by the American College of Chest Physicians : 3 weeks of therapeutic warfarin therapy , then cardioversion , then 4 weeks of warfarin therapy , and then a follow-up examination at the end of the 4 weeks [ 23 ] . Prothrombin times were monitored regularly , and the target international normalized ratio ( INR ) was 2 to 3 . If assigned to the TEE group , patients began receiving anticoagulation therapy at their initial visit . The goal was to have patients therapeutically anticoagulated ( therapeutic anticoagulation was defined as a partial thromboplastin time 1.5 to 2.5 times control values or an INR of 2.0 to 3.0 ) at the time of and after the planned cardioversion , for a total of 4 weeks of therapy . The initial choice of antithrombotic agent was determined by whether the patient was an inpatient or an outpatient at the time of r and omization : Heparin was used for in patients ; warfarin was administered to out patients . Transesophageal echocardiography , with subsequent cardioversion within 24 hours , was then scheduled as soon as stable therapeutic anticoagulation was assured . For example , if a patient was hospitalized and intravenous heparin therapy was administered , TEE was done as soon as a stable therapeutic partial thromboplastin time could be documented ( for 24 to 36 hours ) ; subsequent cardioversion was done if the presence of a thrombus was excluded . A 4- to 5-day overlap of warfarin therapy and intravenous heparin therapy was often necessary to maintain adequate anticoagulation after cardioversion . If the patient was to be managed as an outpatient , warfarin therapy was initiated on the day of study enrollment , and TEE and subsequent possible cardioversion were scheduled for at least 5 to 7 days later . Again , cardioversion was done when the patient was therapeutically anticoagulated , and all patients received maintenance therapy with warfarin for 4 weeks after cardioversion [ 15 ] . In the TEE group , cardioversion was done immediately after or within 24 hours of TEE because of the potential for thrombus formation in the period between TEE and cardioversion . If thrombi were detected in the left or right atrial appendages or atrial cavities , cardioversion was postponed and the patient received warfarin therapy for 4 weeks . After 4 weeks , TEE was repeated and , if no thrombus was detected , cardioversion was done . If a thrombus was still present , another 4-week course of warfarin therapy was administered and cardioversion was not done [ 15 ] . Clinical Outcomes Our feasibility outcomes were frequency of cardioversion , frequency of cardioversion occurring as scheduled , time to cardioversion , and time to sinus rhythm . Our clinical safety outcomes were clinical ly apparent ischemic stroke , transient ischemic attack , systemic embolization , deaths related to cardioversion or episodes of bleeding , and detected episodes of clinical hemodynamic instability ( worsening congestive heart failure or hypotension ) that rendered the patient unable to complete the protocol . Other outcome variables were the prevalence of thrombi , the number of patients without thrombi who had early cardioversion , and the immediate and follow-up rhythms after cardioversion . These outcomes were assessed for as long as 4 weeks after cardioversion but for no longer than 8 weeks after r and omization . In the patients who did not have cardioversion and who spontaneously reverted to sinus rhythm , the variables were assessed at 4 weeks after spontaneous reversion . Study Organization and Procedures The administrative organization of the pilot study is described in the Appendix . Echocardiographic Examination Conventional transthoracic echocardiography was done in both study groups using commercially available equipment . In the TEE group , TEE was done according to st and ard techniques using phased-array biplane or multiplane transducers [ 24 - 26 ] . Complete transesophageal echocardiographic examination was done , and special attention was paid to imaging the left and right atria and left and right atrial appendages to assess the presence or absence of thrombi and spontaneous echo contrast . Echocardiographic Data Analysis Two-dimensional directed M-mode transthoracic echocardiography was used to derive the left ventricular septal and posterior wall thicknesses and the end-diastolic , end-systolic , and left atrial dimensions . Ejection fraction was calculated using st and ard techniques [ 27 , 28 ] . The maximal left atrial and right atrial areas were planimetered on-line , and the severity of mitral regurgitation was qualitatively grade d from 0 to 4 + by using color-flow mapping [ 29 ] . A thrombus was considered to be present if a mass detected in the appendage or body of the atrium appeared to be distinct from the underlying endocardium , was not caused by pectinate muscles , and was detected in more than one imaging plane . The presence or absence of spontaneous echo contrast was analyzed and defined as dynamic intracavitary echoes with a characteristic swirling pattern distinct from artifact . The degree of spontaneous echo contrast was categorized independently as absent , mild , or severe [ 30 , 31 ] . Quality Control Measures St and ard definitions of echocardiographic measurements were available to all of the clinical centers as part of a pilot operations manual . Echocardiograms at each clinical center were interpreted locally by a single physician who was highly experienced in echocardiography . Videotapes that showed the results of the first five echocardiographic examinations and all videotapes that showed thrombi were forwarded from the clinical centers to a central laboratory and overread by three experienced review ers for consensus [ 19 ] . Electrical Cardioversion Cardioversion was done by using the st and ard method of Lown and associates [ 4 ] with an initial energy of at least 40 J for atrial flutter and 200 J for atrial fibrillation . Statistical Analysis Summaries of clinical , echocardiographic , and outcome data are expressed as means or frequencies with 95 % CIs . Data that were not normally distributed were log-transformed and presented as geometric means . Outcomes were compared for the TEE and conventional therapy groups , for patients with and without thrombus ( in the TEE group only ) , and for patients in the TEE and conventional therapy groups who had cardioversion . These analyses were done using the t-test for independent groups for continuous variables and the Fisher exact test for categorical variables . StatXact ( Cytel Software , Cambridge , Massachusetts ) was used to compute binary CIs ; SAS BACKGROUND Asymptomatic , or " silent " atrial fibrillation could increase the risk of stroke . Little is known about the frequency of asymptomatic atrial fibrillation in patients who also have symptomatic atrial fibrillation ; similarly , little is known about the effect of antiarrhythmic drug therapy on asymptomatic atrial fibrillation . METHODS AND RESULTS Patients in sinus rhythm with a history of symptomatic atrial fibrillation or atrial flutter received placebo or azimilide ( 35 to 125 mg ) once daily for 6 or 9 months in 4 similar double-blind trials . The end point was the first recurrence of a symptomatic ECG-documented supraventricular arrhythmia . Routine transtelephonic electrocardiograms , in the absence of symptoms , were recorded for 30 seconds every 2 weeks until patients completed follow-up or documented a symptomatic supraventricular arrhythmia . Of the 1380 patients , 489 received placebo .  Among these patients receiving placebo , 303 transmitted at least one routine ECG while asymptomatic . Asymptomatic atrial fibrillation was recorded in 50 ( 17 % ) within 6 months and before recurrence of symptomatic supraventricular arrhythmia . In the 3 trials evaluating azimilide in therapeutic doses ( 100 and 125 mg ) , asymptomatic atrial fibrillation occurred in 49 of 382 ( 13 % ) receiving azimilide and 43 of 233 ( 18 % ) receiving placebo . Although drug effect on time to first asymptomatic event was not statistically significant ( hazard ratio , 0.70 ; P=0.09 ) , there was a 40 % reduction in asymptomatic atrial fibrillation on azimilide compared with placebo ( P=0.03 ) when repeated observations were considered . CONCLUSIONS Asymptomatic atrial fibrillation is common in untreated patients with a history of symptomatic atrial fibrillation ( and is likely underestimated by this analysis ) . Azimilide may reduce the occurrence of this silent arrhythmia OBJECTIVE The preventative effect of statins on  postoperative atrial fibrillation  has been hypothesized . However , all studies to date have examined patients who did not receive statins  before their further allocation to treatment or no treatment . Because guidelines recommend the routine use of statins in patients with coronary artery disease , we set out to examine the effect of intensive statin pretreatment versus continuation of usual statin dose on atrial fibrillation after cardiac surgery . METHODS Patients receiving routine statin treatment and undergoing coronary artery bypass surgery or aortic valve replacement with no history of atrial fibrillation or antiarrhythmic medication were r and omized to receive atorvastatin 80 mg or atorvastatin 10 mg for 7 days before surgery in a single-blind fashion . The primary end point was the development of postoperative atrial fibrillation during hospital stay . RESULTS A total of 104 consecutive patients were included . Postoperative atrial fibrillation occurred in 33 patients ( 32.4 % ) . No significant differences were found in demographics , medical history , or intraoperative variables between treatment groups , with the exception of higher rate of β-blocker use in the atorvastatin 10 mg group ( 75 % vs 53 % , P = .002 ) and previous myocardial infa rct ion ( 62 % vs 42 % , P = .049 ) . The incidence of postoperative atrial fibrillation was lower in the atorvastatin 80 mg group when compared with the atorvastatin 10 mg group , but this difference did not reach statistical significance ( 29 % vs 36 % , P = .43 ) . CONCLUSIONS High-dose atorvastatin for 7 days before cardiac surgery conferred a nonsignificant reduction in postoperative atrial fibrillation when compared with a low-dose regimen . A larger study would be necessary to confirm the beneficial effect of high-dose statins in this setting Multiple trials have suggested the use of digoxin , digoxin and propranolol , or timolol to prevent atrial fibrillation after coronary artery bypass grafting . No trial has evaluated the efficacy of digoxin verus propranolol . Furthermore , the predictors of postoperative atrial fibrillation and the long-term consequence of atrial fibrillation that reverts to sinus rhythm have not been established . One hundred fifty patients were r and omized to receive no drug , propranolol ( 20 mg every 6 hours ) , or digoxin ( 0.5 mg followed by 0.25 mg daily ) . Twenty-seven patients were excluded from data analysis . In the remaining 123 patients , no preoperative parameter ( age , sex , diabetes , hypertension , smoking , electrocardiographic p wave morphology , or preoperative digoxin or propranolol therapy ) , intraoperative parameter ( bypass time , aortic cross-clamp time , or number of vessels bypassed ) , or postoperative parameter ( peak creatinine kinase , congestive heart failure , or pericarditis ) by univariate or multivariate analysis predicted patients at risk for atrial fibrillation . Sustained atrial fibrillation developed in 37.5 % of control and 32.6 % of digoxin-treated patients . Only 16.2 % of propranolol-treated patients had sustained atrial fibrillation ( p less than 0.03 ) . There were no in-hospital complications in those patients with atrial fibrillation . After 26 + /- 7 months follow-up , those patients with postoperative atrial fibrillation had no increased incidence of angina , cerebral vascular accident , myocardial infa rct ion , or sudden death . Therefore , in this select population , propranolol prophylaxis is effective but discretionary Atrial fibrillation ( AF ) is one of the most common cardiac arrhythmias in the adult population .  Propafenone is a class 1c antiarrhythmic agent that has an electrophysiologic profile suggesting that it might be potentially effective in recent-onset AF . The present study was undertaken , therefore , to examine the time course as well as the frequency of successful conversion in patients with recent-onset AF treated with propafenone administered orally . Fifty patients with recent-onset AF were recruited into 2 groups : 25 patients were given propafenone , 150 mg every 4 h , and 25 patients served as a control group and received verapamil ( a drug known to slow the ventricular response but not to restore sinus rhythm ) 40 mg , every 4 h and up to 48 h or until conversion to sinus rhythm occurred . Of the 50 patients , 2 refused to continue the study and another 2 were excluded because of left heart failure . Conversion to sinus rhythm occurred in 21 of 24 patients ( 87 percent ) in the propafenone group as compared with 9 of 22 ( 41 percent ) in the verapamil group ( p < 0.001 ) . In 10 patients in the propafenone group , conversion occurred within 12 h , within 24 h in another 9 patients , and between 24 and 48 h in the remaining 2 patients . There was no correlation between the duration of AF prior to entry into the study and the subsequent incidence of and time to conversion with propafenone . With respect to cause of AF , all groups showed a high incidence of conversion . Two patients developed heart failure during treatment and one patient ( in the verapamil group ) developed embolic stroke while still having atrial fibrillation . We conclude that in patients with AF , the prognosis for conversion to sinus rhythm within 48 h , with propafenone , is excellent ( 87 percent ) and safe Background : Patients with rheumatic heart disease with atrial fibrillation incur significant morbidity and mortality . Which approach , ventricular rate control or maintenance of sinus rhythm , in this setting might be superior is not known . The role of amiodarone in this patient population for maintaining sinus rhythm has not been evaluated . Methods and Results : We prospect ively studied 144 patients with chronic rheumatic atrial fibrillation in a double-blind protocol in which rhythm control ( group I ) , comprising 48 patients each with amiodarone ( group Ia ) and placebo ( group Ib ) , were compared with each other and with patients in a ventricular rate control group ( group II ) in which the effects by diltiazem were determined ( n = 48 , open-label ) . Direct current cardioversion was attempted in group I. The mean age of the study population was 38.6 ± 10.3 years , left atrial size , 4.7 ±0.6 cm ; atrial fibrillation duration , 6.1 ± 5.4 years ; and 72.9 % had valvular interventions performed . At 1 year , 45 patients with sinus rhythm in group I compared with 48 in group II demonstrated an increase in exercise time ( 2.6 ± 1.9 vs. 0.6 ± 2.5 min , P = .001 ) , improvement in New York Heart Association class of 1 or more ( P = .002 ) , and improvement in the quality -of-life score of one or greater ( P = 0.01 ) with no difference in hospitalizations , systemic bleeds , or thromboembolism . Five patients died in group II ; none died in group I ( P = .02 ) . In group I , 73 of 87 ( 83.9 % ) patients converted to sinus rhythm and 45 of 86 ( 52.3 % ) patients maintained the rhythm at 1 year . Conversion rates were 38 of 43 ( 88.4 % ) with amiodarone versus 34 of 44 ( 77.3 % ) with placebo ( P = .49 ) ; the corresponding rate for maintaining sinus rhythm was 29 of 42 ( 69.1 % ) versus 16 of 44 ( 36.4 % ) ( P = .008 ) . A larger number of electrical cardioversions were required in the placebo group ( 2.1 vs. 1.4 , P = .011 ) . Conclusions : Maintenance of sinus rhythm is superior to ventricular rate control in patients with rheumatic atrial fibrillation with respect to effects on exercise capacity , quality of life , morbidity , and possibly mortality . Sinus rhythm could be restored in most patients , and amiodarone was superior to placebo in the restoration and maintenance of sinus rhythm Background : Although warfarin has been extensively studied in clinical trials , little is known about rates of hemorrhage attributable to its use in routine clinical practice . Our objective was to examine incident hemorrhagic events in a large population -based cohort of patients with atrial fibrillation who were starting treatment with warfarin .  Methods : We conducted a population -based cohort study involving residents of Ontario ( age ≥ 66 yr ) with atrial fibrillation who started taking warfarin between Apr. 1 , 1997 , and Mar. 31 , 2008 . We defined a major hemorrhage as any visit to hospital for hemorrage . We determined crude rates of hemorrhage during warfarin treatment , overall and stratified by CHADS2 score ( congestive heart failure , hypertension , age ≥ 75 yr , diabetes mellitus and prior stroke , transient ischemic attack or thromboembolism ) . Results : We included 125 195 patients with atrial fibrillation who started treatment with warfarin during the study period . Overall , the rate of hemorrhage was 3.8 % ( 95 % confidence interval [ CI ] 3.8%–3.9 % ) per person-year . The risk of major hemorrhage was highest during the first 30 days of treatment . During this period , rates of hemorrhage were 11.8 % ( 95 % CI 11.1%–12.5 % ) per person-year in all patients and 16.7 % ( 95 % CI 14.3%–19.4 % ) per person-year among patients with a CHADS2 scores of 4 or greater . Over the 5-year follow-up , 10 840 patients ( 8.7 % ) visited the hospital for hemorrhage ; of these patients , 1963 ( 18.1 % ) died in hospital or within 7 days of being discharged . Interpretation : In this large cohort of older patients with atrial fibrillation , we found that rates of hemorrhage are highest within the first 30 days of warfarin therapy . These rates are considerably higher than the rates of 1%–3 % reported in r and omized controlled trials of warfarin therapy . Our study provides timely estimates of warfarin-related adverse events that may be useful to clinicians , patients and policy-makers as new options for treatment become available INTRODUCTION AND OBJECTIVES Atrial fibrillation constitutes a serious public health problem because it can lead to complications . Thus , the management of this arrhythmia must include not only its treatment , but antithrombotic therapy as well . The main goal is to determine the proportion of cases of undiagnosed atrial fibrillation and the proportion of patients not being treated with oral anticoagulants . METHODS A multicenter , population -based , retrospective , cross-sectional , observational study . In all , 1043 participants over 60 years of age were r and omly selected to undergo an electrocardiogram in a prearranged appointment .  Demographic data , CHA2DS2-VASc and HAS-BLED scores , international normalized ratio results , and reasons for not receiving oral anticoagulant therapy  were recorded . RESULTS The overall prevalence of atrial fibrillation was 10.9 % ( 95 % confidence interval , 9.1%-12.8 % ) , 20.1 % of which had not been diagnosed previously . In the group with known atrial fibrillation , 23.5 % of those with CHA2DS2-VASc≥2 were not receiving oral anticoagulant therapy , and 47.9 % had a HAS-BLED score≥3 . The odds ratio for not being treated with oral anticoagulation  was 2.04 ( 95 % confidence interval , 1.11 - 3.77 ) for women , 1.10 ( 95 % confidence interval , 1.05 - 1.15 ) for more advanced age at diagnosis , and 8.61 ( 95 % confidence interval 2.38 - 31.0 ) for a CHA2DS2-VASc score<2 . Cognitive impairment ( 15.2 % ) was the main reason for not receiving oral anticoagulant therapy . CONCLUSIONS The prevalence of previously undiagnosed atrial fibrillation in individuals over 60 years of age is 20.1 % , and 23.5 % of those who have been diagnosed receive no treatment with oral anticoagulants BACKGROUND Current guidelines recommend at least 24 hours of electrocardiographic ( ECG ) monitoring after an ischemic stroke to rule out atrial fibrillation . However , the most effective duration and type of monitoring have not been established , and the cause of ischemic stroke remains uncertain despite a complete diagnostic evaluation in 20 to 40 % of cases ( cryptogenic stroke ) . Detection of atrial fibrillation after cryptogenic stroke has therapeutic implication s. METHODS We conducted a r and omized , controlled study of 441 patients to assess whether long-term monitoring with an insertable cardiac monitor ( ICM ) is more effective than conventional follow-up ( control ) for detecting atrial fibrillation in patients with cryptogenic stroke . Patients 40 years of age or older with no evidence of atrial fibrillation during at least 24 hours of ECG monitoring  underwent r and omization within 90 days after the index event . The primary end point was the time to first detection of atrial fibrillation ( lasting > 30 seconds ) within 6 months . Among the secondary end points was the time to first detection of atrial fibrillation within 12 months . Data were analyzed according to the intention-to-treat principle . RESULTS By 6 months , atrial fibrillation had been detected in 8.9 % of patients in the ICM group ( 19 patients ) versus 1.4 % of patients in the control group ( 3 patients ) ( hazard ratio , 6.4 ; 95 % confidence interval [ CI ] , 1.9 to 21.7 ; P<0.001 ) . By 12 months , atrial fibrillation had been detected in 12.4 % of patients in the ICM group ( 29 patients ) versus 2.0 % of patients in the control group ( 4 patients ) ( hazard ratio , 7.3 ; 95 % CI , 2.6 to 20.8 ; P<0.001 ) . CONCLUSIONS ECG monitoring with an ICM was superior to conventional follow-up for detecting atrial fibrillation after cryptogenic stroke . ( Funded by Medtronic ; CRYSTAL AF Clinical Trials.gov number , NCT00924638 . ) BACKGROUND Atrial fibrillation is a leading preventable cause of recurrent stroke for which early detection and treatment are critical . However , paroxysmal atrial fibrillation is often asymptomatic and likely to go undetected and untreated in the routine care of patients with ischemic stroke or transient ischemic attack ( TIA ) . METHODS We r and omly assigned 572 patients 55 years of age or older , without known atrial fibrillation , who had had a cryptogenic ischemic stroke or TIA within the previous 6 months ( cause undetermined after st and ard tests , including 24-hour electrocardiography [ ECG ] ) , to undergo additional noninvasive ambulatory ECG monitoring with either a 30-day event-triggered recorder ( intervention group ) or a conventional 24-hour monitor ( control group ) . The primary outcome was newly detected atrial fibrillation lasting 30 seconds or longer within 90 days after r and omization . Secondary outcomes included episodes of atrial fibrillation lasting 2.5 minutes or longer and anticoagulation status at 90 days . RESULTS Atrial fibrillation lasting 30 seconds or longer was detected in 45 of 280 patients ( 16.1 % ) in the intervention group , as compared with 9 of 277 ( 3.2 % ) in the control group ( absolute difference , 12.9 percentage points ; 95 % confidence interval [ CI ] , 8.0 to 17.6 ; P<0.001 ; number needed to screen , 8) . Atrial fibrillation lasting 2.5 minutes or longer was present in 28 of 284 patients ( 9.9 % ) in the intervention group , as compared with 7 of 277 ( 2.5 % ) in the control group ( absolute difference , 7.4 percentage points ; 95 % CI , 3.4 to 11.3 ; P<0.001 ) . By 90 days , oral anticoagulant therapy had been prescribed for more patients in the intervention group than in the control group ( 52 of 280 patients [ 18.6 % ] vs. 31 of 279 [ 11.1 % ] ; absolute difference , 7.5 percentage points ; 95 % CI , 1.6 to 13.3 ; P=0.01 ) . CONCLUSIONS Among patients with a recent cryptogenic stroke or TIA who were 55 years of age or older , paroxysmal atrial fibrillation was common . Noninvasive ambulatory ECG monitoring for a target of 30 days significantly improved the detection of atrial fibrillation by a factor of more than five and nearly doubled the rate of anticoagulant treatment , as compared with the st and ard practice of short- duration ECG monitoring . ( Funded by the Canadian Stroke Network and others ; EMBRACE Clinical Trials.gov number , NCT00846924 . ) BACKGROUND Atrial fibrillation after cardiac surgery is associated with increased rates of death , complications , and hospitalizations . In patients with postoperative atrial fibrillation who are in stable condition , the best initial treatment strategy --heart-rate control or rhythm control -- remains controversial . METHODS Patients with new-onset postoperative atrial fibrillation were r and omly assigned to undergo either rate control or rhythm control . The primary end point was the total number of days of hospitalization within 60 days after r and omization , as assessed by the Wilcoxon rank-sum test . RESULTS  Postoperative atrial fibrillation  occurred in 695 of the 2109 patients ( 33.0 % ) who were enrolled preoperatively ; of these patients , 523 underwent r and omization . The total numbers of hospital days in the rate-control group and the rhythm-control group were similar ( median , 5.1 days and 5.0 days , respectively ; P=0.76 ) . There were no significant between-group differences in the rates of death ( P=0.64 ) or overall serious adverse events ( 24.8 per 100 patient-months in the rate-control group and 26.4 per 100 patient-months in the rhythm-control group , P=0.61 ) , including thromboembolic and bleeding events . About 25 % of the patients in each group deviated from the assigned therapy , mainly because of drug ineffectiveness ( in the rate-control group ) or amiodarone side effects or adverse drug reactions ( in the rhythm-control group ) . At 60 days , 93.8 % of the patients in the rate-control group and 97.9 % of those in the rhythm-control group had had a stable heart rhythm without atrial fibrillation for the previous 30 days ( P=0.02 ) , and 84.2 % and 86.9 % , respectively , had been free from atrial fibrillation from discharge to 60 days ( P=0.41 ) . CONCLUSIONS Strategies for rate control and rhythm control to treat postoperative atrial fibrillation were associated with equal numbers of days of hospitalization , similar complication rates , and similarly low rates of persistent atrial fibrillation 60 days after onset . Neither treatment strategy showed a net clinical advantage over the other . ( Funded by the National Institutes of Health and the Canadian Institutes of Health Research ; Clinical Trials.gov number , NCT02132767 . ) BACKGROUND The management of emergency department ( ED ) patients with presumed recent-onset atrial fibrillation or flutter≤48h in duration varies widely . OBJECTIVE AND METHOD We conducted a prospect i ve study across three affiliated community EDs within a large integrated health care delivery system to describe the management of patients with recent-onset atrial fibrillation or flutter , to determine the safety and effectiveness of  ED cardioversion  , and to measure the incidence of thromboembolism 30 days after discharge . RESULTS We enrolled 206 patients with convenience sampling between June 2005 and November 2007 . Mean age was 64.0±14.4 years ( range 21 - 96 years ) . Patients were grouped for analysis into four categories based on whether cardioversion was 1 ) spontaneous in the ED ( 59 ; 28.6 % ) ; 2 ) attempted with electrical or pharmacological means ( 115 ; 56.3 % ) , with success in 110 ( 95.7 % ) ; 3 ) hoped for during a short stint of home observation ( 16 ; 7.8 % , 11 of which spontaneously converted to sinus rhythm within 24h ) ; or 4 ) contraindicated ( 16 ; 7.8 % ) . Of the entire group , 183 ( 88.8 % ) patients were discharged home . Adverse events requiring ED interventions were reported in 6 ( 2.9 % ; 95 % confidence interval [ CI ] 1.1 - 6.2 % ) patients , all of whom recovered . Two ( 1.0 % ; 95 % CI 0.1 - 3.5 % ) patients were found to have an embolic event on 30-day follow-up . CONCLUSIONS Our approach to ED patients with presumed recent-onset atrial fibrillation or flutter seems to be safe and effective , with a high rate of cardioversion and discharge to home coupled with a low ED adverse event and 30-day thromboembolic event rate BACKGROUND Patients with rheumatic heart disease and atrial fibrillation incur significant morbidity and mortality . It is not known which approach , rate control or maintenance of sinus rhythm might be most appropriate . The present study was undertaken to compare the strategy of ventricular rate control versus maintenance of sinus rhythm in rheumatic atrial fibrillation , and to evaluate the role of amiodarone in this patient population . METHODS AND RESULTS We prospect ively studied 144 patients with chronic rheumatic atrial fibrillation in a double-blind protocol -rhythm control ( group I : 48 patients each with amiodarone -group Ia ; and  placebo -group  Ib ) and compared the effects with the ventricular rate control ( group II ) by diltiazem ( n=48 , open-label ) . Direct current cardioversion was attempted in group I. The mean age of the study population was 38.6+/-10.3 years , left atrial size was 4.7+/-0.6 cm , atrial fibrillation duration was 6.1+/-5.4 years , and 72.9 % patients had undergone valvular interventions . At 1 year , 45 patients with sinus rhythm in group I compared to 48 patients in group II demonstrated significant increase in exercise to sinus rhythm time , had improvement in functional class and quality of life score . There was no difference in hospitalization rates , systemic bleeds or incidence of thromboembolism . Five patients died in group II but none in group I ( p=0.02 ) . In group I , 73/87 ( 83.9 % ) patients converted , and 45/86 ( 52.3 % ) patients maintained sinus rhythm at 1 year . Conversion rates were 38/43 ( 88.4 % ) with amiodarone versus 34/44 ( 77.3 % ) with placebo ( p=0.49 ) : corresponding rate for maintaining sinus rhythm was 29/42 ( 69.1 % ) versus 16/44 ( 36.4 % ) , p=0.008 respectively . CONCLUSIONS Maintenance of sinus rhythm appeared to be superior to ventricular rate control in patients with rheumatic atrial fibrillation in terms of an effect on mortality and morbidity . Sinus rhythm could be restored in the majority and amiodarone was superior to placebo in this regard Atrial fibrillation is in 20 - 50 % the most frequent dysrhythmia after coronary artery bypass grafting ( CABG ) and a possible cause for hemodynamical complications and prolongation off the medical treatment in patients . Therefore , the effect of beta-blocking with metoprolol for prevention of supraventricular arrhythmias ( SVA ) was investigated in a prospect i ve and r and omized trial . 200 patients after CABG were r and omized in a drug and control group ( average age 63.2 years , 154 male , 46 female ) . Patients of the drug group ( n=100 ) were treated with metoprolol ( 1mg/kg/BW ) beginning on day one after operation , whereas patients of the control group ( n=100 ) received therapy only in case of occurrence of atrial fibrillation .  ECG , blood pressure , and electrolyte concentrations were measured regularly until the tenth day after surgery . Reasons for exclusion were an ejection fraction ( < 30 % , SA- and AV-block or simultaneous application of epinephrine and metoprolol . There were no significant differences between the patients of drug and control group with respect to age , sex ejection fraction , previous medication , number and type of bypass grafts , cardiopulmonary bypass time , and perioperative ischemic events . However , a statistically significant difference was seen in the occurrence of supraventricular arrhythmias in both groups , 4 patients of the therapy group ( 4 % ) in contrast to 37 patients of the control ( 37 % ) developed supraventricular arrhythmias during the postoperative observation period ( p<0.0001 ) . Both groups differed in total time of hospital stay by 1.5 days ( control group : 9.83+/-2.88 days ; drug group : 8.42+/-2.81 days ) , which was statistically significant ( p<0.05 ) . All patients of the drug group could be discharged with a stable sinus rhythm , whereas 7 patients of the control group were discharged with persistent atrial fibrillation . The difference was statistically significant as well ( p<0.01 ) . Neither typical side effects of metoprolol , nor AV-blocks , bradycardia ( f<60/min ) or symptoms of low blood pressure could be observed . The conclusion of this trial is a recommendation for a preventive application of 50 mg metoprolol/day after coronary artery bypass surgery , which can reduce the incidence of SVA as well as the hospital stay statistically significant STUDY OBJECTIVES The relative risks and benefits of strategies of rate control vs rhythm control in patients with atrial fibrillation ( AF ) remain to be fully explored . DESIGN The How to Treat Chronic Atrial Fibrillation ( HOT CAFE ) Polish trial was design ed to evaluate in a r and omized , multicenter , and prospect i ve manner the feasibility and long-term outcomes of rate control vs rhythm control strategies in patients with persistent AF . PATIENTS Our study population comprised 205 patients ( 134 men and 71 women ; mean [ + /- SD ] age , 60.8 + /- 11.2 years ) with a mean AF duration of 273.7 + /- 112.4 days . The mean observation period was 1.7 + /- 0.4 years . One hundred one patients were r and omly assigned to the rate control group and received rate-slowing therapy guided by repeated 24-h Holter monitoring . Direct current cardioversion and atrioventricular junctional ablation with pacemaker placement were alternative nonpharmacologic strategies for patients with tachycardia that was resistant to medical therapy . One hundred four patients were r and omized to sinus rhythm restoration and maintenance using serial cardioversion supported by a predefined stepwise antiarrhythmic drug regimen ( ie , disopyramide , propafenone , sotalol , and amiodarone ) . In both groups , thromboembolic prophylaxis followed current guidelines . MEASUREMENTS AND RESULTS At the end of follow-up , 63.5 % of patients in the rhythm control arm remained in sinus rhythm . No significant differences in the composite end point ( ie , all-cause mortality , number of thromboembolic events , or major bleeding ) were found between the rate control group and the rhythm control group ( odds ratio , 1.98 ; 95 % confidence interval , 0.28 to 22.3 ; p > 0.71 ) . The incidence of hospital admissions was much lower in the rate control arm ( 12 % vs 74 % , respectively ; p < 0.001 ) . New York Heart Association functional class improved in both study groups , while mean exercise tolerance , as measured by the maximal treadmill workload , improved only in the rhythm control group ( 5.2 + /- 5.1 vs 7.6 + /- 3.3 metabolic equivalents , respectively ; p < 0.001 ) . The rhythm control strategy led to an increased mean left ventricular fractional shortening ( 29 + /- 7 % vs 31 + /- 7 % , respectively ; p < 0.01 ) . One episode of pulmonary embolism occurred in the rate control group despite oral anticoagulation therapy , while three patients in the rhythm control arm of the study experienced ischemic strokes ( not significant ) . CONCLUSIONS The Polish HOT CAFE study revealed no significant differences in major end points between the rate control group and the rhythm control group UNLABELLED The Atrial Fibrillation Follow-Up Investigation of Rhythm Management ( AFFIRM ) study concluded that rate control with anticoagulation was equivalent overall to rhythm control with cardioversion for long-term survival and that anticoagulation reduced the risk of stroke . We compared baseline and follow-up data for three ethnic groups : Caucasians ( n=3,599 ) , African Americans ( n=265 ) and Hispanics ( n=132 ) . Caucasians were older and more likely male , African Americans were more likely female and hypertensive , and Hispanics had higher prevalence of cardiomyopathy . Survival was better for rate control than rhythm control in Caucasians , equivalent in African Americans and better for rhythm control in Hispanics . Outcomes may be influenced by differential baseline characteristics , but low numbers of African Americans and Hispanics warrant caution in data interpretation . BACKGROUND The AFFIRM study compared a rate-control strategy to a rhythm-control strategy for the treatment of atrial fibrillation ( AF ) in patients at high risk for stroke or death . It concluded that the rhythm-control strategy offered no survival advantage , and it also confirmed the value of anticoagulation to prevent complications of AF . Data have not previously been available for specific racial ethnic population s. METHODS We compared baseline and follow-up data for the patients r and omized to rate-control versus rhythm-control in three population groups-Caucasian , African-American and Hispanic . RESULTS Among 4,060 total patients , 3,599 were Caucasian , 265 were African-American and 132 were Hispanic . At baseline , Caucasians were older and had a higher percentage of males , normal ejection fractions , AF as their only cardiac diagnosis , a prior antiarrhythmic drug failure and less congestive heart failure . African Americans were more likely to be female , had more hypertension and qualified for the study with a first episode of AF , compared to Caucasians . Hispanics had more cardiomyopathy at baseline than Caucasians . Overall survival in Caucasians at five years for the rate-control and rhythm-control groups was 78.9 % vs. 76.4 % , respectively ( p=0.04 ) ; for African Americans , 79.0 % vs. 69.4 % ( p=0.22 ) ; and for Hispanics , 66.5 % vs. 83.9 % ( p=0.01 ) . Overall , survival was not different between the three population s. However , lower rates of event-free survival were recorded for Hispanics and for African Americans ( p=0.0182 ) . CONCLUSIONS Different survival rates were found for rate-control versus rhythm-control in African-American and Hispanic patients , compared to Caucasian . These findings may be influenced by differences in baseline characteristics , but must be interpreted with caution because of the small sample sizes for African-American and Hispanic participants INTRODUCTION Intraoperative left atrial radiofrequency ( RF ) ablation recently has been suggested as an effective surgical treatment for atrial fibrillation ( AF ) . The aim of this study was to verify the outcome of this technique in a controlled multicenter trial . METHODS AND RESULTS One hundred three consecutive patients ( 39 men and 65 women ; age 62 + /- 11 years ) affected by AF underwent cardiac surgery and RF ablation in the left atrium ( RF group ) . The control group consisted of 27 patients ( 6 men and 21 women ; age 64 + /- 7 years ) with AF who underwent cardiac surgery during the same period and refused RF ablation .  Mitral valve disease was present in 89 ( 86 % ) and 25 ( 92 % ) patients , respectively ( P = NS ) . RF endocardial ablation was performed in order to obtain isolation of both right and left pulmonary veins , a lesion connecting the previous lines , and a lesion connecting the line encircling the left veins to the mitral annulus . Upon discharge from the hospital , sinus rhythm was present in 65 patients ( 63 % ) versus 5 patients ( 18 % ) in the control group ( P < 0.0001 ) . Mean time of cardiopulmonary bypass was longer in the RF group ( 148 + /- 50 min vs 117 + /- 30 min , P = 0.013 ) . The complication rate was similar in both groups , but RF ablation-related complications occurred in 4 RF group patients ( 3.9 % ) . After a mean follow-up of 12.5 + /- 5 months ( range 4 - 24 ) , 83 ( 81 % ) of 102 RF group patients were in stable sinus rhythm versus 3 ( 11 % ) of 27 in the control group ( P < 0.0001 ) . The success rate was similar among the four surgical centers . Atrial contraction was present in 66 ( 79.5 % ) of 83 patients in the RF group in sinus rhythm . CONCLUSION Endocardial RF left atrial compartmentalization during cardiac surgery is effective in restoring sinus rhythm in many patients . This technique is easy to perform and reproducible . Rare RF ablation-related complications can occur . During follow-up , sinus rhythm persistence is good , and biatrial contraction is preserved in most patients OBJECTIVE Atrial fibrillation is a common complication after cardiac surgery .  Magnesium is an effective and safe antiarrhythmic agent for arrhythmias that develop after cardiac surgery . The authors performed a study to evaluate the role of perioperative magnesium for prophylaxis of atrial fibrillation after off-pump coronary artery surgery . DESIGN R and omized controlled study . SETTING University teaching hospital . PARTICIPANTS One hundred sixty consecutive patients undergoing elective , isolated , off-pump coronary artery bypass grafting were prospect ively r and omized into 2 groups . INTERVENTIONS Patients in the magnesium group ( n = 80 ) received a 2.5-g ( 20 mEq ) magnesium sulphate infusion intraoperatively over 30 minutes , and the placebo group ( n = 80 ) received normal saline solution . MEASUREMENTS AND MAIN RESULTS Postoperative atrial fibrillation occurred in 16 of 80 patients ( 20 % ) in the magnesium group and in 18 of 80 ( 22.5 % ) in the placebo group ( p = 0.9 ) . CONCLUSION The use of 2.5 g of intraoperative magnesium showed no effect in preventing atrial fibrillation after off-pump coronary artery bypass OBJECTIVE Previous research has demonstrated that patients with atrial fibrillation ( AF ) possess very little knowledge of their disease , the consequences of AF and the benefits /risks of anti-coagulant therapy . The aim of this pilot study was to examine patient 's knowledge and perceptions of AF and their anticoagulant treatment before and after a brief educational intervention . MATERIAL S AND METHODS Ninety-three patients ( 47 male ; mean ( S.D. ) age 67.3 ( 11.6 ) years ) completed the baseline interview to assess their knowledge and perceptions of AF . All patients were given an information booklet which explained what AF was , associated symptoms , the possible causes and consequences of AF , treatment options and their benefits /risks , what the INR is and what factors may effect it . The booklet was explained to each patient by the research er and given to the patient to take away for reference . Thirty-three ( 35.5 % ) patients ( 12 men ; mean ( S.D. ) age 68.0 ( 13.6 ) years ) completed the follow-up assessment to re-assess their knowledge and perceptions of AF . RESULTS Only 49 % of patients could name their cardiac condition at baseline , although the majority were aware that AF was an arrhythmia ( 80 % baseline vs. 91 % follow-up ) . Only about half the patients perceived AF as a serious condition or were aware that AF predisposes to thromboembolism at baseline . Following the educational intervention there was a non-significant increase in patient knowledge of the risks associated with AF . Of those who completed both question naires , 52 % were aware that anticoagulants prevented blood clots , which increased to 70 % post-intervention . However , few patients were aware of the benefit of stroke prevention associated with anticoagulants at baseline ( 21 % ) or after the educational intervention ( 27 % ) . The intervention had little effect on increasing awareness of the bleeding risks associated with anticoagulants , although three in five people appeared to appreciate these risks . However , the educational intervention significantly improved patient 's knowledge of the target INR range and factors that may affect INR levels ( p=0.001 and p=0.014 , respectively ) for those who completed both question naires . CONCLUSIONS Most patients with AF possess very limited knowledge about their cardiac condition , its consequences , and how anticoagulant treatment can benefit them . This pilot study has demonstrated that a brief educational intervention with an information booklet can help to somewhat improve their knowledge about anticoagulation therapy for AF BACKGROUND Treatment with warfarin sodium is effective for stroke prevention in atrial fibrillation but many physicians hesitate to prescribe it to elderly patients presumably because of the associated risk for bleeding and the inconvenience of frequent blood tests for the patients . METHODS In the Second Copenhagen Atrial Fibrillation , Aspirin , and Anticoagulation ( AFASAK 2 ) Study , we studied the rate of bleeding events associated with the incidence of thromboembolic events in patients receiving warfarin sodium , 1.25 mg/d ; warfarin sodium , 1.25 mg/d , plus aspirin , 300 mg/d ; aspirin , 300 mg/d ; or adjusted-dose warfarin therapy aim ing at an international normalized ratio of the prothrombin time ratio ( INR ) of 2.0 to 3.0 . The study was scheduled for 6 years from May 1 , 1993 , but owing to evidence of inefficiency of low-intensity therapy plus aspirin from another study it was prematurely terminated on October 2 , 1996 . Minor and major bleeding events were recorded prospect ively . The rate of bleeding was calculated using the Kaplan-Meier method and risk factors were identified by the Cox proportional hazards model . RESULTS Of 677 included patients , 130 ( median age , 77 years ; range , 67 - 89 years ) experienced bleeding . One woman and 12 men experienced major bleeding . Four had intracranial bleeding : 2 cases were fatal and 2 were nonfatal . During treatment with mini-dose warfarin , warfarin plus aspirin , aspirin , and adjusted-dose warfarin , the annual rate of major bleeding was 0.8 % , 0.3 % , 1.4 % , and 1.1 % , respectively ( P = .20 ) . After 3 years of treatment the cumulative rate of any bleeding was 24.7 % , 24.4 % , 30.0 % , and 41.1 % ( P = .003 ) , respectively . Increasing INRvalue ( P<.001 ) and prior myocardial infa rct ion ( P = .001 ) were independent risk factors for bleeding , whereas increasing age was not . CONCLUSIONS Fixed mini-dose warfarin and aspirin alone or in combination were associated with both minor and major bleeding . The small number of major bleeding events in patients receiving adjusted-dose warfarin therapy as compared with those receiving less intensive antithrombotic treatments and the finding of no significant influence of age on the risk for bleeding indicate that even elderly patients with atrial fibrillation tolerate adjusted-dose warfarin therapy ( INR , 2.0 - 3.0 ) BACKGROUND Atrial fibrillation is the most common sustained arrhythmia in the elderly . Serum potassium is associated with ventricular arrhythmias and cardiac arrest . Little is known about the association of serum potassium with atrial fibrillation . The objective of this study was to investigate the association of serum potassium and the risk of atrial fibrillation in a population based setting . METHODS The study was performed within the prospect i ve population -based Rotterdam Study . The study population consisted of 4059 participants without atrial fibrillation at baseline for whom baseline levels of serum potassium were measured .  Atrial fibrillation was ascertained from centre visit ECG assessment s as well as medical records . RESULTS During a mean follow up of 11.8 years ( SD=5.2 yr ) , 474 participants developed atrial fibrillation . Participants with hypokalemia ( < 3.5 mmol/l ) had a higher risk of atrial fibrillation ( HR : 1.63 , 95%CI : 1.03 - 2.56 ) than those with normokalemia ( 3.5 - 5.0 mmol/l ) . This association was independent of age , sex , serum magnesium , and other potential confounders . Especially in participants with a history of myocardial infa rct ion , those with hypokalemia had a higher risk of atrial fibrillation than those with normokalemia ( HR : 3.81 , 95%-CI : 1.51 - 9.61 ) . CONCLUSIONS In this study low serum levels of potassium were associated with a higher risk of atrial fibrillation In a single-blind r and omized study , the efficacy and safety of intravenous propafenone ( 2 mg/kg body weight per 10 min ) versus flecainide ( 2 mg/kg per 10 min ) were assessed in 50 patients with atrial fibrillation or flutter . Treatment was considered successful if sinus rhythm occurred within 1 h. Conversion to sinus was achieved in 11 ( 55 % ) of 20 patients with atrial fibrillation treated with propafenone and in 18 ( 90 % ) of 20 with atrial fibrillation treated with flecainide ( p less than 0.02 ) . If atrial fibrillation was present less than or equal to 24 h , conversion to sinus rhythm was achieved in 8 ( 57 % ) of 14 patients in the propafenone group and 13 ( 93 % ) of 14 in the flecainide group ( p less than 0.05 ) . Atrial flutter was converted in two ( 40 % ) of five patients treated with propafenone and in one ( 20 % ) of five with flecainide ( p = NS ) . Mean time to conversion was 16 + /- 10 min in the propafenone group versus 18 + /- 13 min in the flecainide group ( p = NS ) . QRS lengthening ( 83 + /- 15 to 99 + /- 20 ms ) was observed only in the patients treated with flecainide ( p less than 0.001 ) . Patients successfully treated with propafenone showed significantly higher plasma levels than those whose arrhythmia did not convert to sinus rhythm . Transient adverse effects were more frequent in the flecainide group ( 40 % ) than in the propafenone group ( 8 % ) ( p less than 0.01 ) . In conclusion , at a dose of 2 mg/kg in 10 min , flecainide is more effective than propafenone for conversion of paroxysmal atrial fibrillation to sinus rhythm . However , considering the propafenone plasma levels and very few adverse effects , the dose or infusion rate , or both , used in the propafenone group may not have been sufficient to achieve an optimal effect . Neither drug seems very effective in patients with atrial flutter BACKGROUND Electric conversion of atrial fibrillation is the most widely used and effective treatment for sinus rhythm restoration . However , it has a limited success rate and a high recurrence rate . HYPOTHESIS Pretreatment with calcium channel blocker may improve the efficacy by reversing the so-called " electric remodeling " phenomenon , also related to overload in cytosolic calcium . METHODS The efficacy of diltiazem or amiodarone pretreatment ( oral , 1 month before and 1 month after conversion ) on direct-current conversion of persistent atrial fibrillation was assessed in 120 patients , r and omly assigned to 3 matched groups : A ( n = 44 , diltiazem ) ; B ( n = 46 , amiodarone ) , and C ( n = 30 , digoxin ) . RESULTS Before electric conversion , all treatments significantly decreased mean heart rate . Spontaneous conversion to sinus rhythm was achieved in 6 % of patients of group A ( 3 of 46 ) versus 25 % of group B ( 11 of 44 ) and 3 % ( 1 of 30 ) of group C ( A/C vs B , P < .005 ) . Current conversion was more successful in group B ( 91 % ) compared with group A ( 76 % ) and group C ( 67 % ) ( B vs A/C , P < .05 ) , with no difference in the electric threshold for effective conversion ( P = not significant ) . At the 24-hour time point , early relapse of atrial fibrillation was similar between groups A and B ( A , 2 % ; B , 3 % ; P = not significant ) and lower than group C ( 12 % ) ( P < .01 ) , whereas at the 1-month time point the recurrence rate was lower in group B ( 28 % ) versus groups A ( 56 % ) and C ( 78 % ) ( B vs A/C , P < .01 ) . No significant side effects were reported . CONCLUSIONS Although diltiazem seems to be as effective as amiodarone in reducing early atrial fibrillation recurrences , diltiazem is less effective in determining spontaneous or electric conversion , with a higher recurrence rate at 2 months . Diltiazem pretreatment could be considered as only a second choice treatment in those patients in whom amiodarone is contraindicated OBJECTIVE Atrial fibrillation occurs frequently after cardiac surgery and not only prolongs hospitalization but also influences the prognosis . We investigated whether l and iolol hydrochloride , an ultrashort-acting beta-blocker , could reduce postoperative atrial fibrillation in a r and omized controlled trial . METHODS The subjects were 140 patients undergoing coronary artery bypass grafting at the Nihon University School of Medicine . The primary end point was occurrence/non-occurrence of atrial fibrillation up to 1 week postoperatively . Logistic regression analysis was performed to investigate risk factors for atrial fibrillation among preoperative , perioperative , and postoperative variables . RESULTS Atrial fibrillation occurred in 7 patients ( 10 % ) in the l and iolol group versus 24 patients ( 34.3 % ) in the placebo group ; the l and iolol group had a significantly lower incidence ( P = .0006 ) . Postoperative heart rate was significantly lower in the l and iolol group than in the placebo group . On returning to the intensive care unit , the l and iolol group had significantly lower inflammatory and ischemic parameters . Medical costs were also significantly lower in the l and iolol group . Multivariate analysis revealed that significant risk factors for atrial fibrillation were a European System for Cardiac Operative Risk Evaluation of 10 or more , preoperative non-use of angiotensin receptor blockers , and non-use of l and iolol . CONCLUSIONS Postoperative atrial fibrillation was reduced by treatment with l and iolol hydrochloride . Amelioration of ischemia , an anti-inflammatory effect , and inhibition of sympathetic hypertonia by l and iolol presumably reduced the occurrence of atrial fibrillation . Hypotension or bradycardia did not develop in any of the patients , indicating the safety of this beta-blocker . These findings suggest that l and iolol hydrochloride could be useful in the perioperative management of patients undergoing cardiac surgery BACKGROUND The incremental role of bedside tissue Doppler echocardiography and B-type natriuretic peptide ( BNP ) over the clinical judgment has been recently reported in the emergency diagnosis of congestive heart failure with a normal left ventricular ejection fraction ( HFNEF ) . However , how well does this diagnostic strategy be applicable in the setting of atrial fibrillation is unknown . OBJECTIVE To investigate the usefulness of bedside tissue Doppler echocardiography and BNP in the emergency diagnosis of HFNEF in elderly patients with permanent , nonvalvular atrial fibrillation . METHODS Forty-one consecutive elderly patients with an ejection fraction > or = 50 % ( mean age 84 years ; 22 with HFNEF and 19 with noncardiac cause ) , hospitalized for acute dyspnea at rest , were prospect ively enrolled ; bedside septal E/Ea and BNP were obtained at admission . RESULTS By multivariable logistic regression analysis including the clinical judgment of heart failure , E/Ea and BNP , E/Ea ( P = 0.014 ) and BNP ( P = 0.018 ) provided independent diagnostic information . Optimal cutoffs were 13 for E/Ea ( area under the ROC curve of 0.846 , P < 0.0001 ; sensitivity 81.8 % , specificity 89.5 % ) and 253 pg/ml for BNP ( area under the ROC curve of 0.928 , P < 0.0001 ; sensitivity 86.4 % , specificity 89.5 % ) . The concordance between the clinical judgment and BNP concentration at the cutoff of 253 pg/ml correctly classified 24 of 25 patients ; E/Ea at the cutoff of 13 correctly classified 14 of the 16 patients with discrepancy . CONCLUSION Bedside tissue Doppler echocardiography and BNP provide useful additional diagnostic information over the clinical judgment for the emergency diagnosis of HFNEF in elderly patients with permanent , nonvalvular atrial fibrillation Prospect i ve data from Busselton , Western Australia , collected during triennial surveys from 1966 - 81 with follow-up of subjects to 1983 , showed that atrial fibrillation ( AF ) was frequent in elderly people and associated with increased mortality . Of 1770 people aged over 60 years , 40 were in atrial fibrillation when first seen and a further 47 developed it during follow-up . Atrial fibrillation was positively associated with angina , history of a myocardial infa rct ion and left bundle branch block . Relative mortality in those with atrial fibrillation compared with those without it , was 1.92 for all causes , 1.82 for death from cardiovascular causes ( excluding stroke ) and 3.78 for deaths from stroke , after adjustment by proportional hazards regression for confounding effects of age , sex , history of a myocardial infa rct ion , an abnormal electrocardiogram , angina , cholesterol level systolic blood pressure and Quetelet 's Index ( weight/height2 ) . The excess relative mortality declined with increasing age for both women and men . This raised relative mortality remained constant with time from the first detection of AF for all causes and cardiovascular causes but appeared to increase with time from detection for stroke death . The risk of death from stroke was greatest in the younger women . The observed risk of death from stroke in patients with AF suggests that anticoagulant use should be considered in selected patients AIMS The aim of this prospect i ve , r and omized study was to determine the efficacy of a serial external electrical cardioversion strategy in maintaining sinus rhythm after 12 months in patients with recurrent persistent atrial fibrillation . METHODS AND RESULTS Ninety patients with persistent atrial fibrillation lasting more than 72 h but less than 1 year were r and omized in a one to one fashion to repetition of up to two electrical cardioversions in the event of relapse of atrial fibrillation detected within 1 month of the previous electrical cardioversion ( Group AGG ) , or to non-treatment of atrial fibrillation relapse ( Group CTL ) .  ECGs  were scheduled at 6 h , 7 days , and 1 month .  Clinical examination and ECGs  were repeated during the 6-month and 12-month follow-up examinations .  Echocardiography  was repeated during the 6-month follow-up examination . Clinical and echocardiographic characteristics were similar in the two groups . All patients were treated with antiarrhythmic drugs before electrical cardioversion and throughout follow-up . After 12 months , sinus rhythm was maintained in 53 % of Group AGG patients and in 29 % of Group CTL patients ( P<0.03 ) . After 6 months , left ventricular ejection fraction had recovered significantly only in Group AGG ( 56.8 + /- 9.0 % at enrollment vs 60.4 + /- 9.4 % at 6 months , P < 0.001 ) . CONCLUSION These results demonstrate that an aggressive policy towards persistent atrial fibrillation by means of repetition of electrical cardioversion after early atrial fibrillation recurrence is useful in maintaining sinus rhythm after 12 months UNLABELLED The influence of age and gender on the character of paroxysmal atrial fibrillation ( PAD ) has not been described . METHODS The heart rate ( HR ) during  PAF in patients receiving placebo or antiarrhythmic therapy  was analyzed . Data from 177 24-hour Holter recordings  were analyzed to mark the onset and termination of PAF and converted into RR interval files . PAF episodes lasting at least 2 minutes and containing < or = 20 % noise were included . HR during the first 30-second segment versus during the remainder of the episode , and the duration of PAF episodes were compared among groups of different ages and sex ( Wilcoxon test ) . RESULTS 236 episodes from 55 recordings in 32 patients ( all patients : 61.4 + /- 12.8 years ; men ( 19 ) : 58.5 + /- 12.6 years ; women ( 13 ) 65.5 + /- 12.4 years , P = ns for difference in age ) fulfilled the inclusion criteria . Women had a higher mean heart rate at AF onset ( 123 + /- 35 beats/min vs 115 + /- 20 beats/min , P = 0.02 ) and during the remainder of the episode ( 120 + /- 25 beats/min vs 112 + /- 22 beats/min at the start , P = 0.01 , and 116 + /- 26 beats/min vs 108 + /- 18 beats/min subsequently , P = 0.01 ) . Episodes tended to be longer in women ( mean 89.8 min vs 50.5 min , P = NS ) and in the aged ( mean 83.8 min vs 46.9 min , P = NS ) . CONCLUSION PAF episodes are associated with faster heart rates and last longer in women , which may reflect differing autonomic responses to AF . A slower ventricular rate during PAF in older patients probably reflects an increasing prevalence of impaired atrioventricular conduction AIM The aim of our study was to compare the efficacy and safety of ibutilide and amiodarone ( intravenously ) in converting  recent-onset atrial fibrillation ( AF ) and atrial flutter ( Af )  to sinus rhythm ( SR ) . METHODS The study was prospect i ve , r and omized and included 152 ( 103 men and 49 women ) consecutive patients with AF or Af of 3 - 48 h duration .  Ibutilide is a selective class III antiarrhythmic agent which when administered intravenously can terminate AF and Af .  Amiodarone is also a class III antiarrhythmic agent that when given intravenously or orally has proved to be more effective than other agents in terminating AF and Af [ B.N. Singh , F.V. Mody , B. Lopez , J.S. Sarma . Antiarrhythmic agents for atrial fibrillation : focus on prolonging atrial repolarization . Am J Cardiol 1999 Nov 4 ; 84 : 161R-173R . ] . Seventy-nine patients ( 56 with AF and 23 with Af ) that consisted group A were treated with ibutilide .  Seventy-three ( 52 with AF and 21 with Af ) consisted group B and were treated with intravenous infusion of amiodarone . RESULTS The conversion rate of group A ( ibutilide ) was significantly higher than the conversion rate of group B ( amiodarone ) ( 80 % vs. 57 % , p=0.0054 ) . As regards the kind of arrhythmia separately , for AF there was n't significant difference ( 77 % vs. 69 % , p = ns ) whereas for Af ibutilide was superior to amiodarone ( 87 % vs. 29 % , p=0.003 ) . The conversion rates of ibutilide did n't differ for AF and Af ( 77 % vs. 87 % , p = ns ) . CONCLUSIONS Ibutilide is more effective than amiodarone in converting recent-onset Af to SR whereas both drugs are equally effective in converting recent-onset AF to SR BACKGROUND [ corrected ] Atrial fibrillation is an important risk factor for ischaemic stroke . Anticoagulation treatment with warfarin can substantially reduce the risk of stroke in people with atrial fibrillation but concerns about their side-effects have limited their use in clinical practice . However there has been little population -based research on the comorbidity associated with atrial fibrillation and on the prevalence of potential contraindications to anticoagulantion treatment among these patients . AIM To determine the prevalence of known risk factors for ischaemic stroke and possible contraindications to anticoagulant treatment among patients with atrial fibrillation . METHOD One-year prospect i ve cohort study in 60 general practice s in Engl and and Wales with a total population of 502,493 people . Age and sex specific prevalence rates and relative risks of risk factors for ischaemic stroke and possible contraindications to antithrombotic treatment  were calculated . RESULTS The number of patients who had a diagnosis of atrial fibrillation during the year was 1,414 ( 0.3 % ) patients . The prevalence of other nsk factors for ischaemic stroke in patients with atrial fibrillation increased with age in men , from 48 % ( relative risk [ RR ] = 3.78 , 95 % confidence interval [ 95 % CI ] = 3.23 - 4.41 ) at 45 to 64 years to 64 % ( RR = 2.21 , 95 % CI = 2.00 - 2.44 ) at 75years and over A similar increase of 50 % ( RR = 4.36 , 95 % CI = 3.54 - 5.38 ) to 60 % ( RR = 2.07 , 95 % CI = 1.91 - 2.23 ) was seen in women . The percentage of men with atrial fibrillation with at least one contraindication to antithrombotic treatment was 5 % at 45 to 64 years and 14 % at 75 years and over . Among women with atrial fibrillation , 7 % had a contraindication at 45 to 64 years and 16 % at 75 years and over . The all-ages relative risk of a contraindication was 1.17 ( 95 % CI = 0.92 - 1.48 ) in men and 1.53 ( 95 % CI = 1.28 - 1.83 ) in women . Forty per cent ( 575 ) of patients with atrial fibrillation had at least one risk factor for ischaemic stroke and no contraindications to antithrombotic treatment . CONCLUSION Atrial fibrillation is associated with a substantial increase in the prevalence of risk factors for ischaemic stroke . By contrast , potential contraindications for antithrombotic treatment are more evenly distributed among patients with and without atrial fibrillation . Around 40 % of patients with atrial fibrillation in primary care are at high risk of stroke and have no contraindicationsfor antithrombotic treatment In order to compare the relative efficacy of quinidine , disopyramide and a placebo in the maintenance of sinus rhythm after cardioversion from atrial fibrillation and in order to examine the incidence of side-effects , 82 patients with continuous atrial fibrillation ( duration more than 1 month but less than 3 years ) were r and omized in a double-blind fashion to receive quinidine , disopyramide or placebo . Six months after cardioversion there was no significant difference between any of the three groups as regards the number of patients remaining in sinus rhythm . The greater distortion of the atrial architecture which occurs in patients with rheumatic mitral valve disease may explain the failure of these anti-arrhythmic agents to prolong the duration of sinus rhythm in this study , in which patients with valvular heart disease comprised 76 % of the total group
They also have an increased risk for thromboembolism .
Comparing with age-matched controls , the relative risk for stroke is increased 2- to 7-fold in patients with nonrheumatic atrial fibrillation ( 3 , 8 , 13 ) , and the absolute risk for stroke is between 1 % and 5 % per year , depending on clinical characteristics ( 3 , 12 , 14 - 16 ) .
Paroxysmal atrial fibrillation disrupts the lives of patients ( 17 ) , but this perception may not be associated with frequency or duration of symptoms .
Warfarin therapy affects quality of life because of frequent blood testing and recommendations for limiting some activities .
Data Synthesis Does Aggressive Rhythm Control Improve Mortality and Morbidity Compared with Rate Control ?
Atrial fibrillation is the most common type of arrhythmia in adults , accounting for about one third of hospitalizations for arrhythmia ( 1 ) .
The prevalence increases from less than 1 % in persons younger than 60 years of age to more than 8 % in those older than 80 years of age ( 2 - 6 ) .
The incidence ranges from 0.2 % per year for men 30 to 39 years of age to 2.3 % per year in men 80 to 89 years of age ( 7 , 8) .
The age-adjusted incidence for women is about half that of men ( 9 ) .
The cardiac conditions most commonly associated with atrial fibrillation are rheumatic mitral valve disease , coronary artery disease , congestive heart failure , and hypertension ( 8 , 10 ) .
Noncardiac causes include hyperthyroidism , hypoxic conditions , surgery , and alcohol intoxication .
A predisposing condition exists in more than 90 % of cases ( 5 , 11 , 12 ) ; the remaining cases have what is called lone atrial fibrillation .
Patients with atrial fibrillation frequently have symptoms of hemodynamic compromise , ranging from irregular palpitations to the more insidious feeling of malaise .
Little is known about the direct effects of antiarrhythmic therapy and rate-control therapy on quality of life .
The American College of Cardiology/American Heart Association/European Society of Cardiology Task Force on Clinical Guidelines for the Management of Atrial Fibrillation classified atrial fibrillation into 4 types ( 20 ) : first detected episode , paroxysmal ( terminates spontaneously ) , persistent ( electrical or pharmacologic termination necessary ) , and permanent ( resistant to electrical or pharmacologic conversion or accepted by the physician ) .
The purpose of this review was to summarize the evidence that was available during formulation of the guidelines developed by the American College of Physicians ( ACP ) and the American Academy of Family Physicians ( AAFP ) for management of adult patients with nonpostoperative atrial fibrillation .
Although the relative benefits and risks of rate versus rhythm control are of paramount importance in the management of atrial fibrillation , studies directly addressed this issue only recently .