Catheter ablation versus standard conventional treatment in patients with left ventricular dysfunction and atrial fibrillation (CASTLE-AF) - study design. Women hospitalized with atrial fibrillation: gender differences, trends and outcome from a 20-year registry in a Middle Eastern country (1991-2010). Rationale and Design of FIRE AND ICE: A multicenter randomized trial comparing efficacy and safety of pulmonary vein isolation using a cryoballoon versus radiofrequency ablation with 3D-reconstruction. Clinical Significance of Chronic Kidney Disease and Atrial Fibrillation on Morbidity and Mortality in Patients with Acute Myocardial Infarction Impact of intensive glycemic control on the incidence of atrial fibrillation and associated cardiovascular outcomes in patients with type 2 diabetes mellitus (from the Action to Control Cardiovascular Risk in Diabetes Study). Should digoxin be proscribed in elderly subjects in sinus rhythm free from heart failure? A population-based study. Atrial fibrillation postcardiac surgery: a common but a morbid complication. Prevention of atrial fibrillation in patients with symptomatic chronic heart failure by candesartan in the Candesartan in Heart failure: Assessment of Reduction in Mortality and morbidity (CHARM) program. Substrate and Trigger Ablation for Reduction of Atrial Fibrillation (STAR AF): a randomized, multicentre, international trial†
BACKGROUND Electrical isolation of the pulmonary veins by catheter ablation is an emerging treatment modality for the treatment of atrial fibrillation ( AF ) and is increasingly used in patients with heart failure . METHODS The catheter ablation versus st and ard conventional treatment in patients with left ventricular dysfunction and atrial fibrillation trial ( CASTLE-AF ) is a r and omized evaluation of ablative treatment of atrial fibrillation in patients with left ventricular dysfunction . The primary endpoint is the composite of all-cause mortality or worsening of heart failure requiring unplanned hospitalization using a time to first event analysis . Secondary endpoints are all-cause mortality , cardiovascular mortality , cerebrovascular accidents , worsening of heart failure requiring unplanned hospitalization , unplanned hospitalization due to cardiovascular reason , all-cause hospitalization , quality of life , number of therapies ( shock and antitachycardia pacing ) delivered by the implantable cardioverter-defibrillator ( ICD ) , time to first ICD therapy , number of device-detected ventricular tachycardia and ventricular fibrillation episodes , AF burden , AF free interval , left ventricular function , exercise tolerance , and percentage of right ventricular pacing . CASTLE-AF will r and omize 420 patients for a minimum of 3 years at 48 sites in the United States , Europe , Australia , and South America 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 BACKGROUND Atrial fibrillation ( AF ) is the most common sustained cardiac arrhythmia imposing substantial morbidity and mortality . Catheter-based pulmonary vein isolation ( PVI ) using radiofrequency current ( RFC ) has become a st and ard treatment for drug-resistant and symptomatic paroxysmal AF ( PAF ) . In recent years , the cryoballoon-based technique is increasingly used as a promising alternative with a short learning curve . METHODS The FIRE AND ICE trial is a prospect i ve , r and omized , controlled , open , blinded outcome assessment , noninferiority trial comparing cryoballoon- , and RFC-based PVI .  Patients with drug-resistant PAF will be r and omized in a 1:1 matrix in multiple European centers . The primary hypothesis is that cryoballoon ablation is not inferior to RFC ablation using 3-dimensional mapping with respect to clinical efficacy . The primary endpoint is defined as the time to first documented clinical failure , including : ( 1 ) recurrence of AF ; ( 2 ) atrial flutter or atrial tachycardia ; ( 3 ) prescription of class I or III antiarrhythmic drugs ; or ( 4 ) re-ablation , whichever comes first , following a blanking period of 3 months after the index ablation procedure . The primary safety endpoint is a composite of death , stroke/transient ischemic attack , cardiac arrhythmias ( apart from AF recurrence ) causally related to the therapeutic intervention , and procedure-related serious adverse events . CONCLUSION The FIRE AND ICE trial compares 2 different technologies to perform catheter ablation of PAF with respect to efficacy and safety . It aims at providing objective data to guide selection and usage of ablation catheters in the treatment of AF Background / Aims : Atrial fibrillation ( AF ) often coexists with acute myocardial infa rct ion ( AMI ) , and chronic kidney disease ( CKD ) is a major risk for AMI . However , the combined impact of CKD and AF on the mortality and morbidity in AMI population has not been determined . Methods : Between January 2004 and December 2009 , a total of 4,738 AMI patients were enrolled prospect ively . Patients were divided into four groups according to the combined status of CKD and AF . The primary endpoint was a combination of 5-year major adverse cardiac and cerebrovascular events ( MACCE ) . Results : The prevalence of AF was significantly higher in CKD patients than in non-CKD patients ( 6.76 vs. 3.31 % , p < 0.001 ) . The highest cumulative event rate of MACCE and death was observed in patients with both CKD and AF ( 68.5 and 64.0 % ) , respectively . In multivariable analyses , compared with patients with neither AF nor CKD , hazard ratios ( HR ) for composite of MACCE were 1.66 ( 95 % CI , 1.14 - 2.41 ) , 1.24 ( 95 % CI , 1.06 - 1.46 ) , and 2.10 ( 95 % CI , 1.42 - 3.13 ) for patients with AF only , those with CKD only , and those with both CKD and AF , respectively ( p for interaction = 0.935 ) . Patients with both CKD and AF had a greatest risk for all-cause mortality ( HR 2.54 ; 95 % CI , 1.60 - 4.53 ) , and the significant synergistic interaction was observed between CKD and AF ( p for interaction = 0.015 ) . Conclusion : The combined effect of AF and CKD on the risk of MACCE after an AMI is stronger than any separate condition , and it confers a synergistic effect on the all-cause mortality risk Atrial  fibrillation ( AF )  is prevalent in patients with type 2 diabetes mellitus ( DM ) and is associated with markers of poor glycemic control ; however , the impact of glycemic control on incident AF and outcomes is unknown . The aims of this study were to prospect ively evaluate if intensive glycemic control in patients with DM affects incident AF and to evaluate morbidity and mortality in patients with DM and incident AF . A total of 10,082 patients with DM from the Action to Control Cardiovascular Risk in Diabetes ( ACCORD ) cohort were studied in a r and omized , double-blind fashion . Participants were r and omized to an intensive therapeutic strategy targeting a glycated hemoglobin level of < 6.0 % or a st and ard strategy targeting a glycated hemoglobin level of 7.0 % to 7.9 % . Incident AF occurred in 159 patients ( 1.58 % ) over the follow-up period , at a rate of 5.9 per 1,000 patient-years in the intensive-therapy group and a rate of 6.37 per 1,000 patient-years in the st and ard-therapy group ( p = 0.52 ) . In a multivariate model , predictors of incident AF were age , weight , diastolic blood pressure , heart rate , and heart failure history .  Patients with DM and new-onset AF  had a hazard ratio of 2.65 for all-cause mortality ( 95 % confidence interval 1.8 to 3.86 , p < 0.0001 ) , a hazard ratio of 2.1 for myocardial infa rct ion ( 95 % confidence interval 1.33 to 3.31 , p = 0.0015 ) , and a hazard ratio of 3.80 for the development of heart failure ( 95 % confidence interval 2.48 to 5.84 , p < 0.0001 ) . In conclusion , intensive glycemic control did not affect the rate of new-onset AF .  Patients with DM and incident AF had an increased risk for morbidity and mortality compared with those without AF Increased mortality in digoxin-treated subjects has been demonstrated in patients with recent myocardial infa rct ion . Those with congestive heart failure ( CHF ) due to causes other than myocardial infa rct ion seem to be free from this effect . No information is currently available concerning mortality in elderly people who are frequently prescribed digitalis even in the absence of CHF . The aim of this study was to investigate whether subjects improperly receiving digoxin were worse off than those not receiving this drug . This analysis is a part of CASTEL , a population -based prospect i ve study that has enrolled a cohort of 2,254 subjects aged > or = 65 years . CHF was diagnosed in 187 subjects and atrial fibrillation ( AF ) in 90 . The remaining 1,977 were free from CHF and in sinus rhythm , but 447 were treated with digitalis .  Cumulative mortality and morbid events by digitalis treatment were calculated in all these categories . Among subjects free from CHF and AF ( improper use ) , all-cause and cardiovascular mortality was significantly higher among those taking digitalis than in those who did not . Non-fatal events including CHF were also more apparent in the former than in the latter . Cox analysis confirmed digitalis as a predictor of mortality in these subjects . No effect of digitalis on survival was found in patients with CHF or AF ( proper use ) . In elderly subjects without atrial fibrillation or CHF , the use of digitalis worsens morbidity and mortality OBJECTIVES Despite all the advances in cardiac surgery , atrial fibrillation ( AF ) remains a common postoperative complication with unclear predisposing factors . Postoperative AF is often a short-lived and a self-limiting condition , but can result in debilitating and even lethal consequences . The aim of this study is to assess the effect of AF on patients postcardiac surgery . METHODS In this retrospective study , we prospect ively review ed patient data for our institution for a 10-year period ; a total of 17,379 patients with preoperative sinus rhythm ( SR ) who underwent cardiac surgery were included , of which 4984 ( 28.7 % ) had developed postoperative AF for any length of time . After propensity matching for the preoperative characteristics between the two groups ; the group with AF and the group who remained in SR , postoperative complications , in-hospital mortality , mid-term survival rate ( five years ) , and long-term survival rate ( 10 years ) were compared . RESULTS Before and after adjusting for the preoperative characteristics and type of the operation , postoperative complications , such as renal failure , surgical wound infection , stroke and myocardial infa rct ion were significantly higher in the AF group compared to the SR group ( P < 0.001 ) . Inotropic support , use of intra-aortic balloon pump , and ventilation time were also considerably higher in the AF patients ( P < 0.001 ) . In-hospital mortality was also higher in the AF group . Likewise , 30-day , mid-term and long-term mortality rates were found to be considerably higher in the AF group . CONCLUSIONS Despite all the modern anti-arrhythmic drugs , the incidence of AF remains unchanged . Patients who develop AF postcardiac surgery show a significantly worse outcome compared to those without AF . This study also highlights the importance of anticoagulation in AF to prevent the devastating consequences as a result of a cerebral stroke . We believe that not only immediate treatment of AF postoperatively should be implemented , but also measures should be taken to identify the risk factors of AF and to prevent AF postcardiac surgery BACKGROUND Atrial fibrillation ( AF ) is frequent in patients with chronic heart failure ( CHF ) . Experimental and small patient studies have demonstrated that blocking the renin-angiotensin-aldosterone system may prevent AF . In the CHARM program , the effects of the angiotensin receptor blocker c and esartan on cardiovascular mortality and morbidity were evaluated in a broad spectrum of patients with symptomatic CHF . CHARM provided the opportunity to prospect ively determine the effect of c and esartan on the incidence of new AF in this CHF population . METHODS 7601 patients with symptomatic CHF and reduced or preserved left ventricular systolic function were r and omized to c and esartan ( target dose 32 mg once daily , mean dose 24 mg ) or placebo in the 3 component trials of CHARM . The major outcomes were cardiovascular death or CHF hospitalization and all-cause mortality . The incidence of new AF was a prespecified secondary outcome . Median follow-up was 37.7 months . A conditional logistic regression model for stratified data was used . RESULTS 6379 patients ( 83.9 % ) did not have AF on their baseline electrocardiogram . Of these , 392 ( 6.15 % ) developed AF during follow-up , 177 ( 5.55 % ) in the c and esartan group and 215 ( 6.74 % ) in the placebo group ( odds ratio 0.812 , 95 % CI 0.662 - 0.998 , P = .048 ) . After adjustment for baseline covariates , the odds ratio was 0.802 ( 95 % CI 0.650 - 0.990 , P = .039 ) . There was no heterogeneity of the effects of c and esartan in preventing AF between the 3 component trials ( P = .57 ) . CONCLUSIONS Treatment with the angiotensin receptor blocker c and esartan reduced the incidence of AF in a large , broadly-based , population of patients with symptomatic CHF Aims This multicentre , r and omized trial compared three strategies of AF ablation : ablation of complex fractionated electrograms ( CFE ) alone , pulmonary vein isolation ( PVI ) alone , and combined PVI + CFE ablation , using st and ardized automated mapping software . Methods and results Patients with drug-refractory , high-burden paroxysmal ( episodes > 6 h , > 4 in 6 months ) or persistent atrial fibrillation ( AF ) were enrolled at eight centres . Patients ( n = 100 ) were r and omized to one of three arms . For CFE alone ( n = 34 ) , spontaneous/induced AF was mapped using vali date d , automated CFE software and all sites < 120 ms were ablated until AF termination/non-inducibility . For PVI ( n = 32 ) , all four PV antra were isolated and confirmed using a circular catheter . For PVI + CFE ( n = 34 ) , all four PV antra were isolated , followed by AF induction and ablation of all CFE sites until AF termination/non-inducibility . Patients were followed at 3 , 6 , and 12 months with a visit , ECG , 48 h Holter . Atrial fibrillation symptoms were confirmed by loop recording . Repeat procedures were allowed within the first 6 months . The primary endpoint was freedom from AF > 30 s at 1 year . Patients ( age 57 ± 10 years , LA size 42 ± 6 mm ) were 35 % persistent AF . In CFE , ablation terminated AF in 68 % . Only 0.4 PVs per patient were isolated as a result of CFE . In PVI , 94 % had all four PVs successfully isolated . In PVI + CFE , 94 % had all four PVs isolated , 76 % had inducible AF with additional CFE ablation , with 73 % termination of AF . There were significantly more repeat procedures in the CFE arm ( 47 % ) vs. PVI ( 31 % ) or PVI + CFE ( 15 % ) ( P = 0.01 ) . After one procedure , PVI + CFE had a significantly higher freedom from AF ( 74 % ) compared with PVI ( 48 % ) and CFE ( 29 % ) ( P = 0.004 ) . After two procedures , PVI + CFE still had the highest success ( 88 % ) compared with PVI ( 68 % ) and CFE ( 38 % ) ( P = 0.001 ) . Ninety-six percent of these patients were off anti-arrhythmics . Complications were two tamponades , no PV stenosis , and no mortality . Conclusion In high-burden paroxysmal/persistent AF , PVI + CFE has the highest freedom from AF vs. PVI or CFE alone after one or two procedures . Complex fractionated electrogram alone has the lowest one and two procedure success rates with a higher incidence of repeat procedures . Clinical Trials.gov identifier number NCT00367757
Subgroup analysis demonstrated similar trends , with higher freedom from AF in the surgical ablation group for paroxysmal AF patients .
The incidence of pacemaker implantation was higher , while no difference in stroke or cardiac tamponade was demonstrated for the surgical versus catheter ablation groups .
Current evidence suggests that epicardial ablative strategies are associated with higher freedom from AF , higher pacemaker implantation rates and comparable neurological complications and cardiac tamponade incidence to catheter ablative treatment .
BACKGROUND Atrial fibrillation ( AF ) is an increasingly prevalent condition in the ageing population , with significantly associated morbidity and mortality .
Surgical and catheter ablative strategies both aim to reduce mortality and morbidity through freedom from AF .
This review consoli date s all currently available comparative data to evaluate these two interventions .