Self- limited episodes of atrial fibrillation after direct current cardioversion predict recurrence of persistent atrial fibrillation
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Objective To evaluate if self-limited episodes of atrial fibrillation after direct current(DC) cardioversion predict re- currence of persistent atrial fibrillation. Methods Consecutive patients with persistent atrial fibrillation, scheduled for DC cardiover- sion were prospectively included in the study. Ambulatory ECG Hoher monitoring (24 h) was performed one, three and 6 weeks after successful cardioversion. Results A total of 80 patients were prospectively included in the study. Sinus rhythm was restored in 73 pa- tients (88%). At 6 weeks of follow -up 40 patients out of 73 (54%) had sinus thythm, and 33 patients (46%) had relapsed into per- sistent atrial frbrillation. Eight out of these 34 patients (24%) had bursts of atrial fibrillation at their first Holter recording, compared to 12 patients out of 40 (30%) in sinus rhythm at 6 weeks (P > 0.05). On the first, second and third Holter recording 21 patients out of 51 (41%), 22 patients out of 43 (51%) and 15 out of 40 patients (38%) had self - limited bursts of atrial fibrillation,respeetively. Condusion In patients successfully converted to sinus rhythm self- limited bursts of atrial fibrillation do not predict recurrence of persistent atrial fibrillation during 6 weeks of follow up. Brief self- limited episodes of atrial fibrillation are common, and the incidence and duration of such episodes are constant during a 6 weeks period after DC cardioversion.
Key words:
Arrhythmia; Atrial fibrillation; CardioversionParoxysmal atrial fibrillation (AF) is usually preceded by a premature atrial complex (PAC). We hypothesized that patients with a high frequency of atrial ectopic activity after restoration of sinus rhythm following direct current cardioversion would be more likely to experience recurrence of AF.Forty-four patients with documented persistent AF were studied. A 24 h Holter recording was performed from the day of external direct current cardioversion. Patients were reviewed at 1 week, 1 month, and 6 months. After 6 months, 59% of patients had experienced a recurrence of AF. Neither the frequency of PACs nor the frequency or duration of supraventricular tachycardia (SVT) episodes predicted AF recurrence (P=0.60, 0.30, and 0.42, respectively). There was a trend towards maximum rate of SVT predicting recurrence of AF (P=0.08).Frequency of supraventricular ectopy or the number and length of SVT runs in the 24 h after restoration of sinus rhythm are not strong predictors of recurrence of AF after electrical cardioversion. A larger study would be required to detect a small predictive effect.
Electrical cardioversion
Supraventricular arrhythmia
Supraventricular Tachycardia
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Stunning
Myocardial Stunning
Electrical cardioversion
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Abstract In a redesigned practice model, a structural approach to atrial fibrillation (AF) care is desirable. This includes structured follow-up visits to AF specialists to ensure continued management in AF patients. Implementing such an approach implies that professional roles are changing and there is room for shared accountability of care delivery. Continuous symptom evaluation and repeated diagnostic procedures are warranted during follow-up which require coordination of care. Providing comprehensive care requires attention to all aspects of AF management, including treatment of the arrhythmia, prevention of thromboembolic complications, as well as detection and treatment of cardiovascular risk factors and lifestyle management. Active involvement and education of patients in this process is paramount in order to achieve desired outcomes, as well as tuning the organization and delivery of care between the various specialists involved in AF management. Allied health professionals may be best placed to address certain roles in such a multidisciplinary approach.
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Our aim was to determine the immediate and long-term outcome of direct current (DC) electrical cardioversion in patients with atrial fibrillation or flutter, and to determine factors predicting clinical outcome.A retrospective one-year follow-up study of 220 patients with atrial fibrillation or flutter undergoing electrical cardioversion between September 1998 and April 2001 was done.Electrical cardioversion was successful in 82% of the patients. Multivariate analysis revealed that female gender was associated with successful cardioversion (p=0.008). Only 29% remained in sinus rhythm after the one-year follow-up. Maintenance of sinus rhythm was associated with anti-arrhythmic drug treatment (p=0.042). Relapse of atrial fibrillation was associated with reduced left ventricular ejection fraction (p=0.002). Complications occurred in 7.7% of the electrical cardioversions; of these, 1.2% were thromboembolic events.Less than one third of the patients remained in sinus rhythm after the one-year follow-up despite the use of anti-arrhythmic drugs. Electrical cardioversion is not without risk. Thorough consideration of choice of treatment in patients with atrial fibrillation or flutter is therefore important. According to Danish and international guidelines, electrical cardioversion should be considered primarily when symptoms of AF are unacceptable despite optimal frequency regulation or in patients with AF detected for the first time.
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Can We Predict the Failure of Electrical Cardioversion of Acute Atrial Fibrillation? The FinCV Study
Background Data on predictors of failure of electrical cardioversion of acute atrial fibrillation are scarce. Methods We explored 6,906 electrical cardioversions of acute (<48 hours) atrial fibrillation in 2,868 patients in a retrospective multicenter study. Results The success rate of electrical cardioversion was 94.2%. In 26% of unsuccessful cardioversions, the cardioversion was performed successfully later. Antiarrhythmic drug therapy, short (<12 hours) duration of atrial fibrillation episode, advanced age, permanent pacemaker, history of atrial fibrillation episodes within 30 days before cardioversion, and β‐blockers were independent predictors of unsuccessful electrical cardioversion. In the subgroup of patients with cardioversion of the first atrial fibrillation episode (N = 1,411), the short duration of episode (odds ratio [OR] = 2.28; 95% confidence interval [CI] 1.34–3.90, P = 0.003) and advanced age (OR = 1.03; 95% CI 1.02–1.05, P < 0.001) were the only independent predictors of unsuccessful cardioversion. After successful cardioversion, the rate of early (<30 days) clinical recurrence of atrial fibrillation was 17.3%. The index cardioversion being performed due to the first atrial fibrillation episode was the only predictor of remaining in the sinus rhythm. Conclusion A short (<12 hours) duration of acute atrial fibrillation is a significant predictor of unsuccessful cardioversion, especially during the first attack. First atrial fibrillation episode was the only predictor of remaining in the sinus rhythm.
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The aim of this study is to analysis the relationship of clinical variables to the recurrence of atiral fibrillation after cardioversion to optimize the indication for rhythm control. Retrospective study analysed medical records of the atrial fibrillation patients who have undergone cardioversion from 2000 to 2002. The univariate and multivariate associations of immediate efficacy of cardioversion and long-term results with clinical variables were analyzed. Results: 386 patients who had undergone pharmacological cardioversion or electrical cardioversion were enrolled. Almost half of the patients relapsed within 1 week after successful cardioversion. At the end of one year follow-up, 135 patients (35%) recovered from atrial fibrillation. There were no significant difference between the recurrence group and unrecurrence group in age, heart disease and the methodology of cardioversion. The predictors for the recurrence of atrial fibrillation were diameter of the left atrium ≥50mm(OR=1.86, 95%CI 1.02-3.69, P=0.0472),pre-cardioversion duration ≥7 days (OR=2.08, 95%CI 1.19-3.65, P= 0.01) and the duration of atrial fibrillation (OR=1.77, 95%CI 1.01-3.06, P= 0.0456). Conclusions:The enlargement of left atrium and long duration of atrial fibrillation before cardioversion show less successful rate and more recurrence in the future
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To analyse the safety and impact on maintenance of sinus rhythm of transoesophageal echocardiographically guided early cardioversion associated with short-term anticoagulation in a large series of patients with atrial fibrillation and atrial flutter. Patients who were candidates for cardioversion were eligible for inclusion if they had atrial fibrillation or atrial flutter lasting longer than 2 days or of unknown duration. Patients received short-term anticoagulation with warfarin or heparin and underwent transthoracic echocardiography followed by transoesophageal echocardiography. Early cardioversion was performed if no thrombus was seen on the transoesophageal study. Warfarin was maintained for 1 month after cardioversion. In patients with atrial thrombi, cardioversion was deferred and prolonged anticoagulation was prescribed. The study population included 183 patients. One hundred and sixty nine patients without atrial thrombi underwent early cardioversion. Fourteen patients with atrial thrombi (7·6%) underwent a second transoesophageal echocardiogram after a median of 4 weeks of oral warfarin, and cardioversion was performed if clot regression was documented. No patient in our study population had a clinical thromboembolic event at 1 month follow-up (95% C.I. 0–0·016). The immediate success rate of cardioversion was better among patients with atrial fibrillation <4 weeks duration compared with patients with atrial fibrillation of longer or of unknown duration: 96·6% vs 85%, respectively ( P =0·014). At 1 month follow-up, the percentage of arrhythmia relapses in patients with initially successful cardioversion was similar in the two groups (29% vs 26%, P =ns); thus the initial better outcome in patients with recent-onset arrhythmia was not lost. Transoesophageal echocardiography-guided early cardioversion in concert with short-term anticoagulation is safe. This approach permits abbreviation of the overall duration of atrial fibrillation and has a better impact on the maintenance of sinus rhythm for patients in whom the duration of atrial fibrillation is <4 weeks.
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Electrical cardioversion
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In a substantial number of patients, AF recurs after successful electrical cardioversion. The purpose of this study was to investigate if the atrial arrhythmias recorded immediately after cardioversion are associated with the risk of recurrence of the arrhythmia and to compare the prognostic significance of this parameter with that of other established risk factors. In a series of 71 patients, the risk factors for recurrence of AF during the first year after successful electrical cardioversion were analyzed. A new parameter that was investigated was the frequency of atrial premature beats and the presence of runs of supraventricular tachycardia in the Holter recording started immediately after the cardioversion. Age, left atrial size, left ventricular systolic function, duration of the arrhythmia before cardioversion, underlying cardiac disease, or medication taken were not found to be predictive of recurrence of the arrhythmia. However, the natural logarithm of the number of atrial premature complexes per hour of the Holter recording in the 37 patients in whom AF recurred was higher compared to that of the 34 patients who maintained sinus rhythm (P < 0.0005). The same was true if only the first 6 hours of the recording were analyzed (P < 0.0005). There was a trend for more frequent arrhythmia recurrence if runs of supraventricular tachycardia were present. The finding of > 10 atrial premature complexes per hour in the recording had a relative risk of 2.57 (1.51-4.37), a positive predictive accuracy of 76.5%, and a negative predictive accuracy of 70.3% for subsequent arrhythmia recurrence. We can conclude that frequent (> 10/hour) atrial premature complexes in the Holter recording after electrical cardioversion for AF is a significant risk factor for recurrence of the arrhythmia.
P wave
Atrial tachycardia
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