Predicting Intermittent Atrial Fibrillation in Outpatient Clinics.

BACKGROUND AND OBJECTIVES: Palpitations are the most common complaint in cardiology outpatient clinics. These palpitations may be derived from paroxysmal atrial fibrillation (AF) and can be easily overlooked. It is unclear whether inter-atrial conduction time (ICT) may predict the paroxysmal AF in out-patients that present with palpitations. We evaluated the ability of the ICT to predict paroxysmal AF in these patients. SUBJECTS AND METHODS: The study group consisted of 199 patients (110 female). All patients underwent 24-hour Holter electrocardiogram (ECG) monitoring (total of 327 Holter ECG monitorings, mean: 1.64 times per patient). Brief episodes of AF were documented in 35 patients (20 female, Group 1). The remaining patients without AF were designated as Group 2 (90 female). All patients underwent routine transthoracic echocardiographic examination. ICT was also measured by echocardiography. RESULTS: The mean age in Group 1 was greater than in Group 2 (63.02±14 vs. 51.27±16 years, p<0.001). The left atrium was larger in Group 1 than in Group 2 (39.7±3.4 vs. 37.29±4.3 mm, p<0.001). The other echocardiographic variables were comparable between the two groups. The mean ICT was significantly higher in Group 1 than in Group 2 (138±14 vs. 114±12 msn, p<0.001). The ICT of 127 ms was predictive for AF with a sensitivity of 86% and specificity of 87% (p<0.001). CONCLUSION: Our findings show that ICT was prolonged in patients with palpitations who developed a brief episode of AF in Holter ECG monitoring. ICT prolongation may be used to identify patients with palpitation that are at risk of an AF episode. Holter ECG monitoring should be repeated to detect AF episodes in patients with prolonged ICT.

Cardioversion under the guidance of transesophageal echochardiograhy in persistent atrial fibrillation: results with low molecular weight heparin.

BACKGROUND: Transesophageal echocardiography (TEE) guided cardioversion to restoration of sinus rhythm is a therapeutic option in patients with atrial fibrillation (AF). Anticoagulation at the time of and after cardioversion is necessary to prevent formation of new thrombus during atrial stunning period. We aimed to evaluate the efficacy and safety to TEE guided cardioversion with low molecular weight heparin (LMWH) in patients with atrial fibrillation. METHODS: We followed up 208 patients with persistent AF (mean age: 65.5+/-10.2 years) who were attempted TEE guided cardioversion. LMWH were used as an anticoagulant and warfarin therapy was continued. RESULTS: Cardioversion were performed in 183 patients. Sinus rhythm restored in 144 patients (78.7%). Mean follow up duration was 155 days. No cardiac death occurred. In the early follow up period (within 30 day) one thromboembolic event (0.54%) occurred in a patient who was cardioverted. Two patients who had not been cardioverted because of left atrial thrombus presented embolic stroke, one in early and another in late follow up period. All embolic complications occurred in patients who had been taking warfarin and whose INR level was subtherapeutic at the time of stroke. Sinus rhythm was maintained in 64% and total hemorrhagic complications occurred in 4.8% of the patients in long-term follow-up. CONCLUSION: TEE guided cardioversion with a short-term anticoagulation protocol using low molecular weight heparin is a safe and effective method in restoring and maintaining sinus rhythm and enables us to make earlier cardioversion in atrial fibrillation.

The relationship between angiotensin converting enzyme gene polymorphism, coronary artery disease, and stent restenosis: the role of angiotensin converting enzyme inhibitors in stent restenosis in patients with diabetes mellitus.

Patients with diabetes mellitus (DM) have advanced atherosclerosis compared with nondiabetics. Restenosis after intracoronary stent implantation occurs frequently in diabetic patients. Angiotensin II is an important growth factor for the development of neointimal hyperplasia after vascular injury. The aim of our study was to evaluate the relationships between angiotensin converting enzyme (ACE) gene insertion/deletion (I/D) polymorphism and coronary artery disease (CAD) and stent restonosis in diabetic patients. One hundred and thirty consecutive patients with CAD and 47 consecutive patients (14 males, mean age, 58.0 +/- 10.0) without CAD were enrolled in the study. All patients had type 2 (noninsulin dependent) DM. The patients with CAD underwent percutaneous transluminal coronary angioplasty (PTCA) and stenting. Ninety-four (59 males, mean age, 60.3 +/- 9.8) underwent control coronary angiography at the end of the follow-up period (mean duration, 9.1 +/- 2.9 months). ACE gene I/D genotyping was identified in all patients. No significant difference was found among patients with and without CAD with respect to ACE gene I/D polymorphism (P = 0.460). In the control coronary angiography, stent restenosis and new lesion development were comparable in each genotyping subgroup. However, a significant relationship was observed between restenosis and the use of ACE inhibitors (ACEI) in patients with D allele (ACEI ratio, 43.5% in the restenosis group and 56.5% in non-restenotic group, P < 0.05). We did not find any relationship between ACE gene I/D polymorphism and CAD and stent restenosis and new lesion development in diabetic patients. On the other hand, ACEI treatment may reduce stent restenosis in type 2 diabetic patients with D allele (DD or ID).