Fibrilación auricular una arritmia y un sindrome / Atrial fibrillation, an arrhythmia and a syndrome

Atrial Fibrillation (AF) is the most common sustained arrhythmia and is highly prevalent in elderly patients. It confers a higher risk for ischemic stroke, heart failure and death. The diagnosis and treatment of AF has been extensively studied and remain under constant revision. This article reviews the recent European guidelines and the advances observed with the introduction of direct oral anticoagulants in the last ten years. This new family of drugs has clear benefits in terms of efficacy and safety compared with traditional vitamin K antagonists. Treatment of most common comorbidities in patients with AF such as advanced age, heart failure, diabetes, renal failure, and others are also analyzed. New therapies for AF will be shortly available.

Validation of MyDiagnostick tool to identify atrial fibrillation in a multi-ethnic Asian population

INTRODUCTION@#MyDiagnostick is an atrial fibrillation (AF) screening tool that has been validated in the Caucasian population in the primary care setting.@*METHODS@#In our study, we compared MyDiagnostick with manual pulse check for AF screening in the community setting.@*RESULTS@#In our cohort of 671 candidates from a multi-ethnic Asian population, AF prevalence was found to be 1.78%. Of 12 candidates, 6 (50.0%) had a previous history of AF and another 6 (50.0%) were newly diagnosed with AF. Candidates found to have AF during the screening were older (72.0 ± 11.7 years vs. 56.0 ± 13.0 years, P < 0.0001) and had a higher CHADSVASC risk score (2.9 ± 1.5 vs. 1.5 ± 1.1, P = 0.0001). MyDiagnostick had a sensitivity of 100.0% and a specificity of 96.2%. In comparison, manual pulse check had a sensitivity of 83.3% and a specificity of 98.9%.@*CONCLUSION@#MyDiagnostick is a simple AF screening device that can be reliably used by non-specialist professionals in the community setting. Its sensitivity and specificity are comparable and validated across various studies performed in different population cohorts.

Impact of non-valvular atrial fibrillation on global cognitive function and executive function / 中华心血管病杂志

Objective: To explore the impact of non-valvular atrial fibrillation (AF) on the global cognitive function and executive function of patients without dementia, and to observe the differences between different types of AF. Methods: This research is a prospective and cross-sectional study. Non-dementia patients admitted to the department of neurology in the third people's hospital of Chengdu from July 2018 to July 2019 were included. Patients with non-valvular AF were included in the AF group and those with sinus rhythm were included in the control group. General clinical data and compared global cognitive function (mini-mental state examination (MMSE) and montreal cognitive assessment (MOCA)) and executive function (shape trails test (STT) and stroop color and word test (SCWT)) data were obtained and compared between 2 groups, and between different AF type groups. Results: A total of 386 participants were included, including 203 in AF group (52.6%), age was 68 (63, 71) years old, 119 were male (58.6%) and 183 in control group, age was 68 (63, 71) years old, 101 were male (55.2%). MMSE(28 (27, 29)) and MOCA (25 (22, 26)) scores were lower in AF group than those in control group (P<0.05), while STT-A time (84 (64, 140) s), STT-B time (248 (184, 351) s), STT time difference((159 (106, 245) s), SCWT-A time (50 (50, 50) s), SCWT-B time (55 (46, 63) s), SCWT-C time (100 (86, 120) s) and SCWT time interference (46 (34, 65) s) were higher than those in control group (P<0.05). Moreover, there was no difference in above indexes between paroxysmal AF and non-paroxysmal AF. Conclusion: The global cognitive function and executive function of patients with non-valvular AF are both decreased, while there is no obvious difference of the global cognitive function and executive function between paroxysmal AF and non-paroxysmal AF patients.

An Atrial Fibrillation Classification Method Study Based on BP Neural Network and SVM / 中国医疗器械杂志

Atrial fibrillation is a common arrhythmia, and its diagnosis is interfered by many factors. In order to achieve applicability in diagnosis and improve the level of automatic analysis of atrial fibrillation to the level of experts, the automatic detection of atrial fibrillation is very important. This study proposes an automatic detection algorithm for atrial fibrillation based on BP neural network (back propagation network) and support vector machine (SVM). The electrocardiogram (ECG) segments in the MIT-BIH atrial fibrillation database are divided into 10, 32, 64, and 128 heartbeats, respectively, and the Lorentz value, Shannon entropy, K-S test value and exponential moving average value are calculated. These four characteristic parameters are used as the input of SVM and BP neural network for classification and testing, and the label given by experts in the MIT-BIH atrial fibrillation database is used as the reference output. Among them, the use of atrial fibrillation in the MIT-BIH database, the first 18 cases of data are used as the training set, and the last 7 cases of data are used as the test set. The results show that the accuracy rate of 92% is obtained in the classification of 10 heartbeats, and the accuracy rate of 98% is obtained in the latter three categories. The sensitivity and specificity are both above 97.7%, which has certain applicability. Further validation and improvement in clinical ECG data will be done in next study.

Diagnóstico de Fibrilação Atrial na Comunidade Utilizando Eletrocardiograma e Autorrelato: Análise Transversal do ELSA-Brasil / Atrial Fibrillation Diagnosis using ECG Records and Self-Report in the Community: Cross-Sectional Analysis from ELSA-Brasil

Resumo Fundamento: A fibrilação ou flutter atrial (FFA) é a arritmia cardíaca sustentada mais comum. Existem poucos dados sobre a epidemiologia da FFA na América do Sul. Objetivo: O presente estudo procurou descrever a epidemiologia clínica da FFA e o uso de anticoagulantes na avaliação da linha de base do Estudo Longitudinal da Saúde do Adulto (ELSA-Brasil). Métodos: Foram analisados dados de 13.260 participantes do ELSA-Brasil. A FFA foi definida pelo eletrocardiograma ou por autorrelato. Modelos de regressão logística foram construídos para analisar fatores associados à FFA. Este estudo também analisou se idade e sexo estavam associados ao uso de anticoagulantes para evitar acidente vascular cerebral. O nível de significância foi de 5%. Resultados: A idade mediana foi de 51 anos, e 7.213 (54,4%) participantes eram mulheres. A FFA foi detectada em 333 (2,5%) participantes. O aumento da idade (razão de chances [RC]:1,05; intervalo de confiança de 95% [IC95%]: 1,04-1,07), hipertensão (RC:1,44; IC95%:1,14-1,81) coronariopatia (RC: 5,11; IC95%:3,85-6,79), insuficiência cardíaca (RC:7,37; IC95%:5,00-10,87) e febre reumática (RC:3,38; IC95%:2,28-5,02) foram associadas à FFA. Dos 185 participantes com FFA e pontuação no CHA2DS2-VASc≥2, apenas 20 (10,8%) usavam anticoagulantes (50,0% entre aqueles com FFA no eletrocardiograma de linha de base). O uso de anticoagulantes nesse grupo foi associado a maior idade (1,8% vs 17,7% naqueles com idade ≤ 54 e ≥ 65 anos, respectivamente; p=0,013). Observou-se uma tendência ao menor uso de anticoagulantes em mulheres (7,1% vs. 16,4% em mulheres e homens, respectivamente; p=0,055). Conclusões: No recrutamento do ELSA-Brasil, 2,5% dos participantes tinham FFA. O baixo uso de anticoagulantes era comum, o que representa um desafio para os cuidados de saúde nesse cenário.

Abstract Background: Atrial fibrillation or flutter (AFF) is the most common sustained cardiac arrhythmia. Limited data can be found on AFF epidemiology in South America. Objective: The present study sought to describe the clinical epidemiology of AFF and the use of stroke prevention medication in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) baseline assessment. Methods: This study analyzed data from 13,260 ELSA-Brasil participants. AFF was defined according to ECG recording or by self-report. Logistic regression models were built to analyze factors associated with AFF. This study also analyzed if age and sex were associated with anticoagulant use for stroke prevention. Significance level was set at 5%. Results: Median age was 51 years and 7,213 (54.4%) participants were women. AFF was present in 333 (2.5%) participants. Increasing age (odds ratio [OR]:1.05; 95% confidence interval [95%CI]: 1.04-1.07), hypertension (OR:1.44; 95%CI: 1.14-1.81), coronary heart disease (OR: 5.11; 95%CI: 3.85-6.79), heart failure (OR:7.37; 95%CI: 5.00-10.87), and rheumatic fever (OR:3.38; 95%CI: 2.28-5.02) were associated with AFF. From 185 participants with AFF and a CHA2DS2-VASc score ≥2, only 20 (10.8%) used anticoagulants (50.0% among those with AFF in the baseline ECG). Stroke prevention in this group was associated with a higher age (1.8% vs 17.7% in those aged ≤ 54 and ≥ 65 years, respectively; p=0.013). A trend towards a reduced anticoagulant use was observed in women (7.1% vs. 16.4% in women and men, respectively; p=0.055). Conclusions: At the ELSA-Brasil baseline, 2.5% of the participants had AFF. The lack of stroke prevention was common, which is an especially challenging point for healthcare in this setting.

Utilización de un dispositivo móvil de tecnología electrónica para tamizaje de fibrilación auricular: estudio piloto / Use of a mobile electronic technology device for atrial fibrillation screening: pilot study / Uso de dispositivo de tecnologia eletrônica móvel para rastreamento de fibrilação atrial: estudo piloto

La fibrilación auricular (FA) es un problema de salud pública que genera mortalidad y morbilidad, con su mayor impacto en mayores de 65 años. Su detección es especialmente relevante para la población de riesgo. Este estudio piloto propone valorar la utilidad de un dispositivo móvil de tecnología electrónica (DMTE) para el tamizaje de FA. Objetivo primario: evaluar la validez y confiabilidad de un DMTE para identificar FA. Objetivo secundario: validar los procesos de recolección, transmisión, almacenamiento, procesamiento e interpretación de los datos obtenidos. Método: los asistentes a 5 talleres del Plan Ibirapitá (entre el 15 de octubre y el 30 de noviembre de 2018) fueron invitados a participar del estudio. Se utilizó un DMTE (sensor KardiaMobile de AliveCor®) cuyo registro se contrastó con el trazado del ECG de 12 derivaciones realizado en forma casi simultánea. Se compararon los diagnósticos automáticos con los realizados por dos cardiólogos expertos de forma independiente, a partir de la lectura del registro realizado con el DMTE y de un ECG de 12 derivaciones. Resultados: participaron del estudio 114 beneficiarios del Plan Ibirapitá, 78 del sexo femenino. La edad fue de 72,5 ± 5,36 años (rango: 53-87 años). La sensibilidad para el diagnóstico de FA del DMTE fue de 100%, con una especificidad de 96,6%. (VPP = 57,1% VPN = 100%) y una proporción de diagnóstico correcto de 96,8%. El DMTE catalogó como "sin clasificar" al 18,4% de los trazados. Considerando esto, la proporción de diagnóstico correcto disminuyó a 78,9%, sin presentar falsos negativos. Conclusiones: el cribado de FA con la utilización de un DMTE en una población de adultos mayores es factible y confiable. El hallazgo de un 18,4% de trazados con diagnóstico automático "sin clasificar" hace necesario contar con recursos humanos calificados para realizar la confirmación diagnóstica en esos registros.

Atrial fibrillation (AF) is a public health problem generating important morbidity and mortality mainly in > 65 years old population. Detection is key in the population at risk. This pilot study was designed to assess a mobile electronic technology device (METD) usefulness in AF screening. Objective: evaluate validity and reliability of a METD in AF identification. Secondary objective: to validate the process of collection, transmission, storage, method and interpretation of obtained data. Method: participants in 5 Ibirapitá Plan workshops (October 15-November 30, 2018) were invited to participate in the study. A KardiaMobile Alive Cor® METD was used, whose ECG recording was compared with a 12L ECG taken almost at the same time. Automatic METD report was compared with 2 independent cardiologists report considering the METD recording and the 12L ECG. Results: 114 participants (78 female), mean age 72,5 y.o. (SD 5,36; range 53-87) were included. METD sensitivity for AF diagnosis was 100% with a 96.6% specificity (PPV=57,1% NPV=100%), and a 96.8% number of correct diagnosis. A 18.4% of recordings were catalogued as "unclassified" by the METD. Considering this, the proportion of correct diagnosis decreased to 78.9%; there were not false negatives. Conclusions: AF screening with a METD in an older population is feasible and reliable. The finding of 18.4% METD recordings as "unclassified" raises the needs for experts review during diagnosis confirmation.

A fibrilação atrial (FA) é um problema de saúde pública que gera mortalidade e morbidade, com maior impacto em pessoas com mais de 65 anos. Sua detecção é especialmente relevante para a população de risco. Este estudo piloto teve como objetivo avaliar a utilidade de um dispositivo móvel de tecnologia eletrônica (DMTE) para o monitoramento da FA. Objetivo principal: avaliar a validade e confiabilidade de um DMTE para identificar FA. Objetivo secundário: validar os processos de coleta, transmissão, armazenamento, processamento e interpretação dos dados obtidos. Método: participantes de 5 oficinas do Plano Ibirapitá (entre 15 de outubro e 30 de novembro de 2018) foram convidados a participar do estudo. Foi utilizado um DMTE (sensor AliveCor® KardiaMobile), cujo registro foi contrastado com o traçado do ECG de 12 derivações realizado quase simultaneamente. Os diagnósticos automatizados foram comparados com aqueles realizados por dois cardiologistas especialistas independentes, com base na leitura gráfica do DMTE e no ECG de 12 derivações. Resultados: participaram do estudo 114 beneficiários do Plano Ibirapitá, sendo 78 mulheres. A média de idade foi de 72,5 anos (DP 5,36; variação de 53-87 anos). A sensibilidade para o diagnóstico de FA no DMTE foi de 100% com especificidade de 96,6%. (VPP = 57,1% VPN = 100%) e proporção de diagnóstico correto de 96,8%. O DMTE definiu 18,4% dos registros como "não classificados". Portanto, a proporção de diagnósticos corretos diminuiu para 78,9% e não houve falsos negativos. Conclusões: a triagem para FA por meio de DMTE em uma população idosa é viável e confiável. A constatação de 18,4% dos registros com diagnóstico automático "não classificado" torna necessária a existência de recursos humanos qualificados para a realização da confirmação diagnóstica.

Atrial fibrillation diagnosis algorithm based on improved convolutional neural network / 生物医学工程学杂志

Atrial fibrillation (AF) is a common arrhythmia, which can lead to thrombosis and increase the risk of a stroke or even death. In order to meet the need for a low false-negative rate (FNR) of the screening test in clinical application, a convolutional neural network with a low false-negative rate (LFNR-CNN) was proposed. Regularization coefficients were added to the cross-entropy loss function which could make the cost of positive and negative samples different, and the penalty for false negatives could be increased during network training. The inter-patient clinical database of 21 077 patients (CD-21077) collected from the large general hospital was used to verify the effectiveness of the proposed method. For the convolutional neural network (CNN) with the same structure, the improved loss function could reduce the FNR from 2.22% to 0.97% compared with the traditional cross-entropy loss function. The selected regularization coefficient could increase the sensitivity (SE) from 97.78% to 98.35%, and the accuracy (ACC) was 96.62%, which was an increase from 96.49%. The proposed algorithm can reduce the FNR without losing ACC, and reduce the possibility of missed diagnosis to avoid missing the best treatment period. Meanwhile, it provides a universal loss function for the clinical auxiliary diagnosis of other diseases.

Cardiología digital (e-Cardiología): herramientas de utilidad para el diagnóstico y el manejo del paciente con fibrilación auricular / Digital Cardiology (e-Cardiology): useful tools for diagnosis and management of atrial fibrillation / Cardiologia digital (e-Cardiologia): ferramentas úteis para o diagnóstico e tratamiento de pacientes com fibrilação atrial

La tecnología digital móvil (mSalud), recurso aún subutilizado, tiene el potencial para transformarse en un auxiliar imprescindible en la práctica clínica, en particular en Cardiología. La fibrilación auricular es la arritmia más frecuente, cuya prevalencia aumenta con la edad y tiene como complicación más temida el accidente cerebrovascular. Su prevención depende de un diagnóstico oportuno, una adecuada estratificación de riesgo y el uso de anticoagulantes orales. Sin embargo, es con frecuencia paroxística y asintomática, lo que dificulta su diagnóstico. El aporte de la tecnología mediante el desarrollo de aplicaciones para celulares, relojes, dispositivos portátiles o implantables que registran el ritmo cardíaco y permiten el monitoreo prolongado, ambulatorio y a distancia facilitan su detección. Se repasan las principales evidencias que justifican la aplicación de estas estrategias de tamizaje, cuando está indicado realizarlo, cómo y a quiénes hacerlo. Por último, se plantea también la utilidad de estas estrategias de monitoreo prolongado en el manejo y la prevención de la fibrilación auricular.

The mobile digital technology (mHealth), a tool still underutilized, has the potential to become an essential aid in clinical practice, particularly in Cardiology. Atrial fibrillation is the most frequent arrhythmia whose prevalence increases with age and its most feared complication is cerebrovascular accident. Its prevention depends on a timely diagnosis, an adequate risk stratification and the use of oral anticoagulants. However, it is frequently paroxysmal and asymptomatic, which makes its diagnosis difficult. The contribution of technology through the development of applications for cell phones, watches, portable or implantable devices that record the heart rhythm and allow prolonged, outpatient and remote monitoring, facilitate its detection. The main evidences that justify the application of these screening strategies are reviewed, when it is indicated to perform it, how and to whom to do it. Finally, the usefulness of these prolonged monitoring strategies in the management and prevention of atrial fibrillation is also considered.

A utilização da tecnologia digital móvel (m-Saúde), ainda pouco utilizada, tem potencial para se tornar um auxílio essencial na prática clínica, principalmente na Cardiologia. A fibrilação atrial é a arritmia mais frequente, cuja prevalência aumenta com a idade e sua complicação mais temida é o acidente vascular cerebral. Sua prevenção depende de um diagnóstico oportuno, de uma estratificação de risco adequada e do uso de anticoagulantes orais. Porém, freqüentemente é paroxística e assintomática, o que dificulta seu diagnóstico. A contribuição da tecnologia por meio do desenvolvimento de aplicativos para telefones celulares, relógios, dispositivos portáteis ou implantáveis ​​que registram o ritmo cardíaco e permitem monitoramento prolongado, ambulatorial e remoto, facilitam sua detecção. São revisadas as principais evidências que justificam a aplicação dessas estratégias de rastreamento, quando é indicado fazê-lo, como e para quem fazê-lo. Finalmente, a utilidade dessas estratégias de monitoramento prolongado no manejo e prevenção da fibrilação atrial também é considerada.

The validation of the atria and cha2ds2-vasc scores in predicting atrial fibrillation after coronary artery bypass surgery

Abstract Objective: The aim of this study was to evaluate the value of CHA2DS2-VASc and Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) risk scores for prediction of postoperative atrial fibrillation (AF) development in patients undergoing coronary artery bypass grafting (CABG) operation. Methods: The population of this observational study consisted of 370 patients undergoing CABG operation. CHA2DS2-VASc and ATRIA risk scores were calculated for all patients and their association with postoperative AF (AF episode lasting > 5 min) were evaluated. Predictors of postoperative AF were determined by multiple logistic regression analysis. Results: During follow-up, 110 patients (29.7%) developed postoperative AF. With multiple logistic regression analysis, risk factors for postoperative AF were determined: ATRIA risk score (odds ratio [OR] 1.23; 95% confidence interval [CI] 1.11-1.36; P<0.001), fasting glucose level (OR 1.006; 95% CI 1.004-1.009; P<0.001), and 24-hour drainage amount (OR 1.002; 95% CI; 1.001-1.004; P<0.001). Receiver operating characteristic curve analyses showed that CHA2DS2-VASc and ATRIA risk scores were significant predictors for new-onset AF (C-statistic 0.648; 95% CI 0.59-0.69; P<0.001; and C-statistic 0.664; 95% CI 0.61-0.71; P<0.001, respectively). Conclusion: CHA2DS2-VASc and ATRIA risk scores predict new AF in patients undergoing CABG.

Effect of ultrasound-guided right stellate ganglion block on perioperative atrial fibrillation in patients undergoing lung lobectomy: a randomized controlled trial / Efeito do bloqueio do gânglio estrelado direito guiado por ultrassom na fibrilação atrial perioperatória em pacientes submetidos a lobectomia pulmonar: estudo controlado randomizado

Abstract Objective: To observe the effects of preoperative right stellate ganglion block on perioperative atrial fibrillation in patients undergoing lung lobectomy. Methods: Two hundred patients who underwent a scheduled lobectomy were randomly divided into the S and C groups. The S group was injected with 4 mL of 0.2% ropivacaine under ultrasound guidance, and the C group did not receive stellate ganglion block. The patients underwent continuous ECG monitoring, and the incidences of atrial fibrillation and other types of arrhythmias were recorded from the start of surgery to 24 hours after surgery. Results: The respective incidences of atrial fibrillation in the S group and the C group were 3% and 10% (p = 0.045); other atrial arrhythmias were 20% and 38% (p = 0.005); and ventricular arrhythmia were 28% and 39% (p = 0.09). Conclusions: The results of the study indicated that preoperative right stellate ganglion block can effectively reduce the incidence of intraoperative and postoperative atrial fibrillation.

Resumo Objetivo: Observar os efeitos do bloqueio do gânglio estrelado na fibrilação atrial no período perioperatório em pacientes submetidos a lobectomia pulmonar. Método: Duzentos pacientes programados para lobectomia foram divididos aleatoriamente nos grupos S e C. O grupo S recebeu infusão de 4 mL de ropivacaína a 0,2% orientada por ultrassom e o grupo C não foi submetido a bloqueio do gânglio estrelado. Os pacientes foram submetidos à monitoração contínua de ECG, e as incidências de fibrilação atrial e outros tipos de arritmias foram registradas do início da cirurgia até 24 horas depois da cirurgia. Resultados: As incidências de fibrilação atrial no grupo S e no grupo C foram 3% e 10%, respectivamente (p = 0,045); as de outras arritmias atriais foram 20% e 38% (p = 0,005); e de arritmias ventriculares, 28% e 39% (p = 0,09). Conclusões: Os resultados do estudo indicaram que o bloqueio do gânglio estrelado no pré-operatório pode ser efetivo na redução da incidência de fibrilação atrial nos períodos intra- e pós-operatório.

Determination of the increased risk of developing atrial fibrillation in fibromyalgia syndrome

Abstract Introduction: Atrial fibrillation (AF) is the leading cause of ischemic stroke and is one of the most common arrhythmias. Previous studies have shown that impaired diastolic functions, P wave dispersion (Pd), and prolonged atrial conduction times (ACT) are associated with increased incidence of atrial fibrillation (AF). The aim of this study was to evaluate diastolic functions, Pd, and ACT in fibromyalgia syndrome (FMS) patients to determine whether there is an increase in the risk of developing AF. Methods: The study included a total of 140 female patients (70 FMS group, 70 healthy control group). Pd was evaluated using 12 lead electrocardiography (ECG), and diastolic functions and ACT with echocardiography. The ECG and echocardiographic evaluations were performed by different cardiologists blinded to the clinical information of the subjects. Results: There was no difference between the two groups in laboratory and clinical parameters. Patients with FMS had significantly higher echocardiographic parameters of ACT known as left-sided intra-atrial (13.9 ± 5.9 vs. 8.1 ± 1.8, p < 0.001), right-sided intra-atrial (21.9 ± 8.2 vs. 10.4 ± 3.5, p < 0.001) and interatrial [40 (25-64) ms vs. 23 (14-27) ms p < 0.001] electromechanical interval (EMI) compared with the control group. Pd was significantly greater in the FMS group compared with the control group [46 (29-62) ms vs. 32 (25-37) ms, p < 0.001]. In the FMS group, there was no significant relationship of the echocardiographic parameters of ACT, Pmax and Pd with age, E/A ratio and deceleration time (DT); while all these five parameters were significantly correlated with left atrial dimension, isovolumetric relaxation time (IVRT), fibromyalgia impact questionnaire (FIQ) and visual analogue scale (VAS). There was a strong correlation between FIQ and VAS and echocardiographic parameters of ACT, Pmax and Pd. Conclusions: Impaired diastolic functions, an increase in Pd, and prolongation of ACT were observed in FMS. Current disorders are thought to be associated with an increased risk of AF in FMS. The risk of developing AF increases with the severity of FMS and clinical progression.(AU)

Evaluación diagnóstica y manejo terapéutico farmacológico en pacientes con fibrilación auricular / Diagnostic evaluation and pharmacological therapeutic management in patients with atrial fibrillation

La fibrilación auricular (FA) es la arritmia sostenida más frecuente que puede presentarse en una amplia variedad de condiciones clínicas. A pesar de los progresos en el tratamiento de los pacientes con FA, esta arritmia sigue siendo una de las más importantes causas de accidente cerebrovascular, insuficiencia cardiaca, muerte súbita y morbilidad cardiovascular en todo el mundo. El objetivo del tratamiento con fármacos antiarrítmicos es mejorar los síntomas relacionados con la FA, y buscar un equilibrio entre la carga sintomática, la posibilidad de reacciones farmacológicas adversas y las preferencias del paciente. El control de la frecuencia cardiaca a corto y largo plazo se puede lograr con bloqueadores beta, digoxina, bloqueadores de los canales del calcio o tratamiento combinado. Si bien otros fármacos antiarrítmicos de clase III también tienen un efecto limitador de la frecuencia, solo deben emplearse para el control del ritmo cardiaco. Restaurar y mantener el ritmo sinusal también es una parte integral del tratamiento de la FA. Los fármacos antiarrítmicos de clase III duplican la tasa de pacientes en ritmo sinusal. El tratamiento para el control del ritmo está indicado para mejorar los síntomas de los pacientes con FA que siguen sintomáticos a pesar del tratamiento adecuado para el control de la frecuencia cardiaca. La combinación de antiarrítmicos que prolongan el intervalo QT no se debe emplear para el control del ritmo cardiaco en la FA(AU)

Atrial fibrillation (AF) is the most frequent sustained arrhythmia that can occur in a wide variety of clinical conditions. Despite progress in the treatment of patients with AF, this arrhythmia remains one of the most important causes of stroke, heart failure, sudden death and cardiovascular morbidity worldwide. The aim of treatment with antiarrhythmic drugs is to improve the symptoms related to AF, and to look for a balance between the symptomatic load, the possibility of adverse pharmacological reactions and the patient preferences. The short and long term heart rate control can be achieved with beta blockers, digoxin, calcium channel blockers or combination therapy. Although other class III antiarrhythmic drugs also have a frequency-limiting effect, they should only be used for the control of heart rhythm. Restoring and maintaining sinus rhythm is also an integral part of the treatment of AF. Class III antiarrhythmic drugs double the rate of patients who maintain their sinus rhythm. Treatment for rhythm control is indicated to improve the symptoms of patients with AF who remain symptomatic despite adequate treatment for heart rate control. The combination of antiarrhythmics that prolong the QT interval should not be used to control heart rhythm in AF(AU)

The CHA2DS2-VASc score for predicting atrial fibrillation in patients presenting with ST elevation myocardial infarction: prospective observational study

ABSTRACT BACKGROUND: Atrial fibrillation (AF) is the most common form of supraventricular arrhythmia following ST-elevation myocardial infarction (STEMI). The CHA2DS2-VASc and CHADS2 scores are used to estimate thromboembolic risk in cases of AF. Their usefulness in predicting the development of AF in patients presenting STEMI is unknown. OBJECTIVE: To evaluate the predictive value of the CHADS2 and CHA2DS2-VASc scores in patients with AF following STEMI. DESIGN AND SETTING: This prospective cohort study on 696 patients with STEMI was conducted at a tertiary-level cardiology clinic in a public university hospital. METHODS: Models including clinical and laboratory parameters were constructed to test the predictive value of CHADS2 and CHA2DS2-VASc scores. Patients were divided into two groups: with and without AF. Predictors of AF were determined using multivariate regression analysis. RESULTS: In the patients with AF, CHADS2 and CHA2DS2-VASc scores were significantly higher than in those without AF (for both P < 0.001). Factors associated with AF in multivariate analyses included CHA2DS2-VASc score (odds ratio, OR: 1.48; 95% confidence interval, CI: 1.25-1.75; P < 0.001), peak creatine kinase-myocardial binding (OR: 1.002; 95% CI: 1.00-1.003; P = 0.0024), duration of the coronary intensive care unit stay (OR: 1.69; 95% CI: 1.24-12.30; P = 0.001) and no use of renin-angiotensin system blockers (OR: 2.16; 95% CI: 1.14-4.10; P = 0.0017). Receiver operating characteristic curve analyses showed that CHA2DS2-VASc scores were significant predictors for new-onset AF (C-statistic: 0.698; 95% CI: 0.631-0.765; P < 0.001). CONCLUSION: CHADS2 and CHA2DS2-VASc scores predicted new AF in patients presenting STEMI.

Left Atrial Stiffness: A Predictor of Atrial Fibrillation Recurrence after Radiofrequency Catheter Ablation - A Systematic Review and Meta-Analysis / Rigidez do Átrio Esquerdo: Preditor de Recorrência de Fibrilação Atrial após Ablação por Cateter de Radiofrequência - Revisão Sistemática e Metanálise

Abstract Background: Radiofrequency catheter ablation (RFCA) is a standard procedure for patients with atrial fibrillation (AF) not responsive to previous treatments, that has been increasingly considered as a first-line therapy. In this context, perioperative screening for risk factors has become important. A previous study showed that a high left atrial (LA) pressure is associated with AF recurrence after ablation, which may be secondary to a stiff left atrium. Objective: To investigate, through a systematic review and meta-analysis, if LA stiffness could be a predictor of AF recurrence after RFCA, and to discuss its clinical use. Methods: The meta-analysis followed the MOOSE recommendations. The search was performed in MEDLINE and Cochrane Central Register of Controlled Trials databases, until March 2018. Two authors performed screening, data extraction and quality assessment of the studies. Results: All studies were graded with good quality. A funnel plot was constructed, which did not show any publication bias. Four prospective observational studies were included in the systematic review and 3 of them in the meta-analysis. Statistical significance was defined at p value < 0.05. LA stiffness was a strong independent predictor of AF recurrence after RFCA (HR = 3.55, 95% CI 1.75-4.73, p = 0.0002). Conclusion: A non-invasive assessment of LA stiffness prior to ablation can be used as a potential screening factor to select or to closely follow patients with higher risks of AF recurrence and development of the stiff LA syndrome.

Resumo Fundamento: A ablação por cateter de radiofrequência (ACRF) é um procedimento padrão para pacientes com fibrilação atrial (FA) não responsivos a tratamentos prévios, que tem sido cada vez mais considerada como terapia de primeira linha. Nesse contexto, o screening para fatores de risco perioperatório tornou-se importante. Um estudo prévio mostrou que uma pressão do átrio esquerdo (AE) elevada está associada a recorrência de FA após a ablação, podendo ser secundária a um AE rígido. Objetivo: Investigar, por meio de revisão sistemática e metanálise, se a rigidez do AE é um preditor de recorrência de FA após ACRF, e discutir seu uso na prática clínica. Métodos: A metanálise foi realizada seguindo-se as recomendações do MOOSE. A busca foi realizada nas bases de dados MEDLINE e Cochrane Central Register of Controlled Trials, até março de 2018. Dois autores realizaram triagem, extração de dados e avaliação da qualidade dos estudos. Resultados: Todos os estudos obtiveram boa qualidade. Um gráfico de funil foi construído, não identificando viés de publicação. Quatro estudos prospectivos observacionais foram incluídos na revisão sistemática e 3 deles na metanálise. Foi adotado o nível de significância estatística de p < 0,05. Rigidez do AE foi um forte preditor independente da recorrência de FA após ACRF (HR = 3,55, IC 95% 1,75-4,73, p = 0,0002). Conclusão: A avaliação não invasiva da rigidez do AE antes da ablação pode ser utilizada como um potencial fator de rastreamento para a seleção ou acompanhamento de pacientes com maiores riscos de recorrência de FA e desenvolvimento da síndrome do AE rígido.

Parámetros asociados al desarrollo de fibrilación auricular en unidad de cuidados críticos / Parameters associated with the development of atrial fibrillation in a critical care unit

A pesar de los avances en el manejo de los pacientes con fibrilación auricular (FA), esta arritmia es responsable de accidente cerebrovascular, insuficiencia cardíaca, muerte súbita y morbilidad cardiovascular en el mundo. El objetivo de este trabajo fue determinar la frecuencia de fibrilación auricular y analizar las cardiopatías subyacentes y predictores de fibrilación auricular en el servicio de Unidad Coronaria del Instituto de Cardiología de la Ciudad de Corrientes. Estudio observacional y descriptivo donde ingresaron 412 pacientes consecutivos en unidad Coronaria de instituto de Cardiología Juana Francisca Cabral, desde el 1 de enero al 30 de junio de 2018. Del total de la población el 24,51% presentó fibrilación auricular, 80,2% FA paroxística y 19,8% permanente. El 94% de los pacientes con FA paroxística fueron hipertensos. La edad media fue de 71,60±12,19 años, el índice de masa corporal fue de 28,33±6,13, el tamaño de la aurícula izquierda fue de 47,91±7,06 mm y la fracción de eyección de 50,41±17,9%. La presencia de insuficiencia cardiaca estuvo presente en 69% de los pacientes con FA paroxística. Las cardiopatías subyacentes fueron: infarto agudo de miocardio 50,5%, valvulopatías 50,5%, hipertrófica 5%. Más de dos tercios de los pacientes tuvieron FA paroxística. La cardiopatía isquémica fue la más frecuente

SUMMARY Despite the advances in the management of patients with atrial fibrillation (AF), this arrhythmia causes stroke, heart failure, sudden death and cardiovascular morbidity. The aim of this work was to determine the frequency of atrial fibrillation and to analyze the underlying heart diseases and predictors of atrial fibrillation in the Coronary Unit Service of the Institute of Cardiology from Corrientes City. This is a descriptive and observational study. There were admitted 412 consecutive patients to the Coronary unit of "Juana Francisca Cabral Institute of Cardiology", from January 1st to June 30th, 2018. From the total population, 24.51% patients presented atrial fibrillation, 80.2% presented paroxysmal AF and 19.8% permanent AF. The 94% of the patients with paroxysmal AF were hypertensive. The mean age was 71.60 ± 12.19 years, the body mass index was 28.33 ± 6,13, the size of the left atrium was 47.91 ± 7.06 mm and the ejection fraction 50.41 ± 17.9%. Heart failure was present in 69% of patients with paroxysmal AF. The underlying heart diseases were: acute myocardial infarction 50.5%, valvulopathies 50.5%, hypertrophic cardiomyopathy 5%. More than two thirds of the patients had paroxysmal AF. Ischemic heart disease was the most frequent

RESUMO Apesar dos avanços na manipulação de pacientes com fibrilação atrial (FA), essa arritmia é responsável por acidente vascular cerebral, insuficiência cardíaca, morte súbita e morbilidade cardiovascular no mundo. O objetivo deste trabalho foi determinar a frequência de fibrilação atrial e analisar as cardiopatias subjacentes e os preditores de fibrilação atrial no serviço de unidade coronariana do Instituto de Cardiologia da cidade de Corrientes. Estudo observacional descritivo em que 412 pacientes consecutivos foram internados na Unidade Coronariana do Instituto Juana Francisca Cabral de Cardiologia, do día 1º de janeiro a 30 de junho de 2018. Do total da população, 24,51% apresentaram fibrilação atrial, 80,2% AF paroxística e permanente 19,8%. 94% dos pacientes com FA paroxística eram hipertensos. A média de idade foi de 71,60 ± 12,19 anos, o índice de massa corpórea foi de 28,33 ± 6,13, o tamanho do átrio esquerdo foi de 47,91 ± 7,06 mm e a fração de ejeção 50,41 ± 17,9%. A presença de insuficiência cardíaca esteve presente em 69% dos pacientes com FA paroxística. As doenças cardíacas subjacentes foram: infarto agudo do miocárdio 50,5%, valvopatias 50,5%, hipertrófica 5%. Mais de dois terços dos pacientes apresentavam FA paroxística. A doença isquêmica do coração foi a mais frequente.

Guía de práctica clínica para el manejo de pacientes con fibrilación auricular / Clinical practice guideline for the management of patients with atrial fibrillation

La fibrilación auricular (FA) es la arritmia cardiaca más frecuente en la práctica clínica, se caracteriza por presentar una frecuencia auricular desorganizada mayor a 200 latidos por minuto, asociado a una respuesta ventricular variable. La FA se puede clasificar en tres tipos distintos de acuerdo a su presentación: FA paroxística, FA persistente y FA permanente. La FA paroxística es aquella que se presenta como episodios súbitos que se autolimitan y tienen como máximo una duración de una semana. La FA persistente es aquella en la que la alteración del ritmo persiste por más de una semana, luego de ese tiempo se puede autolimitar o puede responder a tratamiento. Por otro lado, la FA permanente es aquella condición donde por consenso del médico y paciente debido a las características clínicas del paciente y la propia arritmia se decide seguir solo las estrategias de control de frecuencia para el control de síntomas, no siendo de interés restaurar el ritmo sinusal del paciente. Tanto la FA paroxística como la persistente pueden convertirse en FA permanente (1). Otro concepto importante es el de FA valvular, definido como FA en portadores de prótesis valvular mecánica o padecen de estenosis mitral moderada o severa, los cuales tendrían mayor riesgo de eventos tromboembólicos (2). Existen diversas técnicas que pueden ser útiles para el diagnóstico de FA, entre ellos se encuentra la palpación del pulso que posee una sensibilidad de 0.92 (IC 95%: 0.85 a 0.96) y una especificidad de 0.82 (IC 95%: 0.76 a 0.88) (3). La baja especificidad de la palpación del pulso significa un aumento de falsos positivos por lo que esta técnica debería ser utilizada solo en pacientes con sospecha de FA como aquellos que presentan: falta de aire/disnea, palpitaciones, síncope/mareos, dolor o disconfort de pecho y desorden cerebrovascular (DCV) isquémico. Por este motivo se considera que la palpación del pulso puede ser útil para identificar pulso irregular en pacientes con síntomas sugestivos de FA. El uso de electrocardiograma (ECG) tiene una sensibilidad de 0.91 (IC 95%: 0.86 a 0.94) y una especificidad de 0.95 (IC 95%: 0.92 a 0.97) para detectar R-R irregulares cuando es interpretado por enfermeras, médicos generales o cardiólogos (3). Por este motivo este método es útil para diagnosticar FA en todos los pacientes, sintomáticos o no, en los que se sospeche fibrilación auricular debido a la detección de pulso irregular.

Cryptogenic Acute Ischemic Stroke: Assessment of the Performance of a New Continuous Long-Term Monitoring System in the Detection of Atrial Fibrillation / AVC Isquêmico Agudo Criptogênico: Avaliação do Desempenho de um Novo Sistema de Monitorização Contínua e Prolongada, via Telefonia Celular, na Detecção de Fibrilação Atrial

Abstract Background: Long-term monitoring has been advocated to enhance the detection of atrial fibrillation (AF) in patients with stroke. Objective: To evaluate the performance of a new ambulatory monitoring system with mobile data transmission (PoIP) compared with 24-hour Holter. We also aimed to evaluate the incidence of arrhythmias in patients with and without stroke or transient ischemic attack. Methods: Consecutive patients with and without stroke or TIA, without AF, were matched by propensity score. Participants underwent 24-hour Holter and 7-day PoIP monitoring. Results: We selected 52 of 84 patients (26 with stroke or TIA and 26 controls). Connection and recording times were 156.5 ± 22.5 and 148.8 ± 20.8 hours, with a signal loss of 6,8% and 11,4%, respectively. Connection time was longer in ambulatory (164.3 ± 15.8 h) than in hospitalized patients (148.8 ± 25.6 h) (p = 0.02), while recording time did not differ between them (153.7 ± 16.9 and 143.0 ± 23.3 h). AF episodes were detected in 1 patient with stroke by Holter, and in 7 individuals (1 control and 6 strokes) by PoIP. There was no difference in the incidence of arrhythmias between the groups. Conclusions: Holter and PoIP performed equally well in the first 24 hours. Data transmission loss (4.5%) occurred by a mismatch between signal transmission (2.5G) and signal reception (3G) protocols in cell phone towers (3G). The incidence of arrhythmias was not different between stroke/TIA and control groups.

Resumo Fundamentos: Monitorização prolongada permite maior detecção de fibrilação atrial (FA) em pacientes com acidente vascular cerebral (AVC) isquêmico criptogênico. Não há consenso sobre a duração ideal da monitorização ou o valor prognóstico da FA de curta duração. Objetivos: Avaliar o desempenho de um novo sistema de monitorização ambulatorial (PoIP) com transmissão por telefonia celular, comparado ao Holter 24 horas, e a ocorrência de arritmias comparando pacientes com e sem AVC ou ataque isquêmico transitório (AIT). Métodos: Pacientes consecutivos com e sem AVC/AIT, sem FA, foram pareados pelo escore de propensão. Foi utilizado Holter 24 horas e o PoIP por 7 dias. Resultados: Selecionamos 52 de 84 pacientes (26 com AVC/AIT agudo e 26 controles). O tempo de conexão foi de 156,5 ± 22,5 horas e o de gravação no servidor foi de 148,8 ± 20,8 horas, com perdas de 6,8 e 11,4%, respectivamente. Houve maior tempo de conexão nos pacientes ambulatoriais (164,3 ± 15,8 h) que nos hospitalizados (148,8 ± 25,6h) (p = 0,02) com tempo de gravação semelhante (153,7 ± 16,9 e 143 ± 23,3 h). Detectamos FA pelo Holter em 1 paciente com AVC e pela monitorização prolongada em 7 (1 controle e 6 AVC). Não houve diferença na incidência de outras arritmias entre os grupos. Conclusões: Holter e PoIP tiveram desempenho equivalente nas primeiras 24 horas. O menor tempo de monitorização nos pacientes hospitalizados ocorreu por sinal de baixa intensidade. Perda de dados (4,5%) ocorreu por discrepância entre protocolos de transmissão (2,5G) e recepção pelas antenas (3G). A incidência de arritmias não diferiu entre os grupos AVC/AIT e controle.

Respuesta a la estimulación multisitio del ventrículo izquierdo en un paciente con terapia de resincronización y fibrilación auricular permanente / Multi-site stimulation of the left ventricle in a patient with dilated cardiomyopathy and permanent atrial fibrillation on resynchronization therapy

Resumen: Se presenta el caso de un hombre de 79 años con miocardiopatía dilatada severa, disfunción ventricular izquierda, fibrilación auricular permanente y portador de un resincronizador ventricular. Al efectuar un recambio del resincronizador se implantó un electrodo adicional para estimulación multisitio del ventrículo izquierdo. Ello condujo a significativa mejoría clínica y de la fracción de eyección del ventrículo izquierdo.

Abstract: A 79-year-old man with dilated cardiomyopathy and atrial fibrillation undergoing resynchronization therapy had and additional electrode implanted in the left ventricle. Multi-site stimulation led to an improved functional class and left ventricular ejection fraction.