Arrhythmias in Female Patients: Incidence, Presentation and Management.

There is a growing appreciation for differences in epidemiology, treatment, and outcomes of cardiovascular conditions by sex. Historically, cardiovascular clinical trials have under-represented females, but findings have nonetheless been applied to clinical care in a sex-agnostic manner. Thus, much of the collective knowledge about sex-specific cardiovascular outcomes result from post hoc and secondary analyses. In some cases, these investigations have revealed important sex-based differences with implications for optimizing care for female patients with arrhythmias. This review explores the available evidence related to cardiac arrhythmia care among females, with emphasis on areas in which important sex differences are known or suggested. Considerations related to improving female enrollment in clinical trials as a way to establish more robust clinical evidence for the treatment of females are discussed. Areas of remaining evidence gaps are provided, and recommendations for areas of future research and specific action items are suggested. The overarching goal is to improve appreciation for sex-based differences in cardiac arrhythmia care as 1 component of a comprehensive plan to optimize arrhythmia care for all patients.

Sex Differences in Atrial Fibrillation.

PURPOSE OF REVIEW: Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia. The estimated lifetime risk of developing AF is higher in men; however, due to differences in life expectancy, the overall prevalence is higher among women, particularly in the older age group. Sex differences play an important role in the pathophysiology, presentation, and clinical outcomes of AF. Awareness of these differences minimizes the potential for disparities in AF management. Our review summarizes the current literature on sex differences in AF, including the epidemiology, pathophysiology, risk factors, clinical symptomatology, mechanisms, treatment, and outcomes. We also explore the implications of these differences for clinical practice and future research. RECENT FINDINGS: Women are more likely to present with atypical symptoms, have a higher stroke risk, and have a worse quality of life with AF when compared to men. Despite this, they are less likely to receive rhythm control strategies and anticoagulants. The sex-based differences in AF pathology and management might be a combination of inherent biological and hormonal differences, and implicit bias of the research entities and treating clinicians. Our review stresses the need for further sex-specific research in the pathophysiology of AF and opens a dialogue on personalized medicine, where management strategies can be tailored to individual patient characteristics, including sex.

An Overview of Arrhythmias in Pregnancy.

Cardiovascular disease significantly jeopardizes pregnancies in the United States, impacting 1% to 4% of pregnancies annually. Among complications, cardiac arrhythmias are prevalent, posing concerns for maternal and fetal health. The incidence of arrhythmias during pregnancy is rising, partly due to advances in congenital heart surgery and a growing population of women with structural heart disease. While most arrhythmias are benign, the increasing prevalence of more serious arrhythmias warrants a proactive approach. Guidance and reassurance suffice in many cases, but persistent symptoms require cautious use of antiarrhythmic drugs or other therapies for a safe outcome. Managing more serious arrhythmias requires a comprehensive, multidisciplinary approach involving specialists, including maternal-fetal medicine physicians, cardiologists, electrophysiologists, and anesthesiologists.

Radiation Exposure, Training, and Safety in Cardiology.

Exposure to ionizing radiation is an inherent occupational health hazard in clinical cardiology. Health risks have been reported previously, including predilection to cancer. In addition, orthopedic injury due to prolonged wearing of heavy protective lead aprons, which are mandatory to reduce radiation risk, have been extensively documented. Cardiology as a specialty has grown with rising volumes of increasingly complex procedures. This includes electrophysiological, coronary, and structural intervention, advanced heart failure/transplant management, and diagnostic imaging. Both the operator as well imaging specialists are exposed to radiation, particularly in structural interventions where interventional cardiologists and structural imagers work closely. Increasingly, women interested in cardiology may deselect the field due to radiation concerns. This expert document highlights the risks of radiation exposure in cardiology, including practical tips within various subspecialty fields such as interventional/structural cardiology, electrophysiology, imaging, advanced heart failure, and pediatric cardiology.

Introduction: Early Diagnosis and Appropriate Treatment of Atrial Fibrillation.

Atrial fibrillation (AF), the most common sustained arrhythmia, represents a significant burden to patients and healthcare systems. Many patients with AF are asymptomatic and often undiagnosed. Improved detection methods and surveillance have resulted in recognition of asymptomatic and subclinical AF, providing earlier diagnosis. The recent EAST-AFNET 4 and Korean studies have demonstrated early rhythm control (ERC) with antiarrhythmic drugs (AADs) or ablation in patients with AF improves outcomes. The EARLY AF and STOP AF First studies have shown that ERC using ablation can slow AF progression. In the following videos, the authors discuss the evolving AF landscape, with an emphasis on the benefits of early diagnosis and treatment. Historic rate versus rhythm control studies and their limitations are reviewed, followed by recent studies that support the use of ERC alongside usual care including rate control. Discussion of ERC treatment includes the selection of appropriate AADs based on safety, when to choose ablation as first-line therapy, and the complementary use of ablation and AADs. The authors summarize the current guidelines for the use of AADs to treat AF, highlighting the importance of concordance with those guidelines. Patient cases are used to relate the contents of the videos to clinical practice and are supplemented with discussion of the importance of shared decision-making involving the patient in treatment decisions. It is anticipated that this digital publication will enable cardiologists and primary care providers to recognize when early treatment of AF will improve patient outcomes, and to empower them to initiate that treatment accordingly.

Chapter 3: Evidence for the Use of Early Rhythm Control to Prevent Atrial Fibrillation Progression.

This chapter reviews atrial fibrillation (AF) progression and its associated mechanisms, including comorbidities and AF as contributors to atrial myopathy, and atrial myopathy as a contributing factor to AF progression. In addition, the chapter discusses the concept of comorbidities and atrial myopathy as synergistic contributors to adverse outcomes, the notion of "AF begets AF," and the consequences of AF burden if left untreated. Clinical trials evaluating outcomes with antiarrhythmic drugs (AADs) compared with placebo have demonstrated efficacy, but also reveal a possible proarrhythmic and mortality risk if AAD selection is not appropriate and patients are not correctly identified based on risk factors and comorbidities. Data from ATHENA, the first and only trial to demonstrate that an AAD (dronedarone) can reduce cardiovascular (CV) hospitalizations in people with AF, are reviewed, along with studies reporting on the use of catheter ablation versus AADs for AF rhythm control. Finally, recent data showing a reduction in major adverse outcomes if rhythm control is initiated early are summarized, including results from the EAST-AFNET 4 trial, as well as confirmatory results from several large "real-world" trials. Chapter 3 is summarized as follows.

Chapter 4: Evidence for the Early Use of Ablation and AADs Post-Ablation.

Both catheter ablation and antiarrhythmic drugs (AADs) are effective treatments for atrial fibrillation (AF) and can be used individually or as complementary treatments. This chapter discusses the use of ablation for early rhythm control in AF, and the use of AADs post-ablation. Decisions on which therapeutic approach to pursue should be based on shared decision-making with the patient. The chapter reviews data from the CABANA trial, in which the intent-to-treat (ITT) analysis failed to show superiority for ablation versus AADs. Statistical significance was achieved, however, when using the pre-specified per-protocol and pre-treatment analyses. The discussion addresses the fact that data analysis was complicated by several factors: (1) not all members of the group assigned to ablation actually received ablation; (2) the AAD arm included rate control treatment without the use of AADs; (3) there were a large number of crossovers from the AAD arm to the ablation arm; and (4) many ablation-treated participants also used AADs. Results from the CABANA trial showed that ablation was better at preventing AF recurrence than AADs alone. Data from the STOP AF and EARLY AF trials that support the observation of ablation being superior to AADs alone for the reduction of recurrent AF are also reviewed. Many patients who undergo catheter ablation for AF either continue to use or need to restart AADs following ablation. This combination therapy is used by up to 40-50% of people at 1-year post ablation, as is clearly demonstrated by the results from the trials discussed above, in addition to those from the 5A trial, the POWDER AF trial, the AMIO-CAT trial, and a substantial meta-analysis. All these trials are reviewed in this chapter, noting that a variety of differences exist between the randomized clinical trials, including in ablation procedures, follow-up periods, physician experience, and AADs. Chapter 4 is summarized as follows.

Chapter 5: Guideline Recommendations: Which AAD and for Whom?

This chapter discusses the American College of Cardiology/American Heart Association/ Heart Rhythm Society (AHA/ACC/HRS) and European Society of Cardiology (ESC) guidelines for atrial fibrillation (AF) management with particular focus on antiarrhythmic drug (AAD) selection and the identification of individuals for whom AAD treatment is appropriate. Discussion includes AAD indications, when to start an AAD, choosing among AADs, how to minimize proarrhythmic risk, how to determine efficacy, and the use of adjuvant interventions. The indications for all AADs are based on safety; the current AHA/ACC/HRS and ESC guidelines state that the choice of AAD is based on the presence or absence of structural heart disease (SHD), coronary artery disease, or heart failure (HF), with further recommendations in the ESC guidelines based on HF type (e.g., HF with reduced ejection fraction [HFrEF] versus HF with preserved ejection fraction [HFpEF]). The chapter closes with a discussion of the lack of consistent use of guideline-directed care, with a review of supportive data from the recently reported AIM-AF survey-a multinational survey on AF management that involved both cardiologists and electrophysiologists. In AIM-AF, inappropriate drug selection in terms of suitable candidate selection and drug choice occurred with all types of drugs and in most patient groups. Most notable was the overuse of amiodarone in patients without SHD, and the widespread use of sotalol, including its use in patients with HFrEF. Chapter 5 is summarized as follows.

Chapter 6: AAD Use in Different Patient Populations, and a Patient-Centric Approach to Optimal Patient Management.

Associated with longer life expectancy, greater survival of patients with cardiovascular disorders, and increased use of wearable and insertable/implantable devices capable of detection, the frequency of atrial fibrillation (AF) diagnosis is increasing. This chapter describes two representative patient cases that were used to enable a discussion of the evaluation and management of AF in different scenarios. One patient is young and healthy with paroxysmal AF but no major comorbidities (though there is a family history of AF). The other is older with multiple complicating comorbidities. These cases sparked an active discussion among the panelists that demonstrated not only the multitude of considerations when choosing the optimal therapy for each individual, but also the individualistic differences in biases and styles that can exist between experts in the field. The results of these discussions revealed agreement that.

Chapter 1: The Evolving Atrial Fibrillation Landscape: Importance of Early Diagnosis and Treatment.

Chapter 1 begins with data that show the rising prevalence of atrial fibrillation (AF), which is increasing in tandem with the growing number of older adults, increased survival of people who have cardiovascular (CV) disorders, and the expanding use of wearable and insertable/implantable devices capable of detection. Together, these increases will result in healthcare providers seeing more patients with AF who present at earlier stages of the disease. The panel discussion covers information regarding symptoms that are common to patients with AF as well as information about the important adverse outcomes that may occur in patients with AF, including heart failure, hospitalization, thromboembolism, and death. Notably, these events may reflect either the comorbidities commonly underlying AF, AF itself, or a combination of these conditions. The chapter also introduces the four pillars of therapy-"upstream therapy," rate control, rhythm control, and embolic prevention-with an emphasis on early rhythm control as being optimal. Chapter 1 is summarized as follows.

Chapter 2: Rate Versus Rhythm Control.

Atrial fibrillation (AF) is a potentially serious health risk, both because of its symptoms and because of its association with an increased risk for heart failure, hospitalization, thromboembolism, and death. Chapter 2 discusses selection of appropriate treatments and when to initiate these therapies. Older trials focused on comparing rate versus rhythm control treatment options for AF. It is now recognized that both rate and rhythm control are important and can be used together. This chapter reviews the historical, pivotal rate versus rhythm control trials that failed to show any overall survival benefit of rhythm over rate control, as well as the trials' now-recognized limitations with respect to modern therapy. In addition, an in-depth discussion of the more recent trials of antiarrhythmic drugs (AAD) and ablation techniques (which have become available since the original rate versus rhythm trials were performed) is included. These updated trials show that when applied to patient- and disease-specific situations, rhythm control can reduce the risk for mortality and hospitalization. The chapter also reviews the guidelines that have been developed to achieve these goals. Chapter 2 is summarized as follows: (1) Rate control is needed (at rest and during exertion) to reduce rate-related symptoms when rhythm control is ineffective or incomplete and to prevent a tachycardia-induced cardiomyopathy. (2) Previous trials with pharmacological therapy alone comparing rate versus rhythm control using the AADs available at that time failed to show any overall survival benefit of rhythm control over rate control. (3) These earlier trials had many methodological limitations and enrolled participants who did not have access to modern therapies. (4) Newer therapies, including those for stroke prevention, dronedarone (the latest approved AAD), and AF ablation, have improved the safety and efficacy of rhythm control strategies.

Outcomes of out of hospital sudden cardiac arrest in India: A review and proposed reforms.

BACKGROUND: Bystander cardiopulmonary resuscitation (CPR) is the cornerstone in managing out-of-hospital cardiac arrest (OHCA). However, India lacks a formal sudden cardiac arrest (SCA) registry and the infrastructure for a robust emergency medical services (EMS) response system. Also, there exists an opportunity to improve widespread health literacy and awareness regarding SCA. Other confounding variables, including religious, societal, and cultural sentiments hindering timely intervention, need to be considered for better SCA outcomes. OBJECTIVES: We highlight the current trends and practices of managing OHCA in India and lay the groundwork for improving the awareness, education, and infrastructure regarding the management of SCA. CONCLUSION: Effective management of OHCA in India needs collaborative grassroots reformation. Establishing a large-scale SCA registry and creating official and societal guidelines will be pivotal for transforming OHCA patient outcomes.

Racial, ethnic, and sex disparities in atrial fibrillation management: rate and rhythm control.

BACKGROUND: Atrial fibrillation (AF) affects around 6 million Americans. AF management involves pharmacologic therapy and/or interventional procedures to control rate and rhythm, as well as anticoagulation for stroke prevention. Different populations may respond differently to distinct management strategies. This review will describe disparities in rate and rhythm control and their impact on outcomes among women and historically underrepresented racial and/or ethnic groups. METHODS: This is a narrative review exploring the topic of sex and racial and/or ethnic disparities in rate and rhythm management of AF. We describe basic terminology, summarize AF epidemiology, discuss diversity in clinical research, and review landmark clinical trials. RESULTS: Despite having higher rates of traditional AF risk factors, Black and Hispanic adults have lower risk of AF than non-Hispanic White (NHW) patients, although those with AF experience more severe symptoms and report lower quality-of-life scores than NHW patients with AF. NHW patients receive antiarrhythmic drugs, cardioversions, and invasive therapies more frequently than Black and Hispanic patients. Women have lower rates of AF than men, but experience more severe symptoms, heart failure, stroke, and death after AF diagnosis. Women and people from diverse racial and ethnic backgrounds are inadequately represented in AF trials; prevalence findings may be a result of underdetection. CONCLUSION: Race, ethnicity, and gender are social determinants of health that may impact the prevalence, evolution, and management of AF. This impact reflects differences in biology as well as disparities in treatment and representation in clinical trials.

Arrhythmias and Heart Failure in Pregnancy: A Dialogue on Multidisciplinary Collaboration.

The prevalence of CVD in pregnant people is estimated to be around 1 to 4%, and it is imperative that clinicians that care for obstetric patients can promptly and accurately diagnose and manage common cardiovascular conditions as well as understand when to promptly refer to a high-risk obstetrics team for a multidisciplinary approach for managing more complex patients. In pregnant patients with CVD, arrhythmias and heart failure (HF) are the most common complications that arise. The difficulty in the management of these patients arises from variable degrees of severity of both arrhythmia and heart failure presentation. For example, arrhythmia-based complications in pregnancy can range from isolated premature ventricular contractions to life-threatening arrhythmias such as sustained ventricular tachycardia. HF also has variable manifestations in pregnant patients ranging from mild left ventricular impairment to patients with advanced heart failure with acute decompensated HF. In high-risk patients, a collaboration between the general obstetrics, maternal-fetal medicine, and cardiovascular teams (which may include cardio-obstetrics, electrophysiology, adult congenital, or advanced HF)-physicians, nurses and allied professionals-can provide the multidisciplinary approach necessary to properly risk-stratify these women and provide appropriate management to improve outcomes.

Arrhythmias in Pregnancy.

Increasing maternal mortality and incidence of arrhythmias in pregnancy have been noted over the past 2 decades in the United States. Pregnancy is associated with a greater risk of arrhythmias, and patients with a history of arrhythmias are at significant risk of arrhythmia recurrence during pregnancy. The incidence of atrial fibrillation in pregnancy is rising. This review discusses the management of tachyarrhythmias and bradyarrhythmias in pregnancy, including management of cardiac arrest. Management of fetal arrhythmias are also reviewed. For patients without structural heart disease, ß-blocker therapy, especially propranolol and metoprolol, and antiarrhythmic drugs, such as flecainide and sotalol, can be safely used to treat tachyarrhythmias. As a last resort, catheter ablation with minimal fluoroscopy can be performed. Device implantation can be safely performed with minimal fluoroscopy and under echocardiographic or ultrasound guidance in patients with clear indications for devices during pregnancy. Because of rising maternal mortality in the United States, which is partly driven by increasing maternal age and comorbidities, a multidisciplinary and/or integrative approach to arrhythmia management from the prepartum to the postpartum period is needed.

Racial and Ethnic Differences in the Management of Atrial Fibrillation.

Atrial fibrillation (AF) is the most common clinical arrhythmia, and it results in adverse outcomes and increased healthcare costs. Racial and ethnic differences in AF management, although recognized, are poorly understood. This review summarizes racial differences in AF epidemiology, genetics, clinical presentation, and management. In addition, it highlights the underrepresentation of racial and ethnic populations in AF clinical trials, especially trials focused on stroke prevention. Specific strategies are proposed for future research and initiatives that have potential to eliminate racial and ethnic differences in the care of patients with AF. Addressing racial and ethnic disparities in healthcare access, enrollment in clinical trials, resource allocation, prevention, and management will likely narrow the gaps in the care and outcomes of racial and ethnic minorities suffering from AF.

La fibrillation auriculaire (FA) est la forme clinique d'arythmie la plus fréquente, et elle entraîne des résultats défavorables ainsi qu'une augmentation du coût des soins de santé. Les différences liées à la race et à l'origine ethnique qui existent dans la prise en charge de la FA, bien que reconnues, sont mal comprises. Le présent article de synthèse résume les différences liées à la race observées sur le plan de l'épidémiologie, de la génétique, du tableau clinique et de la prise en charge de la FA. En outre, il met en lumière la sous-représentation de groupes raciaux et ethniques dans les études cliniques sur la FA, en particulier celles axées sur la prévention des accidents vasculaires cérébraux. Des stratégies ad hoc sont proposées pour que la recherche et les initiatives futures favorisent l'éradication des différences liées à la race et à l'origine ethnique dans les soins prodigués aux patients atteints de FA. Le fait de s'attaquer aux disparités liées à la race et à l'origine ethnique qui touchent l'accès aux soins de santé, l'inscription aux essais cliniques, l'allocation des ressources, la prévention et la prise en charge des patients permettra probablement de réduire les lacunes en matière de soins et de résultats chez les personnes atteintes de FA issues de minorités raciales et ethniques.