Management of atrial fibrillation in the emergency room and in the cardiology ward: the BLITZ AF study.

AIMS: To assess the number of admissions to the emergency room (ER) of patients with atrial fibrillation (AF) or atrial flutter (af) and their subsequent management. To evaluate the clinical profile and the use of antithrombotics and antiarrhythmic therapy in patients with AF admitted to cardiology wards. METHODS AND RESULTS: BLITZ-AF is a multicentre, observational study conducted in 154 centres on patients with AF/af. In each centre, data were collected, retrospectively for 4 weeks in ER and prospectively for 12 weeks in cardiology wards. In ER, there were 6275 admissions. Atrial fibrillation was the main diagnosis in 52.9% of the cases, af in 5.9%. Atrial fibrillation represented 1.0% of all ER admissions and 1.7% of all hospital admissions. A cardioversion has been performed in nearly 25% of the cases. Out of 4126 patients, 52.2% were admitted in cardiology ward; mean age was 74 ± 11 years, 41% were females. Patients with non-valvular AF were 3848 (93.3%); CHA2DS2-VASc score was ≥2 in 87.4%. Cardioversion was attempted in 38.8% of the patients. In-hospital mortality was 1.2%. At discharge, 42.6% of the patients were treated with vitamin K antagonists, 39.5% with direct oral anticoagulants, 13.6% with other antithrombotic drugs, and 4.2% did not take any antithrombotic agent. Rate control strategy was pursued in 47.2%, rhythm control in 44.0%, 45.6% were discharged in sinus rhythm. CONCLUSION: Atrial fibrillation still represents a significant burden on health care system. Oral anticoagulant use increased over time even if compliance with guidelines, with respect to prevention of the risk of stroke, remains suboptimal.

Epidemiology of Heart Failure.

Heart failure (HF) is a major public health problem affecting more than 23 million patients worldwide. Incidence and prevalence rates vary significantly according to the source of data, but both increase with advancing age reaching, in the very elderly, prevalence rates that represent a challenge for the organization of medical care systems. Even if evidence-based treatments have improved prognosis in some patients with HF, patients with HF still need to be carefully characterized, described, and treated. Hospitalizations for acute HF are frequent and costly accounting for the vast majority of HF-related costs.

Outcomes, health costs and use of antiplatelet agents in 7,082 patients admitted for an acute coronary syndrome occurring in a large community setting.

PURPOSE: To assess the outcomes of patients admitted for ACS and the prescription pattern of antiplatelets of patients discharged alive. METHODS: From the ARNO Observatory database, we performed a record linkage analysis of hospital discharge and prescription databases, which included 2,758,872 subjects of 7 Italian Local Health Authorities. The accrual period lasted from January 1 to December 31, 2008. Discharge records and prescription patterns were analyzed for 1 year before and after the accrual period. RESULTS: Of 2,758,872 subjects, 7,082 (2.6‰) were hospitalized for ACS. Mean age was 72±13 years, females and diabetics accounted for 36% and 25% of the cases. Of the 7,082 patients, in-hospital death occurred in 6.9%. Of the survivors, 64.5% was treated medically, 35.5% with PCI. Of the patients discharged alive, 65.8% were treated with an antiplatelet, 21.9% aspirin alone, 33.1% aspirin plus a thienopyridine (mostly clopidogrel), 10.5% a thienopyridine alone. Dual antiplatelet treatment was prescribed more frequently in patients treated with PCI than in those treated medically (57.3% vs 19.7%, p<0.0001). At least one re-hospitalization occurred in 58.6% (18.5% for a recurrent episode of ACS, 24.8% for other CV reasons, 15.3% for non CV reasons). Prescription continuity to antiplatelets was observed in 68.0% and 60.3% of the patients, respectively at 6 and 12 months after discharge. CONCLUSION: In a large community setting, the prescription rate of antiplatelets after ACS seems to be far from the guidelines recommendation. Rates of 1 year re-hospitalizations after ACS remain high, recurrence of ACS accounted for just one third of the cases.

Thromboembolic event rate in paroxysmal and persistent atrial fibrillation: data from the GISSI-AF trial.

BACKGROUND: Few data on the thromboembolic (TE) risk of paroxysmal and persistent atrial fibrillation (AF) are available. This study aimed to assess the incidence of TE events in paroxysmal and persistent AF. METHODS: We performed a subset post hoc analysis of 771 patients with paroxysmal and 463 with persistent AF enrolled in the multicenter, prospective, randomized, double-blind, placebo-controlled GISSI-AF trial - comparing the efficacy of valsartan versus placebo in preventing AF recurrences - where the choice of antithrombotic treatment was left to the judgment of the referring physician. TE and major outcome events were centrally validated. AF recurrences were detected by frequent clinic visits and a transtelephonic monitoring device with weekly and symptomatic transmissions. RESULTS: Eighty-five percent of patients had a history of hypertension, and the 7.7% had heart failure, left ventricular dysfunction, or both. The mean CHADS2 score was 1.41±0.84. TE and major bleeding events were observed at a low incidence among the overall population at 1-year follow-up (0.97% and 0.81%, respectively). The univariate and multivariable analyses revealed no statistically significant differences in the incidence of TE, major bleeding events or mortality in paroxysmal and persistent AF patients. TE events were more common among women than men (p=0.02). The follow-up examination showed under- or overtreatment with warfarin in many patients, according to guideline suggestions. Warfarin was more frequently prescribed to patients with persistent AF (p<0.0001) and patients with AF recurrences (p<0.0001). AF recurrences were noninvasively detected in 632 (51.2%) patients. In patients without AF recurrences, the TE event rate was 0.5% versus 1.74%, 1.28%, and 1.18% for those with only symptomatic, only asymptomatic or both symptomatic and asymptomatic AF recurrences, respectively, but the difference was not statistically significant, even after adjusting for warfarin treatment and the CHADS2 score (HR 2.93; CI 95%; 0.8-10.9; p=0.11). CONCLUSIONS: TE and major bleeding events showed a very low incidence in the GISSI-AF trial population, despite under- or overtreatment with warfarin in many patients. TE events had a similar rate in paroxysmal and persistent AF. TRIAL REGISTRATION NUMBER: NCT00376272.

Type of hospitalisations and in-hospital outcomes in the Italian coronary care unit network at the time of COVID-19 pandemic: the BLITZ-COVID19 Registry.

OBJECTIVE: The aim of the study was to describe the epidemiology and outcome of patients hospitalised during the COVID-19 pandemic in intensive cardiac care units (ICCs). DESIGN: Non-interventional, retrospective and prospective, nationwide study. SETTING: 109 private or public ICCs in Italy. PARTICIPANTS: 6054 consecutive patients admitted to Italian ICCs during COVID-19 pandemic. PRIMARY AND SECONDARY OUTCOME MEASURES: To obtain accurate and up-to-date information on epidemiology and outcome of patients admitted to ICCs during the COVID-19 pandemic, the impact that the COVID-19 infection may have determined on the organisational pathways and in-hospital management of the various clinical conditions being admitted to ICCs. RESULTS: Acute coronary syndromes were the most frequent ICC discharge diagnoses followed by heart failure and hypokinetic arrhythmias. The prevalence of COVID-19 positivity was approximately 3%. Most patients with a COVID-19 diagnosis at discharge (52%) arrived to ICC from other wards, in particular 22% from non-cardiology ICCs. The overall mortality was 4.2% during ICC and 5.8% during hospital stay. The cause of in-hospital death was cardiac in 74.4% of the cases, non-cardiovascular in 13.5%, vascular in 5.8% and related to COVID-19 in 6.3% of the patients. CONCLUSIONS: This study provides a unique nationwide picture of current ICC care during COVID-19 pandemic. TRIAL REGISTRATION NUMBER: NCT04744415.

Clinical characteristics of patients with asymptomatic recurrences of atrial fibrillation in the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico-Atrial Fibrillation (GISSI-AF) trial.

BACKGROUND: Atrial fibrillation (AF) is a common arrhythmia that frequently recurs after restoration of sinus rhythm. In a consistent percentage of cases, AF recurrences are asymptomatic, thus making its clinical management difficult in relation to both therapeutic efficacy and thromboembolic risk. METHODS: The GISSI-AF trial enrolled 1,442 patients in sinus rhythm with previous AF episodes. Patients were randomized to valsartan or placebo and followed for 12 months. To improve the likelihood of detecting arrhythmic recurrences, arrhythmic follow-up was based on both programmed or symptom-related control visits and transtelephonic electrocardiographic transmissions. The present post hoc analysis was performed on 1,638 arrhythmic episodes that occurred in 623 patients. RESULTS: Asymptomatic AF recurrences were present in 49.5% of patients. In multivariable analysis, asymptomatic AF recurrences were significantly associated with a longer duration of qualifying arrhythmias (odds ratio [95% CI] 1.57 (1.26-1.97), P < .0001). A lower ventricular response (P < .001) and a longer duration of the arrhythmic recurrence (P < .001) characterized asymptomatic episodes. Patients with asymptomatic events were more likely to be in AF at the time of electrocardiographic control at the end of the 12-month follow-up (adjusted odds ratio [95% CI] 4.9 (2.8-8.4), P < .001). Moreover, a higher CHADS(2) (Congestive heart failure, history of Hypertension, Age≥75 years, Diabetes mellitus, and past history of Stroke or TIA doubled) score and a more frequent use of amiodarone, calcium-channel blockers, and digitalis characterized patients with asymptomatic, whereas 1C drugs were more often used in subjects with symptomatic recurrences. CONCLUSION: Asymptomatic AF recurrences were frequent in the GISSI-AF study population in patients who were more likely to develop persistent-permanent AF and were characterized by an increased thromboembolic risk.

Age-dependent prognostic significance of atrial fibrillation in outpatients with chronic heart failure: data from the Italian Network on Congestive Heart Failure Registry.

OBJECTIVES: The role of atrial fibrillation (AF) in older patients with heart failure (HF) is controversial because many variables seem to influence their outcome. We investigated the predictivity of AF in 3 age groups of outpatients with HF. METHODS: We analyzed 8,178 outpatients enrolled in the Italian Network on Congestive Heart Failure Registry with HF diagnosed according to the European Society of Cardiology criteria. A trained cardiologist established the diagnosis of AF and HF at the entry visit at each center. We stratified the population into 3 age groups, as follows: group A, < or =65 years; group B, 66-75 years, and group C, >75 years. RESULTS: Group A was composed of 4,261 patients, 683 with AF (16.0%); in group B there were 2,651 patients, 638 with AF (24.1%), and group C was composed of 1,266 patients, 412 with AF (32.5%). The 1-year mortality rate was higher in AF patients in all groups. In a multivariate model, AF remained an independent risk factor for death in groups A and B, but not in group C [group A: hazard ratio (HR) 1.42, 95% confidence interval (CI) 1.10-1.81; group B: HR 1.29, 95% CI 1.00-1.67; group C: HR 1.05, 95% CI 0.78-1.43]. CONCLUSION: The prevalence of AF increased with age and was associated with a higher mortality rate. However, AF independently predicted all-cause mortality only in patients aged < or =75 years.

Effects of rosuvastatin on atrial fibrillation occurrence: ancillary results of the GISSI-HF trial.

AIMS: This ancillary analysis of the GISSI-HF database aims at assessing the effect of rosuvastatin on the occurrence of atrial fibrillation (AF) in patients with chronic heart failure (HF) who were not in AF at study entry. METHODS AND RESULTS: GISSI-HF was a double-blind, placebo-controlled trial testing n-3 PUFA and rosuvastatin vs. corresponding placebos in patients with chronic HF. Atrial fibrillation occurrence was defined as the presence of AF in the electrocardiogram (ECG) performed at each visit during the trial or AF as a cause of worsening HF or hospital admission or as an event during hospitalization. Among the 3690 patients (80.7%) without AF on their baseline ECG, 15.0% developed AF during a median follow-up period of 3.7 years, 258 randomized to rosuvastatin (13.9%) vs. 294 allocated to placebo (16.0%). Although the difference was not significant at unadjusted analysis (P = 0.097) and multivariable analysis adjusting for clinical variables (P = 0.067), it became significant after adjustment for clinical variables and laboratory examinations (P = 0.039), and for clinical variables, laboratory examinations, and background therapies (P = 0.038). CONCLUSION: This study shows that there is some evidence of a beneficial effect of rosuvastatin in terms of reduction of AF occurrence in patients with HF. Larger populations are needed to provide a definite answer to the question. ClinicalTrials.gov Identifier: NCT00336336.

One-year clinical events and management of patients with atrial fibrillation hospitalized in cardiology centers: Data from the BLITZ-AF study.

BACKGROUND: The management of atrial fibrillation (AF) has changed with the introduction of direct anticoagulants (DOACs) and new techniques such as catheter ablation. An update collection of data from "real world" AF patients followed by cardiologists is useful to obtain information on both management, outcomes and guideline adherence in clinical practice. METHODS: Follow-up information on survival, embolic and bleeding events and hospital readmission, persistence of oral anticoagulant (OAC) therapy was collected in 84 centers participating to the BLITZ-AF study. RESULTS: Patients were followed for a median of 366 days (IQR: 356-378) and vital status was available for 2159 patients. Mortality was 9.2%. Heart failure was the most common cardiovascular cause of death (70%) followed by arrhythmias (6.7%), acute coronary syndrome (5.0%) and ischemic stroke (2.5%). During follow-up 18.1% of the patients were readmitted, mainly (81.3%) for cardiovascular causes. Patients on OAC were 83.4%, 9.1% were on antiplatelets and 7.5% did not receive antithrombotic therapy. The use of DOACs increased from 42.1% to 46.4% during the follow-up, OAC discontinuation occurred in 9.1%. AF recurrences occurred in 23.4% of the patients discharged in sinus rhythm. Rate control strategy was adopted in 55.9% and beta-blockers were the most used drugs (81.9%). Amiodarone (22%) and flecainide (9.7%) were the most frequent used antiahrrythmic drugs. CONCLUSIONS: The follow-up of the BLITZ-AF study provide an up to date picture of the clinical course of patients with AF, who appear frequently affected by heart failure and severe comorbidities which might have led to the high mortality rate.

Prevalence Of familial hypercholeSTerolaemia (FH) in Italian Patients with coronary artERy disease: The POSTER study.

BACKGROUND AND AIMS: Familial hypercholesterolaemia (FH) is a powerful risk factor for cardiovascular (CV) events. High levels of low-density lipoprotein cholesterol (LDL-C) since birth are linked to the early onset of atherosclerotic disease. A genetic mutation determining FH is present in about one subject out of 250; FH should be more represented among subjects with a documented diagnosis of coronary artery disease (CAD). The POSTER Study evaluated the prevalence of FH in Italian patients with a recent CAD event. METHODS: Eighty-two cardiology centres enrolled patients with a documented CAD event; CV risk profile, drug therapy and biochemical parameters were collected. Dutch Lipid Clinic Network (DLCN) criteria were used to define patients with a potential FH diagnosis (score ≥6); these patients underwent molecular testing for genetic diagnosis of FH. RESULTS: Overall, 5415 patients were enrolled and the main index events were myocardial infarction with ST-elevation, non ST-elevation acute coronary syndrome (ACS), or a recent coronary revascularization (34.8%, 37.2%, and 28% respectively). Mean age was 66 ± 11 years, men were 78%; about 40% were already treated with statins, proportion that increased after the acute event (96.5%). Based on the DLCN score, the prevalence of potential FH was 5.1%, 0.9% of them had a diagnosis of definite FH (score >8). These patients were younger than patients with a score <6 (56 ± 10 vs 66 ± 11, p < 0.001), and LDL-C levels were in most of them (~87%) >190 mg/dL. FH was genetically confirmed in 42 subjects (15.9%); genetic diagnosis was defined as not conclusive for FH in 63 patients (23.9%). Finally, in 159 subjects (60.2%) no pathogenic mutations in the tested genes were identified, defining them as negative for monogenic familial hypercholesterolemia. CONCLUSIONS: Results underscore a relatively high prevalence of potential FH in patients with a recent CAD event. Therefore, an early identification of these subjects may help improve the management of their high CV risk and, by cascade screening, identify possible FH relatives.

Role of beta-blockers in patients admitted for worsening heart failure in a real world setting: data from the Italian Survey on Acute Heart Failure.

AIMS: Randomized trials have shown that beta-blockers (BBs) reduce mortality in chronic heart failure (HF). Less data are available on the role of BBs in patients with acute HF, specifically if BBs should be continued or temporarily withdrawn. The aim of this study was to evaluate the role of BBs on in-hospital outcomes of patients admitted for worsening HF in a Cardiology setting. METHODS AND RESULTS: One thousand five hundred and seventy-two patients enrolled in the Italian Survey on Acute HF were evaluated. According to the BB therapy before and during hospitalization, four groups were defined: group A, no/no (51.6%); group B, no/yes (16.4%); group C, yes/no (9.0%); and group D, yes/yes (23.0%). Groups B and D had a significantly lower in-hospital mortality rate (group B 1.2%, group D 2.8%, group A 10.1%, and group C 12.1%; P < 0.0001). The association between non-use or withdrawal of BBs and higher mortality rate was confirmed by the multivariable analysis [group D, reference group; odds ratio (OR) 3.28, 95% confidence interval (CI) 1.47-7.32 and OR 4.20, 95% CI 1.59-11.10 for groups A and C, respectively], whereas no difference was found between groups B and D (OR 0.34, 95% CI 0.07-1.78). CONCLUSION: In patients hospitalized for worsening HF, non-use or discontinuation of BBs was associated with a significant higher mortality.

Upstream Treatment of Atrial Fibrillation with n-3 Polyunsaturated Fatty Acids: Myth or Reality?

Atrial fibrillation (AF) is the most common sustained arrhythmia in adults and is associated with an increased risk of fatal and non-fatal events. Antiarrhythmic drugs provide limited protection against AF recurrence and have a poor safety profile. Several mechanisms have been proven to be involved in AF, e.g. inflammation, oxidative stress, fibrosis and ischaemia. Prevention of AF with interventions that target these mechanisms has emerged as a result of experimental studies suggesting the use of upstream therapies. Long chain n-3 polyunsaturated fatty acids (n-3 PUFA) have multiple effects on cardiac electrophysiology, and epidemiological studies on fish oil suggest a possible use of n-3 PUFA in AF prevention. Several randomised clinical trials have been designed to evaluate the efficacy of n-3 PUFA in preventing AF. In this review, we report the conflicting results of these trials in two different clinical settings: recurrence in patients with history of AF and development of post-operative AF in patient undergoing cardiac surgery.

[Ongoing trials and future prospects]. / I trial in corso e le prospettive future.

Rosuvastatin is a new statin with a great number of pharmacological benefits related to the capacity of modifying favorably the lipid profile but also for the selective binding with 3-hydroxy-3-methylglutaryl coenzyme A reductase, relative hydrophilic properties and selectivity for hepatic cells. Rosuvastatin demonstrated to be more efficacious in reducing LDL cholesterol levels than other statins and to be capable of increasing HDL cholesterol levels. It is well tolerated in a wide range of dosages maintaining its effectiveness. Many trials are ongoing with the aim to evaluate not only the efficacy of rosuvastatin in terms of surrogate endpoints but also in terms of cardiovascular morbidity and mortality. The usefulness of rosuvastatin will be evaluated also in selective patient populations affected by advanced renal disease or chronic heart failure. Two relevant research projects have been started recently, the GALAXY Programme, designed for evaluating the efficacy of rosuvastatin in atherosclerosis and ischemic heart disease and the GISSI-HF trial planned with the aim of testing the efficacy of this statin on morbidity and mortality in chronic heart failure and investigating the pharmacological effects on the pathophysiological mechanisms of heart failure.

Use of digitalis in the treatment of heart failure: data from the Italian Network on Congestive Heart Failure (IN-CHF).

BACKGROUND: Since the large multicenter DIG trial has shown no effects of digitalis on the all-cause mortality of patients with chronic heart failure (HF), the broad prescription of this drug in patients with HF appears to be at the very least, questionable. The aims of this study were: to analyze prescription patterns of digitalis, from 1995 to 2000, in a large group of outpatients with HF; to analyze the independent predictors of digitalis prescription and to evaluate the impact of the results of the DIG trial on the prescription rate of this drug. METHODS: From 1995 to 2000, 11 070 HF outpatients (mean age 64 +/- 12 years, ejection fraction 35 +/- 12%) were enrolled in a large Italian database. RESULTS: Out of 11 070 patients, 7198 (65%) were treated with digitalis. At multivariate analysis, the following variables were independently associated with digitalis prescription; atrial fibrillation (odds ratio [OR] 3.3, 95% confidence interval [CI] 2.9-3.8), ejection fraction < 30% (OR 1.7, 95% CI 1.5-1.9), NYHA class III-IV vs II-III (OR 1.3, 95% CI 1.2-1.5), admission for HF during the previous year (OR 1.4, 95% CI 1.2-1.5). After the publication of the DIG trial, there was a significant reduction in the rate of digitalis prescription: the percentage of patients taking digitalis fell from 68% in 1996-1997 to 61% in 1998-1999 (p < 0.001). CONCLUSIONS: Over 60% of Italian outpatients with HF were treated with digitalis; as expected, patients with a low ejection fraction, atrial fibrillation and in a more advanced stage of HF are more likely to receive this drug. Finally, after the publication of the DIG trial, the rate of digitalis prescription significantly decreased.

Variations in lipoprotein levels after myocardial infarction and unstable angina: the LATIN trial.

BACKGROUND: The aim of this study was to prospectively evaluate the magnitude of the variations in lipid levels in a large population of patients admitted for acute myocardial infarction (MI) and unstable angina (UA). Clinical data and blood samples were prospectively collected from consecutive patients with MI and UA. METHODS: The study population consisted of patients with symptoms lasting < or = 12 hours (for MI) or with the last episode of rest pain within 12 hours and associated with ECG changes (for UA). The exclusion criteria were recent hospitalization for any reason or current treatment with lipid-lowering drugs. Blood samples were obtained at admission, the following morning, at discharge and after 3 months. Samples were centrifuged immediately and 4 aliquots of serum were stored at -20 degrees C. The measurements were performed centrally. RESULTS: We enrolled 1864 patients (1275 with MI and 589 with UA). Serum levels of total and LDL-cholesterol decreased significantly after admission, both in MI and UA patients. After 3 months, serum levels of total cholesterol returned to baseline, while those of LDL-cholesterol were still significantly lower. Between admission and the following morning, total and LDL-cholesterol decreased significantly by 7 and 10% respectively for MI and by 5 and 6% for UA. Lipid measurements not performed at admission accounted for a significant decrease in the number of patients identifiable as hyperlipidemic and suitable for lipid-lowering treatment (18% of MI patients and 11% of UA patients). CONCLUSIONS: Serum cholesterol concentrations drop significantly during hospitalization for an acute coronary syndrome after a few hours from admission to the coronary care unit. Lipid profile assessment should be scheduled at admission in order to correctly identify hyperlipidemic patients.

Newest additions to heart failure treatment.

INTRODUCTION: Despite the improvement in heart failure (HF) therapy in the last 30 years, this condition remains a major public health concern with high hospitalization and mortality rates, and related costs. Recently, new pharmacological approaches are under evaluation. AREAS COVERED: For chronic HF with reduced ejection fraction (EF) direct renin inhibitors, neprilysin-angiotensin II receptor inhibitors and aldosterone synthase inhibitors have been tested. For HF with preserved EF, no therapy has been demonstrated up to now to be able to improve patients' outcomes and it remains a substantial unmet need. In acute HF (AHF) new inotropes and vasodilators have been developed and are currently investigated in trials. In this review, mechanism of action and clinical efficacy of new pharmacological approaches on acute and chronic HF will be discussed. EXPERT OPINION: In patients with HF, some unmet needs remain to be challenged in the near future. For patients with chronic HF, the management of comorbidities, a better definition and treatment of patients with preserved EF are the major issues to be solved. The treatment of patients admitted for AHF is even more compelling. Several hypotheses of research focused on these issues are tested in ongoing trials.

Antiarrhythmic strategies in patients with atrial fibrillation managed by cardiologists and internists: Antithrombotic Agents in Atrial Fibrillation (ATA-AF) survey.

AIMS: To provide insights on the antiarrhythmic management of atrial fibrillation among patients enrolled in the Antithrombotic Agents in Atrial Fibrillation (ATA-AF) study, and to assess the adherence of the Italian cardiologists and internists to guidelines recommendations. METHODS AND RESULTS: The ATA-AF study is a multicenter, observational study with prospective data collection on the management and treatment of patients with atrial fibrillation. From March to July 2010, 6910 patients with atrial fibrillation were recruited in 164 Italian Cardiology (Card) and 196 Internal Medicine (IMed) centers. Permanent atrial fibrillation was diagnosed in 50.8%, persistent atrial fibrillation in 24.4%, paroxysmal in 15.5%, and first-detected atrial fibrillation in 9.3% of the patients. Rhythm control (rhyC) strategy was pursued in 27.5% (39.6% Card vs. 12.9% IMed; P < 0.0001) and rate control (raC) in 51.4% (43.7% Card vs. 60.7% IMed; P < 0.0001); in 21.1% the antiarrhythmic strategy was not defined. Patients assigned to rhyC were younger and with less comorbidities than those assigned to raC. Adjusted multivariable analysis showed that atrial fibrillation type, setting of management, age and site of patient discharge were the most important independent predictors of rhyC assignment. The severity of atrial fibrillation-related symptoms was not associated with rhyC assignment. At discharge, beta-blockers, amiodarone and class 1c antiarrhythmic drugs were the drugs mainly used in the Card centers; and beta-blockers, digitalis, amiodarone and diltiazem/verapamil were used in the IMed centers. Amiodarone was overused in both Card and IMed centers. CONCLUSION: In the present study, rhyC was the strategy mainly pursued by cardiologists and raC by internists; treatment strategy assignment and antiarrhythmic therapy often do not agree with the guideline recommendations.

n-3 polyunsaturated fatty acids and atrial fibrillation in patients with chronic heart failure: the GISSI-HF trial.

AIMS: In the last few years, n-3 polyunsaturated acids (PUFAs) have been extensively studied for the prevention of AF, mostly in patients without heart failure (HF) or LV dysfunction. This post-hoc analysis of the GISSI-HF trial assessed the effect of n-3 PUFAs on AF in patients with chronic HF without AF at study entry over a median follow-up of 3.9 years. METHODS AND RESULTS: In the GISSI-HF trial, 6975 patients with chronic HF were randomized to 1 g daily of n-3 PUFAs or placebo on top of recommended therapy for HF. Of these, 1140 (16.3%) had AF at baseline ECG and were excluded from the present analysis. AF during the trial was defined as the presence of AF on the ECGs done at each visit during the trial or AF as a cause of worsening HF or hospital admission or as an event during hospitalization. Dietary fish consumption and the circulating levels of n-3 PUFAs (the latter in a subset of 1203 patients) were also available. Among the 5835 patients without AF at study entry, 444 randomized to n-3 PUFAs (15.2%) and 408 to placebo (14.0%) developed AF (unadjusted hazard 1.10, P = 0.19). Lower circulating n-3 PUFA levels were independently associated with higher AF prevalence at study entry, but not with its new occurrence. CONCLUSIONS: Despite an inverse relationship between plasma n-3 PUFA levels and prevalent AF, this study found no evidence that 1 g daily n-3 PUFA supplementation in patients with chronic HF reduces incident AF.

Decision making for oral anticoagulants in atrial fibrillation: the ATA-AF study.

BACKGROUND: Oral anticoagulants offer the best long-term protection against ischemic stroke in patients with atrial fibrillation (AF). However, vitamin K antagonists (VKA) are cumbersome to use and their prescription is far from guidelines recommendations. We report the results of a large survey on the attitudes of prescription of VKA in patients with AF. METHODS: 7148 patients were enrolled by 196 Internal Medicine (MED) and 164 Cardiology (CARD) centers, and VKA specifically analyzed. Thrombotic and hemorrhagic risks were evaluated by means of CHADS2 and CHA2DS2VASc scores, and a study-specific bleeding score (modified HAS-BLED). RESULTS: 63.9% of non-valvular patients had a CHADS2 score≥2 (MED: 75.3%-CARD: 53.1%), and 28.4% a bleeding score≥3 (41.9% MED-15.8% CARD). VKA were prescribed in 55.5% of non-valvular patients (46.3% MED and 64.2% CARD), in 81% of high-risk valvular patients and in 58.8% of the overall study population. Among patients at high risk of bleeding (score≥3), VKA were prescribed in 26.9% of subjects, while, in the subgroup at high risk of thrombosis (CHADS2 Score<2), these were prescribed in 54.4%. Age≥75, paroxysmal AF, cognitive impairment, need for assistance, CHADS2<2 and bleeding score≥3 were independent predictors of non-use of VKA. CONCLUSIONS: Oral anticoagulants are more frequently used in CARD than in MED, plausibly due to greater complexity of MED patients. Stratification of thrombotic and hemorrhagic risk significantly drives the choice for VKA. However the fraction of patients in whom prescription or non-prescription is based on other individual characteristics is not negligible.

Current presentation and management of 7148 patients with atrial fibrillation in cardiology and internal medicine hospital centers: the ATA AF study.

BACKGROUND: Atrial fibrillation (AF) is associated with a high risk of stroke and mortality. AIMS: To describe the difference in AF management of patients (pts) referred to Cardiology (CARD) or Internal Medicine (MED) units in Italy. METHODS AND RESULTS: From May to July 2010, 360 centers enrolled 7148 pts (54% in CARD and 46% in MED). Median age was 77 years (IQR 70-83). Hypertension was the most prevalent associated condition, followed by hypercholesterolemia (28.9%), heart failure (27.7%) and diabetes (24.3%). MED pts were older, more frequently females and more often with comorbidities than CARD pts. In the 4845 pts with nonvalvular AF, a CHADS2 score ≥ 2 was present in 53.0% of CARD vs 75.3% of MED pts (p<.0001). Oral anticoagulants (OAC) were prescribed in 64.2% of CARD vs 46.3% of MED pts (p<.0001); OAC prescription rate was 49.6% in CHADS2 0 and 56.2% in CHADS2 score ≥ 2 pts. At the adjusted analysis patients managed in MED had a significantly lower probability to be treated with OAC. Rate control strategy was pursued in 51.4% of the pts (60.5% in MED and 43.6% in CARD) while rhythm control was the choice in 39.8% of CARD vs 12.9% of MED pts (p<.0001). CONCLUSIONS: Cardiologists and internists seem to manage pts with large epidemiological differences. Both CARD and MED specialists currently fail to prescribe OAC in accordance with stroke risk. Patients managed by MED specialists have a lower probability to receive an OAC treatment, irrespective of the severity of clinical conditions.