Atrial fibrillation after typical atrial flutter ablation: a long-term follow-up.

OBJECTIVE: Although catheter ablation is an effective treatment for typical atrial flutter (TFL), atrial fibrillation may occur during follow-up. The aim of this study was to assess the frequency of postablation atrial fibrillation in patients with or without atrial fibrillation before TFL ablation. METHODS: One hundred and ninety-two patients (135 men, age 68 ± 9 years) ablated for TFL were divided into two groups: group 1 (80 patients) with isolated TFL and group 2 (112 patients) with TFL and atrial fibrillation before ablation. The end-point of the study was the occurrence of documented atrial fibrillation after ablation. Several predetermined variables were tested with regard to atrial fibrillation occurrence. The patients' perception of the frequency and severity of arrhythmia-related symptoms was evaluated before and after ablation by means of the Symptom Checklist Frequency and Severity scale (SCFSS). RESULTS: At least one episode of atrial fibrillation was recorded in 18 (22.5%) group 1 and 52 (46%) group 2 patients (P = 0.001), during a follow-up of 1086 ± 825 and 1126 ± 962 days, respectively. On multivariate analysis, independent predictors of atrial fibrillation occurrence in group 1 were the number of preablation episodes of TFL and the younger age of the patients. The 37 group 2 patients who continued to have paroxysmal or persistent atrial fibrillation episodes after ablation showed a significant decrease in atrial fibrillation incidence and hospitalizations. SCFSS significantly improved in the 63 group 2 patients in whom it was evaluated. CONCLUSIONS: On long-term follow-up, after ablation of isolated TFL, more than three-quarters of patients remained free from atrial fibrillation. Conversely, in patients with preablation atrial fibrillation, TFL ablation reduced the number of atrial fibrillation episodes as well as the number of hospitalizations and arrhythmia-related symptoms.

[Oral anticoagulants combined with aspirin in the prolonged treatment after acute coronary syndrome]. / Associazione di anticoagulanti orali e aspirina in trattamento prolungato dopo sindrome coronarica acuta.

The incidence of death or myocardial infarction after acute coronary syndrome (ACS) is still high despite the widespread use of aspirin. Oral anticoagulant therapy (OAT) reducing thrombin activity has the potential to be beneficial when administered alone or in combination with aspirin after ACS. Low-intensity OAT in combination with aspirin is not superior to aspirin alone. Moderate-intensity OAT in combination with aspirin is superior to aspirin alone in reducing death, myocardial infarction or stroke after ACS. However, this regimen has higher rates of both minor and major hemorrhages. The bleeding risk combined with the difficulties of OAT management contributes to suboptimal compliance and has the potential to mitigate the superior efficacy of combined regimens.

[Atrial fibrillation: always cardioversion? No]. / Fibrillazione atriale: cardiovertire sempre? Parere contro.

Two major treatment strategies have emerged in the management of patients with atrial fibrillation (AF): restoration of sinus rhythm and antiarrhythmic drug prophylaxis versus ventricular rate control and chronic anticoagulation. Besides the potential benefits of the restoration of sinus rhythm, several considerations support the choice of controlling the heart rate, mainly the poor efficacy of antiarrhythmic drug prophylaxis. The decision of pursuing the AF cardioversion should be based mainly on the importance of sinus rhythm restoration and the probability of sinus rhythm maintenance. The factors conditioning the maintenance of sinus rhythm following cardioversion are the duration of AF, cardiac size and function, underlying heart disease, the NYHA functional class, and the timing and number of AF recurrences. At least one attempt at cardioversion is warranted in the majority of patients with a first ever episode of AF; however, it seems advisable to give up even the first attempt at cardioversion in the mildly symptomatic patients who are very old, in patients with AF episodes dating back more than 24-36 months and in those with severe valvular heart disease or severe left ventricular dysfunction. A repeated attempt at cardioversion is usually indicated at the first recurrence of AF; repeated cardioversion seems unadvisable in patients with long-standing AF and early recurrence, in case of failure of amiodarone prophylaxis or of side effects of antiarrhythmic drugs, and when the patient is inclined not to undergo a new electrical cardioversion procedure. In patients with further recurrences of AF it is convenient to give up the cardioversion in case of mild symptoms, of failure of several antiarrhythmic drug regimens and when the withdrawal of oral anticoagulant therapy following sinus rhythm restoration is not safe. With regard to mortality, morbidity, quality of life and cost-effectiveness, the strategy of choice has not yet been established. Several large prospective randomized clinical trials comparing cardioversion and antiarrhythmic prophylaxis versus ventricular rate control are ongoing. The results of these studies could, in the near future, provide useful indications for the choice of the therapeutic regimen to be employed.