ASSOCIATION OF LEFT ATRIAL SPONTANEOUS ECHO CONTRAST WITH CLINICAL AND HEMODYNAMIC CHARACTERISTICS OF PATIENTS WITH LONG-TERM EPISODES OF PERSISTENT ATRIAL FIBRILLATION.

OBJECTIVE: The aim: To identify clinical and hemodynamic factors, associated with left atrial spontaneous echo contrast (LASEC) (LASEC in general, and the dense LASEC), in non-valvular persistent atrial fibrillation (AF) patients with the duration of AF episode ≥90 days. PATIENTS AND METHODS: Materials and methods: The cross-sectional study consecutively enrolled 115 persistent AF patients with the duration of its episode ≥90 days (82 (71,3 %) males; mean age 59 ± 11 years). Transthoracic (TEE) and transesophageal echocardiography (TEE) were performed. LASEC (by TEE) was observed in 79 (68,7 %) patients. The dense (moder¬ate-to-severe) LASEC was detected in 23 (20,0 %) cases. RESULTS: Results: Heart failure (HF) stage C (OR 2,09 (95 % CI 1,24-3,53); p=0,006), lower TEE-derived left atrial appendage (LAA) flow velocity (FV) (OR 0,94 (95 % CI 0,91-0,98); p=0,003), and the presence of TTE-derived pulmonary hypertension (PH), appeared to be strongly associated with LASEC (AUC for logistic regression model: 0,83 [95 % СI 0,75- 0,89]). The presence of diabetes mellitus type 2 (DM) (OR 2,34 (95 % CI 1,13-4,86); p=0,027), along with lower LAA FV (OR 0,83 (95 % CI 0,76-0,91); p<0,001), were strongly associated with dense LASEC (AUC: 0,89 [95 % CI 0,82-0,94]). CONCLUSION: Conclusions: The TEE-derived LASEC in patients with long term episodes (≥90 days) of persistent AF was strongly associated with HF stage C and TTE-derived PH, and with lower TEE-derived LAA FV. The presence of DM, in addition to lower LAA FV, was related to dense LASEC.

ASSOCIATION OF FRACTIONAL FLOW RESERVE WITH CLINICAL AND ANGIOGRAPHIC CHARACTERISTICS OF PATIENTS WITH STABLE CORONARY ARTERY DISEASE.

OBJECTIVE: The aim: To identify clinical and angiographic factors, associated with fractional flow reserve (FFR), in stable coronary artery disease (CAD) patients. PATIENTS AND METHODS: Materials and methods: The study consecutively enrolled 68 patients with stable CAD (mean age (63±8,0) ys) and angiographically intermediate coronary lesions (diameter stenosis 50-90 %), with FFR assessment. Stable angina of CCS classes II and III was diagnosed in 42 (62 %) and 15 (22 %) patients, respectively; left ventricular hypertrophy (LVH) - 27 (40 %); severe coronary stenosis (SCS) (70-90 %) - 46 (68 %). The overall CAD complexity was assessed by SYNTAX score. FFR «negative¼ group (FFRNEG) included the patients with non-significant FFRs (>0,80) (n=28 [41 %]). In case of at least one significant FFR (≤0,80), a patient was assigned to FFR «positive¼ group (FFRPOS) (n=40 [59 %]). RESULTS: Results: FFRPOS (vs. FFRNEG, respectively) was characterized by the higher frequency of angina class III (32 % vs. 7 %; p<0,001), LVH (53 % vs. 21 %; p=0,010) and SCS (98 % vs. 25 %; p<0,001). The SYNTAX score was strongly associated with FFR ≤0,70 and ≤0,65, and moderately - with FFR ≤0,65. CONCLUSION: Conclusions: In patients with stable CAD and intermediate coronary artery stenosis, the presence of at least one functionally significant lesion (FFR ≤0,80) was associated with the higher prevalence of angina class III, LVH and more advanced coronary stenosis (≥70 %). The greater overall CAD complexity increased the probability for the angiographically significant coronary lesions to be more functionally compromised.

The role of basic pharmacotherapy in the prevention of late adverse events after elective coronary artery bypass grafting.

OBJECTIVE: The aim: To determine the role of adherence to the guidelines on basic pharmacotherapy in prevention of late major adverse clinical events (MAEs) in patients with stable CAD for three years following isolated CABG. PATIENTS AND METHODS: Materials and methods: A prospective single-centre study included 251 consecutive patients with stable CAD (mean age (61±9) years, 218 (86.9%) males), after isolated CABG. In three years MAЕs occurred in 55 (21.9%) patients. The data on pharmacotherapy at follow-up were obtained in 250 patients: 196 (78.4%) patients without MAEs (at scheduled visit) and 54 (21.6%) patients with MAEs (based on in-hospital or archive data). RESULTS: Results: Basic CAD pharmacotherapy after CABG was comparable in MAEs vs. no-MAEs groups, with the vast majority of patients receiving guideline-recommended therapy with angiotensin-converting enzyme inhibitors (ACEII) or angiotensin-II receptors blockers (ARBs), statins and antiplatelet drugs. At three years follow-up, MAEs group, as opposed to no-MAEs group, was characterized by the lower usage of ACEII/ARBs (68.5% vs. 87.2%, respectively; p=0,001) and statins (59.3% vs. 86.7%, respectively; p<0,001), as well as basic triple therapy (ACEII or ARBs/statins/antiplatelet drugs: 35.2% vs. 70.4%, respectively [p<0,001]). CONCLUSION: Conclusions: At three - year follow-up MAEs in patients with stable CAD after CABG were associated with more frequent discontinuation of previously prescribed basic pharmacotherapy, namely ACEII/ARBs and statins, as well as triple therapy (ACEII/ARBs, statins and antiplatelet drugs).

Atrial Fibrillation Management Strategies in Routine Clinical Practice: Insights from the International RealiseAF Survey.

BACKGROUND: Atrial fibrillation (AF) can be managed with rhythm- or rate-control strategies. There are few data from routine clinical practice on the frequency with which each strategy is used and their correlates in terms of patients' clinical characteristics, AF control, and symptom burden. METHODS: RealiseAF was an international, cross-sectional, observational survey of 11,198 patients with AF. The aim of this analysis was to describe patient profiles and symptoms according to the AF management strategy used. A multivariate logistic regression identified factors associated with AF management strategy at the end of the visit. RESULTS: Among 10,497 eligible patients, 53.7% used a rate-control strategy, compared with 34.5% who used a rhythm-control strategy. In 11.8% of patients, no clear strategy was stated. The proportion of patients with AF-related symptoms (EHRA Class > = II) was 78.1% (n = 4396/5630) for those using a rate-control strategy vs. 67.8% for those using a rhythm-control strategy (p<0.001). Multivariate logistic regression analysis revealed that age <75 years or the paroxysmal or persistent form of AF favored the choice of a rhythm-control strategy. A change in strategy was infrequent, even in patients with European Heart Rhythm Association (EHRA) Class > = II. CONCLUSIONS: In the RealiseAF routine clinical practice survey, rate control was more commonly used than rhythm control, and a change in strategy was uncommon, even in symptomatic patients. In almost 12% of patients, no clear strategy was stated. Physician awareness regarding optimal management strategies for AF may be improved.

Heart failure in patients with atrial fibrillation is associated with a high symptom and hospitalization burden: the RealiseAF survey.

BACKGROUND: Atrial fibrillation (AF) and heart failure (HF) often coexist; the consequences of such coexistence are unclear. HYPOTHESIS: HF in patients with AF is associated with poor outcomes. METHODS: This post hoc analysis of RealiseAF, a survey of AF patients, compared symptoms, hospitalizations, management, and AF control in patients with vs without HF. A total of 10,523 AF patients were analyzed according to presence/absence of HF. RESULTS: History of HF was present in 45.8%, and in more patients with permanent vs persistent, paroxysmal, or first-episode AF (55.6%, 44.3%, 32.9%, and 29.8%, respectively; P < 0.0001). Patients with vs those without history of HF, and patients with HF and reduced ejection fraction (HF-REF) vs those with HF and a preserved ejection fraction (HF-PEF), had more frequent cardiovascular (CV) risk factors and more severe symptoms. Presence vs absence of HF, and HF-REF vs HF-PEF, were associated with lower rates of AF control (54.6% vs 62.8% and 49.3% vs 60.3%, respectively; both P < 0.0001). The rate-control strategy was used more frequently in HF patients, particularly those with HF-REF, than the rhythm-control strategy. CV hospitalizations occurred more frequently in patients with HF than those without (41.8% vs 17.5%; P < 0.001) and more frequently in patients with HF-REF than in those with HF-PEF (51.6% vs 35.6%; P < 0.0001). CONCLUSIONS: AF patients with HF, particularly HF-REF, experience heavy symptom and hospitalization burdens, and have relatively low rates of AF control. Further studies are needed to identify ways to improve the management and treatment outcomes of this very high-risk patient population.

Inappropriate use of antiarrhythmic drugs in paroxysmal and persistent atrial fibrillation in a large contemporary international survey: insights from RealiseAF.

AIMS: International atrial fibrillation (AF) guidelines have defined optimal drugs for patients with various underlying diseases, but the extent to which real-life practice complies with these guidelines is unknown. This study aimed to evaluate the appropriate use of antiarrhythmic drugs (AADs) in patients with paroxysmal and persistent AF from the RealiseAF survey, according to the 2006 American College of Cardiology/American Heart Association/European Society of Cardiology AF guidelines. METHODS AND RESULTS: RealiseAF was an international cross-sectional, observational survey of 10 523 eligible patients from 26 countries on 4 continents, with ≥1 AF episode documented by standard electrocardiogram or by Holter monitoring in the last 12 months. Participating physicians were randomly selected during 2009-10 from lists of office-based or hospital-based cardiologists and internists. Overall, 4947 patients with paroxysmal (n = 2606) or persistent AF (n = 2341) were included; mean (standard deviation) age was 64.7 (12.4) and 66.0 (11.8) years, respectively. Class Ic drugs were prescribed in 589 patients (11.9%); however, in 20.0% of these patients, the indication was not consistent with published guidelines. Similarly, for the 219 patients prescribed sotalol (4.4%), 16.0% received treatment for an indication that deviated from the published guidelines. Amiodarone was prescribed as first-line therapy in 1268 patients (25.6%), but 49.9% of these did not have heart failure or hypertension with significant left ventricular hypertrophy. CONCLUSION: The use of AADs for persistent or paroxysmal AF in this large contemporary international survey showed some deviations from international guidelines. The highest discordance came with the use of amiodarone in first line. Clearly, there is a large discrepancy between published guidelines and current practice.

Distribution and risk profile of paroxysmal, persistent, and permanent atrial fibrillation in routine clinical practice: insight from the real-life global survey evaluating patients with atrial fibrillation international registry.

BACKGROUND: There is a paucity of international data on the various types of atrial fibrillation (AF) outside the highly selected populations from randomized trials. This study aimed to describe patient characteristics, risk factors, comorbidities, symptoms, management strategy, and control of different types of AF in real-life practice. METHODS AND RESULTS: Real-life global survey evaluating patients with atrial fibrillation (RealiseAF) was a contemporary, large-scale, cross-sectional international survey of patients with AF who had ≥1 episode in the past 12 months. Investigators were randomly selected to avoid bias. Among 9816 eligible patients from 831 sites in 26 countries, 2606 (26.5%) had paroxysmal, 2341 (23.8%) had persistent, and 4869 (49.6%) had permanent AF. As AF progressed from paroxysmal to persistent and permanent forms, the prevalence of comorbidities, such as heart failure (32.9%, 44.3%, and 55.6%), coronary artery disease (30.0%, 32.9%, and 34.3%), cerebrovascular disease (11.7%, 10.8%, and 17.6%), and valvular disease (16.7%, 21.2%, and 35.8%), increased, and the prevalence of lone AF decreased. Similarly, there was an increase in mean CHADS(2) [cardiac failure, hypertension, age, diabetes, stroke (doubled)] score (1.7, 1.8, and 2.2), and more than half of patients (51.0%, 56.7%, and 67.3%) qualified for oral anticoagulants. Almost 90% of patients received ≥1 antiarrhythmic drug, but >60% had European Heart Rhythm Association symptom scores from II to IV. Furthermore, 40.7% of persistent and 49.8% of permanent AF patients were still in AF with a heart rate >80 beats per minute. CONCLUSIONS: This survey disclosed high cardiovascular risks and an unmet need in daily practice for patients with any type of AF, especially those with the permanent form.

Symptoms, functional status and quality of life in patients with controlled and uncontrolled atrial fibrillation: data from the RealiseAF cross-sectional international registry.

BACKGROUND: Rate control and rhythm control are accepted management strategies for atrial fibrillation (AF). OBJECTIVE: RealiseAF aimed to describe the success of either strategy and the impact of control on symptomatic status of patients with AF. METHODS: This international, observational, cross-sectional survey of patients with any history of AF in the previous year, recorded AF characteristics, management and frequency of control (defined as sinus rhythm or AF with resting heart rate ≤80 bpm). RESULTS: Overall, 9665 patients were evaluable for AF control, with 59.0% controlled (sinus rhythm 26.5%, AF ≤80 bpm 32.5%) and 41.0% uncontrolled. Symptom prevalence in the previous week was lower in controlled than uncontrolled AF (55.7% vs 68.4%; p<0.001) and similar for patients in sinus rhythm versus AF ≤80 bpm (54.8% vs 56.4%; p=0.23). At the visit, AF-related functional impairment (EHRA class >I) was seen in 67.4% of patients with controlled AF and 82.1% of patients with uncontrolled AF (p<0.001). Quality-of-life (QoL, measured using EQ-5D) was better for patients with controlled versus uncontrolled AF using the Visual Analogue Scale (mean (SD) score 67.1 (18.4) vs 63.2 (18.9); p<0.001), single index utility score (median 0.78 vs 0.73; p<0.001), or five dimensions of well-being (all p<0.001). Irrespective of AF control, cardiovascular events had led to hospitalisation in the past year in 28.1%. CONCLUSION: AF control is not optimal. Control appears to be associated with fewer symptoms and better QoL, but even patients with controlled AF have frequent symptoms, functional impairment, altered QoL and cardiovascular events. New treatments are needed to improve control and minimise the functional and QoL burden of AF.