Acute rate control in atrial fibrillation: an urgent need for the clinician.

Rate and rhythm control are still considered equivalent strategies for symptom control using the Atrial Fibrillation Better Care algorithm recommended by the recent atrial fibrillation guideline. In acute situations or critically ill patients, a personalized approach should be used for rapid rhythm or rate control. Even though electrical cardioversion is generally indicated in haemodynamically unstable patients or for rapid effective rhythm control in critically ill patients, this is not always possible due to the high percentage of failure or relapses in such patients. Rate control remains the background therapy for all these patients, and often rapid rate control is mandatory. Short and rapid-onset-acting beta-blockers are the most suitable drugs for acute rate control. Esmolol was the classical example; however, landiolol a newer very selective beta-blocker, recently included in the European atrial fibrillation guideline, has a more favourable pharmacokinetic and pharmacodynamic profile with less haemodynamic interference and is better appropriate for critically ill patients.

Adherence to the ABC (Atrial fibrillation Better Care) pathway in the Balkan region: the BALKAN-AF survey.

INTRODUCTION: The Atrial fibrillation Better Care (ABC) pathway provides a useful way of simplifying decision­making considerations in a holistic approach to atrial fibrillation management. OBJECTIVES: To evaluate adherence to the ABC pathway and to determine major gaps in adherence in patients in the BALKAN­AF survey. PATIENTS AND METHODS: In this ancillary analysis, patients from the BALKAN­AF survey were divided into the following groups: A (avoid stroke) + B (better symptom control) + C (cardiovascular and comorbidity risk management)-adherent and -nonadherent management. RESULTS: Among 2712 enrolled patients, 1013 (43.8%) patients with mean (SD) age of 68.8 (10.2) years and mean CHA2DS2­VASc score of 3.4 (1.8) had A+B+C-adherent management and 1299 (56.2%) had A+B+C-nonadherent management. Independent predictors of increased A+B+C-adherent management were: capital city (odds ratio [OR], 1.23; 95% CI, 1.03-1.46; P = 0.02), treatment by cardiologist (OR, 1.34; 95% CI, 1.08-1.66; P = 0.01), hypertension (OR, 2.2; 95% CI, 1.74-2.77; P <0.001), diabetes mellitus (OR, 1.28; 95% CI, 1.05-1.57; P = 0.01), and multimorbidity (the presence of 2 or more long­ term conditions) (OR, 1.85; 95% CI, 1.43-2.38; P <0.001). Independent predictors of decreased A+B+C-adherent management were: age 80 years or older (OR, 0.61; 95% CI, 0.48-0.76; P <0.001) and history of bleeding (OR, 0.5; 95% CI, 0.33-0.75; P = 0.001). CONCLUSIONS: Physicians' adherence to integrated AF management based on the ABC pathway was suboptimal. Addressing the identified clinical and system­related factors associated with A+B+C-nonadherent management using targeted approaches is needed to optimize treatment of patients with AF in the Balkan region.

Deceleration and Acceleration Capacities in Risk Stratification for Arrhythmias in Patients With Chronic Obstructive Pulmonary Disease.

BACKGROUND: Patients with chronic obstructive pulmonary disease (COPD) have an increased risk for both supraventricular and ventricular arrhythmias. Autonomic dysregulation may be responsible for the development of arrhythmias in these patients, and its analysis could be useful for identifying those at high risk for arrhythmias. STUDY QUESTION: Our purpose is to analyze the role of acceleration capacity (AC) and deceleration capacity (DC), novel markers of the autonomic balance, as potential arrhythmic risk predictors in patients with COPD. STUDY DESIGN: We prospectively included 47 patients diagnosed with COPD, and a control group of 64 age-matched subjects without COPD. AC and DC values were obtained using 24-hour Holter monitoring. The arrhythmias were isolated premature atrial complexes, supraventricular tachycardias, isolated premature ventricular beats (PVC), and combined ventricular arrhythmias consisting in ventricular tachycardias or more than 10 PVC per hour. RESULTS: Supraventricular arrhythmias and isolated PVC were more frequent in the COPD group. The DC was significantly lower (3.10 vs. 5.60, P < 0.0001) and AC higher (-4.60 vs. -6.60, P = 0.002) in patients with COPD. DC was identified as a predictor of arrhythmic events with an area under the curve (AUC) for premature atrial complexes >70/d of 0.72 (0.56-0.87, P = 0.013), for supraventricular tachycardias 0.76 (0.62-0.90, P = 0.002), and for combined ventricular arrhythmias 0.69 (0.54-0.82, P = 0.025). AC was predictor only for combined ventricular arrhythmias with an AUC of 0.74 (0.58-0.85, P = 0.002). CONCLUSIONS: Patients with COPD associate a significant autonomic imbalance and a higher incidence of arrhythmias. DC could be a strong predictor for supraventricular and ventricular arrhythmias in patients with COPD with no clinically apparent cardiac disease. AC could be useful alongside with DC regarding the risk for ventricular arrhythmias, but seems to have lesser value as a predictor for supraventricular arrhythmias.