[Basics of exercise physiology: from Fick principle to the athlete's heart]. / Bases de la physiologie de l'exercice : du principe de Fick au cœur d'athlète.

Physical activity is undeniably associated with numerous health benefits. However, performance of high intensity and/or high-volume exercise poses a significant physiological challenge to the cardiovascular and respiratory systems, which must undergo several adaptations to meet the increased metabolic demands of the organism. Repeated and prolonged exposure to training leads to long-term cardiac remodeling aimed at optimizing the efficiency of the work performed by the heart during exertion. This article discusses some of the fundamental mechanisms of cardiovascular physiology during exercise including adaptive responses to acute bouts of exercise and longer term structural and functional characteristics of the athlete's heart.

L'exercice physique est indéniablement associé à de nombreux bénéfices pour la santé. La réalisation d'un effort représente un défi physiologique important pour le système cardiovasculaire et respiratoire, qui doivent entreprendre plusieurs adaptations permettant l'augmentation du débit cardiaque afin de palier l'augmentation des demandes métaboliques de l'organisme. L'exposition répétée et prolongée à l'entraînement induit à long terme un remodelage cardiaque optimisant l'efficience du système cardiovasculaire à l'effort. Dans cet article, nous analysons certains des mécanismes de base de la physiologie cardiovasculaire à l'effort, en passant des adaptations survenant lors d'un effort, pour finalement discuter des adaptations structurelles et fonctionnelles qui caractérisent le cœur d'athlète.

[Premature ventricular complexes: what to do?] / Extrasystoles ventriculaires : que faire ?

Premature ventricular complexes (PVCs) are frequently encountered arrhythmias in the general population. They can occur in the context of an underlying structural heart disease (SHD) of ischemic, hypertensive or inflammatory cause and therefore be a prognostic factor. Some PVCs can appear in the context of inherited arrhythmic syndromes while others are seen as idiopathic in the absence of an underlying heart condition and are considered benign. Those idiopathic PVCs often arise from the ventricular outflow tracts, mostly from the right ventricle outflow tract (RVOT). The PVCs burden even with no underlying SHD can be associated with PVC-induced cardiomyopathy which is a diagnosis of exclusion.

Les extrasystoles ventriculaires (ESV) sont fréquentes dans la population générale. Elles peuvent résulter d'une cardiopathie sous-jacente d'origine ischémique, hypertensive ou inflammatoire, et représentent alors un facteur pronostique défavorable. Certaines ESV sont l'expression de syndromes arythmiques héréditaires, alors que d'autres sont qualifiées d'idiopathiques lorsqu'elles surviennent en l'absence de cardiopathie structurelle et sont généralement considérées comme bénignes. Elles prennent le plus souvent leur origine dans les chambres de chasse ventriculaires, majoritairement la chambre de chasse droite. Une charge élevée en ESV peut engendrer une cardiomyopathie rythmique avec dysfonction ventriculaire progressive en l'absence de cardiopathie structurelle. Cette entité constitue néanmoins toujours un diagnostic d'exclusion.

Paediatric and adolescent athletes in Switzerland: age-adapted proposals for pre-participation cardiovascular evaluation.

High-level sports competition is popular among Swiss youth. Even though preparticipation evaluation for competitive athletes is widespread, screening strategies for diseases responsible for sudden death during sport are highly variable. Hence, we sought to develop age-specific preparticipation cardiovascular evaluation (PPCE) proposals for Swiss paediatric and adolescent athletes (under 18 years of age). We recommend that all athletes practising in a squad with a training load of at least 6 hours per week should undergo PPCE based on medical history and physical examination from the age of 12 years on. Prior to 12 years, individual judgement of athletic performance is required. We suggest the inclusion of a standard 12-lead electrocardiogram (ECG) evaluation for all post-pubertal athletes (or older than 15 years) with analysis in accordance with the International Criteria for ECG Interpretation in Athletes. Echocardiography should not be a first-line screening tool but rather serve for the investigation of abnormalities detected by the above strategies. We recommend regular follow-up examinations, even for those having normal history, physical examination and ECG findings. Athletes with an abnormal history (including family history), physical examination and/or ECG should be further investigated and pathological findings discussed with a paediatric cardiologist. Importantly, the recommendations provided in this document are not intended for use among patients with congenital heart disease who require individualised care according to current guidelines.

[Sport and heart : « how much is too much ¼ ?] / Sport et cœur : où est la limite ?

Regular physical activity brings benefits, both cardiovascular and for the rest of the body, however, sport can carry risks in patients suffering from heart diseases. Some conditions, such as atrial fibrillation, are more common in athletes, but it has never been shown that there is a limit beyond which sport becomes harmful. It appears, however, that intensive sports activity does not provide more cardiovascular benefit than moderate activity. It should also be kept in mind that sport does not immunize against risk factors and cardiovascular diseases. It is therefore important not to trivialize a patient's symptoms under the pretext that he or she has a level of fitness above average.

Une activité physique régulière apporte des bénéfices tant cardiovasculaires que sur le reste de l'organisme. Cependant, le sport peut comporter des risques chez des patients souffrant de certaines maladies cardiaques. Certaines pathologies, comme la fibrillation auriculaire, sont plus fréquentes chez les athlètes, mais il n'a jamais été démontré qu'il existe une limite au-delà de laquelle le sport devient délétère. Il apparaît, par contre, qu'une activité sportive intensive n'apporte pas plus de bénéfice sur le plan cardiovasculaire qu'une activité modérée. Il faut également garder en tête que le sport ne garantit pas une protection contre les facteurs de risque et les atteintes cardiovasculaires. Il est donc important de ne pas banaliser les symptômes d'un patient sous prétexte qu'il pratique une activité sportive.

[Pacemakers and defibrillators: what the non-specialist needs to know]. / Pacemakers et défibrillateurs: ce que le non-spécialiste doit savoir.

Cardiologists are in charge of the follow-up of patients equipped with pacemakers and defibrillators. In many situations, however, the non-specialist will have to take care of these patients. It is therefore essential that the practitioner understands the basics of how these devices work, the potential complications and the situations in which the cardiologist's intervention is necessary. This article summarizes implantation techniques, post-operative follow-up and potential complications of implantable devices. It recapitulates the differences between pacemaker, defibrillator and resynchronization therapy. It explains the stimulation modes and reminds the reader how the magnet works and the precautions to be taken in the operating theatre, during magnetic resonance imaging or in situations of emergency.

Le suivi des patients porteurs de pacemakers et de défibrillateurs incombe au cardiologue. Dans de nombreuses situations néanmoins, le non-spécialiste devra prendre en charge ces patients. Il demeure donc essentiel que le praticien soit familier avec les bases du fonctionnement de ces dispositifs, les potentielles complications et les situations pour lesquelles l'intervention du cardiologue s'avère nécessaire. Cet article résume les techniques d'implantation, le suivi postopératoire et les complications potentielles de ces dispositifs médicaux; il rappelle également les différences entre pacemaker, défibrillateur et thérapie de resynchronisation. Il revient finalement sur les modes de stimulation, le fonctionnement de l'aimant ainsi que sur les précautions à prendre au bloc opératoire, lors d'examens par résonance magnétique ou en situation d'urgence.

Impact of early sports specialisation on paediatric ECG.

Athletes of pediatric age are growing in number. They are subject to a number of risks, among them sudden cardiac death (SCD). This study aimed to characterize the pediatric athlete population in Switzerland, to evaluate electrocardiographic findings based on the International Criteria for electrocardiography (ECG) Interpretation in Athletes, and to analyze the association between demographic data, sport type, and ECG changes. Retrospective, observational study of pediatric athletes (less than 18 years old) including medical history, physical examination, and a 12-lead resting ECG. The primary focus was on identification of normal, borderline, and abnormal ECG findings. The secondary observation was the relation between ECG and demographic, anthropometric, sport-related, and clinical data. The 891 athletes (mean 14.8 years, 35% girls) practiced 45 different sports on three different levels, representing all types of static and dynamic composition of the Classification of Sports by Mitchell. There were 75.4% of normal ECG findings, among them most commonly early repolarization, sinus bradycardia, and left ventricular hypertrophy; 4.3% had a borderline finding; 2.1% were abnormal and required further investigations, without SCD-related diagnosis. While the normal ECG findings were related to sex, age, and endurance sports, no such observation was found for borderline or abnormal criteria. Our results in an entirely pediatric population of athletes demonstrate that sex, age, and type of sports correlate with normal ECG findings. Abnormal ECG findings in pediatric athletes are rare. The International Criteria for ECG Interpretation in Athletes are appropriate for this age group.

The Impact of Levothyroxine on Cardiac Function in Older Adults With Mild Subclinical Hypothyroidism: A Randomized Clinical Trial.

BACKGROUND: Subclinical hypothyroidism has been associated with heart failure, but only small trials assessed whether treatment with levothyroxine has an impact on cardiac function. METHODS: In a randomized, double-blind, placebo-controlled, trial nested within the TRUST trial, Swiss participants ages ≥65 years with subclinical hypothyroidism (thyroid-stimulating hormone [TSH] 4.60-19.99 mIU/L; free thyroxine level within reference range) were randomized to levothyroxine (starting dose of 50 µg daily) to achieve TSH normalization or placebo. The primary outcomes were the left ventricular ejection fraction for systolic function and the ratio between mitral peak velocity of early filling to early diastolic mitral annular velocity (E/e' ratio) for diastolic function. Secondary outcomes included e' lateral/septal, left atrial volume index, and systolic pulmonary artery pressure. RESULTS: A total of 185 participants (mean age 74.1 years, 47% women) underwent echocardiography at the end of the trial. After a median treatment duration of 18.4 months, the mean TSH decreased from 6.35 mIU/L to 3.55 mIU/L with levothyroxine (n = 96), and it remained elevated at 5.29 mIU/L with placebo (n = 89). The adjusted between-group difference was not significant for the mean left ventricular ejection fraction (62.7% vs 62.5%, difference = 0.4%, 95% confidence interval -1.8% to 2.5%, P = 0.72) and the E/e' ratio (10.6 vs 10.1, difference 0.4, 95% confidence interval -0.7 to 1.4, P = 0.47). No differences were found for the secondary diastolic function parameters or for interaction according to sex, baseline TSH, preexisting heart failure, and treatment duration (P value >0.05). CONCLUSION: Systolic and diastolic heart function did not differ after treatment with levothyroxine compared with placebo in older adults with mild subclinical hypothyroidism.

[Hypoxic tests and prediction of high altitude illnesses]. / Tests hypoxiques et prédictiondes pathologies liées à l'altitude.

More and more travelers are exposed to high altitude, for example, 176'000 trekkers/climbers were registered in Nepal in 2017. Individual predispositions, a history of altitude illness, the existence of risk factors and/or comorbidities increase the risk of developing specific altitude-related diseases that are potentially life threatening. Nevertheless, the prediction of these diseases remains difficult, especially in subjects without prior exposure to high altitude. In this context different altitude simulation tests have been developed. Their indication, practice and validity are summarized in this article.

De plus en plus de voyageurs s'exposent à la haute altitude, par exemple 176 000 trekkers/alpinistes ont été enregistrés au Népal en 2017. Des prédispositions individuelles, des antécédents de maladies d'altitude, l'existence de facteurs de risque et/ou comorbidités augmentent le risque de développer des maladies spécifiques liées à l'altitude qui sont potentiellement mortelles. Néanmoins, la prédiction de ces maladies reste difficile, notamment chez des sujets sans exposition préalable à la haute altitude. Dans ce contexte, différents tests de simulation à l'altitude ont été développés. Leurs indication, pratique et validité sont résumées dans cet article.

[Strategies for cardiovascular disease prevention]. / Stratégies de prévention cardiovasculaire au cabinet.

Atherosclerosis is a disease which develops very gradually over decades. Under the influence of modifiable cardiovascular risk factors, such as blood pressure, LDL-cholesterol level, smoking or lifestyle, clinical symptoms of atherosclerosis manifest more or less early in life. When cardiovascular risk factors accumulate, the risk of having a cardiovascular event increases and the benefits of prevention measures are greater. This article summarizes existing strategies for controlling modifiable cardiovascular risk factors in primary prevention. The physician can rely on an interprofessional network of cardiovascular prevention. Managing risk factors while respecting the autonomy and priorities of the patient will bring the greatest benefit.

L'athérosclérose est une pathologie qui se développe sans symptômes sur des dizaines d'années. Sous l'influence de facteurs de risque cardiovasculaire modifiables, tels que la tension artérielle, le taux de LDL-cholestérol, le tabagisme ou le style de vie, les manifestations cliniques de l'athérosclérose apparaissent plus ou moins précocement. Plus les facteurs de risque cardiovasculaire s'accumulent, plus le bénéfice cardiovasculaire est grand lors de la mise en place de mesures de prévention. Cet article résume les stratégies existantes pour contrôler les facteurs de risque cardiovasculaire en prévention primaire. Le médecin peut s'appuyer sur un réseau interprofessionnel ambulatoire de prévention cardiovasculaire. Agir sur l'ensemble des facteurs de risque en respectant l'autonomie et les priorités du patient apportera le plus grand bénéfice.

Inter-Rater Reliability and Downstream Financial Implications of Electrocardiography Screening in Young Athletes.

BACKGROUND: Preparticipation screening for cardiovascular disease in young athletes with electrocardiography is endorsed by the European Society of Cardiology and several major sporting organizations. One of the concerns of the ECG as a screening test in young athletes relates to the potential for variation in interpretation. We investigated the degree of variation in ECG interpretation in athletes and its financial impact among cardiologists of differing experience. METHODS AND RESULTS: Eight cardiologists (4 with experience in screening athletes) each reported 400 ECGs of consecutively screened young athletes according to the 2010 European Society of Cardiology recommendations, Seattle criteria, and refined criteria. Cohen κ coefficient was used to calculate interobserver reliability. Cardiologists proposed secondary investigations after ECG interpretation, the costs of which were based on the UK National Health Service tariffs. Inexperienced cardiologists were more likely to classify an ECG as abnormal compared with experienced cardiologists (odds ratio, 1.44; 95% confidence interval, 1.03-2.02). Modification of ECG interpretation criteria improved interobserver reliability for categorizing an ECG as abnormal from poor (2010 European Society of Cardiology recommendations; κ=0.15) to moderate (refined criteria; κ=0.41) among inexperienced cardiologists; however, interobserver reliability was moderate for all 3 criteria among experienced cardiologists (κ=0.40-0.53). Inexperienced cardiologists were more likely to refer athletes for further evaluation compared with experienced cardiologists (odds ratio, 4.74; 95% confidence interval, 3.50-6.43) with poorer interobserver reliability (κ=0.22 versus κ=0.47). Interobserver reliability for secondary investigations after ECG interpretation ranged from poor to fair among inexperienced cardiologists (κ=0.15-0.30) and fair to moderate among experienced cardiologists (κ=0.21-0.46). The cost of cardiovascular evaluation per athlete was $175 (95% confidence interval, $142-$228) and $101 (95% confidence interval, $83-$131) for inexperienced and experienced cardiologists, respectively. CONCLUSIONS: Interpretation of the ECG in athletes and the resultant cascade of investigations are highly physician dependent even in experienced hands with important downstream financial implications, emphasizing the need for formal training and standardized diagnostic pathways.

[Electrocardiographic interpretation in athletes : 2017 recommendations for non-cardiologists]. / Interprétation de l'électrocardiogramme de l'athlète Recommandations 2017 pour le non-cardiologue.

A resting electrocardiogram (ECG) is recommended for screening of sudden cardiac death in young athletes. However, ECG interpretation in athletes requires an adequate training because normal physiological training adaptations in athletes can sometimes be hardly distinguished from abnormal findings suggestive of underlying pathology. In 2017, a consensus of international experts established new recommendations for a clear and accurate interpretation of ECGs in athletes. This article aims to guide non-cardiologists according to these new data, allowing a better triage of anomalies requiring further investigations.

L'électrocardiogramme (ECG) de repos est recommandé pour le dépistage de la mort subite d'origine cardiaque du jeune athlète. Cependant, l'interprétation de l'ECG de l'athlète nécessite une formation adéquate car il est parfois difficile de distinguer les modifications physiologiques provoquées par l'entraînement intensif des anomalies témoignant de pathologies sous-jacentes. En 2017, un consensus d'experts internationaux a établi des nouvelles recommandations claires et précises de l'interprétation de l'ECG de l'athlète. Cet article a pour but de guider le non-cardiologue selon ces nouvelles données, lui permettant ainsi d'effectuer un meilleur triage des anomalies nécessitant des examens complémentaires.

[Immersion pulmonary edema]. / Œdème pulmonaire d'immersion.

Immersion pulmonary edema may occur during scuba diving, snorke-ling or swimming. It is a rare and often recurrent disease, mainly affecting individuals aged over 50 with high blood pressure. However it also occurs in young individuals with a healthy heart. The main symptoms are dyspnea, cough and hemoptysis. The outcome is often favorable under oxygen treatment but deaths are reported. A cardiac and pulmonary assessment is necessary to evaluate the risk of recurrence and possible contraindications to immersion.

L'œdème pulmonaire d'immersion peut survenir durant une plongée sous-marine, une plongée en apnée ou durant la natation. C'est une pathologie rare, souvent récidivante, touchant principalement les individus âgés de plus de 50 ans et hypertendus mais qui survient également chez des individus jeunes avec un cœur sain. Les symptômes principaux sont une dyspnée, une toux et des hémoptysies. L'évolution est souvent favorable sous traitement d'oxygène mais des décès sont rapportés. Un bilan cardiologique et pulmonaire est nécessaire pour évaluer le risque de récidive et une éventuelle contre-indication à l'immersion.

[Cardiology update in 2016]. / Cardiologie.

In 2016 the European Society of Cardiology (ESC) published new guidelines. These documents update the knowledge in various fields such as atrial fibrillation, heart failure, cardiovascular prevention and dyslipidemia. Of course it is impossible to summarize these guidelines in detail. Nevertheless, we decided to highlight the major modifications, and to emphasize some key points that are especially useful for the primary care physician.

L'année 2016 en cardiologie a été marquée par la publication de nouvelles recommandations, par la Société européenne de cardiologie (ESC). Ces documents actualisent les connaissances dans des domaines variés que sont la fibrillation auriculaire, l'insuffisance cardiaque, la prévention cardiovasculaire et les dyslipidémies. Il est bien entendu impossible de synthétiser ces recommandations de façon exhaustive. Néanmoins, il nous a paru important de résumer les nouveautés majeures, mais également de rappeler certains points essentiels et surtout utiles pour le médecin de premier recours.

[Heart and sport]. / Cœur et sport.

Physical activity is beneficial for health and the cardiovascular risk profile. However, it can be dangerous in people with cardiac disease that might be asymptomatic. Individuals of all ages and all levels engage in sporting activities. The medical approach is different whether one evaluates a young competitive athlete, a sedentary adult who wants to start a recreational sport or a patient with heart disease who wishes to engage in sport. This article summarizes the various recommendations on the subject.

L'activité physique est bénéfique pour la santé et le profil de risque cardiovasculaire. Toutefois, elle peut s'avérer dangereuse chez les individus atteints d'une pathologie cardiaque, parfois asymptomatiques. Le sport s'est grandement démocratisé et se pratique à tout âge et à tout niveau. L'approche médicale est différente qu'il s'agisse d'un jeune athlète de compétition, d'un adulte sédentaire voulant débuter une activité sportive de loisir ou du patient atteint d'une cardiopathie qui désire faire du sport. Cet article résume les différentes recommandations de prise en charge selon la situation.

Cost Implications of Using Different ECG Criteria for Screening Young Athletes in the United Kingdom.

BACKGROUND: High false-positive rates and cost of additional investigations are an obstacle to electrocardiographic (ECG) screening of young athletes for cardiac disease. However, ECG screening costs have never been systematically assessed in a large cohort of athletes. OBJECTIVE: This study investigated the costs of ECG screening in athletes according to the 2010 European Society of Cardiology (ESC) recommendations and the Seattle and refined interpretation criteria. METHODS: Between 2011 and 2014, 4,925 previously unscreened athletes aged 14 to 35 years were prospectively evaluated with history, physical examination, and ECG (interpreted with the 2010 ESC recommendations). Athletes with abnormal results underwent secondary investigations, the costs of which were based on U.K. National Health Service Tariffs. The impact on cost after applying the Seattle and refined criteria was evaluated retrospectively. RESULTS: Overall, 1,072 (21.8%) athletes had an abnormal ECG on the basis of 2010 ESC recommendations; 11.2% required echocardiography, 1.7% exercise stress test, 1.2% Holter, 1.2% cardiac magnetic resonance imaging, and 0.4% other tests. The Seattle and refined criteria reduced the number of positive ECGs to 6.0% and 4.3%, respectively. Fifteen (0.3%) athletes were diagnosed with potentially serious cardiac disease using all 3 criteria. The overall cost of de novo screening using 2010 ESC recommendations was $539,888 ($110 per athlete and $35,993 per serious diagnosis). The Seattle and refined criteria reduced the cost to $92 and $87 per athlete screened and $30,251 and $28,510 per serious diagnosis, respectively. CONCLUSIONS: Contemporary ECG interpretation criteria decrease costs for de novo screening of athletes, which may be cost permissive for some sporting organizations.

[Cardiology update in 2015]. / Cardiologie.

The present review provides a selected choice of clinical trials and therapeutic advances in the field of cardiology in 2015. A new treatment option in heart failure will become available this year in Switzerland. In interventional cardiology, new trials have been published on the duration of dual antiplatelet therapy, the new stents with bioresorbable scaffold and the long-term results of TAVR in patients who are not surgical candidates or at high surgical risk. RegardingAF the BRIDGE trial provides new evidences to guide the management of patients during warfarin interruption for surgery. Recent publications are changing the paradigm of AF treatment by showing a major impact of the management of cardiometabolic risk factors. Finally, refined criteria for ECG interpretation in athletes have been recently proposed to reduce the burden of false-positive screening.

The prevalence and significance of a short QT interval in 18,825 low-risk individuals including athletes.

OBJECTIVES: The short QT syndrome is a cardiac channelopathy characterised by accelerated repolarisation which manifests as a short QT interval on the ECG. The definition of a short QT interval is debated, ranging from <390 to ≤320 ms, and its clinical significance in healthy young individuals is unknown. We assessed the prevalence and medium-term significance of an isolated short QT interval in a diverse young British population. METHODS: Between 2005 and 2013, 18 825 apparently healthy people aged 14-35 years underwent cardiovascular evaluation with history, physical examination and ECG. QT intervals were measured by cardiologists using 4 recommended guidelines (Seattle 2013, Heart Rhythm Society 2013, European Society of Cardiology 2010 and American Heart Association 2009). RESULTS: The prevalence of a short QT interval was 0.1% (26 patients, ≤320 ms), 0.2% (44 patients, ≤330 ms), 7.9% (1478 patients, <380 ms), 15.8% (2973 patients, <390 ms). Male gender and Afro-Caribbean ethnicity had the strongest association with short QT intervals. Athletes had shorter QT intervals than non-athletes but athletic status did not predict short QT intervals. Individuals with short QT intervals ≤320 ms did not report syncope or a sinister family history, and during a follow-up period of 5.3±1.2 years, there were no deaths in this group. CONCLUSIONS: The prevalence of a short QT interval depends on the recommended cut-off value. Even at values ≤320 ms, there was an excellent medium-term prognosis among 14 people followed. We conclude that a definition of ≤320 ms is realistic to prevent overdiagnosis and excessive investigations.

Short-Term Heparin Kinetics during Catheter Ablation of Atrial Fibrillation.

BACKGROUND: Percutaneous catheter ablation of atrial fibrillation (CA-AF) is a treatment option for symptomatic drug-refractory atrial fibrillation (AF). CA-AF carries a risk for thromboembolic complications that has been minimized by the use of intraprocedural intravenous unfractionated heparin (UFH). The optimal administration of UFH as well as its kinetics are not well established and need to be precisely determined. METHODS AND RESULTS: A total 102 of consecutive patients suffering from symptomatic drug-refractory AF underwent CA-AF. The mean age was 61 ± 10 years old. After transseptal puncture of the fossa ovalis, weight-adjusted UFH bolus (100 U/kg) was infused. A significant increase in activated clotting time (ACT) was observed from an average value of 100 ± 27 seconds at baseline, to 355 ± 94 seconds at 10 min (T10), to 375 ± 90 seconds at 20 min (T20). Twenty-four patients failed to reach the targeted ACT value of ≥300 seconds at T10 and more than half of these remained with subtherapeutic ACT values at T20. This subset of patients showed similar clinical characteristics and amount of UFH but were more frequently prescribed preprocedural vitamin K1 than the rest of the study population. CONCLUSIONS: In a typical intervention setting, UFH displays unexpected slow anticoagulation kinetics in a significant proportion of procedures up to 20 minutes after infusion. These findings support the infusion of UFH before transseptal puncture or any left-sided catheterization with early ACT measurements to identify patients with delayed kinetics. They are in line with recent guidelines to perform CA-AF under therapeutic anticoagulation.