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1.
Circ Arrhythm Electrophysiol ; 14(2): e008961, 2021 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-33419385

RESUMO

BACKGROUND: Antiarrhythmic drug (AAD) therapy for atrial fibrillation (AF) can be associated with both proarrhythmic and noncardiovascular toxicities. Practice guidelines recommend tailored AAD therapy for AF based on patient-specific characteristics, such as coronary artery disease and heart failure, to minimize adverse events. However, current prescription patterns for specific AADs and the degree to which these guidelines are followed in practice are unknown. METHODS: Patients enrolled in the Get With The Guidelines-Atrial Fibrillation registry with a primary diagnosis of AF discharged on an AAD between January 2014 and November 2018 were included. We analyzed rates of prescription of each AAD in several subgroups including those without structural heart disease. We classified AAD use as guideline concordant or nonguideline concordant based on 6 criteria derived from the American Heart Association/American College of Cardiology/Heart Rhythm Society AF guidelines. Guideline concordance for amiodarone was not considered applicable, since its use is not specifically contraindicated in the guidelines for reasons such as structural heart disease or renal function. We analyzed guideline-concordant AAD use by specific patient and hospital characteristics, and regional and temporal trends. RESULTS: Among 21 921 patients from 123 sites, the median age was 69 years, 46% female and 51% had paroxysmal AF. The most commonly prescribed AAD was amiodarone (38%). Sotalol (23.2%) and dofetilide (19.2%) were each more commonly prescribed than either flecainide (9.8%) or propafenone (4.8%). Overall guideline-concordant AAD prescription at discharge was 84%. Guideline-concordant AAD use by drug was as follows: dofetilide 93%, sotalol 66%, flecainide 68%, propafenone 48%, and dronedarone 80%. There was variability in rate of guideline-concordant AAD use by hospital and geographic region. CONCLUSIONS: Amiodarone remains the most commonly prescribed AAD for AF followed by sotalol and dofetilide. Rates of guideline-concordant AAD use were high, and there was significant variability by specific drugs, hospitals, and regions, highlighting opportunities for additional quality improvement.

2.
J Cardiovasc Electrophysiol ; 32(2): 248-259, 2021 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-33368764

RESUMO

INTRODUCTION: Cryoballoon ablation (CBA) is an alternative to radiofrequency ablation (RFA) for ablation of atrial fibrillation (AF) and real-world comparisons of this strategy are lacking. As such, we sought to compare patient and periprocedural characteristics and outcomes of CBA versus RFA in the Get With the Guidelines AFIB Registry. METHODS: Categorical variables were compared via the χ2 test and continuous variables were compared via the Wilcoxon rank-sum test. Adjusted analyses were performed using overlap weighting of propensity scores. RESULTS: A total of 5247 (1465 CBA, 3782 RFA) ablation procedures were reported from 33 sites. Those undergoing CBA more often had paroxysmal AF (60.0% vs. 48.8%) and no prior AF ablation (87.5% vs. 73.8%). CHA2 DS2 -VASc scores were similar. Among de novo ablations, most ablations involved intracardiac echocardiography and electroanatomic mapping, but both were less common with CBA (87.3% vs. 93.9%, p < .0001, and 87.7% vs. 94.6%, p < .0001, respectively). CBA was associated with shorter procedures (129 vs. 179 min, p < .0001), increased fluoroscopy use (19 vs. 11 min, p < .0001), and similar ablation times (27 vs. 35 min, p = .15). Nonpulmonary vein ablation was common with CBA: roof line 38.6%, floor line 20.4%, cavotricuspid isthmus 27.7%. RFA was associated with more total complications compared to CBA (5.4% vs. 2.3%, p < .0001), due to more volume overload and "other" events, although phrenic nerve injury was more common with CBA (0.9% vs 0.1%, p = .0001). In the adjusted model, any complication was less common among CBA cases (odds ratio, 0.45; confidence interval, 0.25-0.79, p = .0056). CONCLUSION: CBA was associated with fewer complications, and shorter procedure times, and greater fluoroscopy times, compared to RFA. Nonpulmonary vein ablation and electroanatomic mapping system use was common with CBA.

3.
J Am Heart Assoc ; 9(23): e017024, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-33241750

RESUMO

Background Knowledge is scarce regarding how multimorbidity is associated with therapeutic decisions regarding oral anticoagulants (OACs) in patients with atrial fibrillation. Methods and Results We conducted a cross-sectional study of hospitalized patients with atrial fibrillation using the Get With The Guidelines-Atrial Fibrillation registry from 2013 to 2019. We identified patients ≥65 years and eligible for OAC therapy. Using 16 available comorbidity categories, patients were stratified by morbidity burden. A multivariable logistic regression model was used to determine the odds of receiving OAC prescription at discharge by morbidity burden. We included 34 174 patients with a median (interquartile range) age of 76 (71-83) years, 56.6% women, and 41.9% were not anticoagulated at admission. Of these patients, 38.6% had 0 to 2 comorbidities, 50.7% had 3 to 5 comorbidities, and 10.7% had ≥6 comorbidities. The overall discharge OAC prescription was high (85.6%). The prevalence of patients with multimorbidity increased from 59.7% in 2014 to 64.3% in 2019 (P trend=0.002). Using 0 to 2 comorbidities as the reference, the adjusted odds ratio (95% CI) of OAC prescription were 0.93 (0.82, 1.05) for patients with 3 to 5 comorbidities and 0.72 (0.60, 0.86) for patients with ≥6 comorbidities. In those with ≥6 comorbidities, the most common reason for nonprescription of OACs were frequent falls/frailty (31.0%). Conclusions In a contemporary quality-of-care database of hospitalized patients with atrial fibrillation eligible for OAC therapy, multimorbidity was common. A higher morbidity burden was associated with a lower odds of OAC prescription. This highlights the need for interventions to improve adherence to guideline-recommended anticoagulation in multimorbid patients with atrial fibrillation.

4.
Circ Arrhythm Electrophysiol ; 13(9): e007944, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32703018

RESUMO

BACKGROUND: Catheter ablation is an increasingly used treatment for symptomatic atrial fibrillation (AF). However, there are limited prospective, nationwide data on patient selection and procedural characteristics. This study describes patient characteristics, techniques, treatment patterns, and safety outcomes of patients undergoing AF ablation. METHODS: A total of 3139 patients undergoing AF ablation between 2016 and 2018 in the Get With The Guidelines-Atrial Fibrillation registry from 24 US centers were included. Patient demographics, medical history, procedural details, and complications were abstracted. Differences between paroxysmal and patients with persistent AF were compared using Pearson χ2 and Wilcoxon rank-sum tests. RESULTS: Patients undergoing AF ablation were predominantly male (63.9%) and White (93.2%) with a median age of 65. Hypertension was the most common comorbidity (67.6%), and patients with persistent AF had more comorbidities than patients with paroxysmal AF. Drug refractory, paroxysmal AF was the most common ablation indication (class I, 53.6%) followed by drug refractory, persistent AF (class I, 41.8%). Radiofrequency ablation with contact force sensing was the most common ablation modality (70.5%); 23.7% of patients underwent cryoballoon ablation. Pulmonary vein isolation was performed in 94.6% of de novo ablations; the most common adjunctive lesions included left atrial roof or posterior/inferior lines, and cavotricuspid isthmus ablation. Complications were uncommon (5.1%) and were life-threatening in 0.7% of cases. CONCLUSIONS: More than 98% of AF ablations among participating sites are performed for class I or class IIA indications. Contact force-guided radiofrequency ablation is the dominant technique and pulmonary vein isolation the principal lesion set. In-hospital complications are uncommon and rarely life-threatening.

6.
Am J Cardiol ; 125(6): 894-900, 2020 03 15.
Artigo em Inglês | MEDLINE | ID: mdl-31980141

RESUMO

Randomized data suggest lenient rate control (resting heart rate <110 beats/min) is noninferior to strict rate control (resting heart rate <80 beats/min) in patients with atrial fibrillation (AF). However, the optimal rate control strategy in patients with AF and heart failure (HF) remains unknown. Accordingly, we performed an observational analysis using data from the Get With The Guidelines-HF Program linked with Medicare data from July 1, 2011, to September 30, 2014. Of 13,981 patients with AF and HF, 9,100 (65.0%) had strict rate control, 4,617 (33.0%) had lenient rate control, and 264 (1.9%) had poor rate control by resting heart rate on the day of discharge. After multivariable adjustment, compared with strict rate control, lenient rate control was associated with higher adjusted risks of death (hazard ratio [HR] 1.21, 95% confidence interval [CI] 1.11 to 1.33, p <0.001), all-cause readmission (HR 1.09, 95% CI 1.03 to 1.15, p <0.002), death or all-cause readmission (HR 1.11, 95% CI 1.05 to 1.18, p <0.001), but not cardiovascular readmission (HR1.08, 95% CI 1.00 to 1.16, p = 0.051) at 90 days. Associations were comparable in patients with poor rate control and with heart rate modeled as a continuous variable. The presence or absence of reduced ejection fraction did not impact the magnitude of most observed associations. In conclusion, in patients with HF and AF, 2 of 3 patients had a heart rate that met strict-control goals at discharge. Heart rates >80 beats/min were associated with adverse outcomes irrespective of left ventricular ejection fraction.


Assuntos
Antiarrítmicos/uso terapêutico , Fibrilação Atrial/tratamento farmacológico , Eletrocardiografia/efeitos dos fármacos , Fidelidade a Diretrizes , Insuficiência Cardíaca/tratamento farmacológico , Frequência Cardíaca/efeitos dos fármacos , Adulto , Idoso , Fibrilação Atrial/mortalidade , Causas de Morte , Feminino , Insuficiência Cardíaca/mortalidade , Humanos , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Risco , Análise de Sobrevida
7.
Eur Heart J ; 41(10): 1132-1140, 2020 Mar 07.
Artigo em Inglês | MEDLINE | ID: mdl-31995195

RESUMO

AIMS: As health systems around the world increasingly look to measure and improve the value of care that they provide to patients, being able to measure the outcomes that matter most to patients is vital. To support the shift towards value-based health care in atrial fibrillation (AF), the International Consortium for Health Outcomes Measurement (ICHOM) assembled an international Working Group (WG) of 30 volunteers, including health professionals and patient representatives to develop a standardized minimum set of outcomes for benchmarking care delivery in clinical settings. METHODS AND RESULTS: Using an online-modified Delphi process, outcomes important to patients and health professionals were selected and categorized into (i) long-term consequences of disease outcomes, (ii) complications of treatment outcomes, and (iii) patient-reported outcomes. The WG identified demographic and clinical variables for use as case-mix risk adjusters. These included baseline demographics, comorbidities, cognitive function, date of diagnosis, disease duration, medications prescribed and AF procedures, as well as smoking, body mass index (BMI), alcohol intake, and physical activity. Where appropriate, and for ease of implementation, standardization of outcomes and case-mix variables was achieved using ICD codes. The standard set underwent an open review process in which over 80% of patients surveyed agreed with the outcomes captured by the standard set. CONCLUSION: Implementation of these consensus recommendations could help institutions to monitor, compare and improve the quality and delivery of chronic AF care. Their consistent definition and collection, using ICD codes where applicable, could also broaden the implementation of more patient-centric clinical outcomes research in AF.

8.
Circulation ; 139(12): 1497-1506, 2019 03 19.
Artigo em Inglês | MEDLINE | ID: mdl-30700141

RESUMO

BACKGROUND: Efforts to improve prescription of oral anticoagulation (OAC) drugs in patients with atrial fibrillation have had limited success in improving guideline adherence. METHODS: We evaluated adherence to the American College of Cardiology/American Heart Association performance measures for OAC in eligible patients with a CHA2DS2-VASc score ≥2 and trends in prescription over time in the American Heart Association's Get With The Guidelines-AFIB (atrial fibrillation) registry. Adjusted associations with in-hospital outcomes were also determined. The cohort included 33 235 patients with a CHA2DS2-VASc score ≥2 who were admitted for atrial fibrillation and were enrolled at 115 sites between January 1, 2013, and September 31, 2017. RESULTS: The median (25th, 75th percentile) age was 73 years (65, 81 years); 51% were female; and the median (25th, 75th percentile) CHA2DS2-VASc score was 4 (3, 5). At admission, 16 206 (59.5%) of 27 221 patients with a previous diagnosis of atrial fibrillation were taking OAC agents, and OAC drug use at admission was associated with a lower adjusted odds of in-hospital ischemic stroke (odds ratio, 0.38; 95% CI, 0.24-0.59; P<0.0001). At discharge, prescription of OAC in eligible patients (no contraindications) was 93.5% (n=25 499 of 27 270). In a sensitivity analysis, when excluding only strict contraindications (4.6%, n=1497 of 32 806), OAC prescription at discharge was 80.3%. OAC prescription at discharge was higher in those aged ≤75 years, men, those with heart failure, those with previous atrial fibrillation ablation, and those with rhythm control ( P<0.0001 for all). OAC use was lowest in Hispanic patients (90.2%, P<0.0001). Prescription of OAC at discharge in eligible patients improved over time from 79.9% to 96.6% ( P<0.0001). CONCLUSIONS: Among hospitals participating in the GWTG-AFIB quality improvement program, OAC prescription at discharge in eligible guideline-indicated patients increased significantly and improved consistently over time. These data confirm that high-level adherence to guideline-recommended stroke prevention is achievable.


Assuntos
Fibrilação Atrial/patologia , Fidelidade a Diretrizes , Acidente Vascular Cerebral/prevenção & controle , Administração Oral , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/uso terapêutico , Fibrilação Atrial/tratamento farmacológico , Fibrilação Atrial/etnologia , Feminino , Humanos , Masculino , Razão de Chances , Alta do Paciente , Melhoria de Qualidade , Sistema de Registros , Índice de Gravidade de Doença , Resultado do Tratamento
9.
Circ Heart Fail ; 11(10): e005356, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-30354398

RESUMO

BACKGROUND: Stroke prophylaxis in patients with atrial fibrillation (AF) and heart failure (HF) in the era of direct oral anticoagulants is not well characterized. Using data from American Heart Association Get With The Guidelines-AFIB, we sought to evaluate oral anticoagulation (OAC) use at discharge among AF patients with concomitant HF. METHODS AND RESULTS: AF patients with a diagnosis of HF hospitalized from January 2013 to March 2017 were included. We compared patient characteristics and use of OAC at discharge among patients with reduced (redundant ejection fraction [EF], EF≤40%), borderline (40%

Assuntos
Fibrilação Atrial/tratamento farmacológico , Insuficiência Cardíaca/tratamento farmacológico , Alta do Paciente , Varfarina/uso terapêutico , Administração Oral , Anticoagulantes/uso terapêutico , Fibrilação Atrial/complicações , Feminino , Insuficiência Cardíaca/diagnóstico , Humanos , Padrões de Prática Médica , Fatores de Risco
11.
JAMA Cardiol ; 2(3): 319-323, 2017 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-28002833

RESUMO

Importance: The joint American College of Cardiology (ACC), American Heart Association (AHA), and Heart Rhythm Society (HRS) guidelines on the management of atrial fibrillation (AF) are used extensively to guide patient care. Objective: To describe the evidence base and changes over time in the AHA/ACC/HRS guidelines on AF with respect to the distribution of recommendations across classes of recommendations and levels of evidence. Data Sources: Data from the AHA/ACC/HRS guidelines on AF from 2001, 2006, 2011, and 2014 were abstracted. A total of 437 recommendations were included. Data Extraction and Synthesis: The number of recommendations and distribution of classes of recommendation (I, II, and III) and levels of evidence (A, B, and C) were determined for each guideline edition. Changes in recommendation class and level of evidence were analyzed using the 2001 and 2014 guidelines. Results: From 2001 to 2014, the total number of AF recommendations increased from 95 to 113. Numerically, there was a nonsignificant increase in the use of level of evidence B (30.5% to 39.8%; P = .17) and a nonsignificant decrease in the use of level of evidence C (60.0% to 51.3%; P = .21), with limited changes in the use of level A evidence (8.4% to 8.8%; P = .92). In the 2014 guideline document, 10 of 113 (8.8%) recommendations were supported by level of evidence A, whereas 58 of 113 (51.3%) were supported by level of evidence C. Most recommendations were equally split among class I (49/113; 43.4%) and class IIa/IIb (49/113; 43.4%), with the minority (15/113; 13.3%) assigned as class III. Most class I recommendations were supported by level of evidence C (29/49; 59.2%), whereas only 6 of 49 (12.2%) were supported by level of evidence A. No rate control category recommendations were supported by level of evidence A. Conclusions and Relevance: Some aspects of the quality of evidence underlying AHA/ACC/HRS AF guidelines have improved over time. However, the use of level of evidence A remains low and has not increased since 2001. These findings highlight the need for focused and pragmatic randomized studies on the clinical management of AF.


Assuntos
American Heart Association , Fibrilação Atrial/terapia , Cardiologia , Gerenciamento Clínico , Medicina Baseada em Evidências , Guias de Prática Clínica como Assunto/normas , Sociedades Médicas , Humanos , Estudos Retrospectivos , Estados Unidos
12.
Cardiol Ther ; 5(1): 85-100, 2016 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-27105998

RESUMO

INTRODUCTION: Novel oral anticoagulants (NOACs) have been approved for prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation (NVAF). A large number of patients are on NOACs when they present for AF ablation. We intended to evaluate the safety and efficacy of NOACs for AF ablation during the periprocedural period by performing a meta-analysis of trials comparing NOACs with warfarin. METHODS: Studies comparing NOACs (dabigatran and rivaroxaban) with warfarin as periprocedural anticoagulants for AF ablation were identified using an electronic search. Primary outcomes were: (1) a composite endpoint of stroke, transient ischemic attack (TIA), peripheral arterial embolism, or silent cerebral lesions on magnetic resonance imaging (MRI) and (2) major bleeding complications. A random effects model was used to pool the safety and efficacy data across all included trials. RESULTS: When compared to warfarin, there was an increased risk of the composite endpoint of stroke, TIA, peripheral arterial embolism, or silent cerebral lesions on MRI with NOACs as periprocedural anticoagulants for AF ablation [odds ratio (OR): 1.69, 95% confidence interval (CI): 1.06-2.68]. Sub-group analysis revealed a higher risk of composite endpoint with dabigatran as a periprocedural anticoagulant for AF ablation (OR: 2.01, 95% CI: 1.19-3.39) whereas the risk was similar with rivaroxaban (OR: 0.90, 95% CI: 0.34-2.41). Sensitivity analysis after excluding silent cerebral lesions on MRI showed there was no increased risk of thromboembolic events with either dabigatran (OR: 1.69, 95% CI: 0.81-3.51) or rivaroxaban (OR: 0.70, 95% CI: 0.12-4.04). Risk of bleeding with NOACs was similar to warfarin (OR: 0.91, 95% CI: 0.62-1.34). CONCLUSION: NOACs are comparable to warfarin in terms of bleeding complications. However, dabigatran therapy is potentially associated with a higher risk of silent cerebral lesions on MRI. The results of this study should be considered as hypothesis-generating and assessed further in prospective randomized clinical studies.

13.
Postgrad Med ; 128(2): 191-200, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-26666288

RESUMO

Atrial fibrillation (AF) is a major risk factor for ischemic stroke. Guidelines recommend anticoagulation for patients with intermediate and high stroke risk (CHA2DS2-VASc score ≥ 2). Underuse of anticoagulants among eligible patients remains a persistent problem. Evidence demonstrates that the psychology of the fear of causing harm (omission bias) results in physicians' hesitancy to initiate anticoagulation and an inaccurate estimation of stroke risk. The American Heart Association (AHA) initiated the Get With The Guidelines-AFIB (GWTG-AFIB) module in June 2013 to enhance guideline adherence for treatment and management of AF. Better quality of care for AF patients can be provided by increasing adherence to anticoagulation guidelines and improving patient compliance with anticoagulation therapy through education and established protocols. Nonvitamin K antagonist oral anticoagulants may facilitate better patient adherence due to ease of administration and reduced monitoring burden. In this review, we discuss the reasons for underuse, omission bias contributing to underuse, and different strategies to address this issue.


Assuntos
Anticoagulantes/administração & dosagem , Fibrilação Atrial/tratamento farmacológico , Administração Oral , Fibrilação Atrial/complicações , Fidelidade a Diretrizes , Hemorragia/etiologia , Humanos , Risco , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controle , Varfarina/administração & dosagem
14.
J Breath Res ; 9(2): 026004, 2015 Apr 20.
Artigo em Inglês | MEDLINE | ID: mdl-25891856

RESUMO

With ascent to altitude, certain individuals are susceptible to high altitude pulmonary edema (HAPE), which in turn can cause disability and even death. The ability to identify individuals at risk of HAPE prior to ascent is poor. The present study examined the profile of volatile organic compounds (VOC) in exhaled breath condensate (EBC) and pulmonary artery systolic pressures (PASP) before and after exposure to normobaric hypoxia (12% O2) in healthy males with and without a history of HAPE (Hx HAPE, n = 5; Control, n = 11). In addition, hypoxic ventilatory response (HVR), and PASP response to normoxic exercise were also measured. Auto-regression/partial least square regression of whole gas chromatography/mass spectrometry (GC/MS) data and binary logistic regression (BLR) of individual GC peaks and physiologic parameters resulted in models that separate individual subjects into their groups with variable success. The result of BLR analysis highlights HVR, PASP response to hypoxia and the amount of benzyl alcohol and dimethylbenzaldehyde dimethyl in expired breath as markers of HAPE history. These findings indicate the utility of EBC VOC analysis to discriminate between individuals with and without a history of HAPE and identified potential novel biomarkers that correlated with physiological responses to hypoxia.


Assuntos
Doença da Altitude/metabolismo , Hipertensão Pulmonar/metabolismo , Hipóxia/metabolismo , Artéria Pulmonar/fisiopatologia , Compostos Orgânicos Voláteis/metabolismo , Adolescente , Adulto , Altitude , Doença da Altitude/fisiopatologia , Pressão Sanguínea , Testes Respiratórios , Estudos de Casos e Controles , Análise Discriminante , Ecocardiografia Doppler , Teste de Esforço , Cromatografia Gasosa-Espectrometria de Massas , Humanos , Hipertensão Pulmonar/fisiopatologia , Hipóxia/fisiopatologia , Masculino , Consumo de Oxigênio , Medição de Risco , Compostos Orgânicos Voláteis/análise , Adulto Jovem
15.
Circ Cardiovasc Qual Outcomes ; 7(5): 770-7, 2014 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-25185244

RESUMO

BACKGROUND: Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia. It is a cause of stroke, heart failure, and death. Guideline-based treatment can improve outcomes in AF. Unfortunately, adherence to these guidelines is low. Get With The Guidelines is a hospital-based performance initiative, which has been shown to improve adherence over time. Get With The Guidelines-AFIB is a novel quality improvement registry designed to improve adherence to AF guidelines. METHODS AND RESULTS: Hospitals will be recruited by regional American Heart Association staff and key stakeholders. Inpatients or observed patients with AF or atrial flutter will be enrolled. Data collected will include demographic, medical history, and clinical characteristics including laboratory values and treatments. Decision support will guide adherence to achievement and quality measures designed to improve adherence to anticoagulation, heart rate control, safe antiarrhythmic drug use, and patient education and follow-up. Increased adherence to guidelines will be facilitated using rapid-cycle quality improvement, site-specific reporting including national and regional benchmarks and hospital recognition for achievement. Primary analyses will include adherence to American Heart Association/American College of Cardiology performance measures and guidelines. Secondary analyses will include processes of care, risk stratification, treatment of special conditions or populations and use of particular treatment techniques. CONCLUSIONS: AF is common clinical problem with significant morbidity and mortality. Get With The Guidelines-AFIB is a national hospital-based AF quality improvement program designed to increase adherence to evidence-based guidelines for AF.


Assuntos
Antiarrítmicos/uso terapêutico , Fibrilação Atrial/epidemiologia , Sistema de Registros , American Heart Association , Anticoagulantes/uso terapêutico , Fibrilação Atrial/tratamento farmacológico , Benchmarking , Medicina Baseada em Evidências , Seguimentos , Fidelidade a Diretrizes , Hospitalização , Humanos , Guias de Prática Clínica como Assunto , Desenvolvimento de Programas , Melhoria de Qualidade , Estados Unidos
17.
Circ Arrhythm Electrophysiol ; 5(2): 302-11, 2012 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-22271713

RESUMO

BACKGROUND: Observational data suggest that performing radiofrequency catheter ablation of atrial fibrillation (AF) under therapeutic warfarin (continuous warfarin [CW]) may reduce the periprocedural risk of complications, such as thromboembolic events, compared to warfarin discontinuation (DW) with periprocedural bridging with heparin. We systematically reviewed the available evidence on the impact of CW compared with DW on periprocedural complications of AF catheter ablation. METHODS AND RESULTS: We searched major Web databases for studies on radiofrequency catheter ablation of AF under CW versus DW with periprocedural bridging with heparin. Data on periprocedural complications were extracted. We identified 9 studies (1 large case series indirectly compared with the latest Worldwide Survey). A total of 27,402 patients were included in the analysis (6400 undergoing ablation with CW). CW was associated with a striking decrease of thromboembolic complications (OR, 0.10; 95% CI, 0.05-0.23; P<0.001) and minor bleeding complications (OR, 0.38; 95% CI, 0.21-0.71; P=0.002) compared with DW. CW also did not increase the risk of major bleeding (OR, 0.67; 95% CI, 0.31-1.43; P=0.30), including cardiac tamponade (OR, 0.69; 95% CI, 0.19-2.47; P=0.57). CONCLUSIONS: There is highly consistent evidence from observational studies that a CW strategy during radiofrequency catheter ablation of AF reduces the risk of thromboembolic complications without increasing the risk of bleeding.


Assuntos
Fibrilação Atrial/cirurgia , Ablação por Cateter/métodos , Período Perioperatório , Tromboembolia/prevenção & controle , Varfarina/uso terapêutico , Anticoagulantes/uso terapêutico , Tamponamento Cardíaco/epidemiologia , Hemorragia/epidemiologia , Humanos , Medição de Risco , Fatores de Risco
18.
Card Electrophysiol Clin ; 4(3): 287-97, 2012 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-26939948

RESUMO

This article addresses the use of catheter ablation (CA) as first-line therapy for atrial fibrillation (AF). CA increases long-term freedom from AF, reduces hospitalizations, and improves quality of life compared with antiarrhythmic drug (AAD) therapy in patients with symptomatic AF who have already failed one AAD. The role of CA as first-line therapy for AF, however, is still controversial. Evidence from randomized controlled trials shows that CA is definitely superior to AADs as first-line therapy for relatively young patients with paroxysmal AF, with comparable complication rates and results consistently reproducible across different institutions, operators, and types of ablation approaches.

19.
Am Heart J ; 162(4): 692-699.e2, 2011 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-21982662

RESUMO

BACKGROUND: Anticoagulation therapy reduces thromboembolic events in patients with atrial fibrillation (AF) and has a class I indication for ischemic stroke patients with AF and no contraindications. We determined the patient and hospital level characteristics associated with an increased use of anticoagulation, including participation in the Get With The Guidelines-Stroke (GWTG-Stroke) Program. METHODS: We assessed the use of anticoagulation at hospital discharge in eligible AF patients with stroke or transient ischemic attack (TIA) at 1,354 participating hospitals between April 1, 2003, and April 1, 2010. RESULTS: Patients with AF (n = 197,778) represented 20.5% of patients with ischemic stroke/TIA. Among patients with AF, 47.6% (n = 94,119) were deemed eligible for anticoagulation, and of these, 94.0% were discharged on therapy. Older patients, African American or Hispanic patients, and those with diabetes were less likely to receive anticoagulation. Hospitals with a higher volume of patients with stroke were more likely to treat with anticoagulation. The Joint Commission Primary Stroke Centers were also more likely to treat eligible patients (odds ratio 2.16, 95% CI 1.82-2.56, P < .0001). From 2003 to 2010, contraindications to anticoagulation therapy declined from 69.7% to 28.4% (P < .0001 for trend). Anticoagulation among eligible patients improved from 88.4% to 95.2% (P < .0001) for 7 years of participation. Time in GWTG-Stroke was associated with improved anticoagulation use (adjusted odds ratio per year in program, 1.11, 95% CI 1.06-1.16, P < .001). CONCLUSIONS: Use of anticoagulation among stroke patients with AF has increased to very high levels overall in GWTG-Stroke over time. Future efforts should focus on improving use among selected populations.


Assuntos
Anticoagulantes/uso terapêutico , Fibrilação Atrial/complicações , Ataque Isquêmico Transitório/etiologia , Ataque Isquêmico Transitório/prevenção & controle , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controle , Idoso , Feminino , Humanos , Masculino
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