Quality of life restored to normal in patients with atrial fibrillation after pulmonary vein ostial isolation

Background

Pulmonary vein isolation (PVI) is effective in patients with paroxysmal atrial fibrillation. However, its impact on quality of life (QOL) is not completely understood.

Methods

Eighty-nine otherwise healthy patients (74 men; age, 53 ± 11 years) were selected for PVI. The Medical Outcomes Short Form 36 (SF-36) and the Symptom Checklist (SCL) QOL questionnaires were obtained before PVI and for as long as 6 months after PVI.

Results

A total of 294 PVs (3.3 PVs/patient) were targeted in 125 procedures (1.4/patient). After a mean follow-up period of 191 ± 109 days, scores for SCL frequency (19.09 ± 8.07 vs 10.67 ± 6.61), SCL severity (15.97 ± 7.68 vs 9.72 ± 5.98), SF-36 physical composite (45.43 ± 9.70 vs 51.70 ± 6.52), and SF-36 mental composite (44.50 ± 11.33 vs 51.67 ± 8.73) improved significantly (P <.0001 each). Seventy-five patients provided data at both the baseline and a late (3- or 6-month) follow-up. This cohort had significantly worse QOL scores in 7 of the 8 SF-36 subscales at baseline compared with age-matched healthy control subjects, but their QOL scores were similar to a comparison group of 152 previously reported patients with atrial fibrillation receiving drug treatment who had similar demographic and clinical variables. After PVI, patients improved significantly, resulting in equivalence with the healthy control population. Logistic regression analysis of demographic variables and baseline QOL scores revealed no significant predictors of PVI responders.

Conclusions

QOL measures in patients with paroxysmal atrial fibrillation are severly depressed before PVI. Within a 6-month follow-up period after ablation, SF-36 subscale scores were restored to equivalence with an age-matched, healthy control population. Neither demographic or clinical variables nor baseline QOL scores were predictive of response to PVI.     

Relationship of Quality of Life With Procedural Success of Atrial Fibrillation (AF) Ablation and Postablation AF Burden: Substudy of the STAR AF Randomized Trial

Background

The Substrate and Trigger Ablation for Reduction of Atrial Fibrillation (STAR AF) trial compared 3 strategies for ablation of high-burden paroxysmal/persistent atrial fibrillation (AF): complex fractionated electrogram ablation (CFE), pulmonary vein isolation (PVI), or a combined approach (PVI with CFE). This subanalysis aimed to identify the effect on quality of life (QOL) conferred by ablation strategy, AF recurrence, and type of AF.

Methods

The STAR AF study (n = 100) found 88%, 68%, and 38% freedom from AF > 30 seconds at 12 months for PVI with CFE, PVI, and CFE approaches, respectively (P = 0.001). QOL was measured before ablation and at 12 months after ablation using the Short-Form Health Survey (SF-36) scale. Transformed scores were calculated for each of the 8 subscales of the SF-36, and also converted to physical health and mental health component scores.

Results

There was a significant improvement in physical health (24%) and mental health (19%) component scores from baseline to 12 months after ablation (P < 0.05 for both). Significant QOL improvements were seen for all 3 ablation strategies despite differences in outcome. QOL measurements also improved regardless of AF recurrence, except in patients with an AF burden in the highest quartile (median 27.2 hours per month). AF recurrence independently predicted aggregate QOL score.

Conclusions

QOL after AF ablation improves regardless of procedural outcome. QOL scores were only negatively affected in patients with a high symptomatic burden of arrhythmia recurrence suggesting that significant reduction in AF burden can improve QOL without total elimination of AF.     

Do baseline atrial electrocardiographic and infarction patterns predict new-onset atrial fibrillation after ST-elevation myocardial infarction? Insights from the Assessment of Pexelizumab in Acute Myocardial Infarction Trial

Background

Atrial infarction reportedly occurs in 0.7% to 52% of ST-elevation myocardial infarctions (STEMIs), up to two thirds of whom develop atrial fibrillation and flutter (AF). Prospective validation of electrocardiographic atrial infarction patterns is lacking. Hence, in STEMI patients treated with primary percutaneous coronary intervention, we examined whether baseline atrial electrocardiographic changes or atrial infarction patterns predicted new AF or mortality.

Methods

Within the Assessment of Pexelizumab in Acute Myocardial Infarction trial, a nested case-control study was conducted. Patients with new AF were matched 1:1 with controls, and baseline atrial electrocardiographic variables were examined.

Results

Abnormal P wave morphology (Liu minor criterion for atrial infarction) was significantly associated with new AF (adjusted odds ratio, 1.68; 1.03-2.73). This was also independently associated with 90-day mortality in the overall case-control cohort (adjusted hazard rate, 1.90; 1.04-3.46) and among patient with new-onset AF (adjusted hazard rate, 2.43; 1.22-4.84).

Conclusions

Abnormal P wave morphology significantly predicted new AF and 90-day mortality in STEMI patients.     

Clinically important differences in health status for patients with heart disease: an expert consensus panel report

Background

The purpose of the study was to develop clinically important difference (CID) standards for patients with coronary artery disease and congestive heart failure that identify small, moderate, and large intraindividual changes with time in a modified version of the Chronic Heart Failure Questionnaire (CHQ) and the Medical Outcomes Study Short-Form 36-Item Health Survey (SF-36, version 2). Prior work in ascertaining important difference standards for the CHQ have centered on patient-perceived changes. No important difference standards for the SF-36 have been published for patients with heart disease. This development of CIDs would facilitate the use of health status measures in daily clinical decision-making.

Methods

We used a modification of the RAND Appropriateness Method to assemble and guide a 9-member consensus panel of physicians with substantial experience in using the CHQ or the SF-36 among patients with heart disease.

Results

On the basis of their own experience using these measures and an extensive review of articles describing the development and use of these instruments, the expert panel achieved consensus on small, medium, and large clinically relevant changes in scores for the CHQ and SF-36. The CID standards established by this panel were slightly higher than the minimal important difference standards previously established for the CHQ using patient-perceived changes.

Conclusions

The CID standards established by this expert panel provide an important and useful tool for determining whether routine clinical health status assessments will benefit patients and enhance physicians' decision-making capacity in clinical settings.     

Circadian variation of arrhythmia onset patterns in patients with persistent atrial fibrillation

Background

The circadian onset patterns and cycle lengths of atrial tachyarrhythmias (AT) were determined in a group of patients with persistent atrial fibrillation.

Methods

Fifteen patients, mean age 63 ± 14 years and 80% male, were implanted with the Jewel AF atrial defibrillator (Medtronic, Minneapolis, Minn) for persistent atrial fibrillation only. Onset times of AT and median onset atrial cycle lengths were determined from device memory.

Results

Over a follow-up period of 23.3 ± 7 months, 227 episodes of persistent AT were treated by patient-activated atrial defibrillation. The peak onset of persistent AT was nocturnal, with 74% of episodes initiating between 8 pm and 8 am. Eighty-seven percent of the patients experienced an additional 403 paroxysmal AT episodes. These episodes showed a “double-peaked” pattern with the least number of episodes occurring between midnight and 8 am. The mean onset atrial cycle length of persistent AT was significantly shorter than the paroxysmal AT episodes (200 ± 37 ms vs 240 ± 39 ms, P < .005). The atrial cycle lengths at arrhythmia onset of both paroxysmal and persistent AT episodes also demonstrated circadian variation.

Conclusion

There is a circadian distribution of onsets for persistent AT with predominance at night. Patients with persistent AF have >1 type of atrial arrhythmia with differences in the onset patterns and atrial cycle lengths, suggesting different triggers and onset mechanisms.     

Influence of structural heart disease on characteristics of atrial fibrillation recurrence in patients with dual-chamber pacemakers

Aims

The aim of the study was to prospectively examine the influence of structural heart disease (SHD) and sinus node dysfunction (SND) on the frequency and duration of atrial fibrillation (AF) episodes in patients with implanted pacemakers.

Methods

We examined episodes of AF in 207 patients (93 with SHD; 165 with SND) with known or suspected paroxysmal AF who underwent dual-chamber pacing.

Results

Seventy-one percent of all patients experienced at least one episode of AF during follow-up, with a mean burden of 3.3 ± 6.4 h/d (median, 0.2 hours) and a mean frequency of 11.7 ± 26.0 episodes per day (median, 1.4). The proportion of episodes longer than 6 hours was greater in patients with SHD when compared to patients without SHD. In a logistic regression model adjusted for SND, gender, and the 2-way interactions of SND, sex, and SHD, SHD was a significant factor (P = .0188) with the odds ratio of having an episode longer than 6 hours 3.4 times higher for patients with SHD than for patients without SHD. Older patients with SHD had less frequent but longer episodes compared to younger patients. In patients without SHD, there was no comparable age difference. Burden, frequency, and average episode length were not influenced by the presence or absence of SND.

Conclusions

Patients with SHD have longer episodes of AF supporting the concept that SHD influences the underlying substrate to favor perpetuation.     

Evaluation of atrial refractoriness immediately after percutaneous mitral balloon commissurotomy in patients with mitral stenosis and sinus rhythm

Background

Chronic atrial stretch and rheumatic inflammatory activity leads to atrial dilatation and conduction slowing, and this increases the susceptibility to atrial fibrillation (AF). The aim of this study was to examine the effects of changes in the chronic atrial stretch on atrial refractoriness in the early period after percutaneous mitral balloon commissurotomy (PMBC) in patients with mitral stenosis and sinus rhythm.

Methods

Twenty-five patients undergoing PMBC were enrolled in this study. We evaluated the changes in pulmonary arterial pressure (PAP), left atrial (LA) pressure, mean mitral diastolic gradient, and mitral valve area in addition to the changes in atrial effective refractory periods (AERPs), AERP dispersion, and intra-atrial and interatrial conduction times after PMBC.

Results

There were significant decreases in mean diastolic gradient, PAP, mean LA pressure, and LA size after PMBC. Accompanying these acute hemodynamic changes after PMBC, AERPs in high right atrium (HRA), distal coronary sinus (DCS), and right posterolateral (RPL) were found to be increased (P <.001), and AERP dispersion, PA_HIS (an interval between P wave on the surface electrocardiogram and atrial electrogram at the His bundle site), and HRA-DCS intervals were significantly reduced after PMBC (P <.001). It was revealed with linear regression and correlation analysis that only the changes in AERP dispersion were correlated with changes in LA pressure.

Conclusions

Relief of chronic atrial stretch results in an increase in AERPs and decrease in AERP dispersion, suggesting the potential reversibility of the electrophysiological features of chronic atrial dilatation. Our study emphasizes that an acute reduction of chronic atrial stretch in mitral stenosis resulted in favorable effects on atrial electrophysiological characteristics, and our results provide the first detailed insights into the electrophysiological changes after PMBC in patients with sinus rhythm.     

Atrial septal pacing to prevent atrial fibrillation in patients with sinus node dysfunction: results of a randomized controlled study

Background

In order to assess the preventive effects of right atrial septal pacing on atrial fibrillation (AF) in patients with sinus node dysfunction, we conducted a prospective randomized controlled study in patients requiring atrial pacing.

Methods

The inclusion criterion was the presence of a sinus node dysfunction with or without episodes of AF. Pacing sites were randomized to either the right atrial septum or appendage. Patients with permanent AF or with atrioventricular (AV) block without sinus node dysfunction were excluded. Patients were discharged at a pacing rate of 65 beats per minute after setting of the optimal AV delay. The antiarrhythmic therapy remained unchanged until the first recurrence of AF. Sequential analyses were performed with the triangular test.

Results

Mean baseline characteristics were not different between the septum (n = 57) and the appendage (n = 67) groups. The triangular test evidenced a lack of effect of septal pacing at the last sequential analysis. The rates of AF-free survival were not different between the septum and the appendage group (65% vs 64%, P = .28).In the subgroup of patients with at least 1 episode of AF 3 months before pacing, AF-free survival was increased by atrial septal pacing (70% vs 40%, P = .018). The mean follow-up was 16 ± 13 months (range, 1-54).

Conclusions

Atrial septal pacing does not have a preventive effect on the occurrence of AF in patient requiring atrial pacing for sinus node dysfunction. Subgroup analysis suggests that atrial septal pacing may benefit patients with ≥1 episode of AF in the 3 months preceding pacing.     

Atrial septal defect closure in the elderly is associated with excellent quality of life, functional improvement, and ventricular remodelling

Background

While atrial septal defect (ASD) closure is known to improve morbidity and mortality in children and adults, data are only beginning to emerge about its role in elderly cohorts. The goals of this study were to compare outcomes after device or surgical closure of ASDs in the elderly, and to quantitatively assess quality of life.

Methods

Patients > 60 years old who underwent ASD repair were studied. Functional status, arrhythmia burden, biventricular size and function were compared before and after ASD closure. Quality of life after ASD closure was assessed with the RAND SF-36 instrument.

Results

Sixty-seven patients, mean age of 68 years (range 60-86 years), were followed for 3.3 years. Nineteen percent underwent surgical closure and 81% underwent device closure. Major complication rates were 23% and 7% respectively with no procedure- related deaths. After surgical and device closure, quality of life was comparable to age-matched healthy controls, right ventricular end-diastolic dimension decreased by 10 mm (P < 0.001), left ventricular end-diastolic dimension increased by 4 mm (P = 0.001), biventricular function improved (right ventricular, P < 0.001; left ventricular, P = 0.007) and New York Heart Association class improved (P < 0.001). Prevalence of atrial arrhythmias however, was unchanged. Beneficial effects were similar for patients treated surgically or with device closure.

Conclusions

Given the favorable structural, functional, and quality of life outcomes after ASD closure in the elderly, advanced age alone should not be a contraindication to recommending surgical or device closure of an ASD.     

Spatial characteristics of atrial fibrillation electrocardiograms

Background

The present study investigates spatial properties of atrial fibrillation (AF) by analyzing vectorcardiogram loops synthesized from 12-lead electrocardiograms (ECGs).

Methods

After atrial signal extraction, spatial properties are characterized through analysis of successive, fixed-length signal segments and expressed in loop orientation, that is, azimuth and elevation, as well as in loop morphology, that is, planarity and planar geometry. It is hypothesized that more organized AF, expressed by a lower AF frequency, is associated with decreased variability in loop morphology. Atrial fibrillation frequency is determined using spectral analysis.

Results

Twenty-six patients with chronic AF were analyzed using 60-second ECG recordings. Loop orientation was similar when determined from either entire 60- or 1-second segments. For 1-second segments, the correlation between AF frequency and the parameters planarity and planar geometry were 0.608 (P < .001) and 0.543 (P < .005), respectively.

Conclusions

Quantification of AF organization based on AF frequency and spatial characteristics from the ECG is possible. The results suggested a relatively weak coupling between loop morphology and AF frequency when determined from the surface ECG.     

Effect of first ventricular tachycardia cycle length on rate of ventricular arrhythmia recurrence in patients with implantable cardioverter-defibrillator

Background

Some controversies exist regarding the proper treatment of hemodynamically tolerated and slow ventricular tachycardia (VT). We intended to assess the effect of cycle length of first VT episode on total ventricular arrhythmia burden in a cohort of patients with implantable cardioverter-defibrillator (ICD).

Method

Between March 2000 and March 2005, 195 patients underwent ICD implantation at our center. We included 158 patients (mean age, 58.3 ± 12.9 years) with follow-up of 3 months or more in this study. Clinical, electrocardiographic, and ICD-stored data and electrograms were collected and analyzed.

Results

During the follow-up of 16.7 ± 10.6 months, 45 (28.5%) and 20 (12.6%) patients received first appropriate ICD therapy for VT and ventricular fibrillation, respectively. We divided the 45 patients with VT (based on the median value of VT cycle length) into 2 groups. Although patients with VT cycle length of less than 350 had higher total mean number of appropriate ICD therapy (25 vs 6.3, P = .023), during multivariate regression analysis, only left ventricular ejection fraction (EF) of less than 25% (P = .020) was correlated with total number of appropriate ICD therapy. First VT cycle length (P = .341), QRS duration (P = .126), age (P = .405), underlying heart disease (P = .310), indication of ICD implantation (P = .113), and sex (P = .886) have failed to predict the total burden of ventricular arrhythmia during the follow-up period.

Conclusion

After adjustment for left ventricular EF, initial VT cycle length per se did not confer a lower risk for subsequent ventricular arrhythmia recurrence compared with those with faster VT. Left ventricular EF of less than 25% was correlated with higher ventricular arrhythmia burden in patients with ICD.     

Amiodarone versus sotalol for the treatment of atrial fibrillation after open heart surgery: the Reduction in Postoperative Cardiovascular Arrhythmic Events (REDUCE) trial

Objectives

This prospective, randomized, double-blind, placebo-controlled study compared the efficacy and safety of amiodarone and sotalol in the prevention of atrial fibrillation (AF) following open heart surgery.

Background

The incidence of supraventricular arrhythmias following open heart surgery ranges from 20% to 40%, with AF being the most common. Both amiodarone and sotalol have been shown to be effective in reducing postoperative arrhythmias, but no direct comparison of these agents has been conducted.

Methods

A total of 160 patients were randomized, of whom 134 underwent coronary artery bypass graft surgery (CABG) alone, 17 underwent CABG and concomitant aortic valve replacement surgery (AVR), 9 underwent AVR only, and 1 patient's surgery was canceled. Patients with signs or symptoms of congestive heart failure (CHF), ejection fraction ≤30%, estimated creatinine clearance <30 mL/min, or serum creatinine ≥2.5 mg/dL were excluded. Patients were randomized to receive either sotalol 80 mg 2 times per day (n = 76) or intravenous amiodarone 15 mg/kg over 24 hours followed by oral amiodarone 200 mg 3 times per day (n = 83). Study drug was started at the time of surgery and continued for 7 days or until discharge, whichever came first.

Results

AF occurred in 17% of patients randomized to amiodarone and 25% of the patients randomized to sotalol (P = .21). However, the duration of AF was significantly shorter in amiodarone-treated patients (169 ± 224 min) compared to sotalol treated patients (487 ± 505 min; P = .04). In a subgroup analysis, the incidence of AF in patients undergoing AVR or CABG with AVR was significantly less with amiodarone (1/15, 7%) compared to sotalol (9/11, 82%) (P < .001). Blood pressure was lower immediately after surgery with amiodarone but comparable to sotalol at 24 hours. Of the hemodynamic indices measured, only stroke volume was significantly lower in patients randomized to sotalol at 24 hours (P = .035).

Conclusions

Amiodarone and sotalol share similar efficacy and safety in reducing postoperative AF. Hemodynamic effects were similar between both drugs at 24 hours, with the exception that stroke volume was lower in sotalol-treated patients. In patients undergoing more complex surgery, postoperative AF occurred more frequently with sotalol than with amiodarone.     

Angiotensin-converting enzyme inhibitors as adjunctive therapy in patients with persistent atrial fibrillation

Objectives

The purpose of the current study was to assess the effect of angiotensin-converting enzyme inhibitor (ACEI) therapy in facilitating cardioversion from persistent atrial fibrillation (AF) and maintaining sinus rhythm.

Background

Pharmacologic therapy and electrical cardioversion for AF are often unsuccessful in maintaining long-term sinus rhythm.

Methods

The current study, a 1-year, prospective follow-up, comprised 47 patients with persistent AF undergoing electrical cardioversion. Patients receiving ACEI were compared with those receiving other medications. The study end point was the number of defibrillation attempts required for atrial defibrillation and the number of hospital admissions. A secondary end point was change in signal-averaged P-wave duration (SAPD) 1 year after successful electrical cardioversion.

Results

Of those admitted and requiring electrical defibrillation, the number of defibrillation attempts required for successful cardioversion was significantly less in the ACEI group (P < .001). The incidence rate ratio for admissions comparing recipients of ACEI with others was 0.14 (P = .03). Patients receiving ACEI therapy had significantly lower SAPD at 1 year when compared with the no-ACEI group (135 ms ± 3 vs 150 ms ± 2, P = .002).

Conclusions

The use of long-term ACEI therapy facilitated electrical defibrillation in patients with persistent AF. ACEI therapy also reduced SAPD, suggesting amelioration of the arrhythmogenic substrate. Furthermore, we confirmed that SAPD is prolonged in patients with persistent AF.     

Influence of coffee and caffeine consumption on atrial fibrillation in hypertensive patients

Background and aims

Coffee and caffeine are widely consumed in Western countries. Little information is available on the influence of coffee and caffeine consumption on atrial fibrillation (AF) in hypertensive patients. We sought to investigate the relationship between coffee consumption and atrial fibrillation with regard to spontaneous conversion of arrhythmia.

Methods and results

A group of 600 patients presenting with a first known episode of AF was investigated, and we identified 247 hypertensive patients. The prevalence of nutritional parameters was assessed with a food frequency questionnaire. Coffee and caffeine intake were specifically estimated. Left ventricular hypertrophy was evaluated by electrocardiogram (ECG) and echocardiogram. Coffee consumption was higher in normotensive patients. High coffee consumers were more frequent in normotensive patients compared with hypertensive patients. On the other hand, the intake of caffeine was similar in hypertensive and normotensive patients, owing to a higher intake in hypertensive patients from sources other than coffee. Within normotensive patients, we report that non-habitual and low coffee consumers showed the highest probability of spontaneous conversion (OR 1.93 95%CI 0.88-3.23; p = 0.001), whereas, within hypertensive patients, moderate but not high coffee consumers had the lowest probability of spontaneous conversion (OR 1.13 95%CI 0.67-1.99; p = 0.05).

Conclusion

Coffee and caffeine consumption influence spontaneous conversion of atrial fibrillation. Normotensive non-habitual coffee consumers are more likely to convert arrhythmia within 48 h from the onset of symptoms. Hypertensive patients showed a U-shaped relationship between coffee consumption and spontaneous conversion of AF, moderate coffee consumers were less likely to show spontaneous conversion of arrhythmia. Patients with left ventricular hypertrophy showed a reduced rate of spontaneous conversion of arrhythmia.     

The effect of cardiac genetic testing on psychological well-being and illness perceptions

Objective

To assess the effects of positive cardiac genetic diagnoses, ICD discharges, and arrhythmias on measures of psychological well-being.

Methods

Fifty-eight adults with prior cardiac genetic testing were enrolled. Patient well-being was determined using the SF-36 (QoL), HADS-A and HADS-D (anxiety/depression), and IPQ-R (patients' perceptions of illness). Patients with positive and negative cardiac genetic test results were compared using non-parametric statistics.

Results

Genetic testing yielded 76% with a positive diagnosis and 29% reported an ICD shock. QoL assessments (n = 33) were within normal ranges (mean of 50) with the exceptions of general health (44.1 ± 12.2, p < 0.01) and bodily pain (55.1 ± 9.1, p < 0.01) domains, but only the bodily pain domain showed differences between those with positive and negative cardiac genetic test results. Subjects with ICD discharges had higher scores than those without shocks in consequential and emotional IPQR subscales as well as greater perceived risks of experiencing a serious cardiac event, developing additional symptoms, or limitations in daily activities.

Conclusion

Positive genetic results did not negatively impact patient well-being with the exception of the bodily pain domain of the SF-36.     

Depression, disability, and quality of life after off-pump coronary artery bypass grafting: A prospective 9-month follow-up study

Background

Several studies have looked at the effects on mood and quality of life (QOL) among patients who underwent on-pump coronary artery bypass grafting (CABG), but few have reported on off-pump CABG (OPCABG).

Methods

We recruited 50 patients undergoing OPCABG. The day before CABG, patients were interviewed using 4 questionnaires: the Beck Depression Index (BDI), Beck Anxiety Index (BAI), Sheehan Disability Scale (SDS), and Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q). The process was repeated at 1, 3, 6, and 9 months.

Results

One month postoperatively, patients showed increased levels of depression (Δ 1.67 in the mean BDI score, P < .05) and disability (Δ 5.28 in the mean SDS score, P < .001) and decreases levels of anxiety (Δ 3.7 in the mean BAI score, P < .001) and QOL compared with baseline. When compared with the first month, at 9 months patients were significantly less depressed (Δ 3.58 in the mean BDI score, P < .001), were less disabled (Δ 5.34 in the mean SDS score, P < .001), and had better QOL (Δ 3.82 in the mean Q-LES-Q score, P = .014). At 9 months, 44% had some degree of depression and 48% had low QOL.

Conclusion

Despite that all scores returned to or below baseline at 9 months, a high percentage of patients still had depressive symptoms and overall poor quality of life (QOL). BDI scores at baseline are good predictors of QOL at all measured intervals. This should make physicians more prudent in diagnosing and observing these patients.     

Association of rate-controlled persistent atrial fibrillation with clinical outcome and ventricular remodelling in recipients of cardiac resynchronization therapy

Background

Whether patients with persistent atrial fibrillation (AF) obtain the same degree of benefit with cardiac resynchronization therapy (CRT) as those in sinus rhythm remains unclear.

Methods

We enrolled 93 patients undergoing CRT implantation, 20 (22%) of whom had rate-controlled persistent AF. The primary endpoint was CRT response defined as 1 class improvement in Specific Activity Scale and 15% reduction in left ventricular end-systolic volume (LVESV) during 12 months. Other endpoints included changes in 6-minute walk distance, quality of life, B-type natriuretic peptide, and survival.

Results

Baseline characteristics were similar in those with and without AF. Response to CRT was observed in 42% vs 54% of those with and without AF, respectively (P = 0.3). Both groups had significant improvements in 6-minute walk distance, quality of life, and LVESV, but the improvement in LVESV was smaller in those with AF (13.7% ± 14.9% vs 27.7% ± 23.7%; P = 0.02). During 2.8 ± 1.4 years of follow-up, AF was associated with a 2.2-fold increased risk of death or transplantation (95% confidence interval, 1.2-3.9; P = 0.01).

Conclusions

Compared with patients without rate-controlled persistent AF, those with rate-controlled persistent AF had similar rates of clinical improvement but less left ventricular reverse remodelling in the first year after CRT. AF was associated with a markedly higher risk of death or transplantation in long-term follow-up. Given these findings, randomized studies assessing CRT efficacy in those with AF are warranted.     

The effects of caffeine on the inducibility of atrial fibrillation

Introduction

There is widespread belief that caffeine consumption is linked to atrial arrhythmias; however, there is a relative lack of systematic evidence to support the assertion. The purpose of this study was to investigate whether caffeine, in doses equivalent to daily use in the general population, alter the propensity for atrial fibrillation (AF) in an experimental model comparing normal and simulated predisposition to AF.

Methods and Material

Caffeine (caffeine Na benzoate, 50:50 mixture) was administered intravenously at 1, 3, and 5 mg/kg doses in dogs producing serum levels of 2 to 4, 5 to 7, and 8 to 10 μg/mL. To simulate focal AF, premature stimulation from the right superior pulmonary vein was delivered at 2×, 4×, and 10× threshold at a rate of 180/min (S₁-S₂ = 330 milliseconds) without and then with low-level stimulation of ganglionated plexi (GP) at the entrance of the right superior pulmonary vein. The window of vulnerability (WOV), a measure of the propensity for AF inducibility, was determined by the longest coupling interval of the premature beat (S₁-S₂) minus the shortest S₁-S₂, which induced AF. The cumulative WOV is the sum of the individually determined WOV.

Results

At each serum level of caffeine, the cumulative WOV was lower without rather than with GP stimulation compared with control. The cumulative WOV for both the stimulated, that is, predisposed to AF, and nonstimulated, that is, normal groups, exhibited a significantly lower average as compared with that exhibited by the control group (P ≤ .003-.02).

Conclusion

These findings suggest that the presence of caffeine may result in an unexpected reduction in the propensity for AF in healthy individuals and in those with a predisposition for AF (enhanced AF inducibility caused by the stimulation of the GP).     

Anxiety, depression, and stress as risk factors for atrial fibrillation after cardiac surgery

Objective

We sought to determine whether preoperative and postoperative anxiety, depression, and stress symptoms were associated with atrial fibrillation (AF) after cardiac surgery.

Methods

Two hundred and twenty-six cardiac surgery patients completed measures of depression, anxiety, and general stress before surgery, and 222 patients completed these measures after surgery. The outcome variable was new-onset AF, confirmed before the median day of discharge (day 5) after cardiac surgery during the index hospitalization.

Results

Fifty-six (24.8%) patients manifested incident AF, and they spent more days in hospital (mean [M], 7.3; standard deviation [SD], 4.6) than patients without AF (M, 5.5; SD, 1.4; P < .001). No baseline psychological predictors were associated with AF. When postoperative distress measures were considered, anxiety was associated with increased odds of AF (odds ratio, 1.09; 95% confidence interval, 1.00 to 1.18; P = .05). This analysis also showed that age was significantly associated with AF (odds ratio, 1.07; 95% confidence interval, 1.03 to 1.12; P < .001). Analyses specific to the symptomatic expression of anxiety indicated that somatic (ie, autonomic arousal) and cognitive-affective (ie, subjective experiences of anxious affect) symptoms were associated with incident AF.

Conclusion

Anxiety symptoms in the postoperative period were associated with AF. Hospital staff in acute cardiac care and cardiac rehabilitation settings should observe anxiety as related to AF after cardiac surgery. It is not clear how anxious cognitions influence the experience of AF symptoms, and whether symptoms of anxiety commonly precede AF.     

Pain and quality of life with chronic obstructive pulmonary disease

Background

Pain as a symptom may be underrecognized in patients with chronic obstructive pulmonary disease (COPD).

Objective

The aim of this study is to explore the prevalence and intensity of pain, its location, how demographic and clinical variables may be related to pain, and how pain is associated with quality of life (QOL).

Methods

In this cross-sectional study, 154 patients with COPD answered the Brief Pain Inventory, Respiratory Quality of Life Questionnaire, and Quality of Life Scale, and performed spirometry.

Results

Seventy-two percent of the patients indicated the location of pain on a body diagram. Lower lung function, higher score of pain intensity, and pain interference were associated with lower disease QOL. A higher score of pain interference was associated with lower global QOL. When controlling for disease QOL in the equation of global QOL, pain interference was no longer significant.

Conclusion

The experience of pain is related to disease QOL in patients with COPD.