Prevalence of atrial fibrillation among patients under observation by an outpatient clinic

Prevalence of atrial fibrillation among patients attending our policlinic (2.44 and 3.78% in 2002 and 2009, respectively) was higher among men than among women and progressively increased with age achieving maximum in the group of patients aged more or equal 85 years. Paroxysmal and persistent forms were more frequent than permanent AF. Thromboembolic complications, heart failure and valvular heart disease were to a greater degree characteristic of permanent AF.     

Anticoagulation for atrial fibrillation: underutilization in a Brazilian tertiary outpatient clinic

Despite a clear benefit of anticoagulation in patients with atrial fibrillation for the prevention of stroke, treatment rates are disappointingly low in clinical practice in the industrialized countries. This survey demonstrates similar rates in a Brazilian tertiary outpatient clinic, with only 55% of patients at high risk receiving dose-adjusted warfarin. Poor patient education and health care system limitations are considered important barriers. Strategies to improve treatment rates should target specific problems at each location.     

Body mass index is associated with prognosis in Japanese elderly patients with atrial fibrillation: an observational study from the outpatient clinic

The relationship between body mass index (BMI) and the prognosis of elderly patients with atrial fibrillation (AF) is unknown. We aimed to examine the association of body weight with the clinical outcomes among Japanese elderly patients with a history of documented AF. This observational study of AF patients from an outpatients clinic in Nagoya University Hospital included 413 patients ≥70 years old (99 obese: BMI ≥25 kg/m²; 256 normal weight: BMI 18.5–24.9 kg/m²; and 58 underweight patients: BMI <18.5 kg/m²). The mean age was 77.5 ± 5.6 years. During a mean follow-up of 19.0 months, all-cause death occurred in 23 patients (obese 1 %, normal weight 5.1 %, and underweight 16 %). The major adverse events including all-cause death, stroke or transient ischemic attack, heart failure requiring admission, and acute coronary syndrome were observed in 53 patients (obese 5.1 %, normal weight 13 %, and underweight 26 %). After adjusting for confounding factors, the underweight group had a significantly greater risk for all-cause death [hazard ratio (HR) 2.91, 95 % confidence interval (CI) 1.12–7.60, p = 0.029], and major adverse events (HR 2.45, 95 % CI 1.25–4.78, p = 0.009) than the normal weight group. In contrast, the obese group had a better prognosis in major adverse events compared with the normal weight group (HR 0.34, 95 % CI 0.13–0.89, p = 0.029). In conclusion, lower BMI was independently associated with poor outcomes among older AF patients. The association between obesity and better prognosis in elderly AF patients was also found.     

Chemoreflexsensitivity among patients with paroxysmal atrial fibrillation

Atrial fibrillation is the most common cardiac arrhythmia with typical complications of thromboembolisms. The autonomic nervous system is an important factor for the initiation of arrhythmias. A vagally or adrenergically hyperfunction could cause the initiation of paroxysmal atrial fibrillation (PAF). METHOD: We measured the chemoreflexsensitivity (CHRS) among 110 patients to determine a disturbed autonomic function as risk factor for PAF. We examined 45 patients with PAF (group A), 45 patients with sinus rhythm (group B) and 20 young volunteers (group C). The ratio between the difference of RR intervals in ECG and venous pO(2) was measured for the determination of CHRS. The margin of the CHRS was 3 ms/mmHg. RESULTS: Patients of group A had a significantly lower CHRS compared to group B (1.56+/-1.46 vs 6.29+/-3.71 ms/mmHg, p<0.0008) or group C (1.56+/-1.46 vs 6.35+/-4.29 ms/ mmHg, p<0.0003). A significant difference between group B and C could not be observed (6.29+/-3.71 vs. 6.35+/-4.29 ms/mmHg, p = n.s.). A specificity of 74% and a sensitivity of 71% was achieved for identifying patients with PAF by using a margin of 3 ms/mmHg for the CHRS. CONCLUSIONS: An analysis of CHRS seems to be an appropriate method to demonstrate a neurovegetative imbalance which might be one possible trigger mechanism of PAF. The predictive power has to be examined by prospective investigations of a larger patient population.     

Masked thyroid dysfunction among elderly patients with atrial fibrillation

Seventy-five elderly patients with atrial fibrillation (41 males and 34 females with a mean age of 75.6 years) were studied to evaluate the incidence of masked thyroid dysfunction. A thyrotropin (TSH)-releasing-hormone (TRH) test (intravenous injection of 250 micrograms of synthetic TRH) was performed in the patients and 30 age matched controls without atrial fibrillation. In the controls, no abnormal TRH stimulated TSH response was observed. In the patients with atrial fibrillation, no response of TSH to TRH (hyperthyroidism) was found in 5 cases (6.6%), while hyperresponse of TSH to TRH (hypothyroidism) was found in 6 cases (8.0%). Thyroid dysfunction (hyper or hypothyroidism) was more frequently observed in the patients than in the controls (p less than 0.05). Two of 5 hyperthyroid patients had normal thyroid hormone levels. All patients with hyperthyroidism were treated with antithyroid drugs or 131I. Unfortunately, atrial fibrillation persisted in all but 1 case. It is concluded that the TRH test is a useful screening test for detecting those patients with abnormal thyroid function among elderly patients with atrial fibrillation, and that hypothyroidism should be considered as a cause of atrial fibrillation in the elderly.     

高密度标测下消融持续性心房颤动临床观察

目的探讨持续性心房颤动(简称房颤)患者环肺静脉电隔离(CPVI)术后再次行心房高密度基质标测,存在低电压区和/或疤痕区域的患者进一步行相关基质改良的价值。方法选取2013年5月至2015年5月在本中心首次接受三维标测系统指导下CPVI术及术后行心房高密度基质标测的129例持续性房颤患者。35例经高密度基质标测证实左房无低电压区和/或疤痕区,作为A组。94例患者左房存在低电压区和/或疤痕区,选取其中29例不进行相关基质改良,作为B组;选取34例针对低电压区和/或疤痕区再次进行基质改良,作为C组;另31例仅针对房顶及二尖瓣峡部进一步行线性消融,作为D组。比较各组射频消融手术成功率的差异性。结果 A、B、C、D组患者随访1年的单次手术成功率分别为65.7%、31%、64.7%、58.1%,4组患者单次手术成功率比较差异有显著性(P0.05);A、C、D组的成功率明显高于B组(P0.01或0.05)。结论以心房高密度标测为指导的基质改良有可能进一步提高持续性房颤射频消融的手术成功率。     

Newly detected atrial fibrillation and compliance with antithrombotic guidelines

BACKGROUND: Guidelines recommend the use of antithrombotic therapy for stroke prevention in patients with atrial fibrillation (AF), but compliance with such guidelines has not been widely studied among patients with newly detected AF. Our objective was to assess compliance with antithrombotic guidelines and to identify patient characteristics associated with warfarin use. METHODS: A population-based study of newly detected AF (patient age, 30-84 years) was conducted within a large health plan. Cardiovascular disease risk factors, comorbid conditions, medication use, and international normalized ratios were abstracted from the medical record. Patients were stratified by embolic risk according to American College of Chest Physicians (ACCP) criteria. We analyzed the proportion of patients with AF receiving warfarin or aspirin (> or =325 mg/d) during the 6 months following AF. Relative risk regression estimated the association of risk factors and patient characteristics with warfarin use. RESULTS: Overall, 73% of patients (418/572) with newly detected AF had evidence of antithrombotic use after AF onset. Among the 76% (437/572) of patients with AF at high risk for stroke, 59% (257/437) used warfarin, 28% (123/437) used aspirin, and 24% (104/437) used neither. The major predictor of warfarin use was AF classification; intermittent or sustained AF had relative risks for warfarin use of 2.8 (95% confidence interval, 2.2-3.6) and 2.9 (95% confidence interval, 2.2-3.7), respectively, compared with transitory AF. CONCLUSIONS: Three quarters of the patients with newly detected AF received antithrombotic therapy, yet many at high risk of stroke did not receive warfarin. Atrial fibrillation classification, rather than stroke risk factors, was strongly associated with warfarin use.     

Newly detected atrial fibrillation following dual chamber pacemaker implantation

Introduction: Pacemaker (PPM)-detected atrial high-rate episodes (AHREs) of even 5-minute duration may identify patients at increased risk for stroke and death. In this study, we sought to determine the incidence of newly detected atrial fibrillation (AF defined as an AHRE ≥5 minutes) in patients following dual-chamber PPM implantation and to define the clinical predictors of developing AF.
Methods and Results: We evaluated 262 patients (142 male; age 74 ± 12 years) without documented AF who underwent PPM implantation for sinus node dysfunction (n = 122) or atrioventricular block (n = 140). Information regarding patient demographics, cardiovascular diseases, and medication history was obtained. The cumulative percentages of ventricular pacing as well as the frequency, duration, and time to first episode of an AHRE were also determined. During follow-up of 596 ± 344 days, an AHRE ≥5 minutes was detected in 77 (29%) patients. Of these, 47 (61%) patients had an AHRE ≥1 hour, 22 (29%) patients had an AHRE ≥1 day, and 12 (16%) patients had an AHRE ≥1 week. An AHRE ≥5 minutes was seen in 24% and 34% of patients at 1 year and 2 years, respectively. Among patients with sinus node dysfunction, ≥50% cumulative ventricular pacing was the only significant predictor of an AHRE ≥5 minutes (HR 2.2; CI 1.0–4.7; P = 0.04).
Conclusions: Within 1 year of PPM implantation, AF is detected in 24% of patients without history of AF. In patients with sinus node dysfunction, ≥50% cumulative right ventricular pacing is associated with a 2-fold increase in risk of developing AF.     

Difficulties encountered by the very elderly with atrial fibrillation on warfarin attending an outpatient anticoagulant monitoring service

IntroductionWarfarin is effective in reducing the stroke risk in atrial fibrillation in the very elderly. This survey aimed to define characteristics and problems of patients aged ≥ 80 with atrial fibrillation attending an outpatient anticoagulant monitoring service (AMS) in a university hospital.MethodsAll patients aged  ≥ 80 from October 2007 to March 2008 were included.ResultsOne hundred and sixty-eight patients, average age 85.8 ± 3.1 years, were included in the study. Average age of commencement was 81.3 ± 4.5 years. Average length of time on warfarin was 4.8 ± 3.3 years. Fifty-three percent of patients managed their own warfarin and took instructions for dosing. In their entire period on warfarin, 61% of patients had problems including bleeding, bruising, falls, medication interactions and erratic International Normalized Ratio (INR) readings. Seven percent of patients had INR readings of > 8.0, necessitating emergency department assessment for reversal with vitamin K. The AMS staff had difficulty contacting 13% of patients with elevated INRs and missed appointments in 11%. In the 6 months, only 45% remained within target INR range of 2.5 ± 0.75 in 90–100% of 10 consecutive readings. Sixteen percent were within target INR in ≤ 60% of readings. Seven percent of patients died, one from a subdural haemorrhage postfall. Fifteen percent were admitted to hospital.DiscussionThe findings illustrate significant difficulties encountered by this elderly, vulnerable age group in proven effective treatment in atrial fibrillation. Changes need to be made to increase resources for monitoring in the community, including home visits, portable INR monitors and point-of-contact dose adjustment. Patients should be assessed carefully for risk to benefit ratio.     

Frailty in patients affected by atrial fibrillation

Atrial fibrillation (AF) is the most common arrhythmia among elderly people. However its relationship with the frailty syndrome is not well understood. It has been suggested that AF may be a marker of frailty in elderly, leading to the loss of independence in performing of routine daily activities. The aim of this study is to investigate the association between AF, frailty and cognitive decline in elderly patients. A total of 140 hospitalized patients, mean age 79.2 ± 7.4 years were enrolled in our study. Of these, 70 were affected by parossistic, persistent or permanent AF and 70, matched for age and gender, were concurrently studied as control. Cognitive impairment and frailty state has been evaluated in each patient using the Mini Mental State Examination (MMSE) and a standard score of accumulated deficits for constructing a frailty index. We have observed a higher number of frail patients in the AF group as compared with controls (88.6% vs 67.1%, p = 0.004). The group of patients with frailty syndrome had MMSE score significantly lower than those of the nonfrail group (16.8 ± 9.8 vs 22.2 ± 6.4, p = 0.005). Furthermore, a negative correlation between MMSE score and frailty index (rho = −0.517, p < 0.001) has been shown. Our study points out a statistical association between frailty and AF. Atrial fibrillation could worsen the frailty state, but perspective studies are necessary to confirm an increased mortality in patients affected by AF and frailty.     

Frailty in patients affected by atrial fibrillation

Atrial fibrillation (AF) is the most common arrhythmia among elderly people. However its relationship with the frailty syndrome is not well understood. It has been suggested that AF may be a marker of frailty in elderly, leading to the loss of independence in performing of routine daily activities. The aim of this study is to investigate the association between AF, frailty and cognitive decline in elderly patients. A total of 140 hospitalized patients, mean age 79.2 ± 7.4 years were enrolled in our study. Of these, 70 were affected by parossistic, persistent or permanent AF and 70, matched for age and gender, were concurrently studied as control. Cognitive impairment and frailty state has been evaluated in each patient using the Mini Mental State Examination (MMSE) and a standard score of accumulated deficits for constructing a frailty index. We have observed a higher number of frail patients in the AF group as compared with controls (88.6% vs 67.1%, p = 0.004). The group of patients with frailty syndrome had MMSE score significantly lower than those of the nonfrail group (16.8 ± 9.8 vs 22.2 ± 6.4, p = 0.005). Furthermore, a negative correlation between MMSE score and frailty index (rho = −0.517, p < 0.001) has been shown. Our study points out a statistical association between frailty and AF. Atrial fibrillation could worsen the frailty state, but perspective studies are necessary to confirm an increased mortality in patients affected by AF and frailty.     

The characteristics of smoking habit among patients evaluated at our outpatient clinic

To determine the prevalence of cigarette smoking, to examine the risk factors affecting smoking amongst adults and to assess the opinion of patients about quitting smoking who were evaluated at our outpatient clinic. Six hundred fifty-nine patients who were evaluated at our outpatient clinic between June 2005 and June 2006 were included in the study. This is a cross-sectional study that evaluates prevalence of smoking. Data gathered by applying face to face questionnaires. The mean age of 659 participants [417 (63.3%) males and 242 (36.7%) females] was 53.1 +/- 16.2 years. The prevalences were; 33% (n= 218) smokers, 39% (n= 258) ex-smokers and 28% (n= 183) non-smokers. Smoking prevalence under age of 50 was significantly higher (p= 0.0001). There was a positive significant relation between education and smoking amongst women, but this relationship was not significant amongst men. The most common reason for beginning smoking was because of friends (72%). 86% wanted to quit smoking. 48.9% tried to quit smoking but couldn't be successful. The prevalence of active smoking and quit smoking among patients who applied to pulmonary medicine outpatient clinic were 33% and 28%, respectively. The ratio of smoking and smoking pack-years was higher among men. Eighty-six percent of patients wanted to quit, 25% tried to quit but could not be successful, and 49% quit smoking but began smoking again. According to these findings, patients who were smoking wanted to quit but couldn't be successful without a professional help. We planned to found a smoking cessation outpatient clinic at our department.     

老年心房颤动者心房颤动类型、左房内径与心功能的关系

目的探讨老年者心房颤动（Af）类型、左房内径（LAD）与心功能关系。方法对2006年01月～2008年08月在我院心血管内科住院的65岁以上Af者99例的临床资料作分析。比较不同A f类型者的LAD、心功能不全严重程度,分析LAD与心功能的关系。结果持续性A f（A组）者LAD较阵发性A f（B组）患者的LAD明显增大,P=0.00;A组者心功能不全严重程度较B组者高,P=0.00;心功能不全的严重程度,与LAD的增大呈正相关,P=0.00,rS=0.49。结论 A f、LAD增大、心功能不全三者相互促进,应采取相应的干预治疗。