Marc Zimmermann

Background: Accurate markers of atrial fibrillation (AF) recurrences after electrical cardioversion (ECV) are lacking. This study was conducted to assess the value of P‐wave signal averaging (SAPW) for predicting AF recurrences in a nonselected patients population submitted to ECV.Methods: A total of 133 patients (107 males, 26 females, mean age 66 ± 9 years) were included after successful ECV for persistent AF (mean duration of AF 3.6 ± 2.2 months). The mean ejection fraction (EF) was 60 ± 9%, and left atrial (LA) diameter was 44 ± 6 mm. SAPW ECG was obtained immediately after ECV and patients were prospectively followed.Results: During a mean follow‐up of 8.9 ± 5.2 months, AF recurrences occurred in 40.6% (54/133). No SAPW parameters was statistically different between the group of patients with and the group without recurrences. Recurrences were less often observed in patients with a total P‐wave duration <150 ms (16/52 or 31% vs 38/81 or 47% in patients with total P‐wave duration ≥150 ms) but the difference was not statistically different (P = 0.07). P‐wave duration was correlated with age (r = 0.32; P < 0.001) and left atrial diameter (r = 0.19; P = 0.02). Age, sex, structural heart disease, amiodarone therapy, or hypertension were not associated with AF recurrences but patients without recurrences had a shorter AF duration (P = 0.001) and more often had a history of previous ablation (P = 0.027).Conclusion: In this unselected “real‐life” group of patients submitted to ECV for persistent AF, none of the SAPW parameters, including total filtered P‐wave duration, was able to predict AF recurrences.

Recurrences of atrial fibrillation (AF) after radiofrequency catheter ablation (RFCA) are usually caused by pulmonary vein (PV) re-conduction, by foci outside the PV or by previous electrical remodelling. Substrate alterations with conduction delays may be detected by signal-averaged P-wave analysis (SAPW). This study was conducted to assess the value of the SAPW to predict recurrences after RFCA in patients with paroxysmal or persistent AF. One hundred and two patients (59 ± 10 years, 83 males) underwent a first RFCA procedure for paroxysmal (n = 61) or persistent/long-standing persistent (n = 41) AF. A SAPW recording with measurement of total filtered P-wave duration (FPD), P-wave integral, and terminal root mean squared voltage was obtained immediately after the ablation procedure and the patients were prospectively followed. During a mean follow-up of 12 ± 7 months, recurrences occurred in 36 of 102 (35.3%) patients, 17 of 61 with paroxysmal AF, and 19 of 41 with persistent AF (P = 0.06). The FPD was significantly longer in patients with recurrences compared to those without (158 ± 22 vs. 140 ± 18 ms, P = 0.0008). The FPD was shorter in patients with paroxysmal AF compared with patients with persistent AF (142 ± 28 vs. 153 ± 20 ms, P = 0.03). A FPD of 140 ms was found to discriminate patients prone to recurrences (log-rank test, P = 0.008) with a sensitivity of 69%, a specificity of 53%, a positive predictive value of 45%, and a negative predictive value of 76%. A FPD >140 ms is a marker of AF recurrences after RFCA and probably reflects the extent of atrial remodelling.

The purpose of this prospective study was to characterize the clinical profile of patients with atrial fibrillation (AF) in the urban population of a sub-Saharan African country and to assess how successfully current guidelines are applied in that context. This prospective study involved 10 cardiologists in Cameroon. Enrolment started on 1 June 2006 and ended on 30 June 2007. Consecutive patients were included if they were >18 years and AF was documented on an ECG during the index office visit. In this survey, 172 patients were enrolled (75 males and 97 females; mean age 65.8 ± 13 years). The prevalence of paroxysmal, persistent, and permanent AF was 22.7, 21.5, and 55.8%, respectively. Underlying cardiac disorders, present in 156/172 patients (90.7%), included hypertensive heart disease (47.7%), valvular heart disease (25.6%), dilated cardiomyopathy (15.7%), and coronary artery disease (6%). A rate-control strategy was chosen in 83.7% of patients (144 of 172) and drugs most commonly used were digoxin and amiodarone. The mean CHADS ₂ score was 1.9 ± 1.1 and 158 of 172 patients (91.9%) had a CHADS ₂ score ≥1. Among patients with an indication for oral anticoagulation (OAC), only 34.2% (54 of 158) actually received it. During a follow-up of 318 ± 124 days, 26 of 88 patients died (29.5%), essentially from a cardiovascular cause (15 of 26). Ten patients (16.1%) had a non-lethal embolic stroke and 23 (26.1%) had symptoms of severe congestive heart failure. Clinical presentation of AF in Cameroon is much more severe than in developed countries. A rate-control strategy is predominant in Cameroon and OAC is prescribed in only 34.2% of eligible patients, despite a high CHADS ₂ score at inclusion. Death and stroke rate at 1 year are very high in Cameroon possibly because of a lower use of OAC, and a higher prevalence of rheumatic mitral disease and of more severe co-morbidities.

The purpose of this prospective study was to characterize the clinical profile of patients with atrial fibrillation (AF) in cardiology practice and to assess how successfully guidelines have been implemented in real-world practice. This prospective study involved 23 cardiologists established in office practice in Geneva. Enrolment started on 1 January 2005 and ended on 31 December 2005. Consecutive patients were included if they were >18 years and had AF documented on an ECG during the index office visit or during the preceding month. In this survey, 622 ambulatory patients were enrolled (390 males and 232 females; mean age 69.8 ± 11.8 years). The prevalence of paroxysmal, persistent, and permanent AF was 35, 18, and 47%, respectively. Underlying cardiac disorders present in 513 patients (82%) included hypertensive heart disease (30%), valvular heart disease (27%), coronary artery disease (18%), and myocardial disease (11%). A rate-control strategy was chosen in 53% of the patients (331/622). The mean CHADS ₂ score was 1.43 ± 1.24, and 458/622 patients (73.6%) had a CHADS ₂ score ≥1. Among patients with an indication to oral anticoagulant therapy (OAT), 88% (403/458) effectively received it. The rate of OAT was closely correlated with an increasing CHADS ₂ score, particularly with patients age (72, 81, and 87% for patients 75 years of age, respectively). True contraindication for OAT was present in 4% (18/458). In the low-risk group (CHADS ₂ score = 0), 58% were prescribed OAT, but in 37% of them only for a short period of time (cardioversion/ablation). After a follow-up of 396 ± 109 days, 72% of the study group (410/570) was still treated by OAT. During follow-up, 23/570 patients died (4%), essentially from a cardiovascular cause (15/23), 15 had a non-lethal embolic stroke (2.7%), and 8 had significant bleeding complications (1.5%). This study shows one of the highest OAT prescription rates for AF reported until now and demonstrates how successfully guidelines can be applied in the real world. A definite overinterpretation of current guidelines is observed in low-risk patients with AF. True contraindication for OAT (4%) and significant bleeding during OAT (1.5%) were rare.

Background: Radiofrequency (RF) catheter ablation is considered the treatment of choice for patients with atrioventricular nodal reentrant tachycardia (AVNRT). This study examined the efficacy and safety of RF ablation in patients with AVNRT ≥65 years of age. Methods: We retrospectively analyzed data collected in 350 consecutive patients who underwent AVNRT RF ablation between 1995 and 2005. They were divided according to whether they were Results: Patients in Group 2 more often had structural heart disease (12/70 vs 17/280, P = 0.002) than in Group 1, though there was no difference in the prevalence of syncope (6/70 vs 18/280, P = 0.52) or atrial fibrillation (1/70 vs 6/280, P = 0.70) between the 2 groups. Before RF ablation, patients in Group 2 had a longer mean A‐H intervals (90 ± 31 ms vs 77 ± 19 ms, P < 0.0001), H‐V intervals (44 ± 6 ms vs 41 ± 5 ms, P < 0.0001), fast pathway refractory period (358 ± 14 ms, vs 335 ± 68 ms, P = 0.01), and tachycardia cycle length (394 ± 71 ms vs. 335 ± 59 ms, P < 0.0001). A >140 ms A‐H interval was present in 3/70 patients in Group 2 versus 0/280 in Group 1 (P < 0.001). No difference was observed between the 2 groups in primary RF ablation success rate (70/70 vs 277/280, P = 0.38), overall procedure duration (75 ± 35 minute vs 78 ± 43 minute, P = 0.61), duration of fluoroscopic exposure (14 ± 12 minute vs 13 ± 12 minute, P = 0.63), or number of RF pulses (median 5 vs 4, P = 0.051). Two patients in Group 1 (0.57%) developed 3rd degree AV block requiring permanent pacing. Recurrences of AVNRT were limited to Group 1 (16/280 vs 0/70, P = 0.001). Conclusions: RF ablation of AVNRT was highly effective and safe in patients ≥65 years of age despite a higher prevalence of structural heart disease and longer A‐H intervals at baseline. RF ablation might be considered as first‐line therapy for the elderly with AVNRT.

Typical or common atrial flutter is a frequent cardiac arrhythmia related to a macroreentrant circuit located entirely within the right atrium. Risks associated with this supraventricular arrhythmia include 1 to 1 conduction with extremely rapid ventricular rates, tachycardia-mediated cardiomyopathy and thromboembolic events. Treatment of choice of atrial flutter is radiofrequency catheter ablation of the cavo-tricuspid isthmus, and this form of treatment may be considered either during the first episode or at the time of the first recurrence of atrial flutter. Anticoagulant therapy is the rule in the presence of atrial flutter because this arrhythmia favors thromboembolic complications and because atrial flutter is frequently associated with atrial fibrillation.