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Background: Atrial fibrillation and flutter (AFF) are the most common cardiac arrhythmias globally, contributing to substantial morbidity and mortality. The Middle East and North Africa (MENA) region face unique challenges in managing cardiovascular diseases, including AFF, due to diverse sociodemographic factors and healthcare infrastructure variability. This study aims to comprehensively evaluate the burden of AFF in MENA from 1990 to 2019., Methods: Data were obtained from the Global Burden of Diseases Study 2019, a comprehensive source incorporating diverse data inputs. The study collected global, regional, and national Age-Standardized Incidence Rate (ASIR), Age-Standardized Mortality Rate (ASMR), and Age-Standardized Disability-Adjusted Rate (ASDR), Mortality across sex, age groups, and years. LOESS regression was employed to determine the relationship between age-standardized rates attributed to AFF and Socio-Demographic Index (SDI)., Results: The study found minimal change in ASIR of AFF in MENA from 1990 to 2019, with a slight increase observed in ASMR and ASDR during the same period. Notably, AFF burden was consistently higher in females compared to males, with age showing a direct positive relationship with AFF burden. Iraq, Iran, and Turkey exhibited the highest ASIR, while Qatar, Bahrain, and Oman had the highest ASMR and ASDR in 2019. Conversely, Kuwait, Libya, and Turkey displayed the lowest ASMR and ASDR rates., Conclusion: This study underscores the persistent burden of AFF in MENA and identifies significant disparities across countries. High systolic blood pressure emerged as a prominent risk factor for mortality in AFF patients. Findings provide crucial insights for policy-making efforts, resource allocation, and intervention strategies aimed at reducing the burden of cardiovascular diseases in the MENA region., (© 2024. The Author(s).)

Atrial flutter, a prevalent cardiac arrhythmia, is primarily characterized by reentrant circuits in the right atrium. However, atypical forms of atrial flutter present distinct challenges in terms of diagnosis and treatment. In this study, we examine three noteworthy clinical cases of atypical atrial flutter, which offer compelling evidence indicating the implication of the lesser-known Septopulmonary Bundle (SPB). This inference is based on the identification of distinct electrocardiographic patterns observed in these patients and their favorable response to catheter ablation, which is a standard treatment for atrial flutter. Remarkably, in each case, targeted ablation at the anterior portion of the left atrial roof effectively terminated the arrhythmia, thus providing further support for the hypothesis of SPB involvement. These insightful observations shed light on the potential significance of the SPB in the etiology of atypical atrial flutter and introduce a promising therapeutic target. We anticipate that this paper will stimulate further exploration into the role of the SPB in atrial flutter and pave the way for the development of targeted ablation strategies., (© 2024. The Author(s).)

Background: Atrial fibrillation (AF) is the most frequent sustained arrhythmia. Cardioversion is a rhythm control strategy to restore normal/sinus rhythm, and can be achieved through drugs (pharmacological) or a synchronised electric shock (electrical cardioversion)., Objectives: To assess the efficacy and safety of pharmacological and electrical cardioversion for atrial fibrillation (AF), atrial flutter and atrial tachycardias., Search Methods: We searched CENTRAL, MEDLINE, Embase, Conference Proceedings Citation Index-Science (CPCI-S) and three trials registers (ClinicalTrials.gov, WHO ICTRP and ISRCTN) on 14 February 2023., Selection Criteria: We included randomised controlled trials (RCTs) at the individual patient level. Patient populations were aged ≥ 18 years with AF of any type and duration, atrial flutter or other sustained related atrial arrhythmias, not occurring as a result of reversible causes., Data Collection and Analysis: We used standard Cochrane methodology to collect data and performed a network meta-analysis using the standard frequentist graph-theoretical approach using the netmeta package in R. We used GRADE to assess the quality of the evidence which we presented in our summary of findings with a judgement on certainty. We calculated differences using risk ratios (RR) and 95% confidence intervals (CI) as well as ranking treatments using a P value. We assessed clinical and statistical heterogeneity and split the networks for the primary outcome and acute procedural success, due to concerns about violating the transitivity assumption., Main Results: We included 112 RCTs (139 records), from which we pooled data from 15,968 patients. The average age ranged from 47 to 72 years and the proportion of male patients ranged from 38% to 92%. Seventy-nine trials were considered to be at high risk of bias for at least one domain, 32 had no high risk of bias domains, but had at least one domain classified as uncertain risk, and one study was considered at low risk for all domains. For paroxysmal AF (35 trials), when compared to placebo, anteroapical (AA)/anteroposterior (AP) biphasic truncated exponential waveform (BTE) cardioversion (RR: 2.42; 95% CI 1.65 to 3.56), quinidine (RR: 2.23; 95% CI 1.49 to 3.34), ibutilide (RR: 2.00; 95% CI 1.28 to 3.12), propafenone (RR: 1.98; 95% CI 1.67 to 2.34), amiodarone (RR: 1.69; 95% CI 1.42 to 2.02), sotalol (RR: 1.58; 95% CI 1.08 to 2.31) and procainamide (RR: 1.49; 95% CI 1.13 to 1.97) likely result in a large increase in maintenance of sinus rhythm until hospital discharge or end of study follow-up (certainty of evidence: moderate). The effect size was larger for AA/AP incremental and was progressively smaller for the subsequent interventions. Despite low certainty of evidence, antazoline may result in a large increase (RR: 28.60; 95% CI 1.77 to 461.30) in this outcome. Similarly, low-certainty evidence suggests a large increase in this outcome for flecainide (RR: 2.17; 95% CI 1.68 to 2.79), vernakalant (RR: 2.13; 95% CI 1.52 to 2.99), and magnesium (RR: 1.73; 95% CI 0.79 to 3.79). For persistent AF (26 trials), one network was created for electrical cardioversion and showed that, when compared to AP BTE incremental energy with patches, AP BTE maximum energy with patches (RR 1.35, 95% CI 1.17 to 1.55) likely results in a large increase, and active compression AP BTE incremental energy with patches (RR: 1.14, 95% CI 1.00 to 1.131) likely results in an increase in maintenance of sinus rhythm at hospital discharge or end of study follow-up (certainty of evidence: high). Use of AP BTE incremental with paddles (RR: 1.03, 95% CI 0.98 to 1.09; certainty of evidence: low) may lead to a slight increase, and AP MDS Incremental paddles (RR: 0.95, 95% CI 0.86 to 1.05; certainty of evidence: low) may lead to a slight decrease in efficacy. On the other hand, AP MDS incremental energy using patches (RR: 0.78, 95% CI 0.70 to 0.87), AA RBW incremental energy with patches (RR: 0.76, 95% CI 0.66 to 0.88), AP RBW incremental energy with patches (RR: 0.76, 95% CI 0.68 to 0.86), AA MDS incremental energy with patches (RR: 0.76, 95% CI 0.67 to 0.86) and AA MDS incremental energy with paddles (RR: 0.68, 95% CI 0.53 to 0.83) probably result in a decrease in this outcome when compared to AP BTE incremental energy with patches (certainty of evidence: moderate). The network for pharmacological cardioversion showed that bepridil (RR: 2.29, 95% CI 1.26 to 4.17) and quindine (RR: 1.53, (95% CI 1.01 to 2.32) probably result in a large increase in maintenance of sinus rhythm at hospital discharge or end of study follow-up when compared to amiodarone (certainty of evidence: moderate). Dofetilide (RR: 0.79, 95% CI 0.56 to 1.44), sotalol (RR: 0.89, 95% CI 0.67 to 1.18), propafenone (RR: 0.79, 95% CI 0.50 to 1.25) and pilsicainide (RR: 0.39, 95% CI 0.02 to 7.01) may result in a reduction in this outcome when compared to amiodarone, but the certainty of evidence is low. For atrial flutter (14 trials), a network could be created only for antiarrhythmic drugs. Using placebo as the common comparator, ibutilide (RR: 21.45, 95% CI 4.41 to 104.37), propafenone (RR: 7.15, 95% CI 1.27 to 40.10), dofetilide (RR: 6.43, 95% CI 1.38 to 29.91), and sotalol (RR: 6.39, 95% CI 1.03 to 39.78) probably result in a large increase in the maintenance of sinus rhythm at hospital discharge or end of study follow-up (certainty of evidence: moderate), and procainamide (RR: 4.29, 95% CI 0.63 to 29.03), flecainide (RR 3.57, 95% CI 0.24 to 52.30) and vernakalant (RR: 1.18, 95% CI 0.05 to 27.37) may result in a large increase in maintenance of sinus rhythm at hospital discharge or end of study follow-up (certainty of evidence: low). All tested electrical cardioversion strategies for atrial flutter had very high efficacy (97.9% to 100%). The rate of mortality (14 deaths) and stroke or systemic embolism (3 events) at 30 days was extremely low. Data on quality of life were scarce and of uncertain clinical significance. No information was available regarding heart failure readmissions. Data on duration of hospitalisation was scarce, of low quality, and could not be pooled., Authors' Conclusions: Despite the low quality of evidence, this systematic review provides important information on electrical and pharmacological strategies to help patients and physicians deal with AF and atrial flutter. In the assessment of the patient comorbidity profile, antiarrhythmic drug onset of action and side effect profile versus the need for a physician with experience in sedation, or anaesthetics support for electrical cardioversion are key aspects when choosing the cardioversion method., (Copyright © 2024 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.)

Rationale: This case report addresses a unique instance of atrial flutter complicating acute respiratory distress syndrome (ARDS), contributing a novel addition to the medical literature. The co-occurrence of these conditions sheds light on a rare clinical scenario that requires careful consideration., Patient Concerns: The patient exhibited symptoms of pronounced dyspnea, tachypnea, and hypoxemia. Clinical assessment revealed irregular heart rhythms, notably atrial flutter, alongside characteristic signs of ARDS, including bilateral pulmonary infiltrates and reduced lung compliance., Diagnoses and Interventions: After a comprehensive evaluation, the patient was diagnosed with atrial flutter complicating ARDS. Therapeutic measures encompassed antiarrhythmic agents, mechanical ventilation, and targeted ARDS management protocols. The intricate interplay between cardiac and respiratory factors necessitated a multidisciplinary approach., Outcomes: Throughout treatment, the patient's respiratory distress gradually improved. Control of the atrial flutter was achieved, and oxygenation levels were restored within acceptable limits. This successful outcome underscores the significance of a well-coordinated treatment strategy in addressing complex cases like this., Lessons: This case highlights the importance of recognizing and managing the intricate relationship between cardiac arrhythmias such as atrial flutter and respiratory complications like ARDS. The successful management of this patient underscores the value of multidisciplinary collaboration and tailored therapeutic interventions. Practitioners should remain vigilant for such rare complications and consider this case a reminder of the potential complexities that can arise in critical care scenarios., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Management of adults with atrial fibrillation (AF) or atrial flutter in the emergency department (ED) includes rate reduction, cardioversion, and stroke prevention. Different approaches to these components of care may lead to variation in frequency of hospitalization and stroke prevention actions, with significant implications for patient experience, cost of care, and risk of complications. Standardization using evidence-based recommendations could reduce variation in management, preventable hospitalizations, and stroke risk., Methods: We describe the rationale for our ED-based AF treatment recommendations. We also describe the development of an electronic clinical decision support system (CDSS) to deliver these recommendations to emergency physicians at the point of care. We implemented the CDSS at three pilot sites to assess feasibility and solicit user feedback. We will evaluate the impact of the CDSS on hospitalization and stroke prevention actions using a stepped-wedge cluster randomized pragmatic clinical trial across 13 community EDs in Northern California., Discussion: We hypothesize that the CDSS intervention will reduce hospitalization of adults with isolated AF or atrial flutter presenting to the ED and increase anticoagulation prescription in eligible patients at the time of ED discharge and within 30 days. If our hypotheses are confirmed, the treatment protocol and CDSS could be recommended to other EDs to improve management of adults with AF or atrial flutter., Trial Registration: ClinicalTrials.gov NCT05009225 .  Registered on 17 August 2021., (© 2023. The Author(s).)

Aims: Atrial fibrillation (AF)/atrial flutter is common during cardiac amyloidosis (CA). Electrical cardioversion (EC) is a strategy to restore sinus rhythm (SR). However, left atrial thrombus (LAT) represents a contraindication for EC. CA patients with AF/atrial flutter have a high prevalence of LAT. We aimed to evaluate EC characteristics, LAT prevalence and risk factors, and AF/atrial flutter outcome in CA patients undergoing EC, predominantly treated with direct oral anticoagulants (DOACs)., Methods and Results: All patients with CA and AF/atrial flutter referred for the first time to our national referral centre of amyloidosis for EC from June 2017 to February 2021 were included in this study. In total, 66 patients (median age 74.5 [70;80.75] years, 67% male) were included with anticoagulation consisted of DOAC in 74% of cases. All patients underwent cardiac imaging before EC to rule out LAT. EC was cancelled due to LAT in 14% of cases. Complete thrombus resolution was observed in only 17% of cases. The two independent parameters associated with LAT were creatinine [hazard ratio (HR) = 1.01; confidence interval (CI) = 1.00-1.03, P = 0.036] and the use of antiplatelet agents (HR = 13.47; CI = 1.85-98.02). EC acute success rate was 88%, and we observed no complication after EC. With 64% of patients under amiodarone, AF/atrial flutter recurrence rate following EC was 51% after a mean follow-up of 30 ± 27 months., Conclusions: Left atrial thrombus was observed in 14% of CA patients listed for EC and mainly treated with DOAC. The acute EC success rate was high with no complication. The long-term EC success rate was acceptable (49%)., (© 2022 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)

An increased body mass index (BMI) is associated with a higher incidence of atrial fibrillation (AF) and a higher risk of thromboembolic complications in AF patients. The aim of this study was to investigate the effect of BMI on the risk of left atrial thrombi (LATs) in patients with nonvalvular AF/atrial flutter (AFl) (NV AF/AFl). Patients diagnosed with NVAF/AFl (between November 2018 and May 2020) were selected from the multicenter, prospective, observational Left Atrial Thrombus on Transesophageal Echocardiography (LATTEE) registry that included AF/AFl patients referred for cardioversion or ablation followed by transesophageal echocardiography. A total of 2816 AF/AFl patients (63.6% males; mean age 65.8 years; mean BMI 29.8 kg/m2) were included in the study. Two hundred and twenty-two of them (7.9%) had LATs. Compared with normal-weight patients, those with BMIs ≥ 25 kg/m2 more frequently presented clinical factors potentially provoking LATs, such as non-paroxysmal AF/AFl (p = 0.04), hypertension (p < 0.001), and diabetes (p < 0.001); had higher CHA2DS2 scores (p < 0.001); and had larger LA dimensions (LA diameter and LA area) (p < 0.001 for both parameters). On the other hand, they showed some features negatively related to thromboembolic risk; for example, they were younger (p < 0.001) and were more often male (p = 0.002). In addition, patients with abnormal BMIs were more likely to be smokers (p = 0.006) and to be treated with oral anticoagulants (p = 0.005). Despite these differences in the prevalence of thromboembolic risk factors, the incidence of LATs was not increased in patients with abnormal body weight (overweight and obese compared to normal-weight patients) in this large real-life cohort of AF/AFl patients. This is probably due to the balanced composition regarding the prevalence of positive and negative thromboembolic risk factors.

Background: Atrial fibrillation (AF) is the most common cardiac arrhythmia in the adult population. Herein, is a systematic review with meta-analysis to determine the impact of AF/atrial flutter (AFL) on mortality, as well as individual complications in patients hospitalized with the coronavirus disease 2019 (COVID-19)., Methods: A systematic search of the SCOPUS, Medline, Web of Science, CINAHL and Cochrane databases was performed. The a priori primary outcome of interest was in-hospital mortality. A random-effects model was used to pool study results., Results: Nineteen studies which included 33,296 patients were involved in this meta-analysis. Inhospital mortality for AF/AFL vs. no-AF/AFL groups varied and amounted to 32.8% vs. 14.2%, respectively (risk ratio [RR]: 2.18; 95% confidence interval [CI]: 1.79-2.65; p < 0.001). In-hospital mortality in new onset AF/AFL compared to no-AFAFL was 22.0% vs. 18.8% (RR: 1.86; 95% CI: 1.54-2.24; p < 0.001). Intensive care unit (ICU) admission was required for 17.7% of patients with AF/AFL compared to 10.8% for patients without AF/AFL (RR: 1.94; 95% CI: 1.04-3.62; p = 0.04)., Conclusions: The present study reveals that AF/AFL is associated with increased in-hospital mortality and worse outcomes in patients with COVID-19 and may be used as a negative prognostic factor in these patients. Patients with AF/AFL are at higher risk of hospitalization in ICU. The presence of AF/AFL in individuals with COVID-19 is associated with higher risk of complications, such as bleeding, acute kidney injury and heart failure. AF/AFL may be associated with unfavorable outcomes due to the hemodynamic compromise of cardiac function itself or hyperinflammatory state typical of these conditions.

Background: Atrial flutter is a rare condition in pediatrics that usually occurs as a late complication after surgery for congenital heart diseases, although it can also appear in structurally normal hearts., Clinical Cases: We conducted a retrospective study of cases of atrial flutter with no structural heart disease diagnosed in a pediatric population (between 0 and 15 years of age) during 2015-2021 in a tertiary hospital. A total of seven cases were diagnosed, with a clear predominance of males (6/7). Of the seven patients, five debuted in the perinatal period: two were diagnosed at 20 and 36 hours of life, and three, prenatally. Among these perinatal cases, more than half (3/5) were preterm. The treatment was electrical cardioversion. The evolution was satisfactory in these cases, and there were no tachycardias in their subsequent development. In contrast, when the debut occurred at a later age (5-7 years), it was associated with channelopathy (Brugada syndrome and catecholaminergic polymorphic ventricular tachycardia), and electrical ablation of the ectopic focus was required due to poor response to pharmacological treatment., Conclusions: This study confirms the low incidence of this pathology in pediatrics and the benignity and good prognosis of neonatal flutter in most cases. The prognosis worsens when atrial flutter is diagnosed in older children, and the probability of concomitant associated heart disease increases., (Copyright: © 2022 Permanyer.)

While the interplay between heart failure (HF) and atrial fibrillation (AF) has been extensively studied, little is known regarding HF and atrial flutter (AFL), which may be managed differently. We reviewed the incidence, prevalence, and predictors of HF in AFL and vice versa, and the outcomes of treatment of AFL in HF. A systematic literature review of PubMed/Medline and EMBASE yielded 65 studies for inclusion and qualitative synthesis. No study described the incidence or prevalence of AFL in unselected patients with HF. Most cohorts enrolled patients with AF/AFL as interchangeable diagnoses, or highly selected patients with tachycardia-induced cardiomyopathy. The prevalence of HF in AFL ranged from 6% to 56%. However, the phenotype of HF was never defined by left ventricular ejection fraction (LVEF). No studies reported the predictors, phenotype, and prognostic implications of AFL in HF. There was significant variation in treatments studied, including the proportion that underwent ablation. When systolic dysfunction was tachycardia-mediated, catheter ablation demonstrated LVEF normalization in up to 88%, as well as reduced cardiovascular mortality. In summary, AFL and HF often coexist but are understudied, with no randomized trial data to inform care. Further research is warranted to define the epidemiology and establish optimal management., (© 2021 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)

Background Anticoagulation is indicated for 4 weeks after cardioversion in patients with atrial fibrillation/flutter. We sought to examine whether there is evidence of sex or racial disparity in anticoagulant prescription following cardioversion, and whether postcardioversion anticoagulation affects outcomes. Methods and Results We identified a representative sample of Medicare patients who underwent elective electric cardioversion in an outpatient setting from 2015 to 2017. We identified patients who had an anticoagulant prescription for 3 months after the cardioversion date. Multivariable logistic regression was used to assess factors associated with a prescription of an anticoagulant after cardioversion. Cox regression analysis was used to test association of anticoagulation with a composite end point of 90-day mortality, ischemic stroke, or arterial embolism. The final study cohort included 7860 patients. Overall, 5510 patients (70.1%) received any anticoagulation following cardioversion, while 2350 (29.9%) did not. Patients who did not receive anticoagulation were younger, with a lower burden of most comorbidities. Patients were less likely to receive anticoagulation if they had dementia or atrial flutter, while patients with valvular heart disease, obesity, heart failure, peripheral vascular or coronary disease, or hypertension were more likely to receive anticoagulation. Female sex (adjusted odds ratio, 0.84; 95% CI, 0.75-0.92; P <0.001), Black and Hispanic race (adjusted odds ratio, 0.50; 95% CI, 0.38-0.65; and odds ratio, 0.56; 95% CI, 0.41-0.75, respectively; P <0.001) were independently associated with lower probability of anticoagulant prescription. Postcardioversion anticoagulation was associated with lower risk of the composite end point (adjusted hazard ratio, 0.38; 95% CI, 0.27-0.52; P <0.001). Conclusions Racial and sex disparities exist in anticoagulant prescription after outpatient elective cardioversion for atrial fibrillation.

Objective: In the United States, atrial fibrillation (AF) accounts for over 400,000 hospitalizations annually. Emergency Department (ED) physicians have few resources available to guide AF/AFL (atrial flutter) patient triage, and the majority of these patients are subsequently admitted. Our aim is to describe the characteristics and disposition of AF/AFL patients presenting to the University of North Carolina (UNC) ED with the goal of developing a protocol to prevent unnecessary hospitalizations., Methods: We performed a retrospective electronic medical chart review of AF/AFL patients presenting to the UNC ED over a 15-month period from January 2015 to March 2016. Demographic and ED visit variables were collected. Additionally, patients were designated as either having primary or secondary AF/AFL where primary AF/AFL patients were those in whom AF/AFL was the primary reason for ED presentation. These primary AF/AFL patients were categorized by AF symptom severity score according to the Canadian Cardiovascular Society Severity of Atrial Fibrillation (CCS-SAF) Scale., Results: A total of 935 patients presented to the ED during the study period with 202 (21.5%) having primary AF/AFL. Of the primary AF/AFL patients, 189 (93.6%) had mild-moderate symptom severity (CCS-SAF ≤ 3). The majority of primary AF/AFL patients were hemodynamically stable, with a mean (SD) SBP of 123.8 (21.3), DBP of 76.6 (14.1), and ventricular rate of 93 (21.9). Patients with secondary AF/AFL were older 76 (13.1), p < 0.001 with a longer mean length of stay 6.1 (7.7), p = 0.31. Despite their mild-moderate symptom severity and hemodynamic stability, nearly 2/3 of primary AF/AFL patients were admitted., Conclusion: Developing a protocol to triage and discharge hemodynamically stable AF/AFL patients without severe AF/AFL symptoms to a dedicated AF/AFL clinic may help to conserve healthcare resources and potentially deliver more effective care., Competing Interests: Declaration of competing interest A.G. reports having received lecture fees from Biotronik, Zoll, St. Jude Medical and research funding support from Bristol Myers Squib Foundation. Other authors have no conflict of interest to report., (Copyright © 2021 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.)

Flecainide, a widely prescribed class IC agent used to treat atrial arrhythmias, can in rare cases cause 1:1 atrial flutter with rapid conduction. We describe the case of a 59-year-old man who was on a maintenance regimen of flecainide for refractory atrial fibrillation. When 1:1 atrial flutter with rapid conduction developed, emergency medical technicians attempted synchronized cardioversion, which caused ventricular fibrillation necessitating defibrillation. The patient ultimately underwent radiofrequency ablation and cryoablation to resolve his symptomatic atrial flutter. We discuss the atrial proarrhythmic effects of flecainide and how to mitigate complications in high-risk patients., (© 2021 by the Texas Heart® Institute, Houston.)

Background: Many centers continue to routinely perform transesophageal echocardiograms before atrial fibrillation (AF) ablation procedures in patients treated with direct oral anticoagulants (DOACs). One study suggested that the procedures could be done without transesophageal echocardiogram but used intracardiac echocardiography imaging of the appendage from the right ventricular outflow. This study aimed to assess the safety of ablation for AF without transesophageal echocardiogram screening or intracardiac echocardiography imaging of the appendage in DOAC compliant patients., Methods: All patients undergoing AF ablation at the Cleveland Clinic (2011-2018) were enrolled in a prospectively maintained data registry. All consecutive patients presenting with AF or atrial flutter on DOAC were included. Periprocedural thromboembolic complications were assessed., Results: A total of 900 patients were included. Their median CHA 2 DS 2 -VASc score was 2 (interquartile range 1-3). All were on DOACs (333 rivaroxaban, 285 dabigatran, 281 apixaban, and 1 edoxaban). Thromboembolic complications occurred in 4 patients (0.3%): 2 ischemic strokes, 1 transient ischemic attack without residual deficit, and 1 splenic infarct; all with no further complications. Bleeding complications occurred in 5 patients (0.4%): 2 pericardial effusions (1 intraoperative, 1 after 30 days, both drained), 3 groin hematomas (1 of them due to needing heparin for venous thrombosis, none required interventions). No patients required emergent surgeries., Conclusions: In DOAC compliant patients who present for ablation in AF/atrial flutter, the procedures could be performed without transesophageal echocardiogram screening or intracardiac echocardiography imaging of the appendage; with low risk of complications.

Cardioversion is widely used in patients with atrial fibrillation (AF) and atrial flutter when a rhythm control strategy is pursued. We sought to summarize the current evidence on this important area of clinical management of patients with AF including electrical and pharmacological cardioversion, peri-procedural anticoagulation and thromboembolic complications, success rate, and risk factors for recurrence to give practical guidance., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Background: The role of antiarrhythmic drugs for atrial fibrillation/atrial flutter (AF/AFL) after catheter ablation is not well established., Hypothesis: We hypothesized that changing the myocardial substrate by ablation may alter the responsiveness to dronedarone., Methods: We assessed the efficacy and safety of dronedarone in the treatment of paroxysmal/persistent atrial fibrillation/atrial flutter (AF/AFL) post-ablation, based on a post hoc analysis of the ATHENA study. A total of 196 patients (dronedarone 90, placebo 106) had an ablation for AF/AFL before study entry. In these patients, the effect of treatment on the first hospitalization because of cardiovascular (CV) events/all-cause death was assessed, as was AF/AFL recurrence in individuals with sinus rhythm at baseline. The safety of dronedarone vs placebo was also determined., Results: In patients with prior ablation, dronedarone reduced the risk of AF/AFL recurrence (hazard ratio [HR]: 0.65 [95% confidence interval [CI]: 0.42, 1.00]; P < .05) as well as the median time to first AF/AFL recurrence (561 vs 180 days) compared with placebo. The HR for first CV hospitalization/all-cause death with dronedarone vs placebo was 0.98 (95% CI: 0.62, 1.53; P = .91). Rates of treatment-emergent adverse events were 83.1% vs 75.5% and rates of serious TEAEs were 27.0% vs 18.9% in the dronedarone and placebo groups, respectively. One death occurred with dronedarone (not treatment-emergent) and five occurred with placebo., Conclusion: In patients with prior ablation for AF/AFL, dronedarone reduced the risk of AF/AFL recurrence compared with placebo, but not the risk of first CV hospitalization/all-cause death. Safety outcomes were consistent with those of the overall ATHENA study., (© 2019 The Authors. Clinical Cardiology published by Wiley Periodicals, Inc.)

Aims: We aimed to assess the novel concept of using the paced PR interval (PRI) on the surface electrocardiogram (ECG) to prove trans-isthmus block after cavotricuspid isthmus (CTI) ablation for typical atrial flutter (AFl)., Methods and Results: Consecutive patients with AFl underwent linear radiofrequency ablation of the inferior CTI (6 o'clock). After AFl termination and/or presumed completion of the CTI line, CTI block was proven by atrial pacing by the ablation catheter medial (5 o'clock) and lateral to the line (7 and 9 o'clock). Corresponding PRIs were measured on the surface ECG. CTI block was assumed, if a sudden increase in the PRI was observed by moving the pacing site from 5 to 7 o'clock, and if the latter was longer than at 9 o'clock. Afterwards, bidirectional CTI block was confirmed by differential pacing. Thirty-one patients (mean age 67 ± 16 years, 81% male) underwent CTI ablation, and 18/31 (58%) were in AFl at the time of ablation (cycle length 249 ± 31 ms). Successful CTI block as defined by the PRI method was achieved in 31/31 (100%), and the mean PRIs during pacing at 5, 7, and 9 o'clock were 203 ± 56 ms, 329 ± 70 ms, and 296 ± 66 ms, respectively. Cavotricuspid isthmus block was confirmed in all patients (100%) by coronary sinus pacing with a reversal of the local activation sequence lateral to the isthmus line., Conclusion: The method of PRI analysis on the surface ECG to guide CTI ablation is easy to apply and highly accurate in confirming CTI block. This simple technique enables the novel concept of CTI ablation and proof of block with a single catheter., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: journals.permissions@oup.com.)

Background: Atrial fibrillation (AF) and atrial flutter (AFL) are associated with increased risk of stroke and mortality after transcatheter aortic valve replacement (TAVR). Many episodes of new-onset AF/AFL (NOAF) occur after hospital discharge and may not be clinically apparent. Pacemakers can detect subclinical episodes of rapid atrial rate, which correlate with electrocardiographically documented AF., Methods: From 2012 to 2017, patients who underwent pacemaker implantation after TAVR were reviewed, and pacemaker data from device checks were analyzed for detection of NOAF. Patients with prior AF/AFL were excluded. Secondary outcomes were mortality and ischemic stroke., Results: A total of 172 patients underwent TAVR and pacemaker implantation, and 95 were without pre-existent AF/AFL. Over a median follow-up of 15 months, a total of 24 patients had NOAF (25%), of which 10 patients (10.5%) had manifest NOAF detected on electrocardiography, and 14 patients (14.7%) had subclinical NOAF first identified on device interrogation. The cumulative incidence of mortality was 16.7% for NOAF and 15.5% for normal sinus rhythm (P=.83). The cumulative incidence of stroke was 12.5% for NOAF and 1.4% for normal sinus rhythm (P=.04). Subclinical NOAF patients were less likely to be started on anticoagulation compared with manifest NOAF patients (70% vs 15.3%, respectively; P=.02)., Conclusion: Subclinical NOAF is common after TAVR, usually occurs months after hospital discharge, and is associated with lack of anticoagulation therapy and increased risk of stroke. Prolonged surveillance of subclinical NOAF may be warranted after TAVR.

Aims: Guidelines recommend initial rate control in haemodynamically stable patients with atrial fibrillation (AF) or atrial flutter (AFL) and acute decompensated heart failure (ADHF). There is limited data on early inpatient rhythm control. We investigated the outcomes of patients managed with early TOE-guided DC cardioversion (DCCV) or ablation., Methods: We retrospectively analysed patients admitted to a single centre with AF or AFL and ADHF with LVEF≤40% that underwent inpatient TOE-guided DCCV or ablation. The primary endpoint was the one year composite outcome of mortality or rehospitalisation for heart failure., Results: We identified 79 patients, including 33 with AF (32 DCCV, one ablation) and 46 with AFL (22 DCCV, 24 ablation). The primary endpoint occurred in 20%. One-year mortality was 2.5%. There were significantly fewer rehospitalisations for arrhythmia or heart failure with AFL-ablation compared to AFL-DCCV (21% vs 64%, p=<0.01). Clinical recurrence of AF or AFL was 43%. At follow-up LV assessment, LVEF>40% was found in 75% (p=<0.01), including 87% of patients without known cardiomyopathy and 82% of patients in sinus rhythm., Conclusion: Early inpatient DCCV or ablation for AF or AFL and ADHF had low mortality rates and rehospitalisation for heart failure with substantial improvement in LV function at follow-up., Competing Interests: Nil.

Background: An implantable loop recorder (ILR) assists in the diagnosis of unexplained syncope and atrial fibrillation (AF). Both become prevalent with age. Limited data exist describing the incidence of AF as the diagnostic rhythm underlying syncope in the elderly. This study aims to report the incidence of AF in older adults with ILRs for unexplained syncope and identify clinical characteristics associated with AF in this population., Methods: Retrospective observational study on patients with unexplained syncope seen in syncope clinics from two Canadian centers. Participants were ≥65 years old, without a history of AF, and received an ILR for unexplained syncope. Data were collected from patient's clinic charts. Arrhythmia diagnosis was based on ILR electrocardiogram reading during syncope (symptom-rhythm correlation). Fisher's exact test and the Student's t test were used to compare participants with and without AF., Results: In our cohort of 222 patients, 124 were females and 98 were males. Mean age at implant was 80 ± 8 years. Arrhythmia was diagnosed in 98 patients (44.1%). Median time to diagnosis was 18 months. AF was diagnosed in 17 (7.7%) participants. There were fewer males in the AF group than the no AF group (11.8%, 46.8%, p = 0.01). Age, baseline EKG, and prevalence of hypertension, diabetes, stroke, or ischemic heart disease were not statistically different between patients with AF and without AF., Conclusions: Atrial fibrillation was a common diagnostic rhythm in this cohort of adults, aged 65 and older, with ILRs for unexplained syncope. It was observed more frequently in females., (© 2019 Wiley Periodicals, Inc.)

Objective: Atrial fibrillation or flutter (AFF) patients with renal impairment have poor long-term prognosis, but their emergency department (ED) management has not been described. We investigated the association of renal impairment upon outcomes after rate or rhythm control (RRC) including ED-based adverse events (AE) and treatment failure., Methods: This cohort study used an electrocardiogram database from two urban centres to identify consecutive AFF patients and reviewed charts to obtain comorbidities, ED management, including RRC, prespecified AE, and treatment failure. Patients were dichotomized into a normal estimated glomerular filtration rate (eGFR) &gt; 60 mL/min/1.73 m2) or impaired renal function ("low eGFR"). Primary and secondary outcomes were prespecified AEs and treatment failure, respectively. We calculated 1) adjusted excess AE risk for patients with decreased renal function receiving RRC; and 2) adjusted odds ratio of RRC treatment failure., Results: Of 1,112 consecutive ED AFF patients, 412 (37.0%) had a low eGFR. Crude AE rates for RRC were 27/238 (11.3%) for patients with normal renal function and 26/103 (25.2%) for patients with low eGFR. For patients with low eGFR receiving RRC, adjusted excess AE risk was 13.7%. (95% CI 1.7 to 25.1%). For patients with low eGFR, adjusted odds ratio for RRC failure was 3.07. (95% CI 1.74 to 5.43) CONCLUSIONS: In this cohort of ED AFF patients receiving RRC, those with low eGFR had significantly increased adjusted excess risk of AE compared with patients with normal renal function. Odds of treatment failure were also significantly increased.

Splenic laceration and rupture are common phenomena among patients in a traumatic setting, especially in blunt trauma. Much more unusual, however, is splenic injury without a known insult. Several case reports and studies have been written about spontaneous splenic injury in patients with viral, haematological or malignant processes. Recently, we encountered a patient with a spontaneous splenic rupture and no preceding trauma apart from semielective cardioversion. Operative decision-making was complicated by the fact that he required systemic anticoagulation for atrial fibrillation. He eventually underwent splenectomy and made an uneventful recovery., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Aims: Takotsubo cardiomyopathy (TTC) is a stress-related transient cardiomyopathy. It is unclear whether TTC is associated with poorer prognosis when atrial arrhythmia (AA), atrial fibrillation or flutter, occurs. The purpose of this study was to assess the incidence of AA in patients with TTC, predictive factors of AA, and its association with mortality., Methods and Results: We studied 214 consecutive cases of TTC over 8 years. The study cohort was divided into two groups-those with newly diagnosed AA (AA-group) and those without (non-AA group). AA occurred in 24.8% of the patients. The AA group presented with lower left ventricular ejection fraction (LVEF) on admission and higher cardiac arrest rate. Admission and peak levels of troponin, B-type natriuretic peptide (BNP), C-reactive protein (CRP), and leucocytes were higher in the AA group. In-hospital, 30-day, cardiovascular, and all-cause mortality were significantly higher in the AA group. Independent predictors of newly diagnosed AA were troponin peak [odds ratio (OR) 1.03 (1.003-1.06); P = 0.029], CRP peak [OR 1.006 (1.001-1.01); P = 0.026], and LVEF on admission [OR 0.96 (0.93-0.99); P = 0.01]. Newly diagnosed AA was not predictive of mortality. The BNP peak [OR 1.00 (1.000-1.001); P = 0.022] and leucocytes peak [OR 1.095 (1.034-1.16); P = 0.002] were predictive factors of in-hospital mortality. LVEF upon discharge [OR 0.935 (0.899-0.972); P = 0.001] and leucocytes peak [OR 1.068 (1.000-1.139); P = 0.049] were predictive of cardiovascular death., Conclusion: Newly diagnosed AA is frequently observed in patients presenting with TTC and is associated with poorer short- and long-term prognosis. Inflammation, myocardial damage, and LVEF are predictors of AA onset and cardiovascular mortality.

Aims: To assess the impact of the introduction of direct oral anticoagulants upon the outcomes from elective electrical cardioversion for atrial fibrillation., Methods: This is a retrospective comparison of delay to elective cardioversion with different anticoagulants. The data was gathered from a large regional hospital from January 2013 to September 2017. There were 3 measured outcomes: 1) the time in weeks from referral to the date of attempted electrical cardioversion; 2) the proportion of patients who were successfully cardioverted; and 3) the proportion of patients who remained in sinus rhythm by the 12 week follow-up. Time-to-cardioversion was non-parametrically distributed so was analysed with Kruskal-Wallis testing and Mann-Whitney-U testing. Maintenance of sinus rhythm was analysed using z-testing., Results: 1,374 patients were submitted to cardioversion. The referrals for cardioversion were either from primary care or from cardiologists. At the time of cardioversion, 789 cases were anticoagulated on warfarin (W), 215 on apixaban (A) and 370 on rivaroxaban (R). All 3 cohorts were initially compared independently using Kruskal-Wallis testing. This demonstrated a significant difference in the delay (measured in weeks) between the A and W group (A = 7, W = 9, P<0.00001); the R and W group (R = 7, W = 9, P<0.00001) and no difference between R and A (A = 7, R = 7, P = 0.92). As there was no difference between the A and R groups, they were combined to form the AR group. The AR group was compared to the W group using Mann-Whitney-U testing which demonstrated a significant delay between the groups (AR = 7, W = 9, P<0.00001). Excluding patients with prior or unknown attempts of cardioversion (n = 791), the W patients (n = 152) were less successful in achieving sinus rhythm at cardioversion than the AR (n = 431) group (W = 95% vs AR = 99% P = 0.04). However at 12 weeks, incidence of sinus rhythm was significantly different (W = 40% vs AR = 49% P = 0.049). These groups were compared by z testing. At 12 weeks' follow-up there was no statistical difference in rate of adverse consequences between the AR group and the W group, but the rate of adverse consequences was too low to draw further conclusions., Conclusion: DOACs appear to significantly shorten the latency between the decision to cardiovert and the cardioversion procedure by at least 2 weeks compared to warfarin in a real-world setting. In this study, patients who had not previously been cardioverted who were anticoagulated with warfarin had a significantly lower probability of conversion to sinus rhythm and a significantly lower probability to remain in sinus rhythm at the 12 week follow-up compared to the combined apixaban and rivaroxaban group., Competing Interests: The authors have declared no competing interest exist.

Supraventricular arrhythmias can cause uncomfortable symptoms for patients. Often, the first point of contact is in the primary care setting, and thus, it is imperative for the general internist to have a clinical framework in place to recognize this cluster of cardiac arrhythmias, be familiar with immediate and long-term management of supraventricular tachycardias, and understand when cardiac electrophysiologic consultation is necessary. The electrocardiographic characteristics can have subtle but important clues to the diagnosis and initial management. An understanding of the mechanisms of these arrhythmias is essential to provide proper therapy to the patient. In addition, there are common practice strategies that should be emphasized to avoid common misperceptions that could pose risk to the patient. In this review, we provide a framework to more easily recognize and classify these arrhythmias. We also illustrate the mechanism for these arrhythmias to provide an understanding of the interventions generally used., (Copyright © 2018 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Recurring questions when dealing with arrhythmias in athletes are about the cause of the arrhythmia and, more importantly, about the eligibility of the athlete to continue sports activities. In essence, the relation between sports and arrhythmias can be understood along three lines: sports as arrhythmia trigger on top of an underlying problem, sports as arrhythmic substrate promotor, or sports as substrate inducer. Often, there is no sharp divider line between these entities. The athlete's heart, a heart that adapts so magically to cope with the demands of exercise, harbours many structural and functional changes that by themselves predispose to arrhythmia development, at the atrial, nodal and ventricular levels. In essence, the athlete's heart is a proarrhythmic heart. This review describes the changes in the athlete's heart that are related to arrhythmic expression and focuses on what this concept means for clinical decision making. The concept of the athlete's heart as a proarrhythmic heart creates a framework for evaluation and counselling of athletes, yet also highlights the difficulty in predicting the magnitude of associated risk. The management uncertainties are discussed for specific conditions like extreme bradycardic remodelling, atrioventricular nodal reentrant tachycardia, atrial fibrillation and flutter, and ventricular arrhythmias.

Atrial fibrillation and flutter (AF) is a common condition among emergency department (ED) patients in the United States. Traditionally, ED care for primary complaints related to AF focus on rate control, and patients are often admitted to an inpatient setting for further care. Inpatient care may include further telemetry monitoring and diagnostic testing, rhythm control, a search for identification of AF etiology, and stroke prophylaxis. However, many patients are eligible for safe and effective outpatient management pathways. They are widely used in Canada and other countries but less widely adopted in the United States. In this project, we convened an expert panel to create a practical framework for the process of creating, implementing, and maintaining an outpatient AF pathway for emergency physicians to assess and treat AF patients, safely reduce hospitalization rates, ensure appropriate stroke prophylaxis, and effectively transition patients to longitudinal outpatient treatment settings from the ED and/or observation unit. To support local pathway creation, the panel also reached agreement on a protocol development plan, a sample pathway, consensus recommendations for pathway components, sample pathway metrics, and a structured literature review framework using a modified Delphi technique by a technical expert panel of emergency medicine, cardiology, and other stakeholder groups., (© 2018 by the Society for Academic Emergency Medicine.)

Background: The relevance of transthoracic impedance (TTI) to electrical cardioversion (ECV) success for atrial tachyarrhythmias when using biphasic waveform defibrillators is unknown., Hypothesis: TTI is predictive of ECV success with contemporary defibrillators., Methods: De-identified data stored in biphasic defibrillator memory cards from ECV attempts for atrial fibrillation (AF) or atrial flutter (AFL) over a 2-year period at our center were evaluated. ECV success, defined as arrhythmia termination and ≥ 1 sinus beat, was adjudicated by 2 blinded cardiac electrophysiologists. The association between TTI and ECV success was assessed via Cochrane-Armitage trend and Spearman rank correlation tests, as well as simple and multivariable logistic regression. The influence of TTI on the number of shocks and on cumulative energy delivered per patient was also examined., Results: 703 patients (593 with AF, 110 with AFL) receiving 1055 shocks were included. Last shock success was achieved in 88.0% and 98.2% of patients with AF and AFL, respectively. In patients with AF, TTI was positively associated with last shock failure (P trend  =0.019), the need for multiple shocks (P trend  <0.001), and cumulative energy delivered (ρ = 0.348; P < 0.001). After adjusting for first shock energy, 10-Ω increments in TTI were associated with odds ratios of 1.36 (95% CI: 1.24-1.49) and 1.22 (95% CI: 1.09-1.37) for first and last shock failure, respectively (P < 0.001 for both)., Conclusions: Although contemporary defibrillators are designed to compensate for TTI, this variable continues to be associated with ECV failure in patients with AF. Strategies to lower TTI during ECV for AF may improve procedural success., (© 2018 Wiley Periodicals, Inc.)

Background: Guidelines recommend performing atrial fibrillation (AF) catheter ablation without interruption of a direct oral anticoagulants (DOACs) and to administer unfractionated heparin (UFH) for an activated clotting time (ACT) ≥300 seconds, by analogy with vitamin K antagonist (VKA). Nevertheless, pharmacological differences between DOACs and VKA, especially regarding ACT sensitivity and UFH response, prevent extrapolation from VKA to DOACs., Hypothesis: The level of anticoagulation at the time of the procedure in uninterrupted DOAC-treated patients is unpredictable and would complicate intraprocedural UFH administration and monitoring., Methods: This prospective study included interrupted DOAC-treated patients requiring AF ablation. Preprocedural DOAC concentration ([DOAC]), intraprocedural UFH administration, and ACT values were recorded. A cohort of DOAC-treated patients requiring flutter catheter ablation was considered to illustrate [DOAC] without DOAC interruption., Results: Forty-eight patients underwent AF and 14 patients underwent flutter ablation, respectively. In uninterrupted DOAC-treated patients, [DOAC] ranged from ≤30 to 466 ng/mL. When DOAC were interrupted, from 54 to 218 hours, [DOAC] were minimal (maximum: 36 ng/mL), preventing DOAC-ACT interference. Anyway, ACT values were poorly correlated with UFH doses (R 2  = 0.2256)., Conclusions: Our data showed that uninterrupted DOAC therapy resulted in an unpredictable and highly variable initial level of anticoagulation before catheter ablation. Moreover, even with DOAC interruption preventing interference between DOAC, UFH, and ACT, intraprocedural UFH monitoring was complex. Altogether, our exploratory results call into question the appropriateness of transposing UFH dose protocols, as well as the relevance of ACT monitoring in uninterrupted DOAC-treated patients., (© 2018 Wiley Periodicals, Inc.)

Objectives: Although procedural sedation for cardioversion is a common event in emergency departments (EDs), there is limited evidence surrounding medication choices. We sought to evaluate geographic and temporal variation in sedative choice at multiple Canadian sites, and to estimate the risk of adverse events due to sedative choice., Methods: This is a secondary analysis of one health records review, the Recent Onset Atrial Fibrillation or Flutter-0 (RAFF-0 [n=420, 2008]) and one prospective cohort study, the Recent Onset Atrial Fibrillation or Flutter-1 (RAFF-1 [n=565, 2010 - 2012]) at eight and six Canadian EDs, respectively. Sedative choices within and among EDs were quantified, and the risk of adverse events was examined with adjusted and unadjusted comparisons of sedative regimes., Results: In RAFF-0 and RAFF-1, the combination of propofol and fentanyl was most popular (63.8% and 52.7%) followed by propofol alone (27.9% and 37.3%). There were substantially more adverse events in the RAFF-0 data set (13.5%) versus RAFF-1 (3.3%). In both data sets, the combination of propofol/fentanyl was not associated with increased adverse event risk compared to propofol alone., Conclusion: There is marked variability in procedural sedation medication choice for a direct current cardioversion in Canadian EDs, with increased use of propofol alone as a sedation agent over time. The risk of adverse events from procedural sedation during cardioversion is low but not insignificant. We did not identify an increased risk of adverse events with the addition of fentanyl as an adjunctive analgesic to propofol.

Yılmaz-Semerci S, Bornaun H, Kurnaz D, Cebeci B, Babayiğit A, Büyükkale G, Çetinkaya M. Neonatal atrial flutter: Three cases and review of the literature. Turk J Pediatr 2018; 60: 306-309. Atrial flutter (AFl) is known to be a seldom type of fetal and neonatal arrhythmia. Although it could end in severe morbidities such as hydrops fetalis or even death, with early prenatal diagnosis and prompt therapeutic approaches the majority of AFl cases show good prognosis. Neonatal AFl might be resistant to first step therapies. Therefore, secondary agents like flecainide, amiodarone, sotalol and cardioversion, if required, could be influent in perinatal tachyarrhythmia. In addition, close follow-up even after discharge is very important to keep all follow-up appointments. Herein, we present three cases of fetal/neonatal AFl in light of the literature and discuss the characteristics, diagnosis and treatment options.

Background: Atrial fibrillation increases stroke risk and adversely affects cardiovascular haemodynamics. Electrical cardioversion may, by restoring sinus rhythm, improve cardiovascular haemodynamics, reduce the risk of stroke, and obviate the need for long-term anticoagulation., Objectives: To assess the effects of electrical cardioversion of atrial fibrillation or flutter on the risk of thromboembolic events, strokes and mortality (primary outcomes), the rate of cognitive decline, quality of life, the use of anticoagulants and the risk of re-hospitalisation (secondary outcomes) in adults (>18 years)., Search Methods: We searched the Cochrane CENTRAL Register of Controlled Trials (1967 to May 2004), MEDLINE (1966 to May 2004), Embase (1980 to May 2004), CINAHL (1982 to May 2004), proceedings of the American College of Cardiology (published in Journal of the American College of Cardiology 1983 to 2003), www.trialscentral.org, www.controlled-trials.com and reference lists of articles. We hand-searched the indexes of the Proceedings of the British Cardiac Society published in British Heart Journal (1980 to 1995) and in Heart (1995 to 2002); proceedings of the European Congress of Cardiology and meetings of the Joint Working Groups of the European Society of Cardiology (published in European Heart Journal 1983-2003); scientific sessions of the American Heart Association (published in Circulation 1990-2003). Personal contact was made with experts., Selection Criteria: Randomised controlled trial or controlled clinical trials of electrical cardioversion plus 'usual care' versus 'usual care' only, where 'usual care' included any combination of anticoagulants, antiplatelet drugs and drugs for 'rate control'. We excluded trials which used pharmacological cardioversion as the first intervention, and trials of new onset atrial fibrillation after cardiac surgery. There were no language restrictions., Data Collection and Analysis: For dichotomous data, odds ratios were calculated; and for continuous data, the weighted mean difference was calculated., Main Results: We found three completed trials of electrical cardioversion (rhythm control) versus rate control, recruiting a total of 927 participants (Hot Cafe; RACE; STAF) and one ongoing trial (J-RHYTHM). There was no difference in mortality between the two strategies (OR 0.83; CI 0.48 to 1.43). There was a trend towards more strokes in the rhythm control group (OR 1.9; 95% CI 0.99 to 3.64). At follow up, three domains of quality of life (physical functioning, physical role function and vitality) were significantly better in the rhythm control group (RACE 2002; STAF 2003)., Authors' Conclusions: Electrical cardioversion (rhythm control) led to a non-significant increase in stroke risk but improved three domains of quality of life.

Atraumatic rupture of the normal spleen is a rare entity. Often, a triggering factor or minor physical event can be ascribed as the aetiology for rupture, including coughing, vomiting or minor medical procedures not involving the spleen. A 65-year-old man who was hospitalised for eosinophilic pneumonia developed haemodynamically unstable atrial flutter that necessitated urgent synchronised direct current cardioversion (DCCV). Two hours after successful cardioversion, he developed signs of an acute abdomen with free intraperitoneal fluid identified on bedside ultrasonography. Exploratory laparotomy revealed gross haemoperitoneum and splenic rupture requiring splenectomy. With exception of capsular defects and haemorrhage suggestive of organ rupture, the gross and histological examination of the spleen was otherwise unremarkable. The patient denied recent trauma. The cause of his spleen rupture was attributed to cardioversion and subsequent abdominal muscle contraction. This represents the first known case of splenic rupture associated with DCCV., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: Atrial flutter (AFL) has been identified to be equivalent to atrial fibrillation (AF) in terms of preventing ischemic stroke, although differences exist in atrial rate, substrate, and electrophysiological mechanisms. This study aimed to investigate differences in clinical outcomes between nonvalvular AF and AFL., Methods and Results: AF and AFL patients without any prescribed anticoagulation were enrolled from a 13-year national cohort database. Under series exclusion criteria, ischemic stroke, heart failure hospitalization, and all-cause mortality were compared between the groups in real-world conditions and after propensity score matching. We identified 175 420 patients in the AF cohort and 6239 patients in the AFL cohort, and the prevalence of most comorbidities and frequency of medications were significantly higher in the AF group than the AFL group. In the real-world setting the AF patients had higher incidence rates of ischemic stroke, heart failure hospitalization, and all-cause mortality than the AFL patients (all P <0.001). After propensity score matching, the incidence rate of ischemic stroke in the AF cohort was 1.63-fold higher than in the AFL cohort ( P <0.001), the incidence rate of heart failure hospitalization in the AF cohort was 1.70-fold higher than in the AFL cohort ( P <0.001), and the incidence rate of all-cause mortality in the AF cohort was 1.08-fold higher than in the AFL cohort ( P =0.002)., Conclusions: There were differences between AF and AFL in comorbidities and prognosis with regard to ischemic stroke, heart failure hospitalization, and all-cause mortality., (© 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.)

Background: Atrial fibrillation (AF) is the most common clinically significant arrhythmia in adults and a major risk factor for ischemic stroke. Nonetheless, previous research suggests that many individuals diagnosed with AF lack awareness about their diagnosis and inadequate health literacy may be an important contributing factor to this finding., Methods and Results: We examined the association between health literacy and awareness of an AF diagnosis in a large, ethnically diverse cohort of Kaiser Permanente Northern and Southern California adults diagnosed with AF between January 1, 2006 and June 30, 2009. Using self-reported questionnaire data completed between May 1, 2010 and September 30, 2010, awareness of an AF diagnosis was evaluated using the question "Have you ever been told by a doctor or other health professional that you have a heart rhythm problem called atrial fibrillation or atrial flutter?" and health literacy was assessed using a validated 3-item instrument examining problems because of reading, understanding, and filling out medical forms. Of the 12 517 patients diagnosed with AF, 14.5% were not aware of their AF diagnosis and 20.4% had inadequate health literacy. Patients with inadequate health literacy were less likely to be aware of their AF diagnosis compared with patients with adequate health literacy (prevalence ratio=0.96; 95% CI [0.94, 0.98]), adjusting for sociodemographics, health behaviors, and clinical characteristics., Conclusions: Lower health literacy is independently associated with less awareness of AF diagnosis. Strategies designed to increase patient awareness of AF and its complications are warranted among individuals with limited health literacy., (© 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.)

We report a 55-year-old man who experienced proximal muscle weakness accompanied by the atrial flutter (AFL) with 1:1 conduction. Detailed examination revealed elevated antimitochondrial antibodies (AMA) and creatine kinase (CK). AFL was converted to sinus rhythm by cardioversion. He was diagnosed as AMA-positive myositis-associated AFL and was treated by prednisolone. Although his muscle weakness and CK level improved, AFL with 1:1 conduction reappeared. Therefore, radiofrequency catheter ablation (RFCA) was needed to treat the AFL, resulting in maintenance of sinus rhythm. This case report describes cardiac involvement in a patient with AMA-positive myositis., (2017 BMJ Publishing Group Ltd.)

Background: Several different defibrillators are currently used for cardioversion and defibrillation of cardiac arrhythmias. The efficacy of a novel pulsed biphasic (PB) waveform has not been compared to other biphasic waveforms. Accordingly, this study aims to compare the efficacy and safety of PB shocks with biphasic truncated exponential (BTE) shocks in patients undergoing cardioversion of atrial fibrillation or -flutter., Methods and Results: This prospective, randomized study included patients admitted for elective direct current cardioversion. Patients were randomized to receive cardioversion using either PB or BTE shocks. We used escalating shocks until sinus rhythm was obtained or to a maximum of 4 shocks. Patients randomized to PB shocks received 90, 120, 150, and 200 J and patients randomized to BTE shocks received 100, 150, 200, and 250 J, as recommended by the manufacturers. In total, 69 patients (51%) received PB shocks and 65 patients (49%) BTE shocks. Successful cardioversion, defined as sinus rhythm 4 hours after cardioversion, was achieved in 43 patients (62%) using PB shocks and in 56 patients (86%) using BTE shocks; ratio 1.4 (95% CI 1.1-1.7) ( P =0.002). There was no difference in safety (ie, myocardial injury judged by changes in high-sensitive troponin I levels; ratio 1.1) (95% CI 1.0-1.3), P =0.15. The study was terminated prematurely because of an adverse event., Conclusions: Cardioversion using a BTE waveform was more effective when compared with a PB waveform. There was no difference in safety between the 2 waveforms, as judged by changes in troponin I levels., Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT02317029., (© 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.)