Should digoxin be proscribed in elderly subjects in sinus rhythm free from heart failure? A population-based study. Digoxin Use and Subsequent Outcomes Among Patients in a Contemporary Atrial Fibrillation Cohort. Spontaneous conversion and maintenance of sinus rhythm by amiodarone in patients with heart failure and atrial fibrillation: observations from the veterans affairs congestive heart failure survival trial of antiarrhythmic therapy (CHF-STAT). The Department of Veterans Affairs CHF-STAT Investigators. Relation of digoxin use in atrial fibrillation and the risk of all-cause mortality in patients ≥65 years of age with versus without heart failure. Quality of life and functional capacity in patients with atrial fibrillation and congestive heart failure. Maintenance of sinus rhythm and survival in patients with heart failure and atrial fibrillation. Catheter ablation in selected patients with depressed left ventricular ejection fraction and persistent atrial fibrillation unresponsive to current cardioversion. Atrial fibrillation and risk of clinical events in chronic heart failure with and without left ventricular systolic dysfunction: results from the Candesartan in Heart failure-Assessment of Reduction in Mortality and morbidity (CHARM) program. The association between atrial fibrillation and sudden cardiac death: the relevance of heart failure. Digoxin use and risk of mortality in hypertensive patients with atrial fibrillation Sinus rhythm restoration by catheter ablation in patients with long-lasting atrial fibrillation and congestive heart failure: impact of the left ventricular ejection fraction improvement on the implantable cardioverter defibrillator insertion indication. Digoxin in atrial fibrillation: report from the Stockholm Cohort study of Atrial Fibrillation (SCAF) Lack of evidence of increased mortality among patients with atrial fibrillation taking digoxin: findings from post hoc propensity-matched analysis of the AFFIRM trial. Predictors, prevention, and long-term prognosis of atrial fibrillation after coronary artery bypass graft operations. Digoxin in patients with permanent atrial fibrillation: data from the RACE II study. Electrical Remodeling of the Atria in Congestive Heart Failure: Electrophysiological and Electroanatomic Mapping in Humans Prevention of atrial fibrillation in patients with symptomatic chronic heart failure by candesartan in the Candesartan in Heart failure: Assessment of Reduction in Mortality and morbidity (CHARM) program. Dofetilide in patients with congestive heart failure and left ventricular dysfunction: safety aspects and effect on atrial fibrillation. The Danish Investigators of Arrhythmia and Mortality on Dofetilide (DIAMOND) Study Group. Rate control versus rhythm control for patients with persistent atrial fibrillation with mild to moderate heart failure: results from the RAte Control versus Electrical cardioversion (RACE) study. A controlled trial of digoxin in congestive heart failure. Women hospitalized with atrial fibrillation: gender differences, trends and outcome from a 20-year registry in a Middle Eastern country (1991-2010). Predictors of congestive heart failure in the elderly: the Cardiovascular Health Study. Pulmonary vein vestibule ablation for the control of atrial fibrillation in patients with impaired left ventricular function.
Increased mortality in digoxin-treated subjects has been demonstrated in patients with recent myocardial infa rct ion . Those with congestive heart failure ( CHF ) due to causes other than myocardial infa rct ion seem to be free from this effect . No information is currently available concerning mortality in elderly people who are frequently prescribed digitalis even in the absence of CHF . The aim of this study was to investigate whether subjects improperly receiving digoxin were worse off than those not receiving this drug . This analysis is a part of CASTEL , a population -based prospect i ve study that has enrolled a cohort of 2,254 subjects aged > or = 65 years . CHF was diagnosed in 187 subjects and atrial fibrillation ( AF ) in 90 . The remaining 1,977 were free from CHF and in sinus rhythm , but 447 were treated with digitalis .  Cumulative mortality and morbid events by digitalis treatment were calculated in all these categories . Among subjects free from CHF and AF ( improper use ) , all-cause and cardiovascular mortality was significantly higher among those taking digitalis than in those who did not . Non-fatal events including CHF were also more apparent in the former than in the latter . Cox analysis confirmed digitalis as a predictor of mortality in these subjects . No effect of digitalis on survival was found in patients with CHF or AF ( proper use ) . In elderly subjects without atrial fibrillation or CHF , the use of digitalis worsens morbidity and mortality BACKGROUND Although digoxin has long been used to treat atrial fibrillation ( AF ) and heart failure ( HF ) , its safety remains controversial . OBJECTIVES This study sought to describe digoxin use over time in patients with AF who were stratified by the presence or absence of HF , to characterize the predictors of digoxin use and initiation , and to correlate digoxin use with outcomes . METHODS Longitudinal patterns of digoxin use and its association with a variety of outcomes were assessed in a prospect i ve outpatient registry conducted at 174 U.S. sites with enrollment from June 2010 to August 2011 . RESULTS Among 9,619 patients with AF and serial follow-up every 6 months for up to 3 years , 2,267 ( 23.6 % ) received digoxin at study enrollment , 681 ( 7.1 % ) were initiated on digoxin during follow-up , and 6,671 ( 69.4 % ) were never prescribed digoxin . After adjusting for other medications , heart rate was 72.9 beats/min among digoxin users and 71.5 beats/min among nonusers ( p < 0.0001 ) . Prevalent digoxin use at registry enrollment was not associated with subsequent onset of symptoms , hospitalization , or mortality ( in patients with HF , adjusted hazard ratio [ HR ] for death : 1.04 ; without HF , HR : 1.22 ) . Incident  digoxin  use during follow-up was not associated with subsequent death in patients with HF ( propensity adjusted HR : 1.05 ) , but was associated with subsequent death in those without HF ( propensity adjusted HR : 1.99 ) . CONCLUSIONS After adjustment for detailed clinical factors , digoxin use in registry patients with AF had a neutral association with outcomes under most circumstances . Because of the multiple conflicting observational reports about digoxin 's safety and possible concerns in specific clinical situations , a large pragmatic trial of digoxin therapy in AF is needed BACKGROUND In a multicenter , double-blind , placebo-controlled study , the long-term effects of amiodarone on morbidity and mortality in patients with congestive heart failure ( CHF ) and atrial fibrillation ( AF ) were evaluated during a 4-year period . METHODS AND RESULTS Of 667 patients with CHF , 103 ( 15 % ) had AF at baseline . Of these , 51 were r and omized to amiodarone and 52 to placebo . The group with sinus rhythm and the group in AF were comparable except for a higher proportion of AF in patients with nonischemic versus ischemic cardiomyopathy ( 41 % versus 27 % , P<0.005 ) . The mean ventricular response ( VR ) during AF over 24 hours was reduced by amiodarone at 2 weeks ( 20 % , P=0.001 ) , at 6 months ( 18 % , P=0.001 ) , and at 12 months ( 16 % , P=0.006 ) . Maximal VR was reduced 22 % ( P=0.001 ) at 2 weeks , 19 % ( P=0.001 ) at 6 months , and 14 % ( P=0.001 ) at 12 months . Sixteen of 51 patients on amiodarone and 4 of 52 on placebo converted to sinus rhythm during the study ( chi2=9.23 , P=0.002 ) . During follow-up , 11 of 268 patients in sinus rhythm on amiodarone at baseline and 22 of the 263 in sinus rhythm on placebo developed AF ; the difference was significant ( chi2=12.88 , P=0.005 ) . Analysis of total mortality during follow-up showed a significantly lower mortality rate ( P=0 . 04 ) in patients in AF at baseline who subsequently converted to sinus rhythm on amiodarone than in those who did not convert to sinus rhythm on the drug . CONCLUSIONS In patients with CHF , amiodarone has a significant potential to spontaneously convert patients in AF to sinus rhythm , with patients who convert having a lower mortality rate than those who do not . The drug prevented the development of new-onset AF and significantly reduced the VR in those with persistent AF Previous studies on digoxin use in patients with atrial fibrillation ( AF ) and the risk of all-cause mortality  found conflicting results . We conducted a population -based , retrospective , cohort study of patients aged ≥65 years admitted to a hospital with a primary or secondary diagnosis of AF , in Quebec province , Canada , from 1998 to 2012 . The AF cohort was grouped into patients with and without heart failure ( HF ) and into  digoxin and no-digoxin users according to the first prescription filled for digoxin within 30 days after AF hospital discharge . We derived propensity score-matched digoxin and no-digoxin treatment groups for the groups of patients with and without HF , respectively , and conducted multivariable Cox proportional hazards regression analyses to determine association between digoxin use and all-cause mortality . The AF propensity score-matched cohorts of patients with and without HF were well balanced on baseline characteristics . In the propensity score-matched HF group , digoxin use was associated with a 14 % greater risk of all-cause mortality ( adjusted hazard ratio 1.14 , 95 % confidence interval 1.10 to 1.17 ) . In the propensity score-matched no-HF group , digoxin use was associated with a 17 % greater risk of all-cause mortality ( adjusted hazard ratio 1.17 , 95 % confidence interval 1.14 to 1.19 ) . In conclusion , our retrospective analyses found that digoxin use was associated with a greater risk for all-cause mortality in patients aged ≥65 years with AF regardless of concomitant HF . Large , multicenter , r and omized controlled trials or prospect i ve cohort studies are required to clarify this issue OBJECTIVES This study sought to assess the impact of rhythm- versus rate-control treatment strategies and of underlying rhythm on quality of life and functional capacity in patients with atrial fibrillation ( AF ) and congestive heart failure ( CHF ) . BACKGROUND Although intention-to-treat and efficacy analyses have demonstrated similar cardiovascular outcomes in patients with AF and CHF r and omized to rhythm or rate control , effects on quality of life remain to be determined . METHODS The AF-CHF ( Atrial Fibrillation and Congestive Heart Failure ) trial r and omized 1,376 patients to rhythm- or rate-control strategies .  For this pre-specified sub study , Medical Outcomes Short Form-36 question naires were administered at baseline and 4 months . Six-min walk tests were conducted at baseline , 3 weeks , 4 months , and 1 year . RESULTS Quality of life improved across all domains to a similar extent with rhythm and rate control . However , a higher proportion of time spent in sinus rhythm was associated with a modestly greater improvement in quality of life scores . Six-min walk distance ( p = 0.2328 ) and New York Heart Association functional class ( p = 0.1712 ) improved to a similar degree with rhythm and rate control . A higher proportion of time spent in sinus rhythm was associated with a greater improvement in New York Heart Association functional class ( p < 0.0001 ) but not in 6-min walk distance ( p = 0.1308 ) . CONCLUSIONS Improvements in quality of life and functional capacity were similar in patients with AF and CHF r and omized to rhythm- versus rate-control strategies . By contrast , sinus rhythm was associated with beneficial effects on New York Heart Association functional class and modest gains in quality of life . ( Atrial Fibrillation and Congestive Heart Failure [ AF-CHF ] ; NCT88597077 ) OBJECTIVES The goal of this study was to evaluate the relationship between the presence of sinus rhythm and outcomes in patients with a history of congestive heart failure ( CHF ) and atrial fibrillation ( AF ) . BACKGROUND The value of sinus rhythm maintenance in patients with AF and heart failure ( HF ) is uncertain . METHODS A total of 1,376 patients with AF , ejection fraction < or = 35 % , and heart failure symptoms were r and omized to a rhythm- or rate-control strategy .  Detailed efficacy analyses were used to evaluate the independent effects of treatment strategy and the presence of sinus rhythm on cardiovascular outcomes . RESULTS Overall , 445 ( 32 % ) patients died and 402 ( 29 % ) experienced worsening HF . The rhythm-control strategy was not predictive of cardiovascular mortality ( hazard ratio [ HR ] : 0.90 , 95 % confidence interval [ CI ] : 0.70 to 1.16 ; p = 0.41 ) , all-cause death ( HR : 0.86 , 95 % CI : 0.69 to 1.08 ; p = 0.19 ) , or worsening HF ( HR : 0.86 , 95 % CI : 0.68 to 1.10 ; p = 0.23 ) . In analyses devised to isolate the effect of underlying rhythm , sinus rhythm was not associated with cardiovascular mortality [ HR : 1.22 , 95 % CI : 0.80 to 1.87 ; p = 0.35 ) , total mortality [ HR : 1.11 , 95 % CI : 0.78 to 1.58 ; p = 0.57 ) , or worsening HF [ HR : 0.62 , 95 % CI : 0.37 to 1.02 ; p = 0.059 ) . CONCLUSIONS A rhythm-control strategy or the presence of sinus rhythm are not associated with better outcomes in patients with AF and CHF AIMS In congestive heart failure ( CHF ) patients with persistent atrial fibrillation ( AF ) , direct current cardioversion ( DCC ) may reveal participation of tachycardiamediated process to left ventricular ( LV ) dysfunction by restoring sinus rhythm ( SR ) . However , if DCC fails to restore SR , patients ' management remains challenging . The aim of the study was to assess the AF catheter ablation benefit in a selected group of CHF patients with LV ejection fraction ( LVEF ) < 40 % and persistent AF unresponsive to DCC , in whom a tachycardia-mediated process is thought to be predominant . METHODS AND RESULTS Between January 2008 and September 2011 , among 129 CHF patients with persistent AF referred to our institution , 34 ( 63.8 ± 9-year old , 24 men ) presented AF refractory to DCC with an estimated high likelihood of tachycardia-mediated LV dysfunction according to a specific set of criteria . These 34 patients underwent stepwise AF ablation and were closely followed up . After a mean 1.9 AF ablation procedures per patient and 17.6 ± 7 months after the last procedure , all patients were in SR . The New York Heart Association class improved from 2.8 ± 0.3 to 1 ± 0.2 ( P < 0.001 ) and the LVEF increased from 30.4 ± 6 to 54.6 ± 6 % ( P < 0.0001 ) after 3 - 6 months of SR , with a persistent benefit as long as the SR was maintained . CONCLUSION Atrial fibrillation catheter ablation in selected CHF patients with persistent AF refractory to DCC and without any other evidence for secondary LV dysfunction leads to a substantial LVEF improvement in the majority of them . However , redo procedures are frequent in order to achieve mid-term SR maintenance OBJECTIVES We assessed the risk of adverse cardiovascular ( CV ) outcomes associated with atrial fibrillation ( AF ) in the C and esartan in Heart failure- Assessment of Reduction in Mortality and morbidity ( CHARM ) program , which enrolled patients with chronic heart failure ( CHF ) and a broad range of ejection fractions ( EFs ) . BACKGROUND Atrial fibrillation is associated with an increased risk of adverse CV outcomes in patients with CHF and reduced EF . The risk of AF in patients with CHF and preserved left ventricular ejection fraction ( PEF ) is unknown . METHODS A total of 7,599 patients with symptomatic CHF were r and omized to c and esartan or placebo . Patients were divided by baseline EF ( < or = 40 % or > 40 % ) in low or preserved EF groups . Major outcomes were cardiovascular death or hospitalization for worsening heart failure , and all-cause mortality . Median follow-up was 37.7 months . RESULTS A total of 670 ( 17 % ) patients in the low EF group and 478 ( 19 % ) in the PEF group had AF at baseline . Atrial fibrillation predicted a high risk of cardiovascular morbidity and mortality regardless of baseline EF . Patients with AF and low EF had the highest absolute risk for adverse CV outcomes . However , AF was associated with greater relative increased risk of the major outcomes in patients with PEF than in patients with low EF : hazard ratio 1.72 ( 95 % confidence interval [ CI ] 1.45 to 2.06 ) versus 1.29 ( 95 % CI 1.14 to 1.46 ) , respectively . The same was true for the risk of all-cause mortality . C and esartan was associated with similar treatment effects regardless of baseline rhythm . CONCLUSIONS Atrial fibrillation is associated with an increased risk of CV outcomes in patients with CHF and either reduced EF or PEF . C and esartan improved outcomes similarly regardless of baseline rhythm OBJECTIVES The purpose of this study was to evaluate the role of congestive heart failure ( CHF ) in the association between  atrial fibrillation ( AF ) and sudden cardiac death ( SCD ) .  BACKGROUND Recent studies have reported the possibility of an independent association between AF and SCD . We hypothesized that a history of CHF is a significant confounder of this association . METHODS In a prospect i ve case-control analysis from the community ( The Oregon-SUDS [ Sudden Unexpected Death Study ] , 2002 to 2012 ) , SCD cases ( n = 652 ) with clinical records available ( including electrocardiography and /or echocardiography ) were compared with age- and sex-matched control patients with coronary artery disease . The association between AF and SCD was analyzed using multivariable logistic regression and propensity score matching . RESULTS Cases ( age 67.3 ± 11.7 years , 65 % male ) were more likely than control patients ( age 67.2 ± 11.4 years , 65 % male ) to have a history of AF ( p = 0.0001 ) , myocardial infa rct ion ( p = 0.007 ) , CHF ( p < 0.0001 ) , stroke ( p < 0.0001 ) , and diabetes ( p < 0.0001 ) . In multivariate analysis without considering CHF , AF was a significant predictor of SCD ( odds ratio [ OR ] : 1.6 ; 95 % confidence interval [ CI ] : 1.2 to 2.0 ; p = 0.002 ) . However , in a model that included CHF , the AF-SCD association was no longer significant ( OR : 1.1 ; 95 % CI : 0.8 to 1.5 ; p = 0.45 ) , whereas CHF was a significant predictor of SCD ( OR : 3.1 ; 95 % CI : 2.4 to 4.1 ; p < 0.0001 ) . Results on the basis of propensity score matching were consistent . CONCLUSIONS Our findings suggest that a history of CHF , including both systolic and diastolic symptomatic dysfunction , may partially explain the AF-SCD association Background : Digoxin is widely used for rate control of atrial fibrillation . However , recent studies have reported conflicting results on the association of digoxin with mortality when used in patients with atrial fibrillation . Moreover , the relationship of digoxin use to mortality in hypertensive patients with atrial fibrillation has not been examined . Methods and results : All-cause mortality was examined in relation to in-treatment digoxin use in 937 hypertensive patients with ECG left ventricular hypertrophy in atrial fibrillation at baseline ( n = 134 ) or who developed atrial fibrillation during follow-up ( n = 803 ) , r and omly assigned to losartan or atenolol-based treatment , in post-hoc analysis of a sub study of the Losartan  Intervention For Endpoint Reduction in hypertension ( LIFE ) trial . During 4.7 ± 1.1 years of mean follow-up , 167 patients died ( 17.8 % ) and 372 ( 39.7 % ) were treated with digoxin . In univariate Cox analyses , in-treatment digoxin use , entered as a time-varying covariate , was associated with a 61 % higher risk of dying ( hazard ratio 1.61 , 95 % confidence interval 1.18–2.19 , P = 0.003 ) . After adjusting for other univariate predictors of death in this population , including age , diabetes , history of ischemic heart disease , stroke , or heart failure , baseline Cornell product , QRS duration , heart rate , serum glucose , creatinine and high-density lipoprotein cholesterol , and a propensity score for digoxin use entered as st and ard covariates , and for in-treatment heart rate , pulse pressure , and Sokolow – Lyon voltage treated as time-varying covariates , digoxin use was no longer a significant predictor of mortality ( hazard ratio 1.04 , 95 % confidence interval 0.73–1.48 , P = 0.839 ) . Conclusion : In hypertensive patients with ECG left ventricular hypertrophy with existing or new atrial fibrillation , digoxin use is not associated with a significantly increased risk of all-cause mortality after adjusting for other independent predictors of death and for the factors associated with the propensity to use digoxin in this population . These findings suggest that factors other than digoxin use may account for the increased mortality found with digoxin use in some studies . Clinical Trials Registration : http:// clinical AIMS In the setting of congestive heart failure ( CHF ) , atrial fibrillation ( AF ) ablation can improve clinical status and the left ventricular ejection fraction ( LVEF ) value . However , the impact of AF ablation on the implantable cardioverter defibrillator ( ICD ) indication has never been specifically addressed . METHODS AND RESULTS Study subject were six CHF ( mean age 61.1 + /- 6.9 years , mean LVEF 25.8 + /- 7.3 % ) patients refractory to conventional medical treatment with long-lasting AF unresponsive to external cardioversion . Five patients had an idiopathic dilated cardiomyopathy ( DCM ) and one had an ischaemic cardiomyopathy ( ICM ) . Their New York Heart Association ( NYHA ) class was III-IV . Two patients had renal insufficiency . No patient had left ventricular delay . All patients underwent AF ablation .  LVEF and NYHA class were dramatically improved in the five DCM patients . New York Heart Association class , but not the LVEF , was improved in the ICM patient . A redo ablative procedure was undertaken in four of five DCM patients and in the ICM patient due to arrhythmia recurrence . Left ventricular ejection fraction and NYHA were improved again in the DCM patients ( 56 + /- 4.4 % , I-II , respectively ) and led to ICD indication preclusion . The LVEF remained low in the ICM patient ( 30 % ) and led to ICD insertion . Sinus rhythm has been stable during the 18.1 + /- 5.7 months follow-up period . CONCLUSION  Atrial fibrillation ablation in CHF patients can improve both the clinical status of patients and their LVEF , especially among those affected by DCM . The LVEF improvement has the potential to preclude the indication for a primary prevention ICD insertion Background Recent studies of patients with heart failure and of patients receiving intensive care indicate that digoxin may increase mortality if the patient has atrial fibrillation ( AF ) . Objective To study which patients receive  digoxin treatment for AF and what the prognosis is for patients given this treatment . Method 2824 patients with AF were studied prospect ively for a mean of 4.6 years . Information about medication was obtained from the local hospital registry . Information about diagnoses , hospitalisations and deaths was obtained from national registries . Propensity score matching and Cox regression was used to account for confounding . Results Factors associated with digoxin use were permanent AF ( hazard ratio ( HR ) = 3.2 , confidence interval ( CI ) 2.7 to 3.9 ) , absence of pacemaker ( HR = 2.3 , CI 1.6 to 3.2 ) , history of heart failure ( HR = 2.0 , CI 1.7 to 2.5 ) , treatment in an internal medicine ward rather than a cardiology ward ( HR = 1.6 , CI 1.3 to 2.0 ) , female sex ( HR = 1.6 , CI 1.3 to 1.9 ) and age ≥80 years ( HR = 1.4 , CI 1.1 to 1.7 ) . More patients with than without digoxin died ( 51 % vs 31 % , p<0.001 ) . After adjustment for covariates , however , no disadvantages related to digoxin use could be found for all-cause mortality , myocardial infa rct ion , ischaemic stroke , time to readmission to hospital or days at hospital/year at risk . The only end point significantly associated with digoxin use was pacemaker implantations , which were more common in digoxin-treated patients ( HR = 2.0 , CI 1.2 to 3.4 ) . Conclusion Digoxin is mainly given to an elderly and frailer subset of patients with AF and is thus associated with an increased mortality . When differences in patient characteristics are accounted for digoxin use seems to have a neutral effect on mortality and major cardiovascular events in patients with AF AIMS Digoxin is recommended for long-term rate control in paroxysmal , persistent , and permanent atrial fibrillation ( AF ) . While some analyses suggest an association of digoxin with a higher mortality in AF , the intrinsic nature of this association has not been examined in propensity-matched cohorts , which is the objective of the current study . METHODS AND RESULTS In Atrial Fibrillation Follow-up Investigation of Rhythm Management ( AFFIRM ) , 4060 patients with paroxysmal and persistent AF were r and omized to rate ( n = 2027 ) vs. rhythm ( n = 2033 ) control strategies . Of these , 1377 received digoxin as initial therapy and 1329 received no digoxin at baseline . Propensity scores for digoxin use were estimated for each of these 2706 patients and used to assemble a cohort of 878 pairs of patients receiving and not receiving digoxin , who were balanced on 59 baseline characteristics . Matched patients had a mean age of 70 years , 40 % were women , and 11 % non-white . During the 3.4 years of the mean follow-up , all-cause mortality occurred in 14 and 13 % of matched patients receiving and not receiving digoxin , respectively [ hazard ratio ( HR ) associated with digoxin use : 1.06 ; 95 % confidence interval ( CI ) : 0.83 - 1.37 ; P = 0.640 ] . Among matched patients , digoxin had no association with all-cause hospitalization ( HR : 0.96 ; 95 % CI : 0.85 - 1.09 ; P = 0.510 ) or incident non-fatal cardiac arrhythmias ( HR : 0.90 ; 95 % CI : 0.37 - 2.23 ; P = 0.827 ) . Digoxin had no multivariable-adjusted or propensity score-adjusted associations with these outcomes in the pre-match cohort . CONCLUSIONS In patients with paroxysmal and persistent AF , we found no evidence of increased mortality or hospitalization in those taking digoxin as baseline initial therapy Multiple trials have suggested the use of digoxin , digoxin and propranolol , or timolol to prevent atrial fibrillation after coronary artery bypass grafting . No trial has evaluated the efficacy of digoxin verus propranolol . Furthermore , the predictors of postoperative atrial fibrillation and the long-term consequence of atrial fibrillation that reverts to sinus rhythm have not been established . One hundred fifty patients were r and omized to receive no drug , propranolol ( 20 mg every 6 hours ) , or digoxin ( 0.5 mg followed by 0.25 mg daily ) . Twenty-seven patients were excluded from data analysis . In the remaining 123 patients , no preoperative parameter ( age , sex , diabetes , hypertension , smoking , electrocardiographic p wave morphology , or preoperative digoxin or propranolol therapy ) , intraoperative parameter ( bypass time , aortic cross-clamp time , or number of vessels bypassed ) , or postoperative parameter ( peak creatinine kinase , congestive heart failure , or pericarditis ) by univariate or multivariate analysis predicted patients at risk for atrial fibrillation . Sustained atrial fibrillation developed in 37.5 % of control and 32.6 % of digoxin-treated patients . Only 16.2 % of propranolol-treated patients had sustained atrial fibrillation ( p less than 0.03 ) . There were no in-hospital complications in those patients with atrial fibrillation . After 26 + /- 7 months follow-up , those patients with postoperative atrial fibrillation had no increased incidence of angina , cerebral vascular accident , myocardial infa rct ion , or sudden death . Therefore , in this select population , propranolol prophylaxis is effective but discretionary BACKGROUND The Atrial Fibrillation Follow-up Investigation of Rhythm Management trial showed that digoxin was associated with increased mortality in patients with atrial fibrillation . OBJECTIVES To assess the association of digoxin with cardiovascular ( CV ) morbidity and mortality in patients with permanent atrial fibrillation enrolled in the Dutch Rate Control Efficacy in Permanent AF : A Comparison Between Lenient Versus Strict Rate Control II trial as well as to assess the role of digoxin to achieve heart rate targets . METHODS The primary outcome was a composite of CV morbidity and mortality . Secondary outcomes included CV hospitalization and all-cause mortality or heart failure ( HF ) hospitalization . Of the 614 patients , 608 ( 99 % ) completed the dose-adjustment phase . Outcome events were analyzed from the end of the dose-adjustment phase until the end of follow-up . The median follow-up period was 2.9 years ( interquartile range 2.7 - 3.0 years ) . RESULTS In total , 284 patients ( 46.7 % ) used digoxin after the dose-adjustment phase ( median dosage 0.250 mg ; interquartile range 0.0625 - 0.750 mg ) . These patients were more often women , previously admitted for HF , had an increased left ventricular end-systolic diameter , and more often r and omized to strict rate control . By using Cox proportional hazards regression analysis , the use of digoxin was not associated with an increased risk for the primary and secondary outcomes . For the primary outcome , the 3-year estimated cumulative incidence was 12.9 % vs 13.4 % in the digoxin group vs the no-digoxin group ( unadjusted hazard ratio [ HR ] 0.97 ; 95 % confidence interval [ CI ] 0.62 - 1.52 ) . Incidence was 19.4 % vs. 19.5 % for CV hospitalization ( unadjusted HR 1.00 ; 95 % CI 0.69 - 1.45 ) and 6.6 % vs. 9.9 % for all-cause mortality or HF hospitalization ( unadjusted HR 0.62 ; 95 % CI 0.34 - 1.13 ) in the digoxin group vs the no-digoxin group . CONCLUSION The use of digoxin was not associated with increased morbidity and mortality Background —Atrial  fibrillation ( AF ) frequently complicates congestive heart failure ( CHF ) . However , the electrophysiological substrate for AF in humans with CHF remains unknown . We evaluated the electrophysiological and electroanatomic characteristics of the atria in patients with CHF . Methods and Results —Twenty-one patients ( aged 53.7±13.6 years ) with symptomatic CHF ( left ventricular ejection fraction 25.5±6.0 % ) and 21 age-matched controls were studied . The following were evaluated : effective refractory periods ( ERPs ) from the high and low lateral right atrium ( LRA ) , high septal right atrium , and distal coronary sinus ( CS ) ; conduction time along the CS and LRA ; corrected sinus node recovery times ; P-wave duration ; and conduction at the crista terminalis . In a subset , electroanatomic mapping was performed to determine atrial activation , regional conduction velocity , double potentials , fractionated electrograms , regional voltage , and areas of electrical silence .  Patients with CHF demonstrated an increase in atrial ERP with no change in the heterogeneity of refractoriness , an increase of atrial conduction time along the LRA and the CS , prolongation of the P-wave duration and corrected sinus node recovery times , and greater number and duration of double potentials along the crista terminalis . Electroanatomic mapping demonstrated regional conduction slowing with a greater number of electrograms with fractionation or double potentials , associated with areas of low voltage and electrical silence ( scar ) . Patients with CHF demonstrated an increased propensity for AF with single extrastimuli , and induced AF was more often sustained . Conclusions —Atrial remodeling due to CHF is characterized by structural changes , abnormalities of conduction , sinus node dysfunction , and increased refractoriness . These abnormalities may be responsible in part for the increased propensity for AF in CHF BACKGROUND Atrial fibrillation ( AF ) is frequent in patients with chronic heart failure ( CHF ) . Experimental and small patient studies have demonstrated that blocking the renin-angiotensin-aldosterone system may prevent AF . In the CHARM program , the effects of the angiotensin receptor blocker c and esartan on cardiovascular mortality and morbidity were evaluated in a broad spectrum of patients with symptomatic CHF . CHARM provided the opportunity to prospect ively determine the effect of c and esartan on the incidence of new AF in this CHF population . METHODS 7601 patients with symptomatic CHF and reduced or preserved left ventricular systolic function were r and omized to c and esartan ( target dose 32 mg once daily , mean dose 24 mg ) or placebo in the 3 component trials of CHARM . The major outcomes were cardiovascular death or CHF hospitalization and all-cause mortality . The incidence of new AF was a prespecified secondary outcome . Median follow-up was 37.7 months . A conditional logistic regression model for stratified data was used . RESULTS 6379 patients ( 83.9 % ) did not have AF on their baseline electrocardiogram . Of these , 392 ( 6.15 % ) developed AF during follow-up , 177 ( 5.55 % ) in the c and esartan group and 215 ( 6.74 % ) in the placebo group ( odds ratio 0.812 , 95 % CI 0.662 - 0.998 , P = .048 ) . After adjustment for baseline covariates , the odds ratio was 0.802 ( 95 % CI 0.650 - 0.990 , P = .039 ) . There was no heterogeneity of the effects of c and esartan in preventing AF between the 3 component trials ( P = .57 ) . CONCLUSIONS Treatment with the angiotensin receptor blocker c and esartan reduced the incidence of AF in a large , broadly-based , population of patients with symptomatic CHF INTRODUCTION . Atrial fibrillation is a frequent cause of worsening of symptoms in patients with congestive heart failure . The drugs currently available for maintenance of sinus rhythm all have major side effects . METHODS . In 34 Danish coronary care units , 1518 patients with congestive heart failure and reduced left ventricular systolic function were r and omized to receive either placebo or a new class III antiarrhythmic drug , dofetilide . The dose of dofetilide was adjusted according to the presence of atrial fibrillation , the length of the QT interval , and renal function . Patients were continuously monitored electrocardiographically for the first 3 days of the study . The primary end point was all-cause mortality and follow-up was for at least 1 year . RESULTS . In the dofetilide/placebo groups , 311/317 patients  died ( 41%/42 % ) . The hazard ratio for dofetilide treatment was 0.95 ( 95 % confidence interval , 0.81 - 1.11 ) . Treatment with dofetilide reduced worsening of heart failure significantly ( hazard ratio , 0.75 ; 0.63 - 0.89 ) . After 1 year , 61 % of patients with atrial fibrillation at the start of the study had converted to sinus rhythm on dofetilide , vs. 33 % in the placebo group . After conversion to sinus rhythm , 78%/43 % of patients in the dofetilide/placebo groups remained in sinus rhythm for at least 1 year . There were 25 instances ( 3 % ) of torsade de pointes ventricular tachycardia in the dofetilide group and none in the placebo group . CONCLUSION . In patients with congestive heart failure , dofetilide can effectively convert atrial fibrillation to sinus rhythm and maintain sinus rhythm after conversion . Hospitalization for congestive heart failure is reduced . Dofetilide does not affect mortality . (c)2001 by CHF , BACKGROUND This study was conducted to compare rate- and rhythm-control therapy in patients with persistent atrial fibrillation ( AF ) and mild to moderate chronic heart failure ( CHF ) .  Rate control is not inferior to rhythm control in preventing mortality and morbidity in patients with AF . In CHF , this issue is still unsettled . METHODS In this predefined analysis of the RACE study , a total of 261 patients were in New York Heart Association ( NYHA ) classes II and III at baseline . These patients were analyzed . The primary end point was a composite of cardiovascular mortality , hospitalization for CHF , thromboembolic complications , bleeding , pacemaker implantation , and life-threatening drug side effects . Furthermore , quality of life was compared . RESULTS After 2.3 + /- 0.6 years , the primary end point occurred in 29 ( 22.3 % ) of the 130 rate-control patients and in 32 ( 24.4 % ) of the 131 rhythm-control patients . More cardiovascular deaths , hospitalization for CHF , and bleeding occurred under rate control . Thromboembolic complications , drug side effects , and pacemaker implantation were more frequent under rhythm control . Quality of life did not differ between strategies . In patients successfully treated with rhythm control , the prevalence of end points was not different from those who were in AF at study end . However , the type of end point was different : mortality , bleeding , hospitalization for heart failure , and pacemaker implantation occurred less frequently . CONCLUSIONS In patients with mild to moderate CHF , rate control is not inferior to rhythm control . However , if sinus rhythm can be maintained , outcome may be improved . A prospect i ve r and omized trial is necessary to confirm these results Because of conflicting results from studies examining the usefulness of digoxin in congestive heart failure ( CHF ) patients in sinus rhythm , a cross-over trial was conducted in which 20 patients received 7 weeks of digoxin titrated to a level of 1.54 to 2.56 nmol/liter and 7 weeks of matched placebo .  The order of treatments was determined by r and om allocation and patients , clinicians and research staff were blind to allocation . In patients with deteriorating condition , the treatment period was terminated and outcome measures were obtained . If deterioration occurred during the first period , the patient was crossed over without the code being broken . Seven patients required premature termination of study periods because of increasing symptoms of CHF .  All 7 were taking placebo at the time ( p = 0.016 ) . Small differences in dyspnea ( p = 0.044 ) , walking test score ( p = 0.055 ) , clinical assessment of CHF ( p = 0.036 ) and ejection fraction ( p = 0.004 ) favored the digoxin treatment group . Patients with more severe CHF were more likely to benefit from digoxin administration . It was concluded that oral digoxin , in doses titrated to produce a serum level of 1.54 to 2.56 nmol/liter , improved quality of life and functional exercise capacity in some patients with CHF in sinus rhythm BACKGROUND Most of the published research on atrial fibrillation ( AF ) is limited to studies in the developed world and included mainly Caucasian patients . Data about women with AF among other ethnicities is very limited . OBJECTIVES The aim of this study was to compare the clinical characteristics , treatment and outcome of women to men hospitalized with AF in a middle-eastern country . METHODS Retrospective analysis of prospect i ve registry of all patients hospitalized with AF in Qatar from 1991 through 2010 was made . Clinical characteristics , management , and outcomes of AF patients were compared according to gender . RESULTS During the 20-years period ; 1417 women and 2432 men were hospitalized for AF . Women were 5 years older and more likely to have diabetes mellitus , hypertension , and chronic renal impairment and were also less likely to be current smokers and to have ischemic heart disease and impaired left ventricular function when compared to men . There was no gender preference in the use of anticoagulation . The prevalence of concomitant ischemic heart disease and hypertension increased , while the prevalence of valvular heart disease and heart failure decreased among patients hospitalized with AF over the study period . In-hospital mortality and stroke rates were comparable between the two groups . CONCLUSIONS Women hospitalized with atrial fibrillation were older in age and had higher prevalence of co-morbid cardiovascular risk factors compared to men whereas , mortality and stroke rates were comparable OBJECTIVES We sought to characterize the predictors of incident congestive heart failure ( CHF ) , as determined by central adjudication , in a community-based elderly population . BACKGROUND The elderly constitute a growing proportion of patients admitted to the hospital with CHF , and CHF is a leading source of morbidity and mortality in this group . Elderly patients differ from younger individuals diagnosed with CHF in terms of biologic characteristics . METHODS We analyzed data from the Cardiovascular Health Study , a prospect i ve population -based study of 5,888 elderly people > 65 years old ( average 73 + /- 5 , range 65 to 100 ) at four locations . Multiple laboratory measures of cardiovascular structure and function , blood chemistries and functional assessment s were obtained . RESULTS During an average follow-up of 5.5 years ( median 6.3 ) , 597 participants developed incident CHF ( rate 19.3/1,000 person-years ) . The incidence of CHF increased progressively across age groups and was greater in men than in women . On multivariate analysis , other independent predictors included prevalent coronary heart disease , stroke or transient ischemic attack at baseline , diabetes , systolic blood pressure ( BP ) , forced expiratory volume 1 s , creatinine > 1.4 mg/dl , C-reactive protein , ankle-arm index < 0.9 , atrial fibrillation , electrocardiographic ( ECG ) left ventricular ( LV ) mass , ECG ST-T segment abnormality , internal carotid artery wall thickness and decreased LV systolic function . Population -attributable risk , determined from predictors of risk and prevalence , was relatively high for prevalent coronary heart disease ( 13.1 % ) , systolic BP > or = 140 mm Hg ( 12.8 % ) and a high level of C-reactive protein ( 9.7 % ) , but was low for subnormal LV function ( 4.1 % ) and atrial fibrillation ( 2.2 % ) . CONCLUSIONS The incidence of CHF is high in the elderly and is related mainly to age , gender , clinical and sub clinical coronary heart disease , systolic BP and inflammation . Despite the high relative risk of subnormal systolic LV function and atrial fibrillation , the actual population risk of these for CHF is small because of their relatively low prevalence in community-dwelling elderly people INTRODUCTION Congestive heart failure ( CHF ) and atrial fibrillation ( AF ) are frequently linked , and when associated produce additive deleterious effects . In this prospect i ve study , the effects of catheter ablation for AF  in patients with impaired left ventricular ( LV ) function are presented . METHODS Baseline data and clinical outcome have been prospect ively collected in 105 consecutive patients who underwent pulmonary vein ablation for the control of AF .  We evaluated 40 patients affected by LV dysfunction with ejection fraction (EF)<40 % and compared them to the remaining 65 patients with normal ventricular function in terms of changes in LV function , maintenance of sinus rhythm , and quality of life during follow-up . RESULTS After a mean follow-up of 14+/-2 months , 87 % of patients with impaired LV function and 92 % of patients with normal ventricular function were in sinus rhythm , with or without antiarrhythmic therapy ( P = NS ) . A significant improvement in LVEF and fractional shortening was documented in patients with CHF ( 33+/-2 % vs 47+/-3 % , and 19+/-4 % vs 30+/-3 % , P<0.01 for both comparisons ) . Evaluation of exercise capacity and quality of life documented better improvements in patients with CHF compared to patients without CHF . CONCLUSIONS Catheter ablation in patients with LV dysfunction is feasible , not associated with higher procedural complications , and provides a significant improvement in LV performance , symptoms , and quality of life during follow-up
The present systematic review and meta- analysis of all available data sources suggest that digoxin use is associated with an increased mortality risk , particularly among patients suffering from AF
There are conflicting data regarding the effect of digoxin use on mortality in patients with atrial fibrillation ( AF ) or with congestive heart failure ( CHF ) .
The aim of this meta- analysis was to provide detailed analysis of the currently available study reports .