Incidence and prognostic significance of atrial fibrillation in acute myocardial infarction: the GISSI-3 data Atrial fibrillation in patients with heart failure: Role of catheter ablation therapies. Catheter ablation for atrial fibrillation in congestive heart failure. Arrhythmia-provoking factors and symptoms at the onset of paroxysmal atrial fibrillation: A study based on interviews with 100 patients seeking hospital assistance Gender-related differences in catheter ablation of atrial fibrillation. Prevalence of atrial fibrillation in Spain. OFRECE study results. A single-center randomized, controlled trial investigating the efficacy of a mHealth ECG technology intervention to improve the detection of atrial fibrillation: the iHEART study protocol Arrhythmias after coronary bypass surgery. Asymptomatic or "silent" atrial fibrillation: frequency in untreated patients and patients receiving azimilide. Left Atrial Appendage: An Underrecognized Trigger Site of Atrial Fibrillation Management of Newly Detected Atrial Fibrillation: A Clinical Practice Guideline from the American Academy of Family Physicians and the American College of Physicians Comorbidity associated with atrial fibrillation: a general practice-based study. Unexpected low prevalence of atrial fibrillation in cryptogenic ischemic stroke: a prospective study Differences in Clinical and Functional Outcomes of Atrial Fibrillation in Women and Men: Two-Year Results From the ORBIT-AF Registry. Catheter Ablation for Atrial Fibrillation in Patients With Obesity [Efficacy of metoprolol in prevention of supraventricular arrhythmias after coronary artery bypass grafting]. A cross-sectional study of quality of life in an elderly population (75 years and over) with atrial fibrillation: secondary analysis of data from the Birmingham Atrial Fibrillation Treatment of the Aged study. A prospective evaluation of haemodynamics, functional status, and quality of life after radiofrequency catheter ablation of long-standing persistent atrial fibrillation. Radiofrequency Ablation of Atrial Fibrillation: Is the Persistence of All Intraprocedural Targets Necessary for Long-Term Maintenance of Sinus Rhythm? An evaluation of the strategy of maintenance of sinus rhythm by antiarrhythmic drug therapy after ablation and pacing therapy in patients with paroxysmal atrial fibrillation. Surgical vs. transcatheter pulmonary vein isolation as first invasive treatment in patients with atrial fibrillation: a matched group comparison. Comparison between anatomical and integrated approaches to atrial fibrillation ablation: adjunctive role of electrical pulmonary vein disconnection. Prevalence of atrial fibrillation and association of atrial fibrillation with prior and new thromboembolic stroke in older patients.
BACKGROUND Atrial fibrillation is the most common supraventricular arrhythmia in patients with acute myocardial infa rct ion . Recent advances in pharmacological treatment of myocardial infa rct ion may have changed the impact of this arrhythmia . OBJECTIVE To assess the incidence and prognosis of atrial fibrillation complicating myocardial infa rct ion in a large population of patients receiving optimal treatment , including angiotensin converting enzyme ( ACE ) inhibitors .  METHODS Data were derived from the GISSI-3 trial , which included 17 944 patients within the first 24 hours after acute myocardial infa rct ion . Atrial fibrillation was recorded during the hospital stay , and follow up visits were planned at six weeks and six months . Survival of the patients at four years was assessed through census offices . RESULTS The incidence of in-hospital atrial fibrillation or flutter was 7.8 % . Atrial fibrillation was associated with indicators of a worse prognosis ( age > 70 years , female sex , higher Killip class , previous myocardial infa rct ion , treated hypertension , high systolic blood pressure at entry , insulin dependent diabetes , signs or symptoms of heart failure ) and with some adverse clinical events ( reinfa rct ion , sustained ventricular tachycardia , ventricular fibrillation ) . After adjustment for other prognostic factors , atrial fibrillation remained an independent predictor of increased in-hospital mortality : 12.6%v 5 % , adjusted relative risk ( RR ) 1.98 , 95 % confidence interval ( CI ) 1.67 to 2.34 . Data on long term mortality ( four years after acute myocardial infa rct ion ) confirmed the persistent negative influence of atrial fibrillation ( RR 1.78 , 95 % CI 1.60 to 1.99 ) . CONCLUSIONS Atrial fibrillation is an indicator of worse prognosis after acute myocardial infa rct ion , both in the short term and in the long term , even in an unselected population Atrial fibrillation ( AF ) represents the most common sustained cardiac arrhythmia in patients with heart failure ( HF ) . AF in HF patients is associated with worsening of symptoms and also results in a substantial increase in mortality . Although HF patients in sinus rhythm have a better outcome than patients with AF , several r and omized studies investigating pharmacological rhythm control versus rate control have shown no advantage of one strategy over the other in terms of patient outcomes . Catheter-based ablation therapy is a newer therapeutic option with a rapidly evolving and changing role in the management of this arrhythmia . In the present review , the authors discuss the epidemiology , pathophysiology and prognostic significance of AF in patients with HF . Exclusively addressed are studies investigating catheter-based ablation for rhythm-control and rate-control therapies in the management of AF in HF patients BACKGROUND Congestive heart failure and atrial fibrillation often coexist , and each adversely affects the other with respect to management and prognosis . We prospect ively evaluated the effect of catheter ablation for atrial fibrillation on left ventricular function in patients with heart failure . METHODS We studied 58 consecutive patients with congestive heart failure and a left ventricular ejection fraction of less than 45 percent who were undergoing catheter ablation for atrial fibrillation .  We selected as controls 58 patients without congestive heart failure who were undergoing ablation for atrial fibrillation , matched according to age , sex , and classification of atrial fibrillation . We evaluated the patients ' left ventricular function and dimensions , symptom score , exercise capacity , and quality of life at baseline and at months 1 , 3 , 6 , and 12 . RESULTS After a mean ( + /-SD ) of 12+/-7 months , 78 percent of the patients with congestive heart failure and 84 percent of the controls remained in sinus rhythm ( P=0.34 ) ( 69 percent and 71 percent , respectively , were in sinus rhythm without the administration of antiarrhythmic drugs ) . The patients with congestive heart failure had significant improvement in left ventricular function ( increases in the ejection fraction and fractional shortening of 21+/-13 percent and 11+/-7 percent , respectively ; P<0.001 for both comparisons ) , left ventricular dimensions ( decreases in the diastolic and systolic diameters of 6+/-6 mm and 8+/-7 mm , respectively ; P=0.03 and P<0.001 , respectively ) , exercise capacity , symptoms , and quality of life . The ejection fraction improved significantly not only in patients without concurrent structural heart disease ( 24+/-10 percent , P<0.001 ) and those with inadequate rate control before ablation ( 23+/-10 percent , P<0.001 ) , but also in those with coexisting heart disease ( 16+/-14 percent , P<0.001 ) and adequate rate control before ablation ( 17+/-15 percent , P<0.001 ) . CONCLUSIONS Restoration and maintenance of sinus rhythm by catheter ablation without the use of drugs in patients with congestive heart failure and atrial fibrillation significantly improve cardiac function , symptoms , exercise capacity , and quality of life Background Surprisingly little information on symptoms of paroxysmal atrial fibrillation is available in scientific literature . Using question naires , we have analyzed the symptoms associated with arrhythmia attacks . Methods One hundred r and omly-selected patients with idiopathic paroxysmal atrial fibrillation filled in a structured question naire . Results Psychic stress was the most common factor triggering arrhythmia ( 54 % ) , followed by physical exertion ( 42 % ) , tiredness ( 41 % ) coffee ( 25 % ) and infections ( 22 % ) . Thirty-four patients cited alcohol , 26 in the form of red wine , 16 as white wine and 26 as spirits . Among these 34 , red wine and spirits produced significantly more episodes of arrhythmia than white wine ( p = 0.01 and 0.005 respectively).Symptoms during arrhythmia were palpitations while exerting ( 88 % ) , reduced physical ability ( 87 % ) , palpitations at rest ( 86 % ) , shortage of breath during exertion ( 70 % ) and anxiety ( 59 % ) . Significant differences between sexes were noted regarding swollen legs ( women 21 % , men 6 % , p = 0.027 ) , nausea ( women 36 % , men 13 % , p = 0.012 ) and anxiety ( females 79 % , males 51 % , p = 0.014 ) . Conclusion Psychic stress was the commonest triggering factor in hospitalized patients with paroxysmal atrial fibrillation .  Red wine and spirits were more proarrhythmic than white wine . Symptoms in women in connection with attacks of arrhythmia vary somewhat from those in men AIMS Women have an increased risk for atrial fibrillation (AF)-related complications and there is evidence towards a reduced efficacy of the rhythm control strategy than men . A catheter-based strategy is therefore widely attractive , but the impact of gender on catheter ablation ( CA ) of AF remains undefined . METHODS AND RESULTS We included 221 consecutive patients ( 150 men ) who underwent CA of drug-refractory AF .  Gender differences in clinical presentation and outcomes were compared . Women were older ( P = 0.002 ) , had a longer history of AF ( P = 0.04 ) , and were more likely to have hypertension ( P = 0.04 ) . Moreover , a concomitant valvular heart disease tended to be more common in women ( 32.4 vs. 23.3 % ; P = 0.28 ) and left atrium dimensions were significantly larger ( P = 0.003 ) . However , acute success rate and complications rate were similar between genders . After 22.5 + /- 11.8 months of follow-up , the overall freedom from arrhythmia recurrences was similar ( 83.1 vs. 82.7 % in men ) , and a similar improvement in SF-36 quality of life scores was achieved in both groups . CONCLUSION Women are referred for AF ablation later with a more complex clinical pre-operative presentation . Despite this higher risk profile in women , no differences were detected in clinical outcomes . Our findings indicate that CA of AF appears to be safe and effective in women as in men INTRODUCTION AND OBJECTIVES Atrial fibrillation is associated with substantial morbidity and mortality and both its incidence and prevalence are high . Nevertheless , comprehensive data on this condition in Spain are lacking . The aim of this study was to estimate the prevalence of atrial fibrillation in Spain . METHODS A cross-sectional study was conducted in the general Spanish population older than 40 years . Two-stage r and om sampling was used , in which first-stage units were primary care physicians r and omly selected in every Spanish province and second-stage units were 20 r and omly selected persons drawn from each participating physician 's assigned population . The reported prevalence was st and ardized for the age and sex distribution of the Spanish population . The  electrocardiogram recordings  were read central ly . RESULTS Overall , 8343 individuals were evaluated . The mean age was 59.2 years ( 95 % confidence interval , 58.6 - 59.8 years ) , and 52.4 % of the participants were female . The overall age-adjusted prevalence of atrial fibrillation was 4.4 % ( 95 % confidence interval , 3.8 - 5.1 ) . Prevalence was similar in both sexes , men 4.4 % ( 3.6 - 5.2 ) and women 4.5 % ( 3.6 - 5.3 ) , rising with increasing age older than 60 years . In patients older than 80 years , the prevalence was 17.7 % ( 14.1 - 21.3 ) . In 10 % of patients an unknown atrial fibrillation was diagnosed . CONCLUSIONS The prevalence of atrial fibrillation in the general Spanish population older than 40 years is high , at 4.4 % . The prevalence is similar in both sexes and rises steeply above 60 years of age . It is estimated that there are over 1 million patients with atrial fibrillation in the Spanish population , of whom over 90,000 are undiagnosed Background Atrial fibrillation is a major public health problem and is the most common cardiac arrhythmia , affecting an estimated 2.7 million Americans . The true prevalence of atrial fibrillation is likely underestimated because episodes are often sporadic ; therefore , it is challenging to detect and record an occurrence in a “ real world ” setting . To date , mobile health tools that promote earlier detection and treatment of atrial fibrillation and improvement in self-management behaviors and knowledge have not been evaluated . This study will be the first to address the epidemic problem of atrial fibrillation with a novel approach utilizing advancements in mobile health electrocardiogram technology to empower patients to actively engage in their healthcare and to evaluate impact on quality of life and quality -adjusted life years . Furthermore , sending a daily electrocardiogram transmission , coupled with receiving educational and motivational text messages aim ed at promoting self-management and a healthy lifestyle may improve the management of chronic cardiovascular conditions ( e.g. , hypertension , diabetes , heart failure , etc . ) . Therefore , we are currently conducting a r and omized controlled trial to assess the efficacy of a mobile health intervention , iPhone ® Helping Evaluate Atrial fibrillation Rhythm through Technology ( iHEART ) versus usual cardiac care . Methods The iHEART study is a single center , prospect i ve , r and omized controlled trial . A total of 300 participants with a recent history of atrial fibrillation will be enrolled . Participants will be r and omized 1:1 to receive the iHEART intervention , receiving an iPhone ® equipped with an AliveCor ® Mobile ECG and accompanying Kardia application and behavioral altering motivational text messages or usual cardiac care for 6 months . Discussion This will be the first study to investigate the utility of a mobile health intervention in a “ real world ” setting . We will evaluate the ability of the iHEART intervention to improve the detection and treatment of recurrent atrial fibrillation and assess the intervention 's impact on improving clinical outcomes , quality of life , quality -adjusted life-years and disease-specific knowledge . Trial registration NCT02731326 ; Verified April Ninety patients undergoing coronary bypass surgery were studied prospect ively by bedside and subsequent ambulatory electrocardiographic monitoring to investigate the incidence , possible causes , and prevention of atrial fibrillation . Patients with good left ventricular function were divided r and omly into a control group or groups treated with digoxin or propranolol . In the control group the incidence of atrial fibrillation was 27 % and of significant ventricular extrasystoles 3 % . Propranolol reduced the incidence of atrial fibrillation ( 14.8 % ) , whereas digoxin had no effect and increased the incidence of ventricular extrasystoles . Age , sex , severity of symptoms , cardiomegaly , heart failure , previous myocardial infa rct ion , and number of grafts did not affect the result . The operative myocardial ischaemic time was related to the occurrence of atrial fibrillation . There was also a significant relation between atrial fibrillation and bundle branch block . Atrial fibrillation is common after coronary artery grafting ; it may be due to diffuse myocardial ischaemia or hypothermic injury . The incidence may be reduced by beta blockade BACKGROUND Asymptomatic , or " silent " atrial fibrillation could increase the risk of stroke . Little is known about the frequency of asymptomatic atrial fibrillation in patients who also have symptomatic atrial fibrillation ; similarly , little is known about the effect of antiarrhythmic drug therapy on asymptomatic atrial fibrillation . METHODS AND RESULTS Patients in sinus rhythm with a history of symptomatic atrial fibrillation or atrial flutter received placebo or azimilide ( 35 to 125 mg ) once daily for 6 or 9 months in 4 similar double-blind trials . The end point was the first recurrence of a symptomatic ECG-documented supraventricular arrhythmia . Routine transtelephonic electrocardiograms , in the absence of symptoms , were recorded for 30 seconds every 2 weeks until patients completed follow-up or documented a symptomatic supraventricular arrhythmia . Of the 1380 patients , 489 received placebo .  Among these patients receiving placebo , 303 transmitted at least one routine ECG while asymptomatic . Asymptomatic atrial fibrillation was recorded in 50 ( 17 % ) within 6 months and before recurrence of symptomatic supraventricular arrhythmia . In the 3 trials evaluating azimilide in therapeutic doses ( 100 and 125 mg ) , asymptomatic atrial fibrillation occurred in 49 of 382 ( 13 % ) receiving azimilide and 43 of 233 ( 18 % ) receiving placebo . Although drug effect on time to first asymptomatic event was not statistically significant ( hazard ratio , 0.70 ; P=0.09 ) , there was a 40 % reduction in asymptomatic atrial fibrillation on azimilide compared with placebo ( P=0.03 ) when repeated observations were considered . CONCLUSIONS Asymptomatic atrial fibrillation is common in untreated patients with a history of symptomatic atrial fibrillation ( and is likely underestimated by this analysis ) . Azimilide may reduce the occurrence of this silent arrhythmia Background — Together with pulmonary veins , many extrapulmonary vein areas may be the source of initiation and maintenance of atrial fibrillation . The left atrial appendage ( LAA ) is an underestimated site of initiation of atrial fibrillation . Here , we report the prevalence of triggers from the LAA and the best strategy for successful ablation . Methods and Results — Nine hundred eighty-seven consecutive patients ( 29 % paroxysmal , 71 % nonparoxysmal ) undergoing redo catheter ablation for atrial fibrillation were enrolled . Two hundred sixty-six patients ( 27 % ) showed firing from the LAA and became the study population . In 86 of 987 patients ( 8.7 % ; 5 paroxysmal , 81 nonparoxysmal ) , the LAA was found to be the only source of arrhythmia with no pulmonary veins or other extrapulmonary vein site reconnection . Ablation was performed either with focal lesion ( n=56 ; group 2 ) or to achieve LAA isolation by placement of the circular catheter at the ostium of the LAA guided by intracardiac echocardiography ( 167 patients ; group 3 ) . In the remaining patients , LAA firing was not ablated ( n=43 ; group 1 ) . At the 12±3-month follow-up , 32 patients ( 74 % ) in group 1 had recurrence compared with 38 ( 68 % ) in group 2 and 25 ( 15 % ) in group 3 ( P<0.001 ) . Conclusions — The LAA appears to be responsible for arrhythmias in 27 % of patients presenting for repeat procedures . Isolation of the LAA could achieve freedom from atrial fibrillation in patients presenting for a repeat procedure when arrhythmias initiating from this structure are demonstrated Atrial fibrillation is the most common type of arrhythmia in adults . It is more common as patients age ; the prevalence is 1 % among those younger than age 60 years and increases to more than 8 % in those older than age 80 years . When data are adjusted for age , men are affected more often than women . Cardiac conditions associated with the development of atrial fibrillation are hypertension , rheumatic mitral valve disease , coronary artery disease , and congestive heart failure . Noncardiac causes include hyperthyroidism , hypoxic pulmonary conditions , surgery , and alcohol intoxication . Patients with atrial fibrillation may have symptoms of hemodynamic compromise , such as irregular palpitations and lightheadedness , or more vague symptoms , such as malaise , but may be asymptomatic . Patients with atrial fibrillation are at increased risk for thromboembolic disease . The purpose of this guideline is to make recommendations on the pharmacologic management of newly detected atrial fibrillation in primary care . The target patient population is adult patients with first-detected atrial fibrillation , defined as the presence of symptoms or electrocardiographic evidence of atrial fibrillation . The American College of Cardiology/American Heart Association has recommended using first-detected atrial fibrillation regardless of whether it is symptomatic or self-limited , recognizing that there can be uncertainty about the duration of the episode and about previous undetected episodes ( 1 ) . This guideline does not apply to patients with postoperative or postmyocardial infa rct ion atrial fibrillation , patients with class IV heart failure , patients already taking antiarrhythmic drugs , or patients with valvular disease . The target physician audience is internists and family physicians dedicated to primary care . This guideline is based on the accompanying background paper by McNamara and colleagues ( 2 ) and on the evidence report Management of New-Onset Atrial Fibrillation ( 3 ) , which was produced by the Johns Hopkins Evidence -based Practice Center under contract to the Agency for Healthcare Research and Quality ( AHRQ ) , Rockville , Maryl and . The American Academy of Family Physicians ( AAFP ) and the American College of Physicians ( ACP ) created this guideline in collaboration . The Joint AAFP/ACP Panel review ed the evidence and developed and grade d the recommendations ( Table 1 ) . The guideline was then approved by both organizations . The guideline makes recommendations in the following areas : rate control versus rhythm control , stroke prevention and anticoagulation , electrical cardioversion versus pharmacologic cardioversion , the role of transesophageal echocardiography in guiding therapy , and maintenance therapy . Table 1 . The Guyatt Approach to Grading Recommendations * Section 1 : Rate Control versus Rhythm Control One of the fundamental questions in the management of atrial fibrillation is whether to attempt cardioversion . The answer to this question depends on whether rate control or rhythm control provides more effective protection from thromboembolic events , improved mortality , better relief of symptoms , or improved quality of life . Another significant clinical question is whether certain population s , such as women , patients with hypertension or congestive heart failure , or young people with structurally healthy hearts , have better outcomes with one or the other strategy . Four studies have compared rate control with rhythm control . The study sample s have generally involved older patients ( > 65 years of age ) , and women and younger patients with healthy hearts and paroxysmal atrial fibrillation have not been well represented ( 5 ) . The Atrial Fibrillation Follow-up Investigation of Rhythm Management ( AFFIRM ) trial compared rhythm control versus rate control , and use of anticoagulation was recommended in both arms ( 6 ) . More than 4000 patients who were at least 65 years of age or who had at least 1 risk factor for stroke or death , such as hypertension , diabetes , previous stroke , or poor ventricular function , were followed for a mean of 3.5 years . Slightly more than one third of the patients were enrolled after their first episode of atrial fibrillation , and more than 90 % had had their qualifying episode within the previous 6 weeks . In more than two thirds of patients , the qualifying episode lasted at least 2 days . The average patient age was 70 years . Sixty-one percent of patients were men , and 89 % were white . Seventy-one percent of patients had hypertension , 38 % had coronary heart disease , 18 % had previously had failure of antiarrhythmic therapy , and 12 % had no apparent heart disease ( lone atrial fibrillation ) . Patients were r and omly assigned to rate or rhythm control , and their physicians chose the specific therapies ( pharmacologic first , then nonpharmacologic if needed ) . Anticoagulation was continued indefinitely in the rate-control group and was encouraged in the rhythm-control group but could be stopped at the physician 's discretion if sinus rhythm had been maintained for at least 4 , and preferably 12 , consecutive weeks with antiarrhythmic therapy . The prevalence of sinus rhythm in the rhythm-control group was 82 % , 73 % , and 63 % at 1 , 3 , and 5 years , respectively . The prevalence of sinus rhythm in the rate-control group was 34.6 % at 5 years . The primary end point in the AFFIRM trial , overall mortality , was not statistically significantly different between the groups . However , the rhythm-control strategy was associated with a higher risk for death than the rate-control strategy among older patients , those without congestive heart failure , and those with coronary disease .  Rates of stroke also did not differ between groups ; 70 % of all strokes occurred in patients who had stopped receiving anticoagulation or who had subtherapeutic international normalized ratios ( < 2.0 ) . More hospitalizations were reported in the rhythm-control group ( P < 0.001 ) . Another recent study , the RAte Control versus Electrical cardioversion for persistent atrial fibrillation ( RACE ) study , r and omly assigned patients to receive aggressive rhythm control or rate control ( 7 ) . This was a smaller study , involving 522 patients ( mean age , 68 years ) . Sixty-four percent of patients were men , 49 % had hypertension , and 27 % had coronary artery disease . All patients had persistent atrial fibrillation lasting less than 1 year and had had at least 1 previous electrical cardioversion ( a maximum of 2 previous cardioversions was permitted for study inclusion ) . The primary end point was a composite of cardiovascular mortality , heart failure , thromboembolic complications , bleeding , pacemaker implantation , and severe side effects of antiarrhythmic drugs . Again , no difference was seen between groups in the primary composite end point . As in the AFFIRM study , most of the strokes occurred in patients whose anticoagulation had been halted or patients whose international normalized ratio was subtherapeutic ( < 2.0 ) . In post hoc analysis , a benefit for rate control over rhythm control was seen in patients with hypertension and in women . Since this was a post hoc analysis , these results will need to be confirmed by further studies . Of note , despite an aggressive treatment protocol , at the end of follow-up only 39 % of the patients in the rhythm-control group were in sinus rhythm . The Pharmacological Intervention in Atrial Fibrillation ( PIAF ) trial r and omly assigned 252 patients 18 to 75 years of age with new-onset or permanent symptomatic atrial fibrillation ( mean duration of atrial fibrillation , approximately 4 months ) to rate control with diltiazem or aggressive conversion ( many times if necessary ) and maintenance therapy with amiodarone ( 8) . The primary end point of the study was improvement in symptoms related to atrial fibrillation . After 1 year of follow-up , relief of symptoms was similar in both groups , as were quality -of-life measures . Walking distance was improved in the rhythm-control group , but hospital admissions were more frequent in this group . Although final results are not yet available , preliminary reports of the Strategies of Treatment of Atrial Fibrillation ( STAF ) trial have been presented ( 9 ) . Patients were r and omly assigned to receive anticoagulation for 3 weeks before conversion and for 4 weeks after attempted conversion , with antiarrhythmic therapy to maintain sinus rhythm , or to long-term anticoagulation and rate control . ( Patients included in this study had at least 1 previous conversion attempt . ) After more than 1.5 years of follow-up , no difference was seen between the groups in rates of the primary end points of death , stroke , transient ischemic attacks , cardiopulmonary resuscitation , or thromboembolism . Of interest , only 40 % of patients in the rhythm-control group were still in sinus rhythm at 1 year , and all primary end points occurred in patients in atrial fibrillation , even in the rhythm-control group . This result has created speculation about whether fewer events would have occurred if anticoagulation had been continued indefinitely in the conversion group . It also suggests that despite aggressive rhythm management , a substantial number of patients can not maintain sinus rhythm . In general , the trial sample s were older and male and had risk factors for stroke , such as hypertension , congestive heart failure , and coronary disease . Certain subgroups of patients with atrial fibrillation , such as younger patients with healthy hearts or paroxysmal atrial fibrillation , were not well represented in the trials . Therefore , it is not certain whether these subgroups of patients may benefit from more aggressive rhythm control or rate control . Recommendation 1 : Rate control with chronic anticoagulation is the recommended strategy for the majority of patients with atrial fibrillation . Rhythm control has not been shown to be superior to rate control ( with chronic anticoagulation ) in reducing morbidity and mortality and may be inferior in some patient subgroups to rate control . Rhythm BACKGROUND [ corrected ] Atrial fibrillation is an important risk factor for ischaemic stroke . Anticoagulation treatment with warfarin can substantially reduce the risk of stroke in people with atrial fibrillation but concerns about their side-effects have limited their use in clinical practice . However there has been little population -based research on the comorbidity associated with atrial fibrillation and on the prevalence of potential contraindications to anticoagulantion treatment among these patients . AIM To determine the prevalence of known risk factors for ischaemic stroke and possible contraindications to anticoagulant treatment among patients with atrial fibrillation . METHOD One-year prospect i ve cohort study in 60 general practice s in Engl and and Wales with a total population of 502,493 people . Age and sex specific prevalence rates and relative risks of risk factors for ischaemic stroke and possible contraindications to antithrombotic treatment  were calculated . RESULTS The number of patients who had a diagnosis of atrial fibrillation during the year was 1,414 ( 0.3 % ) patients . The prevalence of other nsk factors for ischaemic stroke in patients with atrial fibrillation increased with age in men , from 48 % ( relative risk [ RR ] = 3.78 , 95 % confidence interval [ 95 % CI ] = 3.23 - 4.41 ) at 45 to 64 years to 64 % ( RR = 2.21 , 95 % CI = 2.00 - 2.44 ) at 75years and over A similar increase of 50 % ( RR = 4.36 , 95 % CI = 3.54 - 5.38 ) to 60 % ( RR = 2.07 , 95 % CI = 1.91 - 2.23 ) was seen in women . The percentage of men with atrial fibrillation with at least one contraindication to antithrombotic treatment was 5 % at 45 to 64 years and 14 % at 75 years and over . Among women with atrial fibrillation , 7 % had a contraindication at 45 to 64 years and 16 % at 75 years and over . The all-ages relative risk of a contraindication was 1.17 ( 95 % CI = 0.92 - 1.48 ) in men and 1.53 ( 95 % CI = 1.28 - 1.83 ) in women . Forty per cent ( 575 ) of patients with atrial fibrillation had at least one risk factor for ischaemic stroke and no contraindications to antithrombotic treatment . CONCLUSION Atrial fibrillation is associated with a substantial increase in the prevalence of risk factors for ischaemic stroke . By contrast , potential contraindications for antithrombotic treatment are more evenly distributed among patients with and without atrial fibrillation . Around 40 % of patients with atrial fibrillation in primary care are at high risk of stroke and have no contraindicationsfor antithrombotic treatment Purpose Ischemic stroke is a frequent pathology with high rate of recurrence and significant morbidity and mortality . There are several causes of stroke , affecting prognosis , outcomes , and management , but in many cases , the etiology remains undetermined . We hypothesized that atrial fibrillation was involved in this pathology but underdiagnosed by st and ard methods . The aim of the study was to determine the incidence of atrial fibrillation in cryptogenic ischemic stroke by using continuous monitoring of the heart rate over several months . The secondary objective was to test the value of atrial vulnerability assessment in predicting spontaneous atrial fibrillation . Methods and results We prospect ively enrolled 24 patients under 75 years of age , 15 men and 9 women of mean age 49 years , who within the last 4 months had experienced cryptogenic stroke diagnosed by clinical presentation and brain imaging and presumed to be of cardioembolic mechanism . All causes of stroke were excluded by normal 12-lead ECG , 24-h Holter monitoring , echocardiography , cervical Doppler , hematological , and inflammatory tests . All patients underwent electrophysiological study . Of the patients , 37.5 % had latent atrial vulnerability , and 33.3 % had inducible sustained arrhythmia . Patients were secondarily implanted with an implantable loop recorder to look for spontaneous atrial fibrillation over a mean follow-up interval of 14.5 months . No sustained arrhythmia was found . Only one patient had non-significant episodes of atrial fibrillation . Conclusion In this study , symptomatic atrial fibrillation or AF with fast ventricular rate has not been demonstrated by the implantable loop recorder  in patients under 75 years with unexplained cerebral ischemia . The use of this device should not be generalized in the systematic evaluation of these patients . In addition , this study attests that the assessment of atrial vulnerability is poor at predicting spontaneous arrhythmia in such patients IMPORTANCE Despite the frequency of  atrial fibrillation ( AF )  in clinical practice , relatively little is known about sex differences in symptoms and quality of life and how they may affect treatment and outcomes . OBJECTIVE To determine whether symptoms , quality of life , treatment , and outcomes differ between women and men with AF . DESIGN , SETTING , AND PARTICIPANTS This observational cohort study included 10 135 patients with AF . The Outcomes Registry for Better Informed Treatment of Atrial Fibrillation is a prospect i ve , nationwide , multicenter outpatient registry of patients with incident and prevalent AF enrolled at 176 sites between June 2010 and August 2011 . MAIN OUTCOMES AND MEASURES Symptoms , quality of life as measured by Atrial Fibrillation Effects on Quality of Life scores , AF treatment , cardiovascular outcomes , stroke or non- central nervous system embolism , and all-cause mortality . RESULTS Overall , 4293 of the cohort ( 42 % ) were female . Compared with men , women were older ( 77 years ; interquartile range [ IQR ] , 69 - 83 , vs 73 years ; IQR , 65 - 80 ; P < .001 ) and had higher median CHA2DS2-VASc scores ( 5 ; IQR , 4 - 6 , vs 3 ; IQR , 2 - 5 ; P < .001 ) , but less sleep apnea ( 578 [ 13.5 % ] vs 1264 [ 21.6 % ] ; P < .001 ) . Only 32.1 % of women ( n = 1378 ) were asymptomatic ( European Heart Rhythm Association class I ) compared with 42.5 % of men ( n = 2483 ) in unadjusted analyses ( P < .001 ) . Women had lower ( more severe ) unadjusted baseline overall Atrial Fibrillation Effects on Quality of Life scores ( n = 2007 ; 80 ; IQR , 62 - 92 vs 83 ; IQR , 69 - 94 ; P < .001 ) . Women had similar rates of anticoagulation and similar time in therapeutic range . In follow-up , women experienced lower risk-adjusted all-cause mortality ( adjusted hazard ratio , 0.57 ; 95 % CI , 0.49 - 0.67 ) and cardiovascular death ( adjusted hazard ratio , 0.56 ; 95 % CI , 0.44 - 0.72 ) ; however , they had a higher risk for stroke or non- central nervous system embolism ( adjusted hazard ratio , 1.39 ; 95 % CI , 1.05 - 1.84 ; P = .02 ) compared with men . CONCLUSIONS AND RELEVANCE Women with AF have more symptoms and worse quality of life . Despite higher risk , women have lower risk-adjusted all-cause and cardiovascular death compared with men , but higher stroke rates . Future studies should focus on how treatment and interventions specifically affect AF-related quality of life and cardiovascular outcomes in women . TRIAL REGISTRATION clinical trials.gov Identifier : NCT01165710 Background — Obesity is a risk factor for atrial fibrillation and other cardiovascular conditions . Our objective was to determine whether catheter-based ablation effectively treated atrial fibrillation in obese patients . Methods and Results — Five hundred twenty-three consecutive patients with symptomatic , medication-refractory atrial fibrillation underwent catheter ablation .  Patients were grouped by body mass index ( lean , < 25 kg/m2 ; overweight , 25 to 29.9 kg/m2 ; obese , ≥30 kg/m2 ) . Outcome and quality of life were measured with a general health survey ( Medical Outcomes Study 36-item Short-Form General Health Survey [ SF-36 ] ) ; patients were assessed before ablation and at 3 and 12 months after the procedure . Two hundred twenty-eight study patients ( 44 % ) were overweight , and 201 ( 38 % ) were obese . Twelve months after curative ablation , 72 % of patients were free of atrial fibrillation without the use of antiarrhythmic agents ; 84 % were arrhythmia free when those receiving medication were included . Atrial fibrillation was eliminated in 75 % , 72 % , and 70 % of the lean , overweight , and obese patients , respectively , at 12 months ( P=0.41 , trend test ) . SF-36 scores were lower for patients with higher body mass index ( P<0.05 ) at baseline . SF-36 scores improved in every functional domain for all body mass index groups after ablation . The mean SF-36 total physical score increased from 59±20 at baseline to 77±19 in 12 months ( P<0.001 ) . The total mental health score improved from 66±18 to 79±16 in 12 months ( P<0.001 ) . Conclusions — Catheter ablation of atrial fibrillation was effective in obese patients . Coexistence of atrial fibrillation and obesity indicated lower SF-36 scores , but the improvement in quality of life was consistent across all body mass index categories Atrial fibrillation is in 20 - 50 % the most frequent dysrhythmia after coronary artery bypass grafting ( CABG ) and a possible cause for hemodynamical complications and prolongation off the medical treatment in patients . Therefore , the effect of beta-blocking with metoprolol for prevention of supraventricular arrhythmias ( SVA ) was investigated in a prospect i ve and r and omized trial . 200 patients after CABG were r and omized in a drug and control group ( average age 63.2 years , 154 male , 46 female ) . Patients of the drug group ( n=100 ) were treated with metoprolol ( 1mg/kg/BW ) beginning on day one after operation , whereas patients of the control group ( n=100 ) received therapy only in case of occurrence of atrial fibrillation .  ECG , blood pressure , and electrolyte concentrations were measured regularly until the tenth day after surgery . Reasons for exclusion were an ejection fraction ( < 30 % , SA- and AV-block or simultaneous application of epinephrine and metoprolol . There were no significant differences between the patients of drug and control group with respect to age , sex ejection fraction , previous medication , number and type of bypass grafts , cardiopulmonary bypass time , and perioperative ischemic events . However , a statistically significant difference was seen in the occurrence of supraventricular arrhythmias in both groups , 4 patients of the therapy group ( 4 % ) in contrast to 37 patients of the control ( 37 % ) developed supraventricular arrhythmias during the postoperative observation period ( p<0.0001 ) . Both groups differed in total time of hospital stay by 1.5 days ( control group : 9.83+/-2.88 days ; drug group : 8.42+/-2.81 days ) , which was statistically significant ( p<0.05 ) . All patients of the drug group could be discharged with a stable sinus rhythm , whereas 7 patients of the control group were discharged with persistent atrial fibrillation . The difference was statistically significant as well ( p<0.01 ) . Neither typical side effects of metoprolol , nor AV-blocks , bradycardia ( f<60/min ) or symptoms of low blood pressure could be observed . The conclusion of this trial is a recommendation for a preventive application of 50 mg metoprolol/day after coronary artery bypass surgery , which can reduce the incidence of SVA as well as the hospital stay statistically significant AIMS To compare the quality of life ( QoL ) of those in atrial fibrillation ( AF ) aged 75 years and over with that of the general population , to explore what factors affect the QoL of those with AF , and to assess the sensitivity of the EuroQol ( EQ-5D ) and Short-Form 12 ( SF-12 ) generic health question naires in detecting differences in health status in those with AF in this age group . METHODS AND RESULTS The study population was 1762 men and women aged 75 years and over with confirmed AF who attended a r and omization clinic for the Birmingham Atrial Fibrillation Treatment of the Aged ( BAFTA ) study , a primary care based trial of stroke prevention . Patients self-completed the EQ-5D and SF-12 question naires , and a simple measure of disability ( Rankin ) . Cardiovascular co-morbidities were collected and number of drugs used as an additional proxy for co-morbidity . Quality -of-life outcomes were compared with general population sample s of the same age . On multiple regression , female gender , greater medication use , and disability were independently associated with lower QoL scores in AF . Those in AF with a Rankin score ≥2 had lower QoL scores , while those with a Rankin score < 2 had higher scores than the general population . Increasing co-morbidity was associated with reduced QoL scores , with the EQ-5D and SF-12 Physical Component Score showing similar sensitivity to these associations , and the SF-12 Mental Component Score showing less sensitivity . CONCLUSION In the absence of co-morbidity , chronic AF has little impact on generic QoL in an elderly non-acutely ill population AIMS Clinical benefit from ablation for long-st and ing persistent atrial fibrillation has remained unknown . We hypothesized that successful ablation of long-st and ing persistent atrial fibrillation would improve haemodynamics , functional status , and quality of life . METHODS AND RESULTS A total of 160 patients ( aged 59 ± 9 years , 23 % females ) undergoing ablation of long-st and ing ( median of 28 months ) persistent atrial were enrolled in this prospect i ve study . Morphological and functional echocardiographic parameters , N-terminal prohormone of brain natriuretic peptide ( NT-proBNP ) , maximum oxygen consumption during exercise test ( VO2 max ) , and quality of life were assessed at baseline and 1 year after the ablation . At the 1-year follow-up visit , 81 % patients were examined in sinus rhythm ( after repeat ablation in 38 % patients ) . Left atrial appendage outflow velocity increased from 44 ± 20 to 58 ± 23 cm/s , left ventricular ejection fraction from 54 ± 9 to 59 ± 5 % , and VO2 max from 20.4 ± 6.4 to 23.7 ± 8.1 mL/kg/min ; NT-proBNP decreased from median 897 ( interquartile range 603 - 1424 ) to 230 ( interquartile range 120 - 420 ) pg/mL ( all P < 0.0001 ) . These beneficial effects of ablation were predominantly associated with the presence of sinus rhythm . Quality of life ( range 0 - 100 ) increased significantly ( EQ-5D index : from 68.8 ± 12.5 to 75.4 ± 14.4 ; EQ-VAS score : from 62.8 ± 13.2 to 70.6 ± 13.8 ; both P < 0.0001 ) . CONCLUSION Ablation of long-st and ing persistent atrial fibrillation was associated with significant recovery of haemodynamics and exercise capacity that projected onto the long-term improvement in quality of life Background — Several approaches have been developed for radiofrequency catheter ablation of atrial fibrillation , but the correct intraprocedural end point is still under debate , and few data exist about the destiny of ablation lesions over time . The aim of the present study was to evaluate the long-term maintenance of intraprocedural end points of ablation procedures . Methods and Results — Inclusion criteria were ( 1 ) a previous ablation procedure of pulmonary vein ( PV ) encircling performed for drug-refractory persistent atrial fibrillation ; ( 2 ) a “ complete ” intraprocedural end point , which consisted of voltage abatement inside the lesions , PV disconnection , and exit-block pacing from inside the lesions , attained in all PVs ; and ( 3 ) stable sinus rhythm documented during a minimum follow-up of 2.5 years after the procedure . Twenty volunteers were selected ( 12 males , mean age 59±7 years ) and underwent a repeat electrophysiological study . After a follow-up of 36.4±4.7 months , complete voltage abatement was maintained around 32 PVs ( 40.0 % ) , PV disconnection persisted in 12 ( 37.5 % ) of the previously isolated PVs , and exit block was present in 39 PVs ( 48.7 % ) . Ten patients who underwent a redo ablation procedure because of recurrences of atrial fibrillation were used as the control group . Differences in intraprocedural end-point maintenance between the 2 groups were not statistically significant . Conclusions — Common intraprocedural end points such as voltage abatement , PV disconnection , and exit block persist only in a limited number of patients , even when the outcome is favorable during follow-up . Further investigation will be required to determine whether such data will have implication s for ablation strategies AIMS Permanent atrial fibrillation develops in many patients after ablation and pacing therapy .  We compared a strategy that initially allowed patients to remain in atrial fibrillation with a strategy that initially attempted to restore and maintain sinus rhythm . METHODS AND RESULTS In this multicentre r and omized controlled trial , 68 patients affected by severely symptomatic paroxysmal atrial fibrillation were assigned , after successful atrioventricular junction ablation and pacing treatment  , to antiarrhythmic drug therapy with amiodarone , propafenone , flecainide or sotalol and were compared with 69 patients assigned , after successful AV junction ablation and pacing treatment , to no antiarrhythmic drug therapy . The patients were followed-up for 12 to 24 months ( mean 16+/-4 ) . The drug arm patients had a 57 % reduction in the risk of developing permanent atrial fibrillation ( 21 % vs 37 % , P=0.02 ) . Evaluation after 12 months revealed similar quality of life scores and echocardiographic parameters in the two groups , but the drug arm patients had more episodes of heart failure and hospitalizations ( P=0.05 ) . The outcome was similar between the 40 patients who developed permanent atrial fibrillation and the 97 who did not . CONCLUSION Conventional antiarrhythmic therapy reduces the risk of development of permanent atrial fibrillation after ablation and pacing therapy . The present data do not support the concept that the development of permanent atrial fibrillation is related to an adverse outcome when a perfect control of heart rate is obtained by ablation and pacing AIMS Pulmonary vein isolation ( PVI ) can be considered for treatment of symptomatic atrial fibrillation ( AF ) . Nowadays , in addition to transcatheter ablation , thoracoscopic surgical PVI is available . The aim of this study is to compare clinical outcome of surgical with transcatheter PVI as first invasive treatment strategy of AF . METHODS AND RESULTS From June 2009 to November 2011 , 33 patients underwent minimally invasive surgical PVI , and were matched ( 1:2 fashion ) retrospectively according to age , sex , and AF type , with 66 patients who underwent transcatheter PVI .  Success was defined as freedom from atrial arrhythmias on 24 h Holter monitoring without use of anti-arrhythmic drugs ( AADs ) at 1 year . Mean age was 52 ± 10 years , 82 % were male . Paroxysmal AF was present in 76 patients ( 77 % ) , persistent AF in 23 ( 23 % ) patients . None underwent prior ablations , and failed on 1.2 ± 0.6 AADs . At 12 months , complete freedom from atrial arrhythmias without AADs in the surgical PVI group was 88 % compared with 41 % in the transcatheter PVI group ( P < 0.001 ) . Freedom from atrial arrhythmias with AADs was 91 vs. 62 % , in the surgical vs. transcatheter PVI group , respectively ( P = 0.002 ) . Complications occurred in seven ( 21 % ) surgical PVI patients , and three ( 5 % ) transcatheter PVI patients ( P = 0.015 ) . CONCLUSION In present matched study comparing a surgical with transcatheter PVI treatment strategy in symptomatic AF patients failed on AADs , but without prior ablations , a surgical PVI strategy was more effective to prevent recurrence of atrial arrhythmias , than a transcatheter PVI treatment strategy . However , complications were more frequent with surgical PVI INTRODUCTION The aim of this study was to compare the outcome of anatomical pulmonary vein ( PV ) radiofrequency ( RF ) ablation with that of an integrated approach ( anatomical with electrophysiological confirmation of PV disconnection ) . METHODS Sixty consecutive patients affected by drug-refractory paroxysmal ( 39 ) , persistent ( 13 ) , and permanent ( 8) atrial fibrillation ( AF ) were assigned to an anatomical ( group A : 30 patients ; 25 male , 5 female , mean age : 55 + /- 7 years ) or integrated approach ( group B : 30 patients ; 26 male , 4 female , mean age : 52 + /- 9 years ) . In all cases , RF ablation was performed by means of the Carto system in order to anatomically create circumferential lines around PVs . In group B , the persistence of PV potentials was then assessed with a multipolar circular catheter . If PV potentials persisted , RF pulses targeting the electrophysiological breakthroughs were delivered to disconnect PVs . RESULTS Total procedure duration , fluoroscopy time , and RF delivery time were similar in both groups : 227 + /- 43 , 50 + /- 23 , and 43 + /- 16 minutes ( group A ) ; 232 + /- 32 , 55 + /- 15 , and 42 + /- 10 minutes ( group B ) , respectively ( ns ) . One asymptomatic PV stenosis and one pericardial effusion occurred in group A and B , respectively . After 15.4 + /- 7.4 months , 17 ( 57 % ) group A patients and 25 ( 83 % ) group B patients were in stable sinus rhythm ( P = 0.02 ) ( RR 1.78 ; 95 % CI : 1.7 - 2.9 ) . CONCLUSIONS PV ablation by means of an integrated anatomical and electrophysiological approach seems more effective than a purely anatomical RF ablation approach . Electrophysiological confirmation of PV disconnection could be a useful marker of successful RF treatment of AF OBJECTIVE To correlate atrial fibrillation with the incidence of new thromboembolic ( TE ) stroke  in older patients with and without prior TE stroke . DESIGN In a prospect i ve study of 2101 older patients ,  electrocardiograms  showed that atrial fibrillation was present in 283 patients ( 13 % ) . At 42-month mean follow-up , atrial fibrillation was associated with the incidence of new TE stroke in patients with and without prior TE stroke . SETTING A large long-term health care facility where 2101 older patients were studied . PATIENTS The 2101 patients included 1451 women and 650 men , mean age 81 + /- 8 years ( range 60 to 103 ) . MEASUREMENTS AND MAIN RESULTS Atrial fibrillation was present in 283 of 2101 patients ( 13 % ) . The mean age was 84 + /- 7 years in patients with atrial fibrillation and 81 + /- 8 years in patients with sinus rhythm ( P = .0001 ) . The prevalence of atrial fibrillation was 5 % in patients aged 60 to 70 years , 14 % in patients aged 71 to 80 years , 13 % in patients aged 81 to 90 years , and 22 % in patients aged 91 to 103 years ( P < .0001 ) . Mean follow-up was 31 + /- 18 months in patients with atrial fibrillation and 44 + /- 27 months in patients with sinus rhythm ( P = .0001 ) . Previous TE stroke occurred in 123 of 283 patients ( 43 % ) with atrial fibrillation and in 431 of 1818 patients ( 24 % ) with sinus rhythm ( P < .0001 ) . New TE stroke occurred in 131 of 283 patients ( 46 % ) with atrial fibrillation and in 303 of 1818 patients ( 17 % ) with sinus rhythm ( P < .0001 ) . The log-rank test showed that patients with atrial fibrillation had a significantly higher probability of developing new TE stroke than those with sinus rhythm ( P < .0001 ) . The multivariate Cox regression model showed that independent risk factors for new TE stroke were male sex ( relative risk = 1.3 ) , prior TE stroke ( relative risk = 3.1 ) , and atrial fibrillation ( relative risk = 3.3 ) . CONCLUSIONS Atrial fibrillation , prior TE stroke , and male sex are independent risk factors for the development of new TE stroke in older patients
In brief , female atrial fibrillation patients more commonly present comorbidities , leading to a higher prevalence of persistent atrial fibrillation ; moreover , they refer to hospital care later and with a longer disease history .
Atrial fibrillation symptoms relate to low quality of life in female patients ; in fact , atrial fibrillation paroxysm usually presents higher heart rate , leading to preferentially adopt a rate rather than a rhythm-control strategy .
Female atrial fibrillation patients present an increased risk of stroke , worsened by the lower  oral anticoagulant prescription rate related to the concomitant higher haemorrhagic risk profile .
Trans-catheter ablation is under-used in female patients and , on the contrary , they are more commonly affected by anti-arrhythmic drug side effects
Atrial fibrillation is the most common supraventricular arrhythmia .
Its prevalence increases with age and preferentially affects male patients .
Over 75 years of age , however , female patients being more prevalent , the absolute number of patients affected is similar between sexes .
Despite this , few data are available in the literature concerning sex-related differences in atrial fibrillation patients .
The present systematic review therefore considers comorbidities , referring symptoms , quality of life , pharmacological approaches  and  trans-catheter ablation  in female rather than in male atrial fibrillation patients in search of parameters that may have an impact on the treatment outcome .