Focused 2012 update of the Canadian Cardiovascular Society atrial fibrillation guidelines: recommendations for stroke prevention and rate/rhythm control. Effect of single-drug therapy on reduction of left atrial size in mild to moderate hypertension: comparison of six antihypertensive agents. Palpitations are predictive of future atrial fibrillation. An 11-year follow-up of 22,815 men and women: the Tromsø Study Anticoagulation therapy for stroke prevention in atrial fibrillation: how well do randomized trials translate into clinical practice? Reduced incidence of new-onset atrial fibrillation with angiotensin II receptor blockade: the VALUE trial Diagnostic accuracy and yield of screening tests for atrial fibrillation in the family practice setting: a multicentre cohort study. The safety and adequacy of antithrombotic therapy for atrial fibrillation: a regional cohort study. Potentially Preventable Strokes in High-Risk Patients With Atrial Fibrillation Who Are Not Adequately Anticoagulated Usefulness of mean platelet volume for predicting stroke risk in atrial fibrillation patients Comparative Efficacy and Safety of New Oral Anticoagulants in Patients With Atrial Fibrillation Comparison of Probability of Stroke Between the Copenhagen City Heart Study and the Framingham Study A multicenter risk index for atrial fibrillation after cardiac surgery. Analysis of Stroke in ATHENA: A Placebo-Controlled, Double-Blind, Parallel-Arm Trial to Assess the Efficacy of Dronedarone 400 mg BID for the Prevention of Cardiovascular Hospitalization or Death From Any Cause in Patients With Atrial Fibrillation/Atrial Flutter Adjunctive renal sympathetic denervation to modify hypertension as upstream therapy in the treatment of atrial fibrillation (H-FIB) study: clinical background and study design. Comorbidity associated with atrial fibrillation: a general practice-based study. Factors associated with ischemic stroke during aspirin therapy in atrial fibrillation: analysis of 2012 participants in the SPAF I-III clinical trials. The Stroke Prevention in Atrial Fibrillation (SPAF) Investigators. Atrial Fibrillation and Isolated Systolic Hypertension: The Systolic Hypertension in the Elderly Program and Systolic Hypertension in the Elderly Program-Extension Study Prognosis after surgical replacement with a bioprosthetic aortic valve in patients with severe symptomatic aortic stenosis: systematic review of observational studies Stroke with intermittent atrial fibrillation: incidence and predictors during aspirin therapy. Stroke Prevention in Atrial Fibrillation Investigators. Alcohol consumption and risk of incident atrial fibrillation in women. Predictors of thromboembolism in atrial fibrillation: I. Clinical features of patients at risk. The Stroke Prevention in Atrial Fibrillation Investigators. Effect of valsartan and ramipril on atrial fibrillation recurrence and P-wave dispersion in hypertensive patients with recurrent symptomatic lone atrial fibrillation. Asymptomatic or "silent" atrial fibrillation: frequency in untreated patients and patients receiving azimilide.
The Canadian Cardiovascular Society ( CCS ) published the complete set of 2010 Atrial Fibrillation ( AF ) Guidelines in the January , 2011 issue of the Canadian Journal of Cardiology . During its deliberations , the CCS Guidelines Committee engaged to a timely review of future evidence , with periodic composition of focused up date s to address clinical ly important advances . In 2011 , results were published from 3 pivotal AF trials : the Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared with Vitamin K Antagonist for Prevention of Stroke and Embolism Trial in Atrial Fibrillation ( ROCKET-AF ) , the Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation ( ARISTOTLE ) study , and the Permanent Atrial Fibrillation Outcome Study Using Dronedarone on Top of St and ard Therapy ( PALLAS ) , comparing dronedarone with placebo in patients with permanent AF and additional cardiovascular disease risk-factor burden . Each of these large r and omized trials provided clear results with major implication s for AF management . Other important evidence that has emerged since the 2010 Guidelines includes findings about prediction instruments for AF-associated stroke and bleeding risk , stroke risk in paroxysmal-AF patients , risk-benefit considerations related to oral anticoagulation in patients with chronic kidney disease , and risk/benefit considerations in the use of antiplatelet agents , alone and in combination with each other or with oral anticoagulants , in AF patients . The Guidelines Committee judged that this extensive and important new evidence required focused updating of the 2010 Guidelines with respect to stroke prevention and rate/rhythm control . This report presents the details of the new recommendations , along with the background and rationale BACKGROUND Cardiac effects of hypertension include increased left ventricular ( LV ) mass and LV hypertrophy , as well as increased left atrial size , a predictor of stroke and atrial fibrillation . Although literature on reduction of LV mass with antihypertensive therapy is extensive , little information is available on effects of treatment on left atrial size . METHODS AND RESULTS Patients with mild to moderate hypertension ( diastolic blood pressure 95 to 109 mm Hg ) were r and omly allocated to treatment with atenolol , captopril , clonidine , diltiazem , hydrochlorothiazide , or prazosin in a double-masked trial . Two-dimensional targeted M-mode echocardiography was used to assess left atrial size and LV mass at baseline , 8 weeks , and 1 and 2 years . Longitudinal analysis examined changes in left atrial size from the baseline study , statistically adjusting for age , race , pretreatment left atrial size and LV mass , and serial measurements of systolic blood pressure , body weight , urinary sodium excretion , and physical activity score . Without adjustment for covariates , only hydrochlorothiazide was associated with decreases in left atrial size from baseline at 8 weeks ( -1.0 + /- 5.2 mm ; P=0.052 ) , 1 year ( -2.0 + /- 5.1 mm ; P=0.02 ) , and 2 years ( 4.6+/-7.2 mm ; P=0.002 ) . After adjustment for effects of covariates , patients with normal left atrial size had greater reduction ( -3.3 mm ) in left atrial size at 2 years with hydrochlorothiazide than with any other drug . For patients with left atrial enlargement , left atrial size decreased significantly with hydrochlorothiazide , atenolol , clonidine , and diltiazem at 1 year and with all treatments at 2 years . However , reduction at 2 years was greater with hydrochlorothiazide than with captopril or prazosin . CONCLUSIONS Antihypertensive drugs differ in their effects on left atrial size .  Hydrochlorothiazide was associated with greater overall reduction of left atrial size than other drugs effective for the treatment of hypertension . Reduction of left atrial size with therapy is in part independent of factors known to influence left atrial size , including LV mass and reduction of LV mass with treatment . The clinical benefit of reducing left atrial size with antihypertensive treatment remains to be determined Background : Atrial fibrillation ( AF ) is a common cardiac arrhythmia which increases morbidity and mortality . Identification of risk factors is therefore important . We examined the impact of palpitations and cardiovascular risk factors in prediction of AF ( all types ) and lone AF in a large population -based cohort . Design : We carried out a prospect i ve population -based cohort study . Methods : A total of 22,815 participants from a population survey in 1994–1995 were followed-up for a mean of 11.1 years . Mean age at baseline was 46 years . Measurements of height , weight , blood pressure , heart rate , total cholesterol and high-density lipoprotein (HDL)-cholesterol , and information on palpitations , diabetes , angina , myocardial infa rct ion , and antihypertensive treatment were obtained at baseline . The outcome measure was first-ever AF , documented on an electrocardiogram .  Cox proportional hazards regression model was used to estimate hazard ratios ( HRs ) for AF . Results : Palpitations were associated with increased risk of AF in both women ( HR 1.62 , 95 % confidence interval [ CI ] 1.29–2.02 ) and men ( HR 1.91 , 95 % CI 1.54–2.35 ) . For hypertension the HR for AF was 1.98 ( 1.46 - 2.69 ) in women and 1.40 ( 1.13 - 1.74 ) in men . The HR for 1 SD increase in body mass index ( BMI ) was 1.16 ( 1.06–1.27 ) in women and 1.47 ( 1.32–1.63 ) in men . Body height and BMI were associated with increased risk for lone AF in men . Conclusion : Palpitations , hypertension and BMI were predictive of future atrial fibrillation in both sexes CONTEXT Warfarin has been shown to be highly efficacious for preventing  thromboembolism in atrial fibrillation in r and omized trials , but its effectiveness and safety in clinical practice is less clear . OBJECTIVE To evaluate the effect of warfarin on risk of thromboembolism , hemorrhage , and death in atrial fibrillation within a usual care setting . DESIGN Cohort study assembled between July 1 , 1996 , and December 31 , 1997 , and followed up through August 31 , 1999 . SETTING Large integrated health care system in Northern California . PATIENTS Of 13,559 adults with nonvalvular atrial fibrillation , 11,526 were studied , 43 % of whom were women , mean age 71 years , with no known contraindications to anticoagulation at baseline . MAIN OUTCOMES Ischemic stroke , peripheral embolism , hemorrhage , and death according to warfarin use and comorbidity status , as determined by automated data bases , review of medical records , and state mortality files . RESULTS Among 11,526 patients , 397 incident thromboembolic events ( 372 ischemic strokes , 25 peripheral embolism ) occurred during 25,341 person-years of follow-up , and warfarin therapy was associated with a 51 % ( 95 % confidence interval [ CI ] , 39%-60 % ) lower risk of thromboembolism compared with no warfarin therapy ( either no antithrombotic therapy or aspirin ) after adjusting for potential confounders and likelihood of receiving warfarin . Warfarin was effective in reducing thromboembolic risk in the presence or absence of risk factors for stroke . A nested case-control analysis estimated a 64 % reduction in odds of thromboembolism with warfarin compared with no antithrombotic therapy . Warfarin was also associated with a reduced risk of all-cause mortality ( adjusted hazard ratio , 0.69 ; 95 % CI , 0.61 - 0.77 ) . Intracranial hemorrhage was uncommon , but the rate was moderately higher among those taking vs those not taking warfarin ( 0.46 vs 0.23 per 100 person-years , respectively ; P = .003 , adjusted hazard ratio , 1.97 ; 95 % CI , 1.24 - 3.13 ) . However , warfarin therapy was not associated with an increased adjusted risk of nonintracranial major hemorrhage . The effects of warfarin were similar when patients with contraindications at baseline were analyzed separately or combined with those without contraindications ( total cohort of 13,559 ) . CONCLUSIONS Warfarin is very effective for preventing ischemic stroke in patients with atrial fibrillation in clinical practice while the absolute increase in the risk of intracranial hemorrhage is small . Results of r and omized trials of anticoagulation translate well into clinical care for patients with atrial fibrillation Background Atrial fibrillation ( AF ) is the most common arrhythmia and increases cardiovascular risk in hypertensive patients . Therefore , in the Valsartan Antihypertensive Long-term Use Evaluation ( VALUE ) a prespecified objective was to compare the effects of valsartan and amlodipine on new-onset AF . Methods A total of 15 245 hypertensive patients at high cardiovascular risk received valsartan 80–160 mg/day or amlodipine 5–10 mg/day combined with additional antihypertensive agents . Electrocardiograms were obtained every year and analyzed central ly for evidence of left ventricular hypertrophy and new-onset AF . Results At baseline ,  AF was diagnosed in 2.6 % of 7649 valsartan recipients and 2.6 % of 7596 amlodipine recipients . During antihypertensive treatment the incidence of at least one documented occurrence of new-onset AF was 3.67 % with valsartan and 4.34 % with amlodipine { unadjusted hazard ratio 0.843 , [ 95 % confidence interval ( CI ) : 0.713 , 0.997 ] , P = 0.0455}. The incidence of persistent AF was 1.35 % with valsartan and 1.97 % with amlodipine [ unadjusted hazard ratio 0.683 ( 95 % CI : 0.525 , 0.889 ) , P = 0.0046 ] . Conclusions Valsartan-based treatment reduced the development of new-onset AF , particularly sustained AF in hypertensive patients , compared with amlodipine-based therapy . These findings suggest that angiotensin II receptor blockers may result in greater benefits than calcium antagonists in hypertensive patients at risk of new-onset AF BACKGROUND Detection of undiagnosed or undertreated ( " actionable " ) atrial fibrillation could increase the use of appropriate oral anticoagulant therapy and reduce the risk of stroke . We sought to compare newer screening technologies with a pulse-check for the detection of atrial fibrillation and to determine whether the detection of actionable atrial fibrillation increases the use of oral anticoagulant agents . METHODS This prospect i ve multicentre cohort study involved 22 primary care clinics . We recruited participants aged 65 years and older who were attending routine appointments . Each participant underwent 3 methods of screening : a 30-second radial pulse-check ; single-lead electrocardiogram ; and screening by blood pressure machine with atrial fibrillation detection algorithms . Participants who received a positive result on 1 or more test underwent 12-lead electrocardiogram with or withour 24-hour Holter . Screening tests were compared using the McNemar test . Participants with confirmed atrial fibrillation received follow-up at 90 days . RESULTS The mean age of participants was 73.7 ( ± 6.9 ) years , and 53.4 % of participants were female . Of 2171 patients , we had data from all 3 screening tests for 2054 patients . Both single-lead electrocardiogram and the blood pressure device showed superior specificity compared with pulse-check ( p < 0.001 for each ) . Fifty-six patients ( 2.7 % ) had confirmed atrial fibrillation : 12 patients had newly detected atrial fibrillation ( none of the patients were using anticoagulation agents ) , and 44 patients had previously diagnosed atrial fibrillation ( 42 patients were receiving anticoagulant therapy , 2 were not ) . Thus , 14 patients had actionable atrial fibrillation ( 0.7 % ) . By 90 days , 77 % of patients with actionable atrial fibrillation had started anticoagulant therapy . INTERPRETATION Newer screening technologies showed superior specificity compared with a pulse-check . Screening detected undiagnosed or undertreated atrial fibrillation in 0.7 % of participants , and 77 % started appropriate anticoagulant therapy . TRIAL REGISTRATION Clinical Trials.gov , no. NCT02262351 BACKGROUND Atrial fibrillation is a common problem in older people . The evidence base for the safety of warfarin and aspirin in atrial fibrillation is largely derived from selective research studies and secondary care . Further assessment of the safety of warfarin in older people with atrial fibrillation in routine primary care is needed . AIM To measure the complication rates and adequacy of warfarin control in a cohort of patients with atrial fibrillation managed in primary care and compare them with published data from controlled trials and community patients with atrial fibrillation not receiving warfarin . DESIGN OF STUDY Retrospective review of regional cohort . SETTING Twenty-seven general practice s in southwest Scotl and . METHOD Case note review of 601 patients previously identified as having atrial fibrillation by GPs . RESULTS The average age of our cohort was 77 years at recruitment . Two hundred and sixty-four ( 44 % ) patients died within 5 years of follow up . Three hundred and nine of the 601 ( 51 % ) patients with atrial fibrillation took warfarin at some stage during this study . INR ( international normalised ratio ) was maintained between 2 and 3 for 68 % of the time . Bleeding risk was higher in patients taking warfarin than in those on aspirin or no antithrombotic therapy ( warfarin 9.0 % per year versus aspirin 4.7 % per year versus no therapy 4.6 % per year ) . The annual risk of any bleeding complication on warfarin ( 9 % ) was similar to that recorded in r and omised trials ( 9.2 % ) whereas the annual risk of severe bleeding was approximately double ( 2.6 versus 1.3 % ) . CONCLUSION Adequacy of anticoagulant control was broadly comparable to that reported in clinical trials , whereas the risk of severe bleeding was higher , possibly reflecting the older age and the comorbidities of our unselected cohort Background and Purpose — Warfarin is the most effective stroke prevention medication for high-risk individuals with atrial fibrillation , yet it is often underused . This study examined the magnitude of this problem in a large contemporary , prospect i ve stroke registry . Methods — We analyzed data from the Registry of the Canadian Stroke Network , a prospect i ve data base of consecutive patients with stroke admitted to 12 design ated stroke centers in Ontario ( 2003 to 2007 ) . We included patients admitted with an acute ischemic stroke who ( 1 ) had a known history of atrial fibrillation ; ( 2 ) were classified as high risk for systemic emboli according to published guidelines ; and ( 3 ) had no known contraindications to anticoagulation . Primary end points were the use of prestroke antithrombotic medications and admission international normalized ratio . Results — Among patients admitted with a first ischemic stroke who had known atrial fibrillation ( n=597 )  , strokes were disabling in 60 % and fatal in 20 % . Preadmission medications were warfarin ( 40 % ) , antiplatelet therapy ( 30 % ) , and no antithrombotics ( 29 % ) . Of those taking warfarin , three fourths had a subtherapeutic international normalized ratio ( < 2.0 ) at the time of stroke admission . Overall , only 10 % of patients with acute stroke with known atrial fibrillation were therapeutically anticoagulated ( international normalized ratio ≥2.0 ) at admission . In stroke patients with a history of atrial fibrillation and a previous transient ischemic attack or ischemic stroke ( n=323 ) , only 18 % were taking warfarin with therapeutic international normalized ratio at the time of admission for stroke , 39 % were taking warfarin with subtherapeutic international normalized ratio , and 15 % were on no antithrombotic therapy . Conclusions — In high-risk patients with atrial fibrillation admitted with a stroke , and who were c and i date s for anticoagulation , most were either not taking warfarin or were subtherapeutic at the time of ischemic stroke . Many were on no antithrombotic therapy . These findings should encourage greater efforts to prescribe and monitor appropriate antithrombotic therapy to prevent stroke in individuals with atrial fibrillation Early detection of atrial fibrillation patients at high risk for stroke is important . There are some studies which indicate that mean platelet volume ( MPV ) determines the prognosis and risk in patients with a stroke . In this study , our aim was to investigate the association between the MPV measured in stroke patients with atrial fibrillation . Consecutive patients referred to our center between January 2010 and April 2012 were included in this study . The patients with atrial fibrillation were classified into two groups according to presence or absence of a history of stroke by combining data from the medical histories after a thorough review of the medical records . MPV determination was made within 24 h following the onset of stroke . We studied 63 consecutive stroke patients with atrial fibrillation and 77 atrial fibrillation patients without stroke history . In receiver-operating characteristic ( ROC ) curve analysis , the value for MPV levels to detect stroke with a sensitivity of 63.5 % and specificity of 64.4 % was 9.4 fl . High MPV ( > 9.4 fl ) was significantly associated with the occurrence of stroke [ odds ratio ( OR ) 4.021 , 95 % confidence interval ( CI ) 1709–9464 , P < 0.001 ] . Our study supports the hypothesis that a high MPV is associated with an increased risk of stroke in atrial fibrillation patients Background — Dabigatran , an oral thrombin inhibitor , and rivaroxaban and apixaban , oral factor Xa inhibitors , have been found to be safe and effective in reducing stroke risk in patients with atrial fibrillation . We sought to compare the efficacy and safety of the 3 new agents based on data from their published warfarin-controlled r and omized trials , using the method of adjusted indirect comparisons . Methods and Results — We included findings from 44 535 patients enrolled in 3 trials of the efficacy of dabigatran  ( R and omized Evaluation of Long-Term Anticoagulation Therapy [ RELY ] ) , apixaban ( Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation [ ARISTOTLE ] ) , and rivaroxaban ( Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared With Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation [ ROCKET-AF ] ) , each compared with warfarin . The primary efficacy end point was stroke or systemic embolism ; the safety end point we studied was major hemorrhage . To address a lack of comparability between trial population s caused by the restriction of ROCKET-AF to high-risk patients , we conducted a subgroup analysis in patients with a CHADS2 score ≥3 . We found no statistically significant efficacy differences among the 3 drugs , although apixaban and dabigatran were numerically superior to rivaroxaban . Apixaban produced significantly fewer major hemorrhages than dabigatran and rivaroxaban . Conclusions — An indirect comparison of new anticoagulants based on existing trial data indicates that in patients with a CHADS2 score ≥3  dabigatran 150 mg , apixaban 5 mg , and rivaroxaban 20 mg result ed in statistically similar rates of stroke and systemic embolism , but apixaban had a lower risk of major hemorrhage compared with dabigatran and rivaroxaban . Until head-to-head trials or large-scale observational studies that reflect routine use of these agents are available , such adjusted indirect comparisons based on trial data are one tool to guide initial therapeutic choices Background and Purpose We wished to test the validity of a stroke probability point system from the Framingham Study for a sample of the population of Copenhagen , Denmark . In the Framingham cohort , the regression model of Cox established the effect on stroke of the following factors : age , systolic blood pressure , the use of antihypertensive therapy , diabetes mellitus , cigarette smoking , prior cardiovascular disease , atrial fibrillation , and left ventricular hypertrophy . Derived from this model , stroke probabilities were computed for each sex based on a point system . The authors cl aim ed that a physician can use this system for individual stroke prediction . Methods The Copenhagen City Heart Study is a prospect i ve survey of 19 698 women and men aged 20 years or older invited to two cardiovascular examinations at 5‐year intervals . The baseline examination included 3015 men and 3501 women aged 55 to 84 years ; 474 stroke events occurred during 10 years of follow‐up . In both cohorts initial cases of stroke and transient ischemic attack recorded during 10 years of follow‐up were used . We used the statistical model from the Framingham Study to establish a corresponding stroke probability point system using data from the Copenhagen City Heart Study population . We then compared the effects of the relevant risk factors , their combinations , and the corresponding stroke probabilities . We also assessed stroke events during 10 years of follow‐up in several subgroups of the Copenhagen population with different combinations of risk factors . Results For the Copenhagen City Heart Study population some of the risk factors ( diabetes mellitus , cigarette smoking , atrial fibrillation , and left ventricular hypertrophy ) had regression coefficients different from those of the Framingham Study population . Consequently , the probability of stroke for persons presenting these risk factors and their combinations varied between the two studies . For some other risk factors ( age , blood pressure , and cardiovascular disease ) , no major differences were found . The recorded frequency of stroke events in subgroups of the Copenhagen population was compatible with the estimated probability intervals of stroke from the Copenhagen City Heart Study and with those from the Framingham Study , but these intervals were very large . Conclusions The majority of risk factors for stroke identified by the Framingham Study also had a significant effect in the Copenhagen City Heart Study population . The differences found could be due partly to different definitions of these factors used by the two studies . Although estimated stroke probabilities based on point systems from the Copenhagen City Heart Study and the Framingham Study were similar , the points scored in the two systems did not always correspond to the same combination of risk factors . Such systems can be used for estimating stroke probability in a given population , provided that the statistical confidence limits are known and the definitions of risk factors are compatible . However , because of the large statistical uncertainty , a prognostic index should not be applied for individual prediction unless it is used as an indicator of high relative risk associated with the simultaneous presence of several risk factors . ( Stroke . 1994;25:802‐807 . CONTEXT Atrial fibrillation is a common , but potentially preventable , complication following coronary artery bypass graft ( CABG ) surgery . OBJECTIVES To assess the nature and consequences of atrial fibrillation after CABG surgery and to develop a comprehensive risk index that can better identify patients at risk for atrial fibrillation . DESIGN , SETTING , AND PARTICIPANTS Prospect i ve observational study of 4657 patients undergoing CABG surgery between November 1996 and June 2000 at 70 centers located within 17 countries , selected using a systematic sampling technique . From a derivation cohort of 3093 patients , associations between predictor variables and postoperative atrial fibrillation were identified to develop a risk model , which was assessed in a validation cohort of 1564 patients . MAIN OUTCOME MEASURE New-onset atrial fibrillation after CABG surgery . RESULTS A total of 1503 patients ( 32.3 % ) developed atrial fibrillation after CABG surgery . Postoperative atrial fibrillation was associated with subsequent greater re source use as well as with cognitive changes , renal dysfunction , and infection . Among patients in the derivation cohort , risk factors associated with atrial fibrillation were advanced age ( odds ratio [ OR ] for 10-year increase , 1.75 ; 95 % confidence interval [ CI ] , 1.59 - 1.93 ) ; history of atrial fibrillation ( OR , 2.11 ; 95 % CI , 1.57 - 2.85 ) or chronic obstructive pulmonary disease ( OR , 1.43 ; 95 % CI , 1.09 - 1.87 ) ; valve surgery ( OR , 1.74 ; 95 % CI , 1.31 - 2.32 ) ; and postoperative withdrawal of a beta-blocker ( OR , 1.91 ; 95 % CI , 1.52 - 2.40 ) or an angiotensin-converting enzyme ( ACE ) inhibitor ( OR 1.69 ; 95 % CI , 1.38 - 2.08 ) . Conversely , reduced risk was associated with postoperative administration of beta-blockers ( OR , 0.32 ; 95 % CI , 0.22 - 0.46 ) , ACE inhibitors ( OR , 0.62 ; 95 % CI , 0.48 - 0.79 ) , potassium supplementation ( OR , 0.53 ; 95 % CI , 0.42 - 0.68 ) , and nonsteroidal anti-inflammatory drugs ( OR , 0.49 ; 95 % CI , 0.40 - 0.60 ) . The result ing multivariable risk index had adequate discriminative power with an area under the receiver operating characteristic ( ROC ) curve of 0.77 in the validation sample . Forty-three percent ( 640/1503 ) of patients who had atrial fibrillation after CABG surgery experienced more than 1 episode of atrial fibrillation . Predictors of recurrent atrial fibrillation included older age , history of congestive heart failure , left ventricular hypertrophy , aortic atherosclerosis , bicaval venous cannulation , withdrawal of ACE inhibitor or beta-blocker therapy , and use of amiodarone or digoxin ( area under the ROC curve of 0.66 ) . Patients with recurrent atrial fibrillation had longer hospital stays and experienced greater infectious , renal , and neurological complications than those with a single episode . CONCLUSIONS We have developed and vali date d models predicting the occurrence of atrial fibrillation  after CABG surgery based on an analysis of a large multicenter international cohort . Our findings suggest that treatment with beta-blockers , ACE inhibitors , and /or nonsteroidal anti-inflammatory drugs may offer protection . Atrial fibrillation after CABG surgery is associated with important complications Background — Many patients with atrial fibrillation are at high risk for stroke and require antithrombotic therapy . Antiarrhythmic drugs have not previously been shown to reduce the risk of stroke in atrial fibrillation . The effect of dronedarone , a new multichannel-blocking antiarrhythmic drug , on stroke has been evaluated in a r and omized , double-blind clinical trial , ATHENA ( A placebo-controlled , double-blind , parallel-arm Trial to assess the efficacy of dronedarone 400 mg BID for the prevention of cardiovascular Hospitalization or death from any cause in patiENts with Atrial fibrillation/atrial flutter ) . Methods and Results — Patients with persistent or paroxysmal atrial fibrillation and at least 1 risk factor for cardiovascular hospitalization were r and omized to receive dronedarone ( 400 mg BID ) or double-blind matching placebo and followed up for a minimum of 1 year to a common termination at 30 months . All strokes that occurred during the study were included in the present post hoc analysis . There were 4628 patients r and omized to placebo or dronedarone .  The baseline risk factors for stroke were well balanced between the 2 groups , and the baseline mean CHADS2 score was 2 . The baseline use of either oral anticoagulant therapy or antiplatelet agent alone was 60 % . Dronedarone reduced the risk of stroke from 1.8 % per year to 1.2 % per year ( hazard ratio 0.66 , 95 % confidence interval 0.46 to 0.96 , P=0.027 ) . The effect of  dronedarone  was similar whether or not patients were receiving oral anticoagulant therapy , and there was a significantly greater effect of  dronedarone  in patients with higher CHADS2 scores . Conclusions — In this post hoc analysis , a reduction in stroke was observed in patients with atrial fibrillation who were receiving usual care , which included antithrombotic therapy and heart rate control , who were r and omized to dronedarone . Further studies to investigate the effect of dronedarone and other antiarrhythmic agents on stroke are indicated BACKGROUND Hypertension is the most important risk factor directly attributable to the high prevalence of atrial fibrillation ( AF ) , and is one of the few modifiable risk factors for AF . Activation and overactivity of the sympathetic nervous system ( SNS ) have been implicated in the pathogenesis of both essential hypertension and AF . Catheter-based renal sympathetic denervation ( RSDN ) appears to be an effective adjunctive treatment for refractory hypertension , and may be beneficial in other conditions characterized by SNS overactivity , such as left ventricular hypertrophy and atrial arrhythmias . OBJECTIVE The H-FIB study is a multicenter prospect i ve , double-blind , r and omized ( 1:1 ) controlled trial . The primary efficacy endpoint is antiarrhythmic drug-free freedom from AF recurrence through 12 months . METHODS Patients with a history of significant hypertension who are receiving treatment with at least one antihypertensive agent who are planned for a first time ablation for symptomatic paroxysmal or persistent AF will be r and omized to either AF ablation alone ( control group ) or AF ablation + RSDN ( study group ) . CONCLUSIONS H-FIB is a multicenter , r and omized trial that will test the hypothesis that adjunctive renal sympathetic denervation , at the time of AF ablation , will increase the freedom from recurrent AF 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 BACKGROUND AND PURPOSE Nonvalvular atrial fibrillation ( AF ) is a strong , independent risk factor for stroke , but the absolute rate of stroke varies widely among AF patients , importantly influencing the potential benefit of antithrombotic prophylaxis . We explore factors associated with ischemic stroke in AF patients taking aspirin .  METHODS We performed multivariate logistic regression analysis of 2012 participants given aspirin alone or in combination with low , inefficacious doses of warfarin in the Stroke Prevention in Atrial Fibrillation I-III trials followed for a mean of 2.0 years , during which 130 ischemic strokes were observed . RESULTS Age ( relative risk [RR]=1.8 per decade , P<0.001 ) , female sex ( RR=1.6 , P=0.01 ) , history of hypertension ( RR=2.0 , P<0.001 ) , systolic blood pressure > 160 mm Hg ( RR=2.3 , P<0.001 ) , and prior stroke or transient ischemic attack ( RR=2.9 , P<0.001 ) were independently associated with increased stroke risk . Regular consumption of > /=14 alcohol-containing drinks per week was associated with reduced stroke risk ( adjusted RR=0.4 , P=0.04 ) . Among SPAF III participants , estrogen hormone replacement therapy was associated with a higher risk of ischemic stroke ( adjusted RR=3.2 , P=0.007 ) . With the use of these variables , a risk stratification scheme for primary prevention separated participants into those with high ( 7.1%/y , 22 % of the cohort ) , moderate ( 2.6%/y , 37 % of the cohort ) , and low ( 0.9%/y , 41 % of the cohort ) rates of stroke . Ischemic strokes in low-risk participants were less often disabling ( P<0.001 ) . CONCLUSIONS Patients with AF who have high and low rates of stroke during treatment with  aspirin can be identified . However , validation of our risk stratification scheme is necessary before it can be applied with confidence to clinical management . Postmenopausal estrogen replacement therapy and moderate alcohol consumption may additionally modify the risk of stroke in AF , but these findings require confirmation We performed a post hoc analysis of the Systolic Hypertension in the Elderly Program data base to assess the incidence of atrial fibrillation in the elderly hypertensive population , its influence on cardiovascular events , and whether antihypertensive treatment can prevent its onset . The Systolic Hypertension in the Elderly Program was a double-blind placebo-controlled trial in 4736 subjects with isolated systolic hypertension aged ≥60 years . Atrial fibrillation was an exclusion criterion from the trial . Participants were r and omly assigned to stepped care treatment with chlorthalidone and atenolol ( n=2365 ) or placebo ( n=2371 ) . The occurrence of atrial fibrillation and cardiovascular events over 4.7 years as well as the determination of cause of death at 4.7 and 14.3 years were followed . Ninety-eight subjects ( 2.06 % ) developed atrial fibrillation over 4.7 years mean follow-up , without significant difference between treated and placebo groups . Atrial fibrillation increased the risk for : total cardiovascular events ( RR 1.69 ; 95 % CI 1.21 to 2.36 ) , rapid death ( RR 3.29 ; 95 % CI 1.08 to 10.00 ) , total ( RR 5.10 ; 95 % CI 3.12 to 8.37 ) and nonfatal left ventricular failure ( RR 5.31 ; 95 % CI 3.09 to 9.13 ) . All-cause and total cardiovascular death were significantly increased in the atrial fibrillation group at 4.7 years ( HR 3.44 ; 95 % CI 2.18 to 5.42 ; HR 2.39 ; 95 % CI 1.05 to 5.43 ) and 14.3 years follow-up ( HR 2.33 ; 95 % CI 1.83 to 2.98 ; HR 2.21 ; 95 % CI 1.54 to 3.17 ) . Atrial fibrillation increased the risk for total cardiovascular events , rapid death , and left ventricular failure . All-cause mortality and total cardiovascular mortality were significantly increased in hypertensives with atrial fibrillation at 4.7 and 14.3 years follow-up Objective To determine the frequency of survival , stroke , atrial fibrillation , structural valve deterioration , and length of hospital stay after surgical replacement of an aortic valve ( SAVR ) with a bioprosthetic valve in patients with severe symptomatic aortic stenosis . Design Systematic review and meta- analysis of observational studies . Data sources Medline , Embase , PubMed ( non- Medline records only ) , Cochrane Data base of Systematic Review s , and Cochrane CENTRAL from 2002 to June 2016 . Study selection Eligible observational studies followed patients after SAVR with a bioprosthetic valve for at least two years . Methods Review ers , independently and in duplicate , evaluated study eligibility , extracted data , and assessed risk of bias for patient important outcomes . We used the GRADE system to quantify absolute effects and quality of evidence . Published survival curves provided data for survival and freedom from structural valve deterioration , and r and om effect models provided the framework for estimates of pooled incidence rates of stroke , atrial fibrillation , and length of hospital stay . Results In patients undergoing SAVR with a bioprosthetic valve , median survival was 16 years in those aged 65 or less , 12 years in those aged 65 to 75 , seven years in those aged 75 to 85 , and six years in those aged more than 85 . The incidence rate of stroke was 0.25 per 100 patient years ( 95 % confidence interval 0.06 to 0.54 ) and atrial fibrillation 2.90 per 100 patient years ( 1.78 to 4.79 ) . Post-SAVR , freedom from structural valve deterioration was 94.0 % at 10 years , 81.7 % at 15 years , and 52 % at 20 years , and mean length of hospital stay was 12 days ( 95 % confidence interval 9 to 15 ) . Conclusion Patients with severe symptomatic aortic stenosis undergoing SAVR  with a bioprosthetic valve can expect only slightly lower survival than those without aortic stenosis , and a low incidence of stroke and , up to 10 years , of structural valve deterioration . The rate of deterioration increases rapidly after 10 years , and particularly after 15 years OBJECTIVE This study was performed to characterize the risk of stroke in elderly patients with recurrent intermittent atrial fibrillation ( AF ) . BACKGROUND Although intermittent AF is common , relatively little is known about the attendant risk of stroke . METHODS A longitudinal cohort study was performed comparing 460 participants with intermittent AF with 1,552 with sustained AF treated with aspirin in the Stroke Prevention in Atrial Fibrillation studies and followed for a mean of two years . Independent risk factors for ischemic stroke were identified by multivariate analysis . RESULTS Patients with intermittent AF were , on average , younger ( 66 vs. 70 years , p < 0.001 ) , were more often women ( 37 % vs. 26 % p < 0.001 ) and less often had heart failure ( 11 % vs. 21 % , p < 0.001 ) than those with sustained AF . The annualized rate of ischemic stroke was similar for those with intermittent ( 3.2 % ) and sustained AF ( 3.3 % ) . In patients with intermittent AF , independent predictors of ischemic stroke were advancing age ( relative risk [ RR ] = 2.1 per decade , p < 0.001 ) , hypertension ( RR = 3.4 , p = 0.003 ) and prior stroke ( RR = 4.1 , p = 0.01 ) . Of those with intermittent AF predicted to be high risk ( 24 % ) , the observed stroke rate was 7.8 % per year ( 95 % confidence interval 4.5 to 14 ) . CONCLUSIONS In this large cohort of AF patients given aspirin , those with intermittent AF had stroke rates similar to patients with sustained AF and similar stroke risk factors . Many elderly patients with recurrent intermittent AF have substantial rates of stroke and likely benefit from anticoagulation . High-risk patients with intermittent AF can be identified using the same clinical criteria that apply to patients with sustained AF CONTEXT Previous studies suggest that consuming moderate to high amounts of alcohol on a regular basis might increase the risk of developing  atrial fibrillation  in men but not in women . However , these studies were not powered to investigate the association of alcohol consumption and atrial fibrillation among women . OBJECTIVE To prospect ively assess the association between regular alcohol consumption  and incident atrial fibrillation among women . DESIGN , SETTING , AND PARTICIPANTS Participants were 34 715 initially healthy women participating in the Women 's Health Study , a completed r and omized controlled trial conducted in the United States . Participants were older than 45 years and free of atrial fibrillation at baseline and underwent prospect i ve follow-up from 1993 to October 31 , 2006 .  Alcohol consumption  was assessed via question naires at baseline and at 48 months of follow-up and was grouped into 4 categories ( 0 , > 0 and < 1 , > or = 1 and < 2 , and > or = 2 drinks per day ) . Atrial fibrillation was self-reported on the yearly question naires and subsequently confirmed by electrocardiogram and medical record review . MAIN OUTCOME MEASURE Time to first episode of atrial fibrillation . RESULTS Over a median follow-up of 12.4 years , 653 cases of incident atrial fibrillation were confirmed . Age-adjusted incidences among women consuming 0 ( n = 15,370 ) , more than 0 and less than 1 ( n = 15,758 ) , 1 or more and less than 2 ( n = 2228 ) , and 2 or more ( n = 1359 ) drinks per day were 1.59 , 1.55 , 1.27 , and 2.25 events/1000 person-years of follow-up . Thus , compared with nondrinking women , women consuming 2 or more drinks per day had an absolute risk increase of 0.66 events/1000 person-years . The corresponding multivariate-adjusted hazard ratios ( HRs ) for incident atrial fibrillation were 1 , 1.05 ( 95 % CI , 0.88 - 1.25 ) , 0.84 ( 95 % CI , 0.58 - 1.22 ) , and 1.60 ( 95 % CI , 1.13 - 2.25 ) , respectively . The increased hazard in the small group of women consuming 2 or more drinks per day persisted when alcohol intake was up date d at 48 months ( HR , 1.49 ; 95 % CI , 1.05 - 2.11 ) or when women were censored at their first cardiovascular event ( HR , 1.68 ; 95 % CI , 1.18 - 2.39 ) . CONCLUSIONS Among healthy middle-aged women , consumption of up to 2 alcoholic beverages per day was not associated with an increased risk of incident atrial fibrillation . Heavier consumption of 2 or more drinks per day , however , was associated with a small but statistically significant increased risk of atrial fibrillation OBJECTIVE To identify those patients with nonrheumatic atrial fibrillation who are at high risk and those at low risk for arterial thromboembolism .  DESIGN Cohort study of patients assigned to placebo in a r and omized clinical trial . SETTING Five hundred sixty-eight in patients and out patients with nonrheumatic atrial fibrillation assigned to placebo therapy at 15 U.S. medical centers from 1987 to 1989 in the Stroke Prevention in Atrial Fibrillation study . Patients were followed for a mean of 1.3 years . MEASUREMENTS Clinical variables were assessed at study entry and correlated with subsequent ischemic stroke and systemic embolism by multivariate analysis . MAIN RESULTS Recent ( within 3 months ) congestive heart failure , a history of hypertension , and previous arterial thromboembolism were each significantly and independently associated with a substantial risk for thromboembolism ( greater than 7 % per year ; P less than or equal to 0.05 ) . The presence of these three independent clinical predictors ( recent congestive heart failure , history of hypertension , previous thromboembolism of 2.5 % per year ( no risk factors ) , 7.2 % per year ( one risk factor ) , and 17.6 % per year ( two or three risk factors ) . Nondiabetic patients without these risk factors , comprising 38 % of the cohort , had a low risk for thromboembolism ( 1.4 % per year ; 95 % Cl , 0.05 % to 3.7 % ) . Patients without clinical risk factors who were under 60 years of age had no thromboembolic events . CONCLUSION Patients with atrial fibrillation at high risk ( greater than 7 % per year ) and low risk ( less than 3 % per year ) for thromboembolism can be identified by readily available clinical variables BACKGROUND This study compared the effect of antihypertensive treatment with valsartan or ramipril on  atrial fibrillation ( AF ) recurrence  , on P-wave dispersion , ( PWD ) and on serum procollagen type I carboxy terminal peptide ( PIP ) . METHODS A total of 369 mild hypertensive ( systolic blood pressure ( SBP ) > 140 and /or 90 < diastolic blood pressure ( DBP ) < 110 mm Hg ) out patients in sinus rhythm but with at least two episodes of AF in the previous 6 months were r and omized to valsartan ( n = 122 ) , ramipril  ( n = 124 ) , or amlodipine  ( n = 123 ) for 1 year . Clinic blood pressure ( BP ) and a 24-h electrocardiogram ( ECG )  were evaluated monthly . Patients were asked to report any episode of symptomatic AF and to perform an ECG as early as possible . PWD and serum PIP levels were evaluated before and after each treatment period . RESULTS SBP and DBP were significantly reduced by the three treatments ( P < 0.001 ) . A total of 46 ( 47.4 % ) patients treated with amlodipine had a recurrence of AF as did 26 ( 27.9 % ) patients treated with ramipril ( P < 0.01 vs. amlodipine ) and 16 ( 16.1 % ) patients treated with valsartan ( P < 0.01 vs. amlodipine and P < 0.05 vs. ramipril ) . The Kaplan-Meyer analysis showed a significant reduction of AF episodes in the valsartan group ( P = 0.005 log-rank test ) as well as in the ramipril group ( P = 0.021 ) , even if at a lesser degree . PWD values were significantly reduced by ramipril ( -4.2 ms , P < 0.05 ) and even more by valsartan ( -11.2 ms , P < 0.01 ) , the difference being significant ( P < 0.01 ) . Serum PIP levels were reduced by ramipril ( -49.7 microg , P < 0.001 ) and valsartan ( -49.3 microg , P < 0.001 ) . CONCLUSIONS Despite similar BP lowering , valsartan and ramipril were more effective than amlodipine in preventing new episodes of AF , but the effect of valsartan was greater than that of ramipril . This could be related to the greater PWD reduction observed with valsartan 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
Antihypertensive therapy reduces the risk of atrial fibrillation modestly but benefits appear to be larger in patients with heart failure , with no clear evidence of benefit in patients without heart failure .
Previous suggestions of class-specific effects could not be confirmed in this more comprehensive analysis
AIMS High blood pressure is known to be associated with future risk of atrial fibrillation .
Whether such risks can be reduced with antihypertensive therapy is less clear .
We conducted a systematic review and meta- analysis of large-scale r and omized trials that have reported the effect of antihypertensive agents on atrial fibrillation .